The social determinants of child health

Women empowerment indicators and uptake of child health services in sub-Saharan Africa: a multilevel analysis using cross-sectional data from 26 countries

BACKGROUND

The sustainable development goal 3, target 2, seeks to reduce under-five mortality to as low as 25 deaths per 1000 live births by 2030. As such, seeking child health services has become a priority concern for all countries, particularly those in sub-Saharan Africa (SSA). Evidence suggests that empowered women are more likely to seek child health services. Hence, this study examined the association between women empowerment indicators and uptake of child health services in SSA.

METHODS

The study used data from the Demographic and Health Surveys of 26 SSA countries, which were conducted between 2010 and 2019. Two different samples were considered in the study: a total of 12 961 children within the vaccination age of 12-23, and 9489 children under age 5 with diarrhoea symptoms in the last 2 weeks before the survey. Women empowerment indicators comprised disagreement with reasons to justify wife beating, decision-making power and knowledge level, while child health services constituted complete vaccination uptake and seeking diarrhoea treatment. Frequencies, percentages and multivariable, multilevel binary logistic regression models were employed.

RESULTS

The study shows that women with high decision-making power [adjusted odds ratio (AOR) = 1.20, 95% confidence interval (CI) = 1.07, 1.35] had higher odds of seeking treatment for childhood diarrhoea compared to those with low decision-making power. It was also observed that among children aged 12-23 months [AOR = 1.28, 95% CI = 1.14, 1.43], mothers had higher odds of seeking diarrhoea treatment for them compared to those who were aged less than 12 months. Children whose mothers had medium decision-making power [AOR = 1.30, 95% CI = 1.19, 1.41] were more likely to seek complete immunization for their children compared to those with low decision-making power. Also, those with medium [AOR = 1.19, 95% CI = 1.07, 1.31] and high knowledge [AOR = 1.25, 95% CI = 1.10, 1.42] had higher odds of completing immunization for their children compared to those with low knowledge. Women with medium acceptance had lower odds [AOR = 0.76, 95% CI = 0.67, 0.83] of completing immunization for their children compared with those with low acceptance of wife beating.

CONCLUSIONS

This study has demonstrated a strong association between women empowerment indicators and the uptake of child health services. Therefore, efforts should be made to seek policy tools to empower women to help improve the well-being of women and the children they care for.

"Outside the Skin": The Persistence of Black-White Disparities in U.S. Early-Life Mortality

Research on Black-White disparities in mortality emphasizes the cumulative pathways through which racism gets "under the skin" to affect health. Yet this framing is less applicable in early life, when death is primarily attributable to external causes rather than cumulative, biological processes. We use mortality data from the National Vital Statistics System Multiple Cause of Death files and population counts from the Surveillance, Epidemiology, and End Result Program to analyze 705,801 deaths among Black and White males and females, ages 15-24. We estimate age-standardized death rates and single-decrement life tables to show how all-cause and cause-specific mortality changed from 1990 to 2016 by race and sex. Despite overall declines in early-life mortality, Black-White disparities remain unchanged across several causes-especially homicide, for which mortality is nearly 20 times as high among Black as among White males. Suicide and drug-related deaths are higher among White youth during this period, yet their impact on life expectancy at birth is less than half that of homicide among Black youth. Critically, early-life disparities are driven by preventable causes of death whose impact occurs "outside the skin," reflecting racial differences in social exposures and experiences that prove harmful for both Black and White adolescents and young adults.

Work-Family Reconciliation and Children's Well-Being Disparities across OECD Countries

Socioeconomic inequalities in health and well-being are large, beginning early in childhood and accumulating over the life course, but they also vary widely across rich developed nations. Despite this well-known cross-national variation, research has yet to examine why children's health disparities might be larger or smaller based on national policy contexts and macroeconomic conditions. Parental health and well-being suffer under high work-family or economic strain, which may directly impact children's health inequalities by family social class. These childhood health disadvantages, if not substantially improved, compound to even larger adult inequalities. To examine the role of national work-family reconciliation in children's health, we merge country-level policy data with 2006 and 2010 World Health Organization child-level data on mental and physical well-being and family economic disadvantage. Based on adjusted estimates, we find greatly narrowed disparities in children's self-rated health as work flexibility and vacation-sick leave mandates become more generous. However, cash transfer policies including family benefits spending and childcare costs were not associated with the size of children's health disparities. Taken together, our results suggest the distinctive value of better work-family accommodations, rather than any generic cash allowances, for lessening family-based inequalities in children's health and human capital development.

From Policy Statement to Practice: Integrating Social Needs Screening and Referral Assistance With Community Health Workers in an Urban Academic Health Center

Purpose: Social and economic factors have been shown to affect health outcomes. In particular, social determinants of health (SDH) are linked to poor health outcomes in children. Research and some professional academies support routine social needs screening during primary care visits. Translating this recommendation into practice remains challenging due to the resources required and dearth of evidence-based research to guide health center level implementation. We describe our experience implementing a novel social needs screening program at an academic pediatric clinic. Methods: The Community Linkage to Care (CLC) pilot program integrates social needs screening and referral support using community health workers (CHWs) as part of routine primary care visits. Our multidisciplinary team performed process mapping, developed workflows, and led ongoing performance improvement activities. We established key elements of the CLC program through an iterative process We conducted social needs screens at 65% of eligible well-child visits from May 2017 to April 2018; 19.7% of screens had one or more positive responses. Childcare (48.8%), housing quality and/or availability (39.9%), and food insecurity (22.8%) were the most frequently reported needs. On average, 76% of providers had their patients screened on more than half of eligible well-child visits. Discussion: Our experience suggests that screening for social needs at well-child visits is feasible as part of routine primary care. We attribute progress to leveraging resources, obtaining provider buy-in, and defining program components to sustain activities.

Associations between women's empowerment and children's health status in Ethiopia

Although women's empowerment has gained attention over the last two decades, our understanding of the associations between different dimensions of women's empowerment and different children's health outcomes is limited. This study aims to measure the extent of women's empowerment and to examine its associations with the children's health status in Ethiopia. Data were obtained from the 2016 Ethiopian Demographic and Health Survey (EDHS). The sample is restricted to a sub-sample of 10,641 women from 15 to 49 years old and their children under the age of five years. We used children's height-for-age and weight-for-height Z-scores and pneumonia and anemia experience as indicators of children's health outcome. Women's empowerment is measured by five indices reflecting their participation in decision-making, attitudes towards wife-beating by husband, barriers to health care access, asset ownership, and socio-economic variables. These indicators of empowerment were constructed using exploratory and confirmatory factor analysis. A Multiple Indicators Multiple Causes (MIMIC) model was employed to examine the relationship between women's empowerment and latent child health outcomes, after controlling for relevant covariates. Results suggests that enhancing women's empowerment in the household in terms of their socio-economic status (i.e., increasing women's access to education, information, media, and promoting saving) was associated with less likelihood of the children's being stunted or wasted (p<0.05). Higher women's empowerment in terms of household decision-making power were also associated with better children's health status measured by the children's experience of pneumonia and anemia (p<0.05). All aspects of women's empowerment are not related with children's health indicators. Women's empowerment dimensions related with child health have a varying degree of association with the different children's health indicators. Gender-specific policies focusing on increasing women's access to education, media, information, and promoting saving and their participation in the household decision making are some of the strategies for improving their children's health and wellbeing.

Unmet Social Needs and No-Show Visits in Primary Care in a US Northeastern Urban Health System, 2018-2019

Objectives. To characterize the association between social needs prevalence and no-show proportion and variation in these associations among specific social needs.Methods. In this study, we used results from a 10-item social needs screener conducted across 19 primary care practices in a large urban health system in Bronx County, New York, between April 2018 and July 2019. We estimated the association between unmet needs and 2-year history of missed appointments from 41 637 patients by using negative binomial regression models.Results. The overall no-show appointment proportion was 26.6%. Adjusted models suggest that patients with 1 or more social needs had a significantly higher no-show proportion (31.5%) than those without any social needs (26.3%), representing an 19.8% increase (P < .001). We observed a positive trend (P < .001) between the number of reported social needs and the no-show proportion-26.3% for those with no needs, 30.0% for 1 need, 32.1% for 2 needs, and 33.8% for 3 or more needs. The strongest association was for those with health care transportation need as compared with those without (36.0% vs 26.9%).Conclusions. We found unmet social needs to have a significant association with missed primary care appointments with potential implications on cost, quality, and access for health systems.

Integrating Social Needs Screening and Community Health Workers in Primary Care: The Community Linkage to Care Program

Clinic-based social needs screening has been associated with increased access to social services and improved health outcomes. Using a pragmatic study design in an urban pediatric practice, we used logistic regression to identify factors associated with successful social service uptake. From December 2017 to November 2018, 4948 households were screened for social needs, and 20% self-reported at least one. Of the 287 households with unmet needs who were referred and interested in further assistance, 43% reported successful social service uptake. Greater than 4 outreach encounters (adjusted odds ratio = 1.92; 95% confidence interval = 1.06-3.49) and follow-up time >30 days (adjusted odds ratio = 0.43; 95% confidence interval = 0.25-0.73) were significantly associated with successful referrals. These findings have implementation implications for programs aiming to address social needs in practice. Less than half of households reported successful referrals, which suggests the need for additional research and an opportunity for further program optimization.

Social Determinants of Health, the Family, and Children's Personal Hygiene: A Comparative Study

Habits of personal hygiene are mostly acquired during childhood, and are, therefore, influenced by one’s family. Poor hygiene habits are a risk factor for preventable disease and social rejection. Social Determinants of Health (SDH) consist of contextual factors, structural mechanisms, and the individual’s socioeconomic position, which, via intermediary determinants, result in inequities of health and well–being. Dysfunctional family situations may, therefore, be generated by an unequal distribution of factors determining SDH. Little attention has been paid to the influence of the family on personal hygiene and the perception of social rejection in children. We designed a study to examine differences in personal hygiene and in the perception of social rejection between children in reception centers and children living in a family setting. A validated questionnaire on children’s personal hygiene habits was completed by 51 children in reception centers and 454 children in normal families. Hygiene habits were more deficient among the children in reception centers than among the other children in all dimensions studied. Deficient hygiene habits were observed in the offspring of families affected by the main features of social inequality, who were more likely to perceive social rejection for this reason and less likely to consider their family as the greatest influence on their personal hygiene practices.

Household relationships and healthcare seeking behaviour for common childhood illnesses in sub-Saharan Africa: a cross-national mixed effects analysis

Background

Intra-household dynamics play crucial roles in utilisation of healthcare services for children. We investigated the influence of household relationships on healthcare seeking behaviour for common childhood illnesses in four sub-Sahara African regions.

Methods

Data on 247,061 under-five children were extracted from recent Demographic and Health Surveys conducted between 2012 and 2016 in 25 countries. Data were combined and analysed per sub-region. Dependent variables (DVs) were uptake of health facility care for diarrhea and Acute Respiratory Tract Infection (ARI) symptoms. The main independent variable (IV) was household relationship which was represented by maternal marital profile (marital status, family type and number of marriages) and maternal relationship to household head. Mixed effects logit models were fitted to assess independent relationship between the IVs and DVs with adjustment for relevant demographic and socio-economic characteristics at 5% significance level.

Results

The percentage of children who received care for diarrhea and ARI symptoms from health facilities across sub-regions was: Western Africa (WA) 42.4, 44.1%; Central Africa (CA) 32.6, 33.9%; Eastern Africa (EA) 41.5, 48.7% and Southern Africa (SA) 58.9, 62.7%. Maternal marital profile was not associated with healthcare seeking behaviour for diarrhea and ARI symptoms in any of the sub-regions. Children whose mothers were daughter/daughter-in-law to household head were significantly less likely to be taken to health facility for diarrhea treatment in Eastern Africa (AOR = 0.81, CI: 0.51–0.95). Having a mother who is the head of household was significantly associated with higher odds of facility care for ARI symptoms for children from Western (AOR = 1.20, CI: 1.02–1.43) and Southern Africa (AOR = 1.49, CI: 1.20–1.85).

Conclusion

The type of relationship between mother of under-fives and head of households affect health seeking behaviour for treatment of diarrhea and ARI symptoms in Eastern, Western and Southern Africa. Countries in these regions need to adapt best practices for promoting healthcare utilisation for children such that household relationship does not constitute barriers.

Electronic supplementary material

The online version of this article (10.1186/s12913-019-4142-x) contains supplementary material, which is available to authorized users.

Household member substance problems and children's health in the United States

A sizable number of children are exposed to household member substance problems, an adverse childhood experience (ACE), yet little research uses a nationally representative sample of U.S. children to examine this association. We used newly released data from the 2016 National Survey of Children's Health (NSCH), a nationally representative sample of noninstitutionalized children in the United States, and logistic regression models to investigate the relationship between household member substance problems and 14 indicators of children's health. We find 9.0% of children in the United States have experienced household member substance problems. We also find children exposed to household member substance problems are more likely to have health problems than children not exposed to household member substance problems, but that most of these descriptive differences can be explained by household characteristics and other ACEs. Children exposed to household member substance problems are a vulnerable population. Given that household member substance problems are concentrated among socioeconomically disadvantaged children, children at a greater risk of health problems than their counterparts, this ACE may exacerbate existing socioeconomic inequalities in children's health.

Cumulative family risks across income levels predict deterioration of children's general health during childhood and adolescence

Family is considered an important agent in the health development of children. This process is significant but quite complex because the prevalence of potential risk factors in the family can hinder children’s health. This study examined if multiple family risks might have cumulative effect on children and youth’s health across various levels of household income. The data in this study were drawn from the 2011–2012 U.S. National Survey of Children’s Health (N = 79,601). A cumulative family risk (CFR) index was developed, which included such constructs as single-parenthood, unstable employment, large family, parenting stress, poor maternal education, poor maternal general health and poor maternal mental health. Multiple logistic regression analyses showed that CFR level was significantly related to children and youth’s poor health outcome (p < .001). When poverty levels were considered, however, the impact of CFRs on children and youth’s health was attenuated. The impact of CFRs was higher on children and youth from affluent families than on those from poor families. Overall there was a consistent pattern of trend in the point estimate as well as confidence limits as levels of affluence and numbers of family risk increased although some of the confidence intervals overlapped. Living in disadvantaged families might serve as a protective factor against CFRs possibly through repeated exposure to hardships and subsequent formation of resilience among some of the disadvantaged children.

Child access to the nutritional safety net during and after the Great Recession: The case of WIC

Because children disproportionately live in poverty, they are especially vulnerable during economic crises, making the social safety net a key buffer against the effects of economic disadvantage on their development. The Great Recession of 2007-2009 had strong and lasting effects on American children and families, including striking negative effects on their health environments. Understanding access to the health safety net during this time of increased economic need, as well as the extent to which all children-regardless of age, income or race/ethnicity-share in the increased use of transfer programs, is therefore important in identifying the availability and accessibility of government assistance for those in need. Focusing on the Special Supplemental Nutrition Program for Women, Infants and Children (WIC) program because of its strong effects on child development, we use longitudinal data from the Survey of Income and Program Participation (SIPP) to examine change and stability in children's WIC enrollment before, during and after the recession. Specifically, we examine: 1) whether children's WIC enrollment increased alongside changing family income, and 2) the extent to which changes in participation were shared by all subpopulations, regardless of age, income, and race/ethnicity. Analyses reveal that WIC participation among eligible children increased leading up to, during, and after the Great Recession, suggesting that the program was responsive to increasing economic need. Examining the distribution of WIC enrollment across demographic groups largely reveals a pattern of stable inequality in access and "take up." Children born to poorer and less-educated mothers were more likely to be enrolled prior to the recession, and these differences remain mostly constant during and after the recession. Eligible Hispanic children had consistently higher enrollment, particularly among those in families with foreign-born mothers. The findings suggest that not all eligible children equally enroll in WIC, but that these differences have not been drastically exacerbated by macroeconomic instability.

Socio-economic environment, area facilities and obesity and physical inactivity among children

BACKGROUND

To evaluate whether the relationship between socio-economic environment and obesity and physical inactivity in children can be explained by household socio-economic position and area facilities.

METHODS

Two indicators of the socio-economic context of neighbourhood of residence based on wealth and deprivation were estimated in a sample of 727 children and adolescents residents in Madrid (Spain). Multilevel logit models were used to calculate the relationship between each indicator and obesity and physical inactivity.

RESULTS

After adjusting for household socio-economic position, obesity prevalence was 3.79 times higher among subjects living in deprived areas than among those living in non-deprived areas (CI: 1.95-7.34), and 2.38 higher among subjects living in less wealthy areas than in those living in wealthier areas (CI: 0.85-6.65). Adjustment for the availability of retail shops in subjects' neighbourhood of residence failed to change the magnitude of the association. Neither neighbourhood socio-economic context nor availability of sports facilities was related to physical inactivity.

CONCLUSION

In the city of Madrid, socio-economic context of neighbourhood of residence shows an inverse relationship with obesity but not with physical inactivity among children. The relationship observed with obesity is not explained by the availability of area facilities.

Associations between parents' subjective time pressure and mental health problems among children in the Nordic countries: a population based study

Background

The home, the family and the parents represent a context of everyday life that is important for child health and development, with parent-child relationships highlighted as crucial for children’s mental health. Time pressure is an emerging feature of modern societies and previous studies indicates that parents with children living at home experience time pressure to a greater extent than people with no children living at home. Previous studies of children’s mental health in relation to parents’ time pressure are lacking. Hence, the purpose of this study was to examine the association between parents’ subjective time pressure and mental health problems among children in the Nordic countries as well as potential disparities between boys and girls in different age groups.

Methods

4592 children, aged 4-16 from Denmark, Finland, Norway and Sweden, participating in the 2011 version of the NordChild study, were included. The Strength and Difficulties Questionnaire was used to measure children’s mental health and associations to parents’ time pressure were assessed by multiple logistic regression analysis.

Results

Among children of parents experiencing time pressure, 18.6% had mental health problems compared to 10.1% among children of parents experiencing time pressure not or sometimes. The odds of mental health problems were higher among both boys (OR 1.80 95% CI 1.32-2.46) and girls (OR 1.95 95% CI 1.42-2.66) if their parents experienced time pressure when adjusted for financial stress. The highest prevalence of mental health problems in the case of parental time pressure was found among girls 13-16 years old (23.6%) and the lowest prevalence was found among boys 13-16 years old (10.7%).

Conclusions

In this study an association between parents’ subjective time pressure and increased mental health problems among children was found. Given that time pressure is a growing feature of modern societies, the results might contribute to an explanation as to mental health problems are common among children in the Nordic countries in spite of otherwise favourable conditions. Additional research on the linkage between parents’ experienced time pressure and children’s and adolescents’ mental health problems is needed to confirm the novel findings of this study.

Health among Black children by maternal and child nativity

OBJECTIVES

We examined 5 health outcomes among Black children born to US-born and foreign-born mothers and whether differences by mother's region of birth could be explained by maternal duration of US residence, child's place of birth, and familial sociodemographic characteristics.

METHODS

Data were from the 2000-2011 National Health Interview Surveys. We examined 3 groups of children, based on mother's region of birth: US origin, African origin, and Latin American or Caribbean origin. We estimated multivariate regression models.

RESULTS

Children of foreign-born mothers were healthier across all 5 outcomes than were children of US-born mothers. Among children of foreign-born mothers, US-born children performed worse on all health outcomes than children born abroad. African-origin children had the most favorable health profile. Longer duration of US residence among foreign-born mothers was associated with poorer child health. Maternal educational attainment and other sociodemographic characteristics did little to explain these differences.

CONCLUSIONS

Further studies are needed to understand the role of selective migration and the behavioral, cultural, socioeconomic, and contextual origins of the health advantage of Black children of foreign-born mothers.