Health outcomes of experiencing poverty in the early years: evidence review

Chapter 4: Moving forward: overarching evidence

As mentioned in Chapter 3 (The health outcomes of experiencing poverty in the early years), the health impacts of child poverty are not inevitable but become more likely when children and families experiencing persistent adversities are not adequately supported^[386]. The literature suggests that primary prevention is key to changing this trajectory.

In particular, the reproductive years in a woman’s life present an opportunity to involve both her and her partner in promoting their health as well as that of their future children through their engagement with a range of health care providers^[387]. While health issues can be addressed at any stage of life, promoting healthy development before the baby is conceived and from the very beginning of life, and addressing challenges early, is far more effective and cost-efficient than attempting to resolve issues later^[388].

In the previous chapter, the discussion focused on evidence closely linked to the key indicators that have shaped this report. However, several overarching findings emerged within the literature that extend beyond the indicators themselves, highlighting broader actions that could be taken to create preventative change for children, families, and their health outcomes. This chapter sets out this overarching evidence. The order in which findings are presented is not intended to suggest a hierarchy in their importance; instead, they are all important for driving improvements in the lives and health outcomes of children, including those living in poverty and deprivation.

The evidence suggests that initiatives targeted at the individual can result in better individual outcomes for children and families, however addressing wider structural inequalities at the societal level is essential to achieve greater impact at scale^[389]. Findings further highlight that policies and programmes aimed at alleviating poverty may have the greatest impact on child development when implemented during children’s earliest years^[390]. Additionally, understanding intersectionality is crucial to tackling poverty and inequalities, as poverty is experienced in diverse and complex ways, creating unique lived experiences. Research indicates that a 'one-size-fits-all' approach to reducing inequality often fails to reach those most affected, particularly where multiple inequalities intersect^[391].

It is worth highlighting that much of this evidence emphasises universal support rather than specific interventions for families in poverty, potentially reflecting the significant role of universal policies as primary prevention approaches. The core principle of universal support is that everybody is expected to benefit regardless of their risk or financial means. While universal strategies are important for supporting all children and families, they may not fully address the specific challenges faced by those living in poverty, highlighting the need for more targeted action for families experiencing poverty and living in more deprived areas^[392]. The literature points to gaps in both the availability of evidence on effective and impactful tailored interventions and potential implementation gaps^[393] in delivering these interventions.

While evaluating the effectiveness of each programme is crucial for ensuring meaningful impact, research has identified common characteristics associated with successful interventions across various ages and contexts. Analysis from the Center on the Developing Child at Harvard University highlights five key factors consistently linked to positive outcomes: strengthening caregiver skills to equip them with the knowledge and capabilities needed for healthy child development; tailoring interventions to reduce significant sources of stress; supporting parental health and nutrition before, during, and after birth; improving the broader caregiving environment; and implementing well-defined, age-appropriate programmes guided by appropriate theories of change^[394].

Overarching findings

Coordinated approach

A consistent message in the literature is the need for a coordinated approach to improve health outcomes related to child poverty. Many families will experience a range of inter-related drivers of poverty concurrently. Addressing these requires a system-wide approach, including the public, private, and third sectors, along with the public itself. The World Health Organization’s Nurturing Care Framework emphasises this message, stating that, to holistically address the needs of children living in poverty, action should be taken across a range of sectors, including health, education, finance/welfare, and child protection^[395].

Other evidence notes that efforts should move from ‘health in all policies’ to ‘health for all policies’^[396]. In this context, health is recognised as central to all policy areas, advocating for a shift from merely integrating health considerations into policies (‘health in all policies’) to ensuring that health outcomes drive and shape policies across sectors (‘health for all policies’). This perspective emphasises that improving health has substantial benefits for other sectors, which is particularly important for children in poverty who often experience overlapping adversities, including food insecurity, inadequate access to healthcare, and poor-quality housing^[397]. Improving health outcomes can not only address health-related challenges but also support broader societal and economic improvements (and vice versa).

At the same time, achieving fairness across different places and geographies – so that all children can grow up in environments that support their healthy development – requires policies that address the causes and consequences of place-based and intergenerational poverty which lead to preventable inequalities in child development and lifelong health^[398]. These findings emphasise the importance of considering and addressing inequalities within health policies.

Children in all policies

Beyond ‘health in all policies’, there are other calls for a more child-centred approach to policymaking and to addressing the health and social needs of children, particularly those living in poverty and deprivation. Evidence emphasises the importance of a ‘children in all policies’ approach, which highlights the role of all sectors in improving children’s quality of life, health and wellbeing^[399]. This approach links with rights-based approaches, including the adoption of the UNCRC, which is discussed in more detail below.

A ‘children in all policies’ approach advocates for policies to be developed in environments where children can actively express their views in decision-making processes in child-friendly, age-sensitive, safe, and voluntary ways^[400]. Furthermore, such an approach requires all policies to be assessed for their potential impact on child health and wellbeing^[401], ensuring that poverty reduction strategies include a specific child-focused perspective^[402]. By doing so, a ‘children in all policies’ framework would enable a more nuanced understanding of the complex and interrelated factors that influence children’s wellbeing, fostering targeted interventions that address these complexities^[403].

Frameworks to support children and families

Legal frameworks play a crucial role in tackling child poverty and related health concerns by creating the context for, and a unified vision of, change. This can be seen in the Child Poverty (Scotland) Act 2017, which sets targets to reduce child poverty by 2030 in Scotland, as discussed in the Introduction^[404]. Such frameworks are significant because they unify efforts across the system, fostering collaboration and enabling change to address interconnected issues and improve outcomes^[405].

Other evidence suggests adopting a rights-based approach to tackling child poverty, with a focus on children's rights to advocacy, accessible information, targeted support, and data-informed policies^[406]. Scotland has incorporated the UNCRC into domestic law through the UNCRC (Incorporation) (Scotland) Act 2024, making it the first country in the UK to do so^[407]. The aims of incorporating the UNCRC include: legally protecting children's rights in Scotland; ensuring that public authorities take steps to respect children's rights in their decisions and actions; and ensuring that children, young people and their representatives are able to use courts in Scotland to enforce their rights^[408].

Beyond these aims, adopting the UNCRC and having a focus on children’s human rights are also closely linked to rights-based approaches to budget and creating a ‘wellbeing economy’ that particularly takes into account children. This approach is intended to support taking action at individual level for children, but also for families, addressing and improving inequalities and introducing support that can tackle poverty and improve health outcomes^[409].

Representation of children’s voices: co-production with children and children’s organisations

The literature highlights the lack of representation of children’s voices in important decisions that impact their lives. This is particularly evident in maternal and newborn care, as very young children often lack representation, and their families often face significant challenges in having their perspectives heard^[410]. Addressing this gap requires efforts to amplify children’s voices in decision-making processes.

In particular, findings emphasise the importance of incorporating firsthand experiences of poverty into policy development^[411] and service development and delivery^[412]. Engaging directly with children and families experiencing poverty not only informs the creation of meaningful policies but can also raise awareness of adversities faced by these groups^[413]. For example, listening to children can uncover hidden aspects of poverty, such as those unique to rural areas, and contribute to developing local intelligence that supports targeted actions^[414]. Empowering local governance that considers the specific needs and characteristics of local contexts can bridge the gap between households and communities facing challenges in participating in decision-making and broader national initiatives^[415].

Evidence also indicates that children of all ages, where possible, should have their perspectives heard regarding what is needed to improve their wellbeing, with their input actively influencing the budget allocation process^[416]. This includes creating opportunities for children to participate across all stages of the budget and prioritising their interests over organisational cultures and systems^[417].

Budgets and resourcing

As discussed above, budget and resource considerations are significant to ensuring the best outcomes for children and a range of sources, both within and outwith the Scottish context, emphasise this for health outcomes in particular. Alongside the above-mentioned participatory and rights-based processes (UNCRC incorporation) and incorporating children’s voices into budget decisions, other sources point to allocating additional spending to: early years in more deprived areas^[418]; monitoring and tracking funding usage^[419]; increasing collaboration between local authorities, health boards, and other stakeholders^[420]; and embedding prevention into the spending framework^[421].

Analysis in the BMJ by Hiam et al. (2024) suggests addressing the UK’s economic decline and implementing poverty-reduction policies to improve health outcomes for children, particularly following a period of austerity^[422]. Austerity has been associated with rising child poverty rates^[423], reduced public service provision for supporting healthy outcomes^[424] and worsening mental and physical health outcomes for children^[425]. In response, the Scottish Government has taken steps to mitigate some of these impacts through the enactment of the Social Security (Scotland) Act 2018^[426] and related devolved social security powers^[427], alongside other policies^[428]. While these efforts demonstrate the Scottish Government’s proactive commitment to protecting children’s health^[429], the effects of austerity continue to impact low-income households, highlighting the need for further action^[430]. Key sources point to setting clear, focused, and achievable short-term goals within a longer-term preventive framework^[431], as well as prioritising ongoing evaluation to assess the impact of initiatives^[432].

Addressing the social determinants of health

The wider determinants of health (see Chapter 1: Introduction and context) play a pivotal role in shaping child poverty and health outcomes by influencing the environments in which families live and grow. These determinants shape both the risks to which children are exposed and the protective factors they can draw upon to navigate challenges. Addressing these broader influences is recognised as an essential component of efforts to improve outcomes for children, particularly through system change and place-based initiatives. Evidence suggests that these approaches can support tackling the drivers of poverty through more holistic service provision^[433].

Among these determinants, employment emerges as a key priority area to improve child health outcomes. Since financial stability plays a vital role in family planning, raising children and being able to make healthier choices at the individual level, supportive employment policies are highlighted as crucial in breaking the cycle of inequalities and improving health outcomes for future generations^[434]. Key supportive employment policies include supporting parents to maximise their household income, investing in active labour market programs to reduce long-term unemployment, and tackling in-work poverty with a true living wage^[435]. Other key takeaways include addressing gender and ethnicity pay gaps, supporting in-work progression and enabling flexible working^[436].

Lifting families with children out of poverty requires a targeted focus on those at greater risk. Evidence highlights the need for actions addressing younger men, who face reduced earning potential due to lower participation rates in higher education, declining employment rates among those aged 16-24, and a shift toward lower-paid, part-time roles in the service sector^[437]. Similarly, efforts should also focus on women, who are disproportionately represented in part-time and low-paid employment, multiple employment^[438], and multiple low-paid employment^[439]. This is often attributed to experiences of uneven responsibility for caregiving duties, which require mothers to adapt their employment patterns to fit their family roles^[440]. Additionally, women's employment is often concentrated in sectors that pay minimum wages, further limiting their financial security and contributing to economic inequality^[441].

However, having paid work is not always enough to lift families out of poverty^[442]. Parents’ ability to participate in and sustain employment depends on a range of factors, including access to social policies, such as funded childcare^[443]. Parents report that childcare plays a key role in enabling them to return to work and that funded hours in childcare are a significant support for them^[444]. Ensuring that childcare is both accessible and aligned with job requirements is essential for supporting families holistically and helping them balance working life with family commitments^[445].

Maternity pay is also relevant in this context; recent findings show that maternity pay is a critical factor in financial stability during early parenthood. This is because this period often brings significant financial strain, as women and households struggle with inadequate maternity pay and a reduced income^[446]. A respondent participating in a Maternity Action survey stated, ‘Statutory maternity pay is not enough to meet the basic costs of living right now, let alone when you consider the extra costs that having a baby involves. It's impossible to live a good life.’^[447]

Efforts that combine measures to support parents in accessing stable employment and enhancing financial security, along with affordable early-years childcare and work-life balance measures, can help reduce maternal depression by mitigating the impacts of financial stress and fostering a sense of identity and self-esteem^[448]. These improvements can, in turn, contribute to better physical and mental health outcomes for children^[449].

In the Scottish context, there have been significant strides in these areas through various social security measures. The Scottish Child Payment helps with the costs of raising children^[450], the Best Start Foods helps pregnant women and families with young children buy healthy foods, and the Best Start Grant provides financial support in the form of one-off payments at key stages of a child's early life^[451]. Additionally, the Living Wage movement has had a long-standing 10-year impact, and the Scottish Government is acting on the evidence-base through the No One Left Behind policy, among others^[452]. An area for further improvement includes enhancing awareness of and access to benefits and targeted actions for people that are more likely to be marginalised by barriers to claiming benefits, such as large families, young parents and single parents^[453].

Other sources point to changes needed across other social determinants of health. Ensuring access to warm, safe, and affordable homes can enable parents to reduce financial adversities and provide a stable and nurturing environment that supports their children’s health and development^[454]. Enhancing access to and affordability of public transport can enable parents to participate in the labour market and reach healthcare services, education, and community resources more easily, all of which play a critical role in promoting children’s physical and mental health^[455]. Additionally, expanding social security benefits and removing social barriers to uptake can boost families’ income^[456], which can help ensure that children have access to the resources and opportunities needed to achieve their potential. Focusing on improving family wellbeing can establish the conditions that enable families to move out of poverty^[457], and evidence suggests that emotional, practical, and financial support play a particularly crucial role in this process, especially for families with babies under one^[458].

Healthcare system

Ensuring access to high-quality healthcare before, during, and after pregnancy is highlighted as essential to tackling poor pregnancy outcomes and associated inequalities throughout the life course, as is empowering patients from lower socioeconomic backgrounds to participate more in decisions about their care^[459]. Evidence suggests that all children should be able to access high-quality, supportive services in order to experience an environment that is conducive to the development of good health^[460]. For children and parents facing adversity, evidence suggests that ensuring easy access with ‘no wrong doors’ can make the system less daunting to navigate^[461]. Building trust between services and families, along with effectively promoting available support, are highlighted as key strategies to fostering engagement and addressing poverty stigma, which, as previously mentioned, can be pervasive and act as a significant barrier to engagement^[462].

Investing in services that operate on the principle of proportionate universalism – where support is universally available but scaled and intensified according to need – is particularly important in the context of child poverty and poor health. In practice, this includes actions such as increasing health service provision in areas of greater need, offering longer appointment times, and tailoring support for the most deprived communities and groups at higher risk^[463].

Prioritising life course programmes of support is also important for addressing poverty and poor health throughout the life course. A life-course approach recognises that each stage of development builds on the last and emphasises reinforcing gains in the early years through interventions in later life to sustain their impact and promote lifelong health^[464]. In practice, this involves minimising risk factors and enhancing protective factors through evidence-based interventions at key life stages, from the perinatal period and early childhood to adolescence, adulthood, and older age^[465]. Key actions include providing high-quality services with resources allocated proportionate to need, training the workforce to understand and address inequalities, forming effective cross-sector partnerships, and advocating for systemic changes to reduce health inequalities^[466].

Monitoring and evaluation

Lastly, the evidence emphasises the key role of data in improving care and support for children and their families. Building a strong evidence base is key to reducing health inequalities and improving outcomes for children, especially during their early years.

Enhancing data collection and linkage for research purposes, while ensuring the inclusion of diverse perspectives from children, parents, and carers, is identified as a key priority in developing inclusive and effective initiatives that address diverse needs holistically^[467]. Such data is also vital for understanding and addressing cumulative risks. Exposure to multiple adversities, each of which may pose only small risks on its own, can collectively have significant public health consequences. Developing tools to assess these combined exposures is therefore critical for ensuring comprehensive and targeted responses to health challenges^[468].

Furthermore, investing in research, evaluation, and routine collection of national data during the antenatal and perinatal periods is important for influencing policy development and improving health outcomes^[469]. Such investments can foster a deeper understanding of how socioeconomic factors affect pregnancy outcomes and help identify ways to strengthen care for children and families facing poverty. Some specific areas for improvement mentioned in the literature are:

• Increasing the frequency of children’s health surveys, to match those of adults^[470]
• Addressing gaps in quality measures specific to children and young people^[471]
• Enhancing the quality and completeness of data on children and young people^[472]
• Considering the health of children living in remote and rural areas, how this might differ from children in urban areas, and ensuring measurements take account of these differences^[473].

The next chapter will summarise the conclusions of the report.