1. Inequalities in Children’s Educational Outcomes: Using Administrative Data to Gain a Population-Based Perspective on Health Marni Brownell, Noralou Roos, Randy Fransoo, Leslie Roos, Anne Guèvremont, Leonard MacWilliam, Lauren Yallop, Ben Levin & Beth Edwards

2. Questions to be Addressed: 1.Why focus on educational outcomes when studying population health? 2.What are administrative databases? 3.What do administrative databases tell us about child outcomes that is different from other data sources?

3. 1. Why focus on educational outcomes when studying population health? First, what is health? WHO originally defined it as: A state of complete physical, mental and social well-being and not merely the absence of disease or infirmity. (1948) In 1986 the WHO stated that at every level of planning health promotion should emphasize “a social, economic and ecological, rather than a purely physical and mental perspective on health.” (3)(3)

4. Research on the social determinants of health – much more to health than health care Examples: Marmot et al. (1991) - Whitehall study of British Civil Servants (6)Marmot et al. (1991) (6) Evans et al. (1994) – Why Are Some People Healthy and Others Not? (2)Evans et al. (1994) (2) Hertzman et al. (2002) – Child development as a determinant of later health outcomes (4)Hertzman et al. (2002) (4)

5. Education levels strongly related to health outcomes Education outcomes have inter-generational effects Education levels may be more readily changed by policy initiatives than other components of socioeconomic status (SES)

6. 2. What are administrative databases? Data originally collected to provide and manage services extremely useful for research Linkages made across data sets using anonymized identifiers make cross-service and longitudinal research possible Manitoba Centre for Health Policy – model for linked administrative databasesManitoba Centre for Health Policy

7. Manitoba Population Health Research Data Repository Population-Based Research Registry Hospital Home Care Pharmaceuticals Immunize Vital Statistics Costs Nursing Home Physician Family Services Education Key health databases start in 1970 Census Data at area level National surveys Healthy Child Program Data - Birth weight, gestation - Injuries - Chronic diseases (asthma, diabetes) -Meds -dosage - diagnosis -income assistance -in care -standards tests -high school marks -graduation -retention -residence -marital status -family size

8. 3. What do administrative databases tell us about child outcomes that is different from other data sources? Combined with information from a research registry they provide a population-based perspective that might not be available otherwise We can combine information to examine underlying causes of inequalities in child health: - Area level socioeconomic status - Age of mother - Birth weight - Apgar scores - Educational Outcomes The following slides will demonstrate how educational outcomes vary with socioeconomic status

9. SES Groups, Winnipeg 2001 Census Neighbourhood Socioeconomic Status High SES (Most Advantaged) Pop = 48,789; Child pop: 13,087 Middle Class Pop = 354,712; Child pop: 90,272 Low-Mid Pop = 140,469; Child pop: 32,803 Low SES (Most Disadvantaged) Pop = 104,989; Child pop: 28,202 Assessed by: High school education, Unemployment rate, Single parent families, Female singe parent families, Female labour force participation

10. Grade 12 (S4) Performance by SES Group Language Arts Standards Test 2001/02 Pass/Fail rates of test writers17/18 year olds who should have written N= 221 121 98 276 31

11. Recovery: What happens to the retained students in 2 yrs after 01/02? (Percent Graduated) SES Low High

12. High School Completion by SES & Mother’s Age Grade 9 (S1) students in 1997/98: What happens in next 5 years?

13. Grade 3 Performance by SES and Mother’s Age (Language Arts Standards Test 1998/99) Pass/Fail Rate of Test WritersEight year olds who should have written

14. Healthiness of Children at Birth (1984) by Winnipeg SES Group

15. Infant Hospitalization Rate First Year of Life: (Children Born 1998/99-2000/01)

16. Percent Winnipeg Children Enrolled in Reading Recovery Program, Grade One, 2001 Reading Recovery Program SES

17. Child Care Spaces for 0 to 12 year olds, by Winnipeg Neighbourhoods, 2001 (per 1000 children) High SES Middle Low- Mid Low SES

18. What can be done? Enriched early childhood environments –Quality child care, especially for kids in low SES families –Research shows that quality ECD helps all, but makes largest difference for those at highest risk Enhanced programs in school years (e.g. early literacy programs) Engage with health authorities, community groups, and parents to make programs aimed at enhancing childhood development universal and needs-based Appreciate the short and long term health implications of educational outcomes.

19. Conclusions Differences in outcomes across SES may be dramatically underestimated without a population-based approach – Disadvantaged groups are at very high risk for poor outcomes Not all disadvantaged children do poorly Of the total number of kids with poor academic outcomes, the majority are not in the most disadvantaged groups –But low SES kids are much less likely to recover from a setback

20. This research has centered on school achievement, but the focus of policies aimed at changing the trajectories of disadvantaged children should not be limited to the school system. Our analyses and work by others (e.g. Hertzman et al. 2002)(4) reveal that, while the vast majority of children at every socioeconomic level show remarkable similarities at birth, inequalities in achievement are evident early in childhood, prior to school entry. Children who are already behind their peers when they begin school will likely fall further behind; engaging them in the educational process may be difficult. This makes it imperative for governments to provide effective early childhood programs (starting in the first few years of life) to improve the experiences of children at risk, and to improve the physical, mental and social well-being of all children. Hertzman et al. 2002)(4) Final Thoughts…