Sefton Council: Exploring the link between childhood stunting and socioeconomic inequalities

Poverty has a profound impact on children’s health and wellbeing. Children living in poverty are more likely to have poorer health outcomes such as higher mortality, poor physical health and mental health issues. This higher risk of ill health can have an impact on their education, life experiences and employment opportunities. 

Like many places, the Merseyside borough of Sefton includes areas of significant poverty. In 2023/24, more than 10,500 under-16s in the borough (22.1 per cent) were living in relative low-income households. 

Sefton Council is committed to addressing the wider determinants and effects of child poverty, using a collaborative and evidence-based approach. Tim Martin, Public Health Registrar, recently completed a research project looking at the link between childhood stunting and socioeconomic deprivation. While this work was focused on Sefton, it will be of interest to public health teams across the country. 

‘Childhood stunting’ is a term used to identify children who are not meeting their full growth potential, with lower-than-expected growth. Previous studies have shown socioeconomic inequalities in childhood height in the UK, linking childhood stunting to worse outcomes in health, wellbeing and education. 

This research had three main objectives: 

• Demonstrate the socioeconomic inequalities in childhood stunting in Sefton.
• Identify possible mechanisms through which socioeconomic deprivation leads to childhood stunting.
• Measure the changes in rates of childhood stunting in Sefton over time. 

The study used data from the National Childhood Measurement Programme (NCMP), which measures height in state schools in reception class (4-5 years) and year six (10-11 years). Data from 2013/14 to 2022/23 was examined to identify rates of childhood stunting. 

Data for the various factors that could affect stunting was available at a small area level, including deprivation through the Income Deprivation Affecting Childhood Index. This was applied to the NCMP data to understand the relationship with childhood stunting. 

For the pupils in reception class: 

• Risk of stunting was 61.5 per cent higher in the most deprived fifth of the population compared to the least deprived fifth, after adjustment.
• One in 41 children from the most deprived fifth of the population had stunted growth, compared to one in 72 from the least deprived fifth. 

For the year six pupils: 

• Stunting rates were 67 per cent higher in the most deprived fifth of the population compared to the least deprived fifth, after adjustment.
• One in 62 pupils from the most deprived fifth of the population had stunted growth compared to one in 122 from the least deprived.

The study hypothesised that the ‘proposed mechanisms’ – or causal pathways – behind childhood stunting could include low birth weight, pre-term birth, lower rates of breastfeeding, food insecurity and less access to healthcare. 

The key findings included: 

• There were higher rates of stunting in the most deprived fifth of the population, versus the least deprived fifth, in both school years.
• In the reception class, none of the effects of socioeconomic deprivation on rates of stunting were explained through the proposed mechanisms listed above.
• In the year six pupils, most of the socioeconomic inequalities in rates of stunting could be explained through the proposed mechanisms (the difference could be due to ‘catch-up’ growth in the year six group in those children not affected by socioeconomic inequalities).
• There was no significant change in rates of childhood stunting over the 10-year period. 

Tim Martin’s study concludes that more individual-level research is needed to establish the causal pathways from socioeconomic deprivation to childhood stunting, and to examine other possible factors – such as air pollution, smoking in pregnancy and adverse childhood experiences.

He said: “What this research highlights is that inequalities in childhood stunting are driven by differences in the social determinants. This shows the importance of addressing child poverty and finding ways to mitigate the negative effects on children’s health from poverty.” 

Sefton’s public health team is now looking at how this research can influence workstreams that relate to child poverty – such as the poverty proofing work underway in schools. 

Sefton’s Child Poverty Strategy was launched in 2022 and has galvanised support and momentum from a wide range of partners, working together as part of a child poverty steering group. The steering group is working in partnership with Children North East (CNE) and an initial group of six schools to implement CNE’s ‘Poverty Proofing the School Day’ programme. 

This programme aims to highlight to teachers and school staff the challenges faced by children and young people living in poverty. As well as missing out on opportunities, pupils can face stigma. The senior leadership teams of participating schools will receive ‘train the trainer’ Poverty Proofing the School Day training, which will then be disseminated to the wider school staff. 

This will focus on how to reduce the costs and barriers to participation for children living in poverty, such as: 

• access to good quality food (breakfast clubs, snacks, eligibility for free school meals)
• access to additional opportunities (such as music lessons, photos, school trips)
• reducing school costs (events, resources for homework and lessons)
• access to student mental health support
• reducing uniform costs
• support to parents and families. 

Schools will audit each other to monitor progress on these areas and then work together to develop plans for tackling the issues identified. 

Adopting the ‘Poverty Proofing’ approach to the school day can provide a structured way to minimise school costs for families, enabling pupils to take part in all aspects of school life. Developed by CNE, the Poverty Proofing programmes are practical sector-led change initiatives designed to poverty proof the way that education, training, and access to healthcare, arts and culture are resourced, designed and delivered. 

Sefton Child Poverty Strategy 2022-30