Inequality and poverty affect the health of Italian children

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1.4 million children in absolute poverty, the pandemic has amplified the interweaving between inequality and health

Second “How have you been?“, the 13th Atlas of Childhood at risk in Italy, entitled ” released today by Save the Children in view of the World Day of Childhood and Adolescence, “In Italy, where almost one million and four hundred thousand children live in absolute poverty – an average percentage of 14.2% of all minors, which rises to 16% in the South – there are socio-economic inequalities that directly affect the health of children, penalizing those who would most need, in their territory, the services of care, prevention and promotion of health and psycho-physical well-being”.

And the Atlam nte brings out these differences: “If in Italy the life expectancy at birth in 2021 stands at 82.4 years, there are 3.7 years of difference between the life expectancy of those born in Caltanissetta (80.2) and those born in Florence (83.9). The latest Istat report on fair and sustainable Well-being highlights an even greater difference than life expectancy in good health: there are over 12 years of difference, for example, between those born in the province of Bolzano (67.2 years) and those born in Calabria (54.4 years). Among girls, the scissors are even wider, 15 years less in Calabria than in Trentino. Before the pandemic, according to the latest available data, the infant mortality rate (within the first year of life) was 1.45 deaths per 1000 live births in Tuscany but was more than double in Sicily (3.34) and triple in Calabria (4.42), with 38% of deaths related to children with mothers of foreign origin. A child from the South who fell ill in 2019 had a 70% higher chance of having to migrate to other regions for treatment than a child from Central or Northern Italy. It is not only the health system that influences the health of children, on which all the social determinants related to the territorial context in which one grows up, economic conditions, the level of education, the environment, social networks and services weigh”.

The Atlas tries to explore the health of children from the moment of birth until adulthood. Data, maps and interviews photograph the interweaving between inequalities and health that the pandemic has amplified, and the many, too many different faces of a health service that is often “national” only on paper, due to the serious territorial inequalities and the distance between its peaks of excellence and its chasms.

Claudio Tesauro, president of Save the Children Italy, underlines that “” How are you?” it is the question that many boys and girls would have liked to be asked during the pandemic and that is still not addressed to them by adults today. We wanted to dedicate the 2022 Atlas to health because it is necessary to ensure that all children and adolescents have a network of prevention and treatment services that meet their needs, overcoming the serious territorial inequalities that today affect the system. In the world, our national health service is positioned as an excellence for the care of children, but this should not lead us to ignore the gaps and criticalities that the pandemic has contributed to accentuate.  At the same time, the Atlas data show the need to put children’s health at the center of all policy choices, from the protection of the urban environment to school canteens, up to spaces for sport and movement, with a particular focus on the mental health of adolescents, strongly affected by the pandemic. This commitment is even more urgent today, in a country that is going through a difficult economic phase and that has reached the peak of almost one million and 400 thousand children in absolute poverty. For many of them, material and educational poverty also translates into poverty of health and everything must be done to break this vicious circle, directing the resources available to the territories that most suffer these difficulties”.

Save the Children states that ” The National Health Service is characterized by high professionalism, quality of care and a strong inclusiveness, all characteristics that still place Italy among the most advanced countries in the world in terms of protection of childhood health. The pandemic has, however, sharpened territorial gaps and exploded layered problems over the years. Net of the recent extraordinary funding for the pandemic, in the pre-Covid-19 decade Italy devoted less and less public resources to health care for which in 2019 it invested 6.4% of GDP, much less than Germany (9.8%) or France (9.3%), while household health spending increased, equal to 2.3% of GDP, when in France and Germany it was limited to 1.9 and 1.8%. The most affluent Italian families with minor children (5 quint quintile) spend on average about 250 euros per month for health, relying therefore more on private individuals, while the less affluent (1 quint quintile) do not reach a fifth of this expenditure (less than 50 euros) in the north center, or slightly exceed it in the South, relying therefore much more on the NHS, when present”.

In the allocation of public funds for health, only 12% is used in prevention and basic medicine, which are essential for the health of children in the medium and long term. The main share (44%) is used for hospital care, but only 6% of these resources are allocated to minors, compared to a percentage of these out of the total population of 15.6%, and in 2020 the ordinary inpatient beds in pediatric wards were only 4.1% of the total. Despite the demographic collapse – with less than 400 thousand born in 2021 – 1,400 basic pediatricians are missing from the appeal on the territories and the average of under14 children assisted per pediatrician is equal to 883, although there is a limit established by law of a maximum of 800 assisted per pediatrician, while neonatal screening still excludes, in many regions, some even very serious diseases, which could be diagnosed early.

In the 2020-21 biennium, the effects of the pandemic were strongly felt. For example, vaccinations in the first months of life have been significantly reduced, and there has been, among other things, a drastic reduction in pediatric cancer diagnoses that have decreased by 33% in 2020. Even before Covid19, the number of family consultors had dwindled. Between 2014 and 2020 there was a reduction of over 6% in the number of active centers and in the two-year period 2018-19 the average of users per single structure was 32,325 people, well above the 20,000 established by law (34/1996), and with a wide territorial disparity (Lazio, Veneto and Campania have on average catchment areas of over 40 thousand people for each consultation). The pejorative effects of the pandemic are also evident in the increasing mental distress of preteens and adolescents. In 9 Italian regions subject to monitoring, admissions for child neuropsychiatric pathology grew by 39.5% between 2019 and 2021 (the first two causes, psychosis and eating disorders), while throughout the country there are only 394 inpatient beds in these departments. There are regions that do not even have one, such as Calabria, Molise, Umbria and Valle d’Aosta, in Lombardy there are 100. But the absence or lack of semi-residential facilities, day-care centers, facilities for intensive care at home, the whole coordinated network of care that should avoid hospitalization is also very serious. Unfortunately, instead, a survey conducted by the Italian Society of Pediatrics between March 2020 and March 2021 in 9 Italian regions (Abruzzo, Basilicata, Emilia Romagna, Friuli Venezia Giulia, Lazio, Liguria, Lombardy, Marche, Umbria), shows a 39.5% increase in admissions for child neuropsychiatric pathology; the main cause was suicidal ideation followed by depression and eating disorders.  In general, we are faced with a need for consistent support that is not answered. According to estimates, even before the pandemic 200 out of 1000 children and young people had a neuropsychiatric disorder (1,890,000 minors), but less than a third had access to a territorial neuropsychiatry service of childhood and adolescence and in half of the cases could not have appropriate therapeutic-rehabilitative responses in their territory.

As is evident in the pages of the Atlas, it is not only the health system that has to ensure the health of a child. It is the entire growth environment, in many aspects, that plays a decisive role. It should therefore be considered that 81.9% of children live in areas where the concentration of fine dust is greater than the limit values indicated by the World Health Organization as not hazardous to health (100% in 8 regions: Emilia Romagna, Friuli Venezia Giulia, Liguria, Lombardy, Piedmont, Puglia, Trentino Alto Adige, Veneto). These pollutants are a possible trigger for asthma affecting 8.4% of children between 6 and 7 years old, but they also affect children’s cognitive development, which improves by 13% in schools with the lowest levels of fine dust in the air[10]. One child or boy in 4 never practices sport (3-17 years), with a wide range ranging from 45.5% of Campania to 6.9% of the Autonomous Province of Bolzano. With the pandemic, children between 3 and 10 years old who are overweight or obese have gone from 32.6% (2018-19) to 34.5% (2020-21). Food poverty affects 1 in 20 children[11], while access to the school canteen, which for some would be the only daily chance of a balanced and protein meal, is limited to 1 in 2 children in primary school; the school canteen should be considered as an essential service between the ages of 3 and 10. Good nutrition is also bad for 32% of adolescents 11-17 years old, who never eat fruit and vegetables.

Raffaela Milano, director of the Italy-Europe programs of Save the Children, recalls that “The PNRR foresees a significant investment in the Health Mission (more than 15 billion) and designs a territorial health reform that can respond to many of the critical issues identified by the Atlas. Starting from the Community Houses that could become the fulcrum of a new integrated network with social and educational services, supported by the relaunch of Consultors and services for juvenile health, to be built with the participation of citizens. But in order for this to be possible, it is essential to accompany the investment in structures with a long-term investment in human resources and it is necessary to bridge in the first place the very serious inequalities of access to services that we see exploding today in the most deprived areas of the country, with waiting lists of years to access rehabilitation services for children, children without a pediatrician, adolescents who enter psychiatric emergency departments after unnecessarily looking for a territorial service to turn to in time. These and many others, in the flesh, are the health questions that await answers. the right to the health of boys, girls and adolescents imposes courageous choices for the relaunch of a national health service that has pushed Italy to the first places in the world panorama over many years and that makes the universality of access a fundamental principle. Overcoming inequalities in children’s health is a long-term investment, but very precious, because we know that if you change the beginning of history, you can change the whole history”.

Here are the highlights of the report: 

The first 1000 days

Experiences during pregnancy and up to two years of life affect health, learning, as well as social and emotional well-being with effects that last throughout childhood and into adolescence and adulthood. For example, it has been shown that some early interventions are able to improve the cardiovascular health of the adult and that interpersonal skills – promoted through a safe and affectionate relationship with parents – generate empathy and self-control that inhibit antisocial behavior and violence.

Most of the critical situations at this crucial stage seem to be linked to the socioeconomic difficulties of the parents, with obvious territorial inequalities and not only. Between 2020 and 2021, the incidence of absolute poverty for families with 3 or more minor children has still increased, from 19.8 to 20.4%, reaching a triple value compared to families with only one minor child, and relative poverty affects 2 families with minor children out of 5 in Campania compared to 1 in 6 in the north. The factor linked to citizenship also weighs: 16.3% of parturient women without Italian citizenship make less than five medical visits during pregnancy, against 3.8% of Italian women, often the first gynecological check takes place only after the twelfth week of gestation (12.5% against 3.8% for Italians) and only one obstetric ultrasound is performed (3.8% against 1%).

Access to care and support for parenting are therefore crucial to reduce risk factors and strengthen those of protection and stimulus that will have a positive impact from the birth of the child until adulthood. Pending the implementation of the PNRR’s investments for early childhood services, only 13.7% of children under 3 years old access public and affiliated kindergartens, with a range ranging from 2.8% of Calabria to 28.4% of Emilia Romagna, and the per-capita expenditure of the Municipalities is limited on average to 909 euros, and if it even reaches 2,617 euros in the Autonomous Province of Trento or 1,996 in Emilia Romagna, in the south it does not exceed 600 euros and goes from 570 in Sardinia at the negative peak of the 110 euros of Calabria.

Health and well-being between 3 and 10 years

It is between the ages of 3 and 10 that the effect of the environment that surrounds children comes into play in a domineering way. Whether he is healthy or sick can make a big difference. To combat pollution in cities we would also need green in the city, but if the average in the provincial capitals is 31 square meters per inhabitant, in Puglia and Molise the square meters are reduced to about 10, and do not exceed 20 even in Campania, Sicily, Liguria and Valle d’Aosta. Housing deprivation also affects well-being and health, as happens to more than half (55.7%) of children in relative poverty, forced to live in overcrowded homes. Heating, already in 2021 before the expensive bills, was almost a dream for 16.5% of families with dependent children in relative poverty. For the poorest families (1 quint quintile) almost half of the monthly family budget is allocated to housing – about 47% in the North Center and 41% in the South, while the richest (5 quint quintile) spend in absolute terms triple for this item which, however, affects only 1/3 of their family budget.

In this age group, Special Educational Needs are also manifested, linked to physical, biological, physiological or even psychological and social reasons, which according to official data concern 6.5% of primary school pupils. In the case of children with disabilities or functional limitations, the Italian model of school inclusion is among the most advanced in the world, but the implementation leaves something to be desired. On average, only 32% of schools are barrier-free for pupils with motor disabilities, just over 40% in the two most organized regions (Lombardy and Marche), but it drops to 23% in regions such as Campania and Liguria. Only one in 100 schools, on the other hand, is equipped with aids for the accessibility of pupils with blindness or visually impaired[. In the 2020/21 school year, the number of pupils and disabled pupils in the public school system was more than 268,000, 3.6% of all students, but the support teachers were about 152 thousand and a third did not have specific training, 20% had been assigned late.

Teenager

Adolescents are experiencing the most delicate transition phase of life, which the pandemic has put even more strain on. According to a recent study carried out among 30 thousand high school and university students, more than 1 in 4 in the first months of 2022 had experiences of eating disorders (28%), 15.5% acts of self-harm, 10% used drugs, 12% alcohol in excessive amounts.

Throughout the country, admissions to hospital for causes related to eating disorders have tripled between 2019 and 2021, and in 2022 the age of onset of these diseases has fallen to 11-13 years: almost all girls (90%) are guests of public and private facilities specialized for the treatment of eating disorders (so far 123 have been surveyed by the ISS, of which 61 in the North, 23 in the Center and 39 in the South); the most frequent diagnoses are anorexia nervosa (36.2%), bulimia nervosa (17.9%) and binge eating disorder (12.4%). Voluntary isolation also affects a significant number of adolescents. Net of limits imposed by Covid19 restrictions and outings to go to school, the 5.6% of students report never leaving their home or room for activities and activities. In Italy then, in 2021, about one teenager between 14 and 19 years of age smoked out of 10, with a maximum value recorded in Sardinia (15.8%). Over half a million students (21%), also in 2021, consumed alcoholic beverages to the point of staggering, not being able to speak properly, vomiting or forgetting what happened and for about 15 thousand of them it was a frequent behavior. Drinking at least six glasses of alcoholic beverages on a single occasion (binge drinking) is a common practice for 4.6% of adolescents who consume alcohol. Alarming the growing percentages of girls. In the same year, about 77 thousand students between 15 and 19 years old have used New Psychoactive Substances (NPS). Among the new forms of addiction, more than 350 thousand students have a risk profile for the use of the Internet, and the number of victims (46%) and persecutors (29%) of cerb The percentage of those with a high risk of problematic gaming is close to 30% in Italy, well above the European average (20%). Finally, a sensitive topic for adolescent health is that of sex education. Although the WHO identifies sexuality education in school as a protection factor even with respect to sexual abuse, Italy is one of the few countries in the European Union (along with Bulgaria, Croatia, Lithuania and Romania) in which these courses are not mandatory.

Gender inequalities also matter in the adolescent stage. The chance of experiencing precocious puberty, for example, is 10 to 20 times higher in girls, celiac disease or eating disorders also have a female prevalence, while autism spectrum disorders are 4 times more frequent in boys.

Also important are the health issues of children and adolescents facing migration: in the case of unaccompanied foreign minors, which number about 17 thousand, and come for 32% from Ukraine, depression and post-traumatic stress disorder are reported in the first years after resettlement, for the trauma and violence often suffered in fleeing their country and on a journey that can last months or even years.

Permanent data collection on childhood and adolescence

The Atlas this year presents a great news, the dialogue with readers does not stop, but continues on the new Data hub of Save the Children (datahub.savethechildren.it), a virtual space open to all that will be dedicated to the collection and constant dissemination of information, data, analysis and research on childhood and adolescence, in Italy and in the world. It is a space that will be progressively and continuously nourished thanks to the generous collaboration of the main research institutions, universities, study centers and foundations, a network that is intended to further enrich many other actors, united in the common interest of promoting and protecting girls, boys and adolescents, in our country as in the rest of the world.

Save the Children in the territories

The interventions of Save the Children in Italy for years have been carried out on territories and districts of cities in territories where there is a strong impact of socio-economic and educational inequalities on girls, boys and adolescents. They are programs that aim to be innovative, measurable in their impact, replicable and realized in network with institutions and third sector realities engaged in the front line.

The specific support to maternal and child health and well-being is ensured with the project Fiocchi in Ospedale, active for 10 years and realized in collaboration with local Health companies, hospitals, University Polyclinics and territorial associations of 9 Italian cities (Turin, Milan, Pescara, Rome, Naples, Bari, Sassari, Brindisi, Ancona). Since 2012, the project has reached almost 41,500 boys and girls and more than 38,000 adults, including parents and caregivers, with information, support and guidance activities, with care skills (integrated care path) and personalized emergency support. It is an intervention that extends through the Mother Spaces, present in the peripheral contexts of 11 cities (Turin, Genoa, Milan, Rome, Naples, Brindisi, Bari, Sassari, San Luca (RC), Palermo, Catania) and oriented to families at high risk of marginalization and social exclusion with children up to 6 years of age, which have reached since 2014 almost 36,000 parents and more than 25,000 girls and boys. More than one “dowry” out of 3, among the 97 provided in 2022, concerned specialist visits, therapies, medical expenses, pharmaceutical expenses, wellness kits for new mothers, summer camps or gymnastics for the little ones or recreational moments for the family.

In the same type of context and vulnerability, there are 26 Points of Light, free daily spaces with high educational intensity, in 20 Italian cities and 15 regions (Abruzzo, Basilicata, Calabria, Campania, Friuli Venezia Giulia, Lazio, Liguria, Lombardy, Marche, Piedmont, Puglia, Sardinia, Sicily, Tuscany, Veneto). The Points of Light have accompanied since 2014 more than 46,700 girls, boys and adolescents between 6 and 17 years on their journey to learn, experiment, develop and let skills, talents and aspirations flourish freely, thanks also to more than 4,000 individual educational gifts.  They are a strong active garrison for the fight against educational poverty and pisco-social discomfort, and for the promotion of psychophysical well-being. In order to reach an even wider basin during the pandemic, Save the Children launched in 2021 the Officina del Benessere platform, aimed at strengthening the knowledge and preparation of reference adults – parents, teachers, educators – so that they can better prevent, timely recognize and adequately address the forms of discomfort related to the psychophysical health of girls, boys and adolescents, which has more than 132 thousand users. Many interventions are then carried out within schools, to combat early school leaving and to educate in a correct and conscious use of digital. A strong push to consider the issue of adolescent mental health emerged, during the pandemic, from the Sottosopra network, the youth movement for Save the Children today present in 15 cities.

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