Health Promotion International, 2015, Vol. 30, No.

S2 ii102–ii115
doi: 10.1093/heapro/dav031

Early childhood development and the social

determinants of health inequities
Timothy G. Moore1,*, Myfanwy McDonald1, Leanne Carlon2, and
Kerryn O’Rourke2
1
Murdoch Childrens Research Institute, Royal Children’s Hospital, 50 Flemington Road, Parkville, Victoria
3052, Australia, and 2VicHealth, 15-31 Pelham Street, Carlton, VIC 3053, Australia

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*Corresponding author. E-mail: tim.moore@mcri.edu.au

‘Fair Foundations: The VicHealth framework for health equity’ was developed by VicHealth under the leadership of
author O’Rourke. It was published in 2013. It is a conceptual and planning framework adapted from work done by
the WHO Commission on the Social Determinants of Health (Solar and Irwin, 2010). Social determinants of health
inequities are depicted as three layers of influence – socioeconomic, political and cultural context; daily living
conditions; and individual health-related factors. These determinants and their unequal distribution according to
social position, result in differences in health status between population groups that are avoidable and unfair. The
layers of influence also provide practical entry points for action (VicHealth, 2013). Fair Foundations can be accessed
at www.vichealth.vic.gov.au.

Summary
Children’s health and development outcomes follow a social gradient: the further up the socio-
economic spectrum, the better the outcomes. Based upon a review of multiple forms of evidence,
and with a specific focus upon Australia, this article investigates the causes of these socially produced
inequities, their impact upon health and development during the early years and what works to reduce
these inequities. Using VicHealth’s Fair Foundations framework, we report upon child health inequity at
three different levels: the socioeconomic, political and cultural level; daily living conditions; the individ-
ual health-related behaviours. Although intensive interventions may improve the absolute conditions of
significantly disadvantaged children and families, interventions that have been shown to effectively
reduce the gap between the best and worst off families are rare. Numerous interventions have been
shown to improve some aspect of prenatal, postnatal, family, physical and social environments for
young children; however, sustainable or direct effects are difficult to achieve. Inequitable access to ser-
vices has the potential to maintain or increase inequities during the early years, because those families
most in need of services are typically least able to access them. Reducing inequities during early child-
hood requires a multi-level, multi-faceted response that incorporates: approaches to governance and
decision-making; policies that improve access to quality services and facilitate secure, stable, flexible
workplaces for parents; service systems that reflect the characteristics of proportionate universalism,
function collaboratively, and deliver evidence-based programs in inclusive environments; strong, sup-
portive communities; and information and timely assistance for parents so they feel supported and
confident.

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Early childhood development and the social determinants, 2015, Vol. 30, No. S2 ii103

Key words: children, health and social policy, Australia, inequalities in health

INTRODUCTION Developing Child, 2007; Shonkoff et al., 2009; Currie

and Rossin-Slater, 2014). There are three key ways in
In every society, including Australia, differences in socio-
which the life-long effects of early experiences impact on
economic status translate into inequities in child develop-
the later achievements, health and longevity of individuals:
ment (Hertzman et al., 2010; Strategic Review of Health
Inequalities in England post-2010 Committee, 2010; • ‘Biological embedding’ is a developmental process
Goldfeld and West, 2014). Discrepancies between children whereby prenatal and early childhood experiences
that are based upon avoidable differences in social and affect physiological and neurological development in
economic circumstances are evident as early as 9 months ways that have long-term consequences (Gluckman
of age in a range of domains, and they grow larger over et al., 2010; Hertzman and Boyce, 2010);
time (Heckman, 2008; Halle et al., 2009). • ‘The cumulative effect of adverse experiences’ during

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It is well established that health follows a social gradi- childhood can lead to toxic stress that influences
ent: progressively better health is associated with increasing every aspect of health and well-being in childhood
socioeconomic position (WHO Commission on the Social and beyond (Anda et al., 2009; Brown et al., 2009;
Determinants of Health, 2008; Bambra et al., 2010). This Shonkoff et al., 2009; Shonkoff, 2012); and
phenomenon is also evident across a wide range of indica- • ‘Escalations in risk over time’ shape children’s develop-
tors pertaining to children and families: outcomes for chil- ment so that exposure to adverse experiences at one
dren and families improve progressively the further up the stage of the life course increases the probability of simi-
socioeconomic spectrum they are, and worsen progressively lar exposures subsequently (Repetti et al., 2002;
the further down they move (Hertzman et al., 2010; Hertzman and Boyce, 2010).
Strategic Review of Health Inequalities in England
post-2010 Committee, 2010). Hence, poor child and family This article focuses on the social determinants of health in-
outcomes are not concentrated exclusively at the bottom of equities during these critical early childhood years. The
the socioeconomic spectrum in a small group of disadvan- questions we seek to answer are:
taged families but are distributed across the entire spectrum
1. What are the causes of inequities in health and devel-
in a graded fashion (Denburg and Daneman, 2010;
opment during early childhood, and how do these in-
Strategic Review of Health Inequalities in England
equities impact upon health and development during
post-2010 Committee, 2010; Wilkinson and Pickett, 2009).
this period?
The circumstances in which children are born
2. What works to reduce inequities in health and devel-
determine their exposure to environments that promote
opment during the early years?
or compromise healthy development. Children’s health,
development and well-being can be compromised by a In terms of reducing inequities, we focus upon policies and
number of direct adverse experiences during the prenatal practices that work—or show promise—in the Australian
and postnatal periods including: sustained poverty, context or in countries similar to Australia such as the UK,
recurrent abuse and neglect, parental alcohol or drug Ireland, the USA, Canada and New Zealand.
abuse, homelessness, and family violence. The trends re- The ‘layers of influence’ outlined in Fair Foundations:
garding the prevalence of these problems in the families The VicHealth framework for health equity (VicHealth,
of Australian children are worrying (Moore and 2013) are used to explore each question. According to
McDonald, 2013). the Fair Foundations framework, there are three layers
Inequities during the early years (typically defined as of influence that lead to inequitable, socially produced,
the first 8 years of life) are especially concerning because systematic differential health and well-being outcomes:
of the nature of early childhood development. During
this period, a number of key capabilities and competencies 1. The socioeconomic, political and cultural context, en-
develop (McCain and Mustard, 1999; Shonkoff, 2012), a compassing governance, policy, and dominant cul-
process that is particularly sensitive to social determinants tural and societal norms and values
(Dyson et al., 2010; Hertzman, 2010). 2. Daily living conditions, which are the circumstances
Experiences during early childhood play a major role in which people are born, grow, live, work and age;
in shaping later life (National Scientific Council on the and
ii104 T. G. Moore et al., 2015, Vol. 30, No. S2

3. Individual health-related factors, that is the health- influences. What follows is a brief description of the find-
related knowledge, attitudes and behaviours of indivi- ings of our review, including some key illustrations of how
duals that result from, and are responses to, their inequities in health and development during early child-
socioeconomic, political and cultural context, social hood could be achieved. We conclude with a description
position and daily living conditions. of the strategies that, based upon the evidence we re-
viewed, appear to have the strongest potential to reduce in-
The socioeconomic, political and cultural context gener-
equities during early childhood in the Australian context.
ates a process of social stratification that allocates people
to different social positions, with the end result being un-
equal distribution of power, economic resources and pres-
Socioeconomic, political and cultural level
tige (VicHealth, 2013).
Over the last 50 years, developed nations have experienced
For the purposes of this article, health inequities are
rapid and dramatic social changes resulting in significant
defined as differences in health status between population
changes in the conditions under which families are raising
groups that are socially produced, systematic in their un-
young children (Giddens, 2002; Trask, 2010; Bauman,
equal distribution across the population, avoidable and
2011). Although most children have benefited from these

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unfair (as opposed to health inequalities which can also
changes, a minority have not and experience significant
refer to biological differences between children that impact
problems across all aspects of development, health and
upon their health, well-being and development and that
well-being (Stanley et al., 2005; Li et al., 2008).
are not preventable, e.g. a chromosomal abnormality).
One outcome of these rapid social changes is that the
Secondly, early childhood is defined here as the first
nature of the problems facing society and governments
8 years of life and the prenatal period. Our inclusion of
have altered—they are now more likely to be ‘wicked’ pro-
the prenatal period is based upon the fact that inequities
blems (Weber and Khademian, 2008; Moore and Fry,
during this stage can impact upon an individual’s out-
2011). Wicked problems are complex and intractable
comes during infancy, childhood and adulthood (Guyer
and, as such, cannot be resolved using traditional govern-
et al., 2009; Shonkoff, 2010).
ance and leadership models, nor by service-driven ap-
proaches (Grint, 2010; Moore and Fry, 2011). Some
METHODOLOGY wicked problems (e.g. poverty, child abuse) are not new,
but have become more of a concern because of an increas-
The search strategy we used for this review combined three
ing awareness regarding the adverse consequences of these
different approaches:
problems upon child development and the complex nature
1. A traditional database search: a targeted search of of their underlying causes.
electronic databases to identify literature; One ‘wicked’ problem that has wide-ranging and
2. A search for authoritative summaries, conceptual and long-lasting consequences on young children is sustained
theoretical works outlined in various sources includ- poverty, which impacts on brain development and health
ing books, grey literature and handbooks; and during childhood, and psychological health and educa-
3. A search of relevant websites: websites that were likely tional outcomes in adulthood (Gibb et al., 2012;
to have relevant grey literature from developed coun- Blackburn et al., 2013; Duncan et al., 2013). Evidence
tries similar to Australia. suggests that policies targeting disadvantaged families—
such as welfare-to-work initiatives—can have positive
A more detailed description of the methodology is pro- effects for both children and their families (Coley et al.,
vided in Supplementary Appendix 1. 2007; Millar, 2010). However, the evidence indicates
that factors such as mandatory employment requirements
What are the causes of inequities in health and and irregular or insecure forms of employment can have a
development during early childhood, and what negative impact on children (Strazdins et al., 2010;
works to reduce those inequities? Cooklin et al., 2011; Coley and Lombardi, 2012). Such
The causes of inequities in health and development social policies have differing impacts depending upon
during early childhood are vast and wide ranging, from the context within which they are implemented; in the
macro-level social and economic factors right down to Australian context, the limited research available suggests
micro-level factors such as parent knowledge regarding that welfare-to-work initiatives have largely negative effects
health services. As such, reducing inequities in early child- (Summerfield et al., 2010; Grahame and Marston, 2011).
hood is likely to be a complex task involving a range International evidence indicates that policies targeting
of stakeholders, environments, interventions and external financially disadvantaged families that involve the
Early childhood development and the social determinants, 2015, Vol. 30, No. S2 ii105

provision of additional money through, for example, dir- how a specific view of early childhood can impact upon
ect cash payments and tax credits, have a limited effect on public support for early childhood initiatives. In
the circumstances in which young children from disadvan- Australia, education and care during the early years has
taged backgrounds develop, or indeed upon child out- typically been viewed as a personal rather than a public
comes (Lucas et al., 2008; McEwen and Stewart, 2014). concern. As a result, there has been limited public support
Evidence from the USA suggests that intensive, long-term for universal high-quality early childhood education for all
initiatives that provide a range of support in addition to children in Australia (Fenech, 2013)]. Government invest-
financial support (e.g. child-care, health care benefits) may ment in initiatives that seek to improve the quality of learn-
be a more effective means of improving outcomes for chil- ing environments experienced by young children, for
dren living in significantly disadvantaged households [see, example, may be viewed as being of lesser importance
for example, the New Hope program (Huston et al., 2005; than other education investments if young children lives
Miller et al., 2008)]. However, it is unclear whether—and are perceived to be as ‘uncluttered by influences.’
to what extent—these lessons are equally applicable to the
Australia where, in comparison to the USA, more generous
welfare provisions lessen the impact of poverty on families Daily living conditions

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(Kalil et al., 2012) [It may be that these policies are inef- Early child development
fective (in as far as outcomes for children are concerned) Children’s development in both the short- and long term is
because of the complex nature of wicked problems, or it shaped by the environments they experience in the pre-
may be that the amount of money families received was natal and post-natal periods. These environments are not
too small to make a significant difference to their daily liv- always optimal: common environmental risk factors in
ing conditions (Lucas et al., 2008)]. pregnancy and early life include: stress, cigarette
Although there are a range of interventions that have smoking, alcohol consumption, obesity, poor nutrition,
been shown to improve the absolute position of the most poverty and exposure to environmental toxins (Martin
disadvantaged families, evidence pertaining to interven- and Dombrowski, 2008; Brown et al., 2011; Robinson,
tions that have been shown to reduce the relative gap be- 2013; Platt, 2014; Taylor et al., 2014).
tween the best and worst off families is fairly limited. One There is now strong evidence that the biological and
exception pertains to income-related nutritional dispar- neurological development of an individual can be shaped
ities among pregnant women: instituting a policy of man- by environmental conditions in the womb (Martin and
datory fortification of commonly consumed foods with Dombrowski, 2008; Robinson, 2013). One effect of sub-
folate reduces income-related nutritional disparities be- optimal prenatal conditions is premature birth, which is
tween women, thereby limiting the potential for inequities associated with greater risk of problems both in the
in foetal tube defects among children (Riccuito and short and in the longer term (Patton et al., 2004; Platt,
Tarasuk, 2007). One intervention that has been shown 2014). One relatively common method for improving
to potentially increase inequities between children in the prenatal conditions is food subsidy and food voucher pro-
long term is smoke-free legislation designed to reduce grams that target pregnant women experiencing disadvan-
children’s exposure to second-hand smoke in the home. tage. Although these programs may have some direct
Evidence demonstrates that such legislation is ineffective impact on pregnant women’s nutritional levels, there is
at reducing inequities relating to second-hand smoke ex- limited evidence to support a sustainable impact on diet-
posure between children from the highest and lowest SES ary behaviour (Black et al., 2012). Similarly, there is a
groups, and may increase those inequities in the long term lack of evidence to recommend one intervention over an-
(Akhtar et al., 2010; Moore et al., 2012a). other in regards to the cessation of smoking during preg-
In addition to considering the socioeconomic causes of nancy, although those that focus on parent attitudes and
childhood inequity, it is important to also consider the im- behaviours, as opposed to parent knowledge, appear to
pact of cultural factors. One abiding cultural misperception be more successful (Priest et al., 2008). Targeted motiv-
among Australians is that young children are ‘passive ab- ational smoking cessation interventions and holistic cessa-
sorbers of content’ and their lives ‘simplified and unclut- tion support have demonstrated some promising results
tered by influences’ (Kendall-Taylor and Lindland, 2013). among low-income pregnant women in the USA and the
These misconceptions could indirectly maintain or increase UK (Parker et al., 2007; Bryce et al., 2009).
inequity in early childhood by influencing how the general Postnatal environments are also vitally important for
public views—and the extent to which they support—gov- health and development, with early caregiving relation-
ernment investment in early childhood initiatives designed ships being critical (National Scientific Council on the
to reduce inequity [Fenech (2013) provides an example of Developing Child, 2004; Siegel, 2012). Sensitive and
ii106 T. G. Moore et al., 2015, Vol. 30, No. S2

responsive care giving and positive attachments with care- disadvantaged groups access ECEC at a lower rate than
givers are essential for the healthy neurophysiological, other children, and the quality of ECEC in disadvantaged
physical and psychological development of a child neighbourhoods is generally poorer than other neighbour-
(Cozolino, 2012; Shonkoff, 2012). Workplace flexibility hoods (Baxter and Hand, 2013; CCCH, 2013). It is im-
for parents and caregivers (e.g. parental leave schemes) portant to note that if an improvement in the quality of
during their child’s early years is especially important in ECEC results in increased costs for families from disad-
this respect as it provides parents and caregivers with vantaged backgrounds, there is likely to be increased in-
greater opportunity to build those critical relationships equity; children from higher socioeconomic backgrounds
with their children (O’Brien, 2009). whose parents can afford ECEC will reap the benefits and
Caregiving that is inadequate and negligent, and attach- enter school with skills their disadvantaged counterparts
ments that are weak or disrupted, results in adverse conse- will not have had as many chances to develop.
quences for children’s health and development (Waldfogel,
2006; McCrory et al., 2010). Physical and emotional abuse, Family environments
neglect and family violence can have long-term conse- While families who are relatively well resourced have
quences for the mental and physical health of children, as benefitted from recent rapid social change, poorly re-

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well as their social adjustment, academic achievements sourced families can find the heightened demands of con-
and employment histories in adulthood (Fergusson and temporary living and parenting overwhelming (Gallo and
Horwood, 1998; Reeve and van Gool, 2013; McLeod Matthews, 2003; Barnes et al., 2006a,b), with negative
et al., 2014). Some parenting programs have been shown impacts on their children. Gaps in family functioning are
to reduce behaviours associated with child maltreatment cumulative: the more advantaged families are initially, the
among parents who have previously abused their children better they are able to capitalize and build on the enhanced
or are involved with child protection authorities (Barlow opportunities available, so that the gap between them and
et al., 2006; Thomas and Zimmer-Gembeck, 2012); how- those unable to do so progressively widens (Social
ever, evidence regarding direct impact (i.e. actual maltreat- Exclusion Task Force, 2007; Rigney, 2010).
ment) is limited (MacVear et al., 2014). There also appears to be an increase in the numbers of
Early environments vary in the extent to which they families with multiple and complex needs (Cleaver et al.,
support learning: the development of competence and au- 2007; Bromfield et al., 2010). Such families are often ex-
tonomy depend upon the learning opportunities and sup- periencing a range of external stressors (such as housing
port provided to the child in their daily home and instability, poverty and social isolation) and parents with-
community environments (Deci and Ryan, 2011; Blair in those families may also be grappling with their own ex-
and Raver, 2012; Pianta, 2013). Learning and develop- periences of trauma and victimization (Bromfield et al.,
ment are cumulative—the skills acquired early form the 2010).
basis for later skill development (Cunha et al., 2006; Poor quality or insecure housing, and especially home-
Rigney, 2010). High-quality ECEC programs support lessness, negatively affects child health and well-being
young children’s learning and, in this sense, play an im- (Dockery et al., 2010; McCoy-Roth et al., 2012). In
portant role in reducing inequity across the social gradient, Australia, housing is especially relevant to the health in-
because they benefit all children in a range of ways includ- equities experienced by ATSI children, particularly in re-
ing cognitively, socially, behaviourally and in relation to mote communities where the type of infectious diseases
school readiness (Durlak, 2003; Camilli et al., 2010). that infants commonly present with are linked to poor
The quality of ECEC programs is especially important; housing conditions and overcrowding (Kearns et al.,
high-quality ECEC programs produce better outcomes 2013; Jervis-Bardy et al., 2014). Interventions that focus
for children than lower quality programs in both the primarily on housing infrastructure do not appear to
short- and long term (Sylva et al., 2003, 2012) [The qual- solve housing inequities in these communities. Housing in-
ity of ECEC is determined according to structural factors terventions that aim to improve the absolute position of
(e.g. the number of children in a room) and process factors children in remote ATSI communities require a multi-level,
(e.g. the nature of adult-child interactions) (CCCH, multi-faceted, ‘ecological’ approach (McDonald et al.,
2013)]. Furthermore, high-quality ECEC has been 2008; Bailie et al., 2011, 2012).
shown to be especially beneficial for children from signifi-
cantly disadvantaged backgrounds (Schweinhart et al., Physical and social environments
2011; Campbell, 2012). The nature and quality of the physical environment in
In Australia access to high-quality ECEC is especially which children grow up can have a significant impact on
important considering young children from traditionally their health and development (Evans, 2006; Sustainable
Early childhood development and the social determinants, 2015, Vol. 30, No. S2 ii107

Development Commission, 2008). Key aspects of the Ou et al., 2011) and it is often those with the greatest
physical environment include access to parks and green need that are least able to access available services
spaces, the nature of the built environment and exposure (Ghate and Hazel, 2002; Fram, 2003).
to environmental toxins (Louv, 2005; Martin and The importance of providing accessible, comprehen-
Dombrowski, 2008; Sandercock et al., 2010). People liv- sive universal services for reducing inequity during the
ing in low socioeconomic status communities are more early years is underlined by a recent study which demon-
likely to be exposed to toxic wastes, air pollutants, poor strates significant differences in levels of vulnerability
water quality, excessive noise, residential crowding or among Australian children by jurisdiction. Differences in
poor housing quality (Evans and Katrowitz, 2002; the availability of universal health services could account
Currie, 2011). for differences in jurisdictional levels of developmental in-
The nature and quality of the social environment also equity; two of the three states with the most comprehen-
influence the development of young children and the func- sive universal service coverage during the early years
tioning of families (Kawachi and Berkman, 2003; Pearson also have the smallest levels of inequity in child develop-
et al., 2013). Poor social cohesion, social capital and social mental vulnerability (Brinkman et al., 2012).
support have been associated with increased rates of post- One approach to improving service access is intake

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natal maternal depressive symptoms, child maltreatment promotion and support (e.g. contacting parents prior to
and concurrent drinking and smoking during pregnancy appointment to discuss potential barriers to attendance).
(Wandersman and Nation, 1998; Surkan et al., 2006; Pre-intake prompting and support for improving families’
Powers et al., 2013; Eastwood et al., 2014), as well as po- registration with and use of services in UK have reported
tentially playing a role in the actual health gradient that mixed findings (Yuan et al., 2007; Michelson and Day,
exists among children (Vyncke et al., 2013). 2014). The processes of service delivery (i.e. how services
One way of responding to poor quality social environ- are delivered) appear to play a key role in vulnerable fam-
ments is through area-based interventions that target a spe- ilies’ engagement with services (CCCH, 2006; Moore
cific geographical location and aim to bring about change et al., 2012b).
to a whole community (e.g. Communities for Children, Another major problem with the current service system
Muir et al., 2010). In the UK and Australia, large-scale is that the planning and delivery of services continues to be
area-based interventions have had some positive, albeit heavily segmented, with government departments and
typically small, effects on children and families living in dis- their funding streams operating autonomously as ‘silos’,
advantaged communities, although the impact of these in- making it difficult to conduct the joint planning needed
terventions typically ‘fade out’ once children start school to develop and implement a cohesive approach to support-
(NESS, 2012; Edwards et al., 2014). Experiences in ing families of young children, especially those with mul-
Australia and elsewhere suggest that, when working with tiple and complex needs (Moore, 2008). Place-based or
indigenous communities, the involvement of Indigenous ‘collective impact’ approaches to service delivery—involv-
people in health promotion initiatives is critical (Potvin ing a comprehensive, collaborative multi-level effort to
et al., 2003; Signal et al., 2007; FaHCSIA, 2011). simultaneously address all the factors that affect child,
Community-based, multi-setting, multi-strategy ap- family and community functioning in a defined a socio-
proaches to preventing childhood obesity in disadvan- geographic area—would appear to address at least some
taged communities in the UK and Australia demonstrate of these problems; however, the evaluation of such ap-
promise (Williams et al., 2011; Swinburn et al., 2012; proaches is still in the early stages (Moore and Fry, 2011).
Institute of Health Equity, 2014). A focus upon disadvan-
taged communities is important considering a social gradi- Individual health-related behaviours and attitudes
ent in childhood obesity (Bambra et al., 2013). The health and well-being of children are strongly influ-
enced by the knowledge, attitudes and behaviours of
Health care and other services their parents, caregivers and family (Law et al., 2012;
Even in countries with universal health services, there are Peters et al., 2013). Parent knowledge regarding child de-
inequities of access to health care among children and in- velopment and nutrition are associated with improved
equitable outcomes in health (Teitler et al., 2007). In part, child outcomes (Hess et al., 2004; Campbell et al.,
this is because disadvantaged areas tend to receive fewer 2013). Vulnerable families may not have the same level
services. However, it is also because many vulnerable fam- of access to health information as other families or may
ilies find accessing health services, as well as other types of not even know that particular health services exist
services, a challenge. A minority of vulnerable families (Carbone et al., 2004; Claas et al., 2011; Leurer, 2011).
make little or no use of existing services (Leurer, 2011; Migrants and families from non-English-speaking
ii108 T. G. Moore et al., 2015, Vol. 30, No. S2

backgrounds are particularly disadvantaged in this respect Socioeconomic, political and cultural context
(Parvin et al., 2004; Carolan and Cassar, 2007; Boerleider 1. Because traditional governance and leadership ap-
et al., 2013; Clark et al., 2014). proaches are not an appropriate or effective means
Targeted approaches to providing health-related infor- for addressing the complex problems that lead
mation, such as text messaging and telephone-delivered to inequity (Grint, 2010; Moore and Fry, 2011)
health education interventions, demonstrate promise in decision-makers (e.g. government, non-government
terms of improving some aspects of maternal and child organizations) need to ask questions of and engage
health among disadvantaged families (Pukallus et al., communities, service providers and institutions.
2013; Song et al., 2013). Other approaches to improving 2. Because all children benefit from high-quality
parents’ knowledge regarding infant and child health and ECEC, especially children experiencing disadvantage
development include peer-support interventions. For ex- (Durlak, 2003; Sylva et al., 2003, 2012; Camilli et al.,
ample, peer-support breastfeeding interventions demon- 2010), the quality agenda in early childhood educa-
strate promise in terms of their effectiveness among tion and care needs to be maintained.
women living in disadvantaged communities in the UK 3. Because families with young children experiencing
(Alexander et al., 2003; Dykes, 2005). disadvantage are less likely to utilize ECEC services

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Parental child-rearing attitudes and behaviours (Baxter and Hand, 2013), we need to implement pol-
also shape parenting behaviours, and parent–child rela- icies that make it easy for families with young children
tionships are influenced by a range of factors including experiencing disadvantage to access high-quality
the parents’ own experiences of being parented, the child’s ECEC.
behaviour, the parents’ cultural background and social 4. Because for young children, the key developmental
norms (Gutman and Feinstein, 2007; Kruske et al., environments are relational (National Scientific
2012; Prady et al., 2014). One service delivery strategy Council on the Developing Child, 2004; Siegel,
that has been shown to have had positive effects on the be- 2012), we need to implement policies that enable
haviour and attitudes of parents is home visiting. Home greater workforce flexibility for all parents and care-
visiting is a service delivery strategy that aims to provide givers so they can spend more time with their children
a range of supports for families and typically targets sig- during the early years.
nificantly disadvantaged children, parents and families 5. Because employment for parents at any cost could in-
(Boller et al., 2010). Until recently, there was little evi- crease inequity (those in the most disadvantaged groups
dence indicating the effectiveness of home visiting pro- are likely to be employed in the most insecure and in-
grams in Australia (Kemp et al., 2008); however, in stable jobs, and insecure, unstable employment can
recent years, Australian home visiting programs have de- have a negative impact upon children) (Strazdins et al.,
monstrated their beneficial effects on a range of outcomes 2010; Cooklin et al., 2011; Coley and Lombardi, 2012),
including health behaviours among significantly disad- we need to implement policies that ensure secure and
vantaged parents (Kemp et al., 2011). stable employment for primary caregivers.
6. Because public perceptions of early childhood can
impact upon public support for strategies that aim to
support young children’s learning and development
DISCUSSION (Fenech, 2013), and because a number of misconcep-
Based upon the evidence we identified, the following strat- tions about early childhood and ECEC exist among
egies have the strongest potential to reduce inequities dur- Australia’s general public [e.g. young children are ‘pas-
ing early childhood in Australia. These strategies are based sive absorbers of content’ and ECEC is a ‘child mind-
upon an analysis of what the evidence tells us about the ing service’ (Kendall-Taylor and Lindland, 2013)], we
causes and impacts of inequity in early childhood and need to improve public understanding of the import-
what the evidence from Australia—and from countries ance of the early years and the role of ECEC.
similar to Australia—tells us about what works to reduce
those inequities in early childhood. Perhaps the most im-
portant point to make about the strategies is that none of Daily living conditions
them alone are likely to resolve the type of problems that 7. Because most Australian families are doing well (and
cause inequity during the early years, and many are reliant will continue to do well if any risks or problems are
upon another to be effective. What is needed is a multi- identified early) and because all families will struggle
level, multi-faceted response involving all layers of the at some point (and some will struggle more than
Fair Foundations framework. others) (Moore and McDonald, 2013), we need a
Early childhood development and the social determinants, 2015, Vol. 30, No. S2 ii109

service system that reflects these realities of family life. to engage in decision-making and collaborative
Proportionate universalism reflects these realities, be- processes.
cause it provides a baseline of universal services for all 15. Because knowing what services exist, and what they
families (i.e. those who are doing well) and additional provide, is a key facilitator of families’ engagement
services according to need (for those who are strug- with services (Parvin et al., 2004; Carolan and
gling, including those who are struggling the most). Cassar, 2007; Boerleider et al., 2013), families need
8. Because there is some evidence to indicate that chil- information about services and child development in
dren in more affluent neighbourhoods of Australia a range of different languages, tailored to differing
are receiving a higher quality of ECEC than children circumstances and via a range of mediums.
in less affluent neighbourhoods (CCCH, 2014) and
because this has the potential to increase inequities
among children (i.e. those who are already worse Individual health-related context
off receive a poorer quality of care), we need to ensure 16. Because parents need to be able to get support for
universal high-quality ECEC in all neighbourhoods. themselves, their child and their family when it is
9. Because the prenatal period plays a critical role in bio- needed, parents needs to know what services are

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logical and neurological development (Martin and available, what type of support is offered by those ser-
Dombrowski, 2008; Robinson, 2013) and inequities vices and feel confident to approach those services
during the prenatal period have the potential to lead (Carbone et al., 2004; Carolan and Cassar, 2007;
to inequities in children’s development, and subse- Boerleider et al., 2013). For some families, the confi-
quent long-term outcomes (see, for example, Patton dence to approach services will rely upon the ‘ap-
et al., 2004; Platt, 2014), we need universal high- proachability’ of those services (see Strategy 12).
quality antenatal services. 17. Because knowledge of child development helps parents
10. Because the type of problems that cause inequity dur- understand their child and their child’s behaviour (see,
ing early childhood are characterized by complexity for example, Campbell et al., 2013; Hess et al., 2004),
and no single organization or sector can resolve parents need to know about child development, the fac-
those problems alone (Grint, 2010; Moore and Fry, tors that promote positive health and development, and
2011), we need service systems that enable collabor- have the capacity to support their child’s development.
ation between professions, between services, between 18. Because a parent’s attitudes about parenting mediate
sectors and with communities. how they behave towards their children (Gutman and
11. Because we need to ensure that the programs we invest Feinstein, 2007; Kruske et al., 2012; Prady et al.,
in will have the best chance of achieving the desired 2014), parents need to feel confident and supported
outcomes in the most efficient way (Bromfield and in their role as parents. Some parents will be confident
Arney, 2008), we need evidence-based programs. in their parenting role, some will require reassurance
12. Because how services are provided is as important as and others may require more intensive support.
what services are provided (i.e. the characteristics of
the service environment will strongly influence the ex-
tent to which families engage in the programs services
CONCLUSIONS
have to offer) (CCCH, 2006; Moore et al., 2012a, b), As Urie Bronfenbrenner claimed: ‘every child needs at
we need welcoming, inclusive services that employ a least one person who is crazy about [them]’. But in add-
strength-based, partnership-based approach. ition to that one person, children also need a network of
13. Because informal support from extended family, support—as do their parents, and their families. They
friends, neighbours and colleagues can benefit fam- need a service system and broader socio-political envir-
ilies with young children by providing a form of flex- onment that facilitates positive parent–child interactions
ible and sustainable assistance, as well as promoting a and attachments, high-quality care and learning experi-
sense of belonging, and reducing the potential for so- ences in all environments and timely, appropriate and ef-
cial isolation (Surkan et al., 2006; Vyncke et al., fective support when problems arise. If, as a nation, we
2013), we need more supportive communities. truly prize children, then we need to work collectively
14. Because not all communities will have the resources to ensure that the social and economic circumstances of
to participate in new forms of governance and com- their families and communities—particularly during the
munity participation (such as those recommended in antenatal period and the early childhood years—do not
strategies 1 and 10) (Skidmore et al., 2006; Adamson compromise their health and well-being, and do not
and Bromiley, 2008), communities need support limit who they are, and who they can become.
ii110 T. G. Moore et al., 2015, Vol. 30, No. S2

SUPPLEMENTARY MATERIAL Barnes J., MacPherson K., Senior R. (2006b) Factors influencing the
acceptance of volunteer home-visiting support offered to families
Supplementary material is available at Health Promotion with new babies. Child & Family Social Work, 11, 107–117.
International online. Bauman Z. (2011) Collateral Damage: Social Inequalities in a
Global Age. Polity Press, Cambridge, UK.
Baxter J., Hand K. (2013) Access to early childhood education in
FUNDING Australia (Research Report No. 24). Australian Institute of
Family Studies, Melbourne, Australia.
This work was commissioned by VicHealth.
Black A. P., Brimblecombe J., Eyles H., Morris P., Vally H.,
O Dea K. (2012) Food subsidy programs and the health and
nutritional status of disadvantaged families in high income
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