Whenever I describe my work with families who live in poverty, I get gasps followed by the question, "Is there poverty in Singapore?". This disbelief is a recurrent response in my conversations with my colleagues and friends. In a fast-developing country like ours, especially in the medical fraternity where many of us originate from privileged backgrounds, poverty is often a term that does not fall into the narrative of Singapore's progress. But my work with KidSTART, a government-led home visitation initiative that supports children aged six and below from low-income families, has opened my eyes to this seemingly invisible group of Singaporeans, and I hope this article can raise awareness and generate good discussion on how we can collectively help the younger generation from a lower socioeconomic status to maximise their potential and development.
Numerous studies in the US have demonstrated the lifetime effects of adverse childhood experiences (ACEs) on individuals, which can result in heart diseases and depression. These ACEs include abuse (physical, emotional and sexual), neglect (physical and emotional), and household dysfunction (due to a caregiver's mental illness, having an incarcerated household member, having caregivers with substance abuse, parental divorce and spousal violence), which are common in Singapore. Closer to home, a study by the Institute of Mental Health and KK Women's and Children's Hospital (KKH) found that individuals who have undergone traumatic experiences in their childhood, such as emotional neglect or parental death or separation, could cost Singapore about $1.18 billion a year in absenteeism, reduced productivity and use of healthcare resources.1 The impact of such events which happen during the first 18 years of life continues throughout a person's lifespan, leading to higher costs of healthcare and productivity losses at work.
These robust research findings will be an impetus for relevant agencies and community services to provide upstream intervention, by addressing challenges that prevent children from reaching their full potential and counter the impact of adverse experiences on child development.
How it all began
In March 2016, KidSTART was initiated by the Early Childhood Development Agency and piloted in Kreta Ayer, Bukit Merah, Taman Jurong, Boon Lay and Geylang Serai. Fast-forward to the present, the programme has been going strong and will be expanded island-wide by 2025. KidSTART aims to empower low-income families to build strong foundations for their children and foster positive child developmental outcomes. The four desired outcomes are (1) achieving age-appropriate developmental outcomes, (2) receiving up-to-date immunisations, (3) improving parent-child interactions and family functioning, and (4) enrolling into preschool and achieving regular attendances.
With the upscaling efforts, the programme aims to enrol 80% of the eligible birth cohort by the time the child reaches six years old, starting with the 2023 birth cohort. The eligibility criteria are:
The programme is now helmed by KidSTART Singapore Limited, a non-profit organisation and an Institution of a Public Character that specialises in supporting families in early childhood development.
The programme can be further differentiated into two arms: KidSTART @ Hospital and KidSTART @ Home. The former caters to pregnant mothers on their follow-up appointments with KKH, Singapore General Hospital and National University Hospital. These teams are staffed by KidSTART practitioners (KSPs), who complement the hospitals' routine obstetric care of pregnant mothers' well-being, support mothers' mental wellness, and provide anticipatory guidance to mothers in preparation for the arrival of the baby and on how to care for their newborn.
KidSTART @ Home caters to children aged zero to six years old, in which an assigned KSP supports caregivers on ways to promote the child(ren)'s growth and development through enhanced parent-child interactions and routine-based enriched care. Understanding that children and families thrive within an ecosystem of support, KSPs also partner healthcare providers, preschools and social service agencies in providing support for families. In both arms, the home visitation model is the primary mode of support, as international research has shown that secure and nurturing home factors drive outcomes before three years of age.
How we have helped
Let me share a case that I had worked on with a KSP to demonstrate the collaboration between the healthcare and social service sector. Let us call our index child "A". A is a four-month-old female infant who was born to a 32-year-old father and 31-year-old mother. Both parents have intellectual disability and attended special school till secondary level. A's father works as a deliveryman but has a history of not sustaining his employment, while her mother is a homemaker. This family is also known to a Family Service Centre (FSC), and a social worker is involved as the family has poor self-help skills. The family was enrolled with KidSTART based on income eligibility. During the first home visit, it was noted by the KidSTART nurse and KSP that the parents had been preparing the formula milk erroneously, resulting in the dilution of milk. A was noted to appear small for her age, with her four-month-old weight at only 3.6 kg (her birth weight was 2.8 kg)! Apart from having received her BCG and first dose of Hepatitis B vaccines, no other vaccinations have been administered post-discharge. Using the Ages and Stages Questionnaires – a developmental screening tool – delays were noted in multiple domains as well.
The nurse alerted me to this case and we identified several care gaps through a case discussion with the KSP. A was directed for admission to KKH for nutritional rehabilitation and monitoring of growth. Through subsequent case discussions with the FSC's social worker and the KKH medical social worker, we identified that the parents had missed all required vaccinations and childhood developmental screenings at the polyclinic after A's birth, as "they were not aware of the need to do so". The Child Protective Service was thus involved in view of these concerns.
Over a period of six weeks, our KKH inpatient team worked hand in hand with the dietitian and ensured that A had a gradual and steady growth prior to her discharge to kinship care. A was also enrolled to an infant care provider. Subsequently, the multidisciplinary approach between the KSP, social worker, hospital team, preschool and Child Protective Service ensured that a safety contract was established for the parents and kinship carers to abide by. The KSP continues to have frequent home visits to monitor the family's well-being and ensure that A's immunisations are up to date and her preschool attendance is regular. The KSP also continues to provide support in areas of childhood nutrition and parent-child bonding. A has since completed all compulsory vaccinations and her preschool attendance has stabilised from the initial 15% to the current 75%. I continue to see A in my general paediatric outpatient clinic for growth and developmental monitoring, and I am proud to say that her growth has improved significantly. A referral to the Early Intervention Programme for Infants and Children was also made and she has been enrolled since May 2024.
As you can see, with A's parents having intellectual disability, it is understandable that they need tremendous handholding to provide the necessary support for A's development and growth. Without these collaborations, A's health and well-being may worsen and she would not be able to receive the necessary support and interventions.
Every role matters in the team
I first joined the KidSTART programme in 2017 and have worked with many KSPs over the years. These professionals may come from varied backgrounds – social work sector, healthcare industry, early childhood educators – but they all carry the same passion to improve the lives of the young from families belonging to the lower socioeconomic status. From just six KSPs when the programme first started, the team has now grown to over 200 in number. Most of my interactions with KSPs are during case consults and training where they would update regarding the medical issues, typically revolving around themes such as failure to thrive, common paediatric issues (eg, eczema, asthma) and developmental delays. Not only do the KSPs have to provide the details of the medical or developmental issues, but they also bring in the sociocultural context to help me appreciate the complex background of these families.
Often, these disadvantaged families have urgent bread-and-butter issues to address, such as securing employment, settling arrears in utility bills, etc. As such, the caregivers' priority is often not focused on addressing the child's medical needs but rather putting out the "fires" of their day-to-day burning issues. KSPs must demonstrate empathy to the families before gaining trust from the caregivers to enter their world (both emotionally and physically through home visits), which are often filled with uncertainties and distress. Only when rapport is established can the KSPs hear from caregivers their hope for their children to do better. KSPs will then guide the caregivers on how to enhance the child's growth and development by leveraging on the parents' existing knowledge, skills and strengths, highlighting opportunities for them to interact with the child, and sharing strategies that will empower them to be confident caregivers.
I often hear from KSPs that families like A's are mired with multiple stressors. Apart from signposting them to the right avenues for crisis management, KSPs will often redirect the focus back to the child's development. These dedicated KSPs work weeknights and sometimes even weekends to accommodate caregivers' working hours, as sessions ideally take place when both caregivers and children are at home. With such "heart work", KSPs are supported with robust reflective supervision and mentoring to ensure their emotional wellness in providing care to the families they serve. Over years of regular visits and engagement, deep meaningful bonds are made with these families. These relationships may experience periodic setbacks when preset goals are not achieved, but they are also often filled with immense pride and satisfaction when families overcome hurdles to be better versions of themselves. I have certainly developed my utmost respect for the KSPs that I worked with. Hats off to their unwavering dedication and commitment to these families!
KidSTART@KKH
Our KidSTART@KKH's multidisciplinary team (MDT) consists of professionals from varied backgrounds, including paediatricians, nurses, speech and language therapists, occupational therapists, physiotherapists, psychologists, dietitians, and more. Just as the saying goes, "The whole is greater than the sum of its parts", our unique approach leverages individual professionals' capabilities and we synergise these strengths by coming together to formulate a robust child-focused and family-centric plan for our clients. This is further supported by the KSP in charge of the family who bears the biopsychosocial framework in mind during interprofessional collaborations with the MDT members. Our MDT members are always collegial and open-minded during discussion, with the ultimate goal being in the best interest of the child. We provide capability building by upskilling our KSPs and community stakeholders with cross-domain expertise in childhood health and social services. Our team also have periodic in-service sessions where we learn more about each other's role.
Conclusion
Singaporeans generally aspire to be good parents. If parenting is deemed difficult for the majority of Singaporeans, it is even more so for our KidSTART families who have fewer resources. Some live hand-to-mouth, working hourly paid jobs or irregular shift work. Many brave bad weathers and even work through the night in jobs such as security and food delivery services to make a living for their families. We must applaud their grit and resilience in wanting the best for their children. Collectively, as a compassionate and mature society, we must endeavour to uplift these families with hard and heart work. It is a social responsibility, where we leave no Singaporeans behind. We can then look forward to a brighter future for our children, no matter what background they come from. As the saying goes, "It takes a village to raise a child", and I am proud to be part of this kampung!