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Child poverty: A public health issue?

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Children living in poverty are at increased risk Children living in poverty are at increased risk of poor health outcomes

Over two million children are living in relative poverty in the UK, according to a recent report by the Institute of Financial Statistics1, and the effects of deprivation have rarely left the news. Alan Milburn, chair of the Social Mobility and Child Poverty Commission, called it 'a deep scar in the fabric of our nation' after the publication of a report by the commission which examined the effects of poverty. In the UK today, a household in poverty is defined as one with total earnings of less than 60% of the average wage, or approximately £15,600 each year.2

But what effect does growing up in poverty have on the health of a child?

At a debate on the issue at the RCN Congress in Bournemouth in June, Rachel Hollis, a children's nurse and the proposer of the debate, said: 'The UK is one of the most unequal societies in Western Europe, and this inequality is at its most stark for children and young people.'

Studies have shown that being born into a family defined as living in poverty has a lifelong impact on the health outcomes of children.3

These begin at conception, with babies born to deprived mothers more likely to be underweight at birth, and lead to complications in later life. Infants born into the lowest socioeconomic group are nearly 10 times more likely to die from Sudden Infant Death Syndrome as babies born into the highest socioeconomic group.2 The UK has one of the worst rates of infant mortality in Western Europe, often more in line with much poorer Eastern European countries.4

The effect is not just limited to the early years. Adults who were raised in poverty are significantly more likely to develop mental health conditions, and suffer from alcohol and drug addiction. Indeed, one study found that if all children had the same risk of mental ill health as the highest income groups, there would be 40.6% fewer mental health conditions, 59.3% fewer conduct disorders (antisocial behaviours), 53.7% fewer hyperkinetic disorders, such as ADHD, and 34.4% fewer cases of conditions like anxiety and depression.3

Inequality and deprivation
A report called Due North: Report of the inquiry into health equity for the North,5 which examined the causes of health inequality between the north of England and the more affluent South, was published in September 2014. It revealed the alarming pressures that poverty can put on NHS services. For example, an infant raised in a home affected by fuel poverty (being unable to pay for heating year round) was 30% more likely to present in primary care with a condition requiring treatment.5

While there is a wealth of information linking poor health to poverty, the causes are less clear.

Heather Henry, an independent nurse and co-vice chair of the NHS Alliance, who has worked extensively with deprived communities in Merseyside and Manchester, believes that poverty itself is a causative factor in the disparity of health between the poorest and the most affluent. She says: 'People in poverty have little control over their lives. They are reliant on others, the state and charities to provide for them and this creates a great deal of stress. This has a physical impact on the body, such as raising blood pressure.'

Ms Hollis agrees. 'Poverty and deprivation is a major public health issue. Cuts to welfare and benefits disproportionately impact children and young people, and as nurses we can lobby the government to do something about this. We need to make sure our voices are heard. Additionally, we need a children's health strategy for the country, which we do not currently have.'

The last major policy document on children's health, the Report of the Children and Young People's Health Outcomes Forum6, was released in July 2012. It highlighted the importance of intervening as early as possible to support a child's mother and family to reduce the impact of unhealthy lifestyles.

Factors such as poor diet and smoking have been shown to be more prevalent in lower socioeconomic groups.2,5 Children from poor backgrounds are more likely to have worse diets, leading to chronic conditions such as diabetes and obesity. One study reported that people on low incomes eat more processed foods, which are much higher in saturated fats and salt, and people from lower socio-economics tend to eat a less varied selection
of foods.5

People living on state benefits also eat less fruit and vegetables, less fish and less high-fibre breakfast cereals. In 2014, the Faculty for Public Health reported the resurgence of diseases such as rickets in certain groups.6 Additionally, prenatal smoking rates are higher in lower socio-economic groups. Smoking in pregnancy is associated with a 20–30% higher likelihood of stillbirth, and a 40% higher rate of infant mortality.4

Education and training
Cheryll Adams, chief executive of the Institute of Health Visiting, believes educating parents about their lifestyle has a positive effect on the health of the child. She says: 'Through education and information, health visitors can improve the health outcome for a child, and also support the health of mothers, fathers, siblings and other family members. Health visitors are trained to support the health of children, so they can do a lot to improve health gains.'

Carmel Lloyd, the Royal College of Midwifery's head of education, says it is crucial that mothers attend antenatal appointments with their midwife in the first trimester of the pregnancy to help minimise the risks to the child. 'Some women may be unable to access antenatal services early at the 12 week target. The earlier a woman sees a midwife, the easier it will be to monitor the baby's weight and identify any problems.

'Midwives can also conduct health interventions and signpost mothers if there are any concerns about factors such as smoking or poor diet.'

While education for families is essential, training on child health issues for nurses has also been cited as necessary to improve public health outcomes for children.

The Report of the Children and Young People's Health Outcomes Forum said: 'Some [healthcare professionals] have training only in adult healthcare, while others do not have sufficient training in physical and mental health to be able to undertake their work with children and young people safely and well. This is one of the most important reasons why children and young people's health outcomes are poor in so many areas. Improving professional education and training would deliver real improvements in their health outcomes.'

This year's Shape of Caring review by Lord Willis recommended the adoption of a model of education based on two years of core whole-person training, then a year of specialisation and preceptorship. Children's nursing would be one of the specialisms. This has been criticised by some but choosing a branch of nursing and specialising from day one means many healthcare professionals receive no training in caring for children.

Lindsey Rigby, a children's nurse, believes there is a need for all nurses and other healthcare professions to have training in child health. She said: 'To view the field of child health as a specialism is to ignore the broad spectrum of children, young people, and their families. They need nurses who are trained to care for the whole child.'

Ms Hollis agrees. 'Our health services are completely focused on the treatment of adults. Children are big users of primary care services, around 25%, but GPs and practice nurses are not required to have any paediatric training.'

While education and training are necessary, accessibility to healthcare services can be a barrier to health equality for children and adults.

Ms Henry suggests there is a tendency for health, social, and housing services to work in silos.

She says: 'Patients I work with, disadvantaged people, may have problems with benefits, mental health, housing, domestic violence, and all of these things add up. But because of austerity, they do not reach the threshold of care in any one of those service areas. Services look at individual needs, so coordination to help the disadvantaged does not occur.'

Ms Hollis also suggests that disparity in access to primary and community care services is harming children's health. She says: 'There are some areas where children with long-term conditions like asthma and diabetes are not able to access community care to help manage their conditions, while adults generally can.'

Ms Adams says that health visitors are well placed to foster integration with other services, as they can see a patient's living circumstances and act if they need support. 'I think of health visitors as the centre of a wheel, with primary care, social services, housing as spokes of the wheel,' she says.

'Health visitors can assess the needs of the mother and child, and inform the appropriate services if a child needs support. For example, if a health visitor notices poor housing conditions, they can help the family get in touch with housing services.'

The impact of deprivation on the lives of children is undeniable, and a major issue for the NHS and nurses to tackle.

Speaking in 2014, Sir Michael Marmot, author of the Marmot Review, which examined healthcare inequalities, said: 'We must do more to tackle health inequalities, starting from birth. If we need motivation beyond our ethical responsibilities, then we would do well to remember that health inequalities come at a huge cost. More children reaching a good level of development means less financial burdens on the NHS in later life.'


1. Institute for Financial Statistics. Living standards, poverty and Inequality in the UK. 2015

2. Department of Work and Pensions. Households below average income: An analysis of the income distribution 1994/95–2013/14. June 2015

3. End Child Poverty. Health consequences of poverty for children.

4. Royal College of Paediatrics and Child Health. Why children die: death in infants, children and young people in the UK. Part A. 2014.

5. Greater Manchester Centre for Voluntary Organisations. Due North: Report of the inquiry on health equity for the North. 2014. Liverpool.

6. Faculty of Public Health. Food poverty and health: briefing statement. 2005.

7. The Children and Young People's Outcomes Forum. Report of the Children and Young People's Outcomes Forum. 2012.

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