Understanding child disadvantage from a social determinants perspective

The mediating role of behavioral risk factors in the pathway between childhood disadvantage and adult psychological distress in a Finnish employee cohort

Childhood disadvantage is associated with increased adult psychological distress, but the role of behavioral risk factors in the pathway remains unclear. We examined whether behavioral risk factors mediate the effects of childhood disadvantage on adult psychological distress. We used the Helsinki Health Study data of employees of the City of Helsinki, Finland, aged 19-39 (mean age 32.0) years at baseline (2017). We included women (n = 2397) and men (n = 586) who responded to both baseline and follow-up (2022) surveys. At baseline, eight types of childhood disadvantage were asked retrospectively, and six adult behavioral risk factors were included. Psychological distress was measured by the DASS-21 at follow-up. We conducted mediation analyses using generalized structural equation modeling. Among women, we found indirect path effects of childhood disadvantage on adult psychological distress through behavioral risk factors (symptoms of depression: β = 0.68, 95% CI 0.20-1.17; anxiety: β = 0.54, 95% CI 0.13-0.95; and stress: β = 0.69, 95% CI 0.20-1.09). Among men, childhood disadvantage contributed only directly to adult depressive (β = 0.71, 95% CI 0.16-1.26) and stress (β = 0.61, 95% CI 0.10-1.13) symptoms. Our findings suggest that behavioral risk factors can mediate some of the adverse effects of childhood disadvantage on adult psychological distress among women.

The role of adolescent social inclusion in educational attainment among vulnerable youth

BACKGROUND

Completing high school enables access to educational and employment opportunities associated with better physical and mental health and improved quality of life. Identifying modifiable factors that promote optimal educational trajectories for youth experiencing disadvantage is an important research focus. Social inclusion has been theorised to play a role in promoting better educational outcomes for this priority population, however limited research has examined this relationship.

METHOD

This study used three waves of data from the state-representative Australian arm of the International Youth Development Study (IYDS) (youngest cohort, N = 733; 54% female, 95% Australian born) to examine the extent to which vulnerability in primary school (Grade 5; Mage = 10.97, SD = 0.38) and social inclusion in mid-adolescence (Year 10; Mage = 15.50, SD = 0.53), were associated with school completion in young adulthood (post-secondary; Mage = 19.02, SD = 0.43).

RESULTS

Regression models identified an interaction between social inclusion and vulnerability (OR = 1.37, 95% CI [1.06, 1.77], p = .016), indicating that the association between vulnerability and school completion varied as a student's level of social inclusion increased. Higher social inclusion was beneficial for youth with lower levels of vulnerability but did not appear to influence school completion for the most vulnerable students.

CONCLUSIONS

For many young people, promoting social inclusion may support engagement in education and play a protective role. However, further research is needed to better understand the role of social inclusion for highly vulnerable youth, particularly the mechanisms via which social inclusion may have differential effects on school completion.

Establishing spirituality as an intermediary determinant of health among 42,843 children from eight countries

The World Health Organization (WHO) Commission on the Social Determinants of Health (CSDH) conceptual framework identifies socio-economic position as a structural determinant of health. Recognized intermediary determinants include biological, behavioural, and psychosocial factors. We examined whether connections afforded by a healthy spirituality potentially act as unrecognized intermediary determinants in adolescent populations, contributing to inequities in mental health. Reports from 42,843 children (21,007 boys, 21,836 girls) from eight countries who participated in the 2017-2018 Health Behaviour in School-aged Children (HBSC) study were used to describe correlations between family affluence and positive levels of mental health, using a cross-sectional design. Based on the CSDH conceptual framework and multivariable regression analyses, we then examined whether these associations were mediated by spiritual health. Connections afforded by a high level of spiritual health were universally correlated with positive mental health status. In three Western European nations (England, Scotland, and Wales) and Canada affluence was correlated with better mental health and this was partially mediated by spiritual health. Among the four Eastern European countries (Latvia, Lithuania, Moldova, Poland), our findings did not support aspects of the CSDH framework that focus on affluence as a direct determinant of health. Spiritual health potentially is an intermediary determinant of children's health in some Western countries, but not in Eastern countries. The universality of social determinants of health models and the measures used in their evaluation require careful assessment across cultures, political contexts, and health outcomes.

Household income supplements in early childhood to reduce inequities in children's development

BACKGROUND

Early childhood interventions have the potential to reduce children's developmental inequities. We aimed to estimate the extent to which household income supplements for lower-income families in early childhood could close the gap in children's developmental outcomes and parental mental health.

METHODS

Data were drawn from a nationally representative birth cohort, the Longitudinal Study of Australian Children (N = 5107), which commenced in 2004 and conducted follow-ups every two years. Exposure was annual household income (0-1 year). Outcomes were children's developmental outcomes, specifically social-emotional, physical functioning, and learning (bottom 15% versus top 85%) at 4-5 years, and an intermediate outcome, parental mental health (poor versus good) at 2-3 years. We modelled hypothetical interventions that provided a fixed-income supplement to lower-income families with a child aged 0-1 year. Considering varying eligibility scenarios and amounts motivated by actual policies in the Australian context, we estimated the risk of poor outcomes for eligible families under no intervention and the hypothetical intervention using marginal structural models. The reduction in risk under intervention relative to no intervention was estimated.

RESULTS

A single hypothetical supplement of AU$26,000 (equivalent to ∼USD$17,350) provided to lower-income families (below AU$56,137 (∼USD$37,915) per annum) in a child's first year of life demonstrated an absolute reduction of 2.7%, 1.9% and 2.6% in the risk of poor social-emotional, physical functioning and learning outcomes in children, respectively (equivalent to relative reductions of 12%, 10% and 11%, respectively). The absolute reduction in risk of poor mental health in eligible parents was 1.0%, equivalent to a relative reduction of 7%. Benefits were similar across other income thresholds used to assess eligibility (range, AU$73,329-$99,864).

CONCLUSIONS

Household income supplements provided to lower-income families may benefit children's development and parental mental health. This intervention should be considered within a social-ecological approach by stacking complementary interventions to eliminate developmental inequities.

Intervention targets for reducing mortality between mid-adolescence and mid-adulthood: a protocol for a machine-learning facilitated systematic umbrella review

INTRODUCTION

A rise in premature mortality-defined here as death during the most productive years of life, between adolescence and middle adulthood (15-60 years)-is contributing to stalling life expectancy in high-income countries. Causes of mortality vary, but often include substance misuse, suicide, unintentional injury and non-communicable disease. The development of evidence-informed policy frameworks to guide new approaches to prevention require knowledge of early targets for intervention, and interactions between higher level drivers. Here, we aim to: (1) identify systematic reviews with or without meta-analyses focused on intervention targets for premature mortality (in which intervention targets are causes of mortality that can, at least hypothetically, be modified to reduce risk); (2) evaluate the review quality and risk of bias; (3) compare and evaluate each review's, and their relevant primary studies, findings to identify existing evidence gaps.

METHODS AND ANALYSIS

In May 2023, we searched electronic databases (MEDLINE, PubMed, Embase, Cochrane Library) for peer-reviewed papers published in the English language in the 12 years from 2012 to 2023 that examined intervention targets for mortality. Screening will narrow these papers to focus on systematic reviews with or without meta-analyses, and their primary papers. Our outcome is death between ages 15 and 60 years; with potential intervention targets measured prior to death. A MeaSurement Tool to Assess systematic Reviews (AMSTAR 2) will be used to assess quality and risk of bias within included systematic reviews. Results will be synthesised narratively due to anticipated heterogeneity between reviews and between primary studies contained within included reviews.

ETHICS AND DISSEMINATION

This review will synthesise findings from published systematic reviews and meta-analyses, and their primary reviewed studies, meaning ethics committee approval is not required. Our findings will inform cross-cohort consortium development, be published in a peer-reviewed journal, and be presented at national and international conferences.

PROSPERO REGISTRATION NUMBER

CRD42022355861.

The potential of intervening on childhood adversity to reduce socioeconomic inequities in body mass index and inflammation among Australian and UK children: A causal mediation analysis

BACKGROUND

Lower maternal education is associated with higher body mass index (BMI) and higher chronic inflammation in offspring. Childhood adversity potentially mediates these associations. We examined the extent to which addressing childhood adversity could reduce socioeconomic inequities in these outcomes.

METHODS

We analysed data from two early-life longitudinal cohorts: the Longitudinal Study of Australian Children (LSAC; n=1873) and the UK Avon Longitudinal Study of Parents and Children (ALSPAC; n=7085).

EXPOSURE

low/medium (below university degree) versus high maternal education, as a key indicator of family socioeconomic position (0-1 year).

OUTCOMES

BMI and log-transformed glycoprotein acetyls (GlycA) (LSAC: 11-12 years; ALSPAC: 15.5 years). Mediator: multiple adversities (≥2/<2) indicated by family violence, mental illness, substance abuse and harsh parenting (LSAC: 2-11 years; ALSPAC: 1-12 years). A causal mediation analysis was conducted.

RESULTS

Low/medium maternal education was associated with up to 1.03 kg/m2 higher BMI (95% CI: 0.95 to 1.10) and up to 1.69% higher GlycA (95% CI: 1.68 to 1.71) compared with high maternal education, adjusting for confounders. Causal mediation analysis estimated that decreasing the levels of multiple adversities in children with low/medium maternal education to be like their high maternal education peers could reduce BMI inequalities by up to 1.8% and up to 3.3% in GlycA.

CONCLUSIONS

Our findings in both cohorts suggest that slight reductions in socioeconomic inequities in children's BMI and inflammation could be achieved by addressing childhood adversities. Public health and social policy efforts should help those affected by childhood adversity, but also consider underlying socioeconomic conditions that drive health inequities.

Environment and child well-being: A scoping review of reviews to guide policies

Background

Acting on social determinants is the most effective, efficient, and fairest strategy to improve population health and health equity. Because of their vulnerability and dependence, children are particularly exposed to the deleterious effects of their living environment. Taking these issues into account in the development of public policies and identifying levers for action are crucial. The objective of this scoping review of reviews is to identify the main environmental determinants on children's health and development, and their mechanisms of effect, to be addressed by public policies.

Methods

We conducted a scoping review of reviews in accordance with the method developed by Arksey and O'Malley, and Levac and colleagues' methodology advancement and the PRISMA guideline. Inclusion criteria were identified with the PICos (population-phenomena of interest-context-study design) framework. We used the PubMed database and conducted a thematic analyze.

Results

Forty-seven articles were selected. Their analysis allowed us to identify five categories of interdependent environmental determinants of child health: i) urban design ii) contaminants, iii) parenting environment, iv) social conditions, v) climate change. Together and in a systemic way, they act on the health of the child.

Conclusion

The review carried out allows us to propose a pragmatic framework for clarifying the effects of the physical, social, and economic environment on children's health and wellbeing.

Connections associated with a healthy spirituality: are these unrecognized intermediary determinants that shape health inequities in Canadian young people?

BACKGROUND

The health of adolescents is determined by structural and intermediary factors. Such factors operate through pathways that foster different opportunities to achieve health and wellbeing, contributing to inequities. Past analyses of cross-national adolescent health data show that measures of child spirituality, conceptualized as the strength of the connections in our lives, may operate as intermediary determinants in some Western countries. Inspired by this idea, the current analysis provides an in-depth exploration of such pathways among Canadian adolescents. Our objectives were to confirm the existence of relationships between economic position and seven indicators of adolescent health status, then explore whether any observed inequities could be explained by the strength of connections afforded by a healthy spirituality.

METHODS

Cycle 8 of the Canadian Health Behaviour in School-aged Children (HBSC) study was conducted in 2017-18. A school-based sample (n = 18,962) of adolescents was obtained from across Canada following a standard cross-national protocol. Eligible participants completed a general survey about their health, health behaviours and their determinants. Survey data were used to model the potential effect of perceived levels of relative affluence on each of seven health indicators. Comparison of crude and adjusted relative risks estimates from weighted log-binomial regression models provided evidence of indirect mediating effects attributable to each of four domains of spirituality.

RESULTS

As perceived levels of family affluence increased, the percentages of young people who reported each (7/7) of the negative health outcomes decreased. The spiritual health domain "connections to self" (i.e., the importance of meaning, purpose, joy and happiness in life) mediated the strength of relationships between relative affluence and each (7/7) of the outcomes in boys and girls. "Connections to others" (the importance of kindness, respect and forgiveness) mediated the strength of relationships between relative affluence and each (7/7) of the outcomes among girls. Inconsistent evidence of possible mediation was identified for connections to others in boys, as well as the other two domains of spirituality (connections to nature, then connections to the transcendent) in boys and girls.

CONCLUSION

Specific connections afforded by a healthy spirituality could be intermediary determinants of health in Canadian adolescent populations.

Modeling Adolescent Social Inclusion to Improve School Completion

Enhancing social inclusion in young people could increase engagement in education, yet few longitudinal studies have examined this relationship. This study aimed to identify whether social inclusion in an Australian adolescent sample predicted high school completion three years later. Using state-representative data from the International Youth Development Study, two waves of the youngest cohort (51.6% female and 94.6% Australian born) during mid-adolescence (n = 825, M_age = 15.99, SD = 0.39) and post-secondary school (n = 809, M_age = 19.03, SD = 0.44) were analyzed. Factor analysis identified a 4-factor structure that represented an overarching social inclusion construct: (1) Citizenship, (2) Connectedness to Community, (3) Connectedness to Family, and (4) Connectedness to and Participation in School. Multivariate regression analyses indicated higher social inclusion levels in mid-adolescence predicted an increased likelihood of high school completion three years later. The implementation of strategies that incorporate the enhancement of social inclusion may improve educational outcomes for young people.

Evaluation of the effectiveness of the standard traditional Korean medicine-based health promotion program for disadvantaged children in South Korea

Background

Traditional Korean Medicine (TKM) is highly integrated with the modern health care system of South Korea and is actively used in the public health field. Since 2014, the Ministry of Health and Welfare of South Korea has supported the development of standard models for TKM-based health promotion programs. This study aimed to develop and evaluate a standard TKM-based health promotion program for disadvantaged children.

Methods

Using convenience sampling, we recruited 16 Community Children’s Centers (CCCs) located in Busan and Yangsan, South Korea, which are welfare daytime facilities for children from socially disadvantaged families. The CCCs were divided into two groups of eight CCCs—intervention CCCs and control CCCs—through random allocation, and children in each group were selected as subjects for the study. For 12 weeks, the TKM-based health promotion program developed in this study along with the basic services of CCCs were applied to children in the intervention group, and only the basic services of CCCs were provided to children in the control group. Data were obtained through pre- and post-surveys with the legal representatives of the children prior to implementing the program and after the 12-week program, respectively. The outcome variables—the number of outpatient visits, absences, lateness/early leaves, infectious symptoms, and EuroQol-5D and EQ-visual analog scale scores–were measured and statistically compared between the groups by descriptive analysis, chi-square test, t-test, and difference-in-differences model with regression analysis.

Results

At baseline, there were 156 children in the intervention group and 153 children in the control group, among which 155 and 147 children, respectively, were included in the analysis. Results indicated that the number of outpatient visits was significantly lower (by 65%) in the intervention group than in the control group (p = 0.03), and this was similar in the sensitivity analysis. Regarding other outcome variables, the effects were not consistently significant.

Conclusions

A standard TKM-based health promotion program has the potential to improve the health of disadvantaged children. In the future, studies with long-term interventions and a larger sample are needed to enhance the applicability of these programs in communities.

Concordance in Adolescent and Caregiver Report of Social Determinants of Health

INTRODUCTION

Screening youth for negative social determinants of health is a widespread practice across healthcare settings in the U.S., with such systems almost exclusively relying on caregiver reports. Little work has sought to identify the social determinants of health adolescents identify as having the largest influence on their health and well-being or the extent to which adolescents agree with their caregiver. This study sought to (1) identify the most prevalent and influential negative social determinants of health, according to adolescent reports, and (2) assess concordance between adolescent and caregiver reports of social determinants of health.

METHODS

In Fall 2021, the study team conducted a cross-sectional, observational study within a predominately Latinx urban high school. The team invited all students and their caregivers to participate, resulting in 520 adolescent and 66 caregiver respondents (73% and 9% response rates, respectively). Data analyses occurred in 2022.

RESULTS

The most frequent adolescent-reported negative social determinants of health was stress (67%), followed by financial hardship (27%). The negative social determinant of health with the highest ranking of preventing adolescents from living their best and healthiest lives was depression, followed by isolation and stress. Concordance between caregiver and adolescent report of negative social determinants of health was very low across all negative social determinants of health (Krippendorf's α= -0.08 to 0.21). Caregivers under-reported adolescents' social and mental health needs, whereas adolescents under-reported material needs.

CONCLUSIONS

A hybrid informant approach may be a best practice for social determinants of health screening among adolescents, whereby caregivers and adolescents report material needs, and adolescents report social and mental health needs. Future work should evaluate the concordance between adolescent and caregiver social determinants of health reports in other settings.

Deprivation trends in potentially avoidable medical hospitalisations of under-25-year-old Māori and non-Māori non-Pacific in Aotearoa New Zealand: a 20-year perspective

Unnecessary hospitalisations for preventable or treatable conditions provides an indication of the health of a country and its systems. We present data on potentially avoidable hospitalisations of Māori and non-Māori non-Pacific (NMNP) under-25-year-olds for medical conditions during the period 2000-2019, with particular focus on the magnitude of inequity by area deprivation. Potentially avoidable hospitalisation rates of under-25 years for medical conditions were consistently higher for Māori than for NMNP over the 20-year study period. The absolute difference in potentially avoidable hospitalisation rates between the most and least deprived areas were greater for Māori than for NMNP in all years of the study. Respiratory conditions and skin infections accounted for more than 60% of potentially avoidable hospitalisations of Māori under-25-year-olds. The persistent trends in deprivation-based inequities in health outcomes for Māori, on both absolute and relative scales, suggest greater attention needs to be paid to implementing effective policy focussed on reducing these deprivation-based inequities and on improving access to and quality of care.

Trends in deprivation in hospitalisations of Indigenous children and young people in Aotearoa New Zealand

AIM

To examine the 20-year trends in socio-economic inequities in hospitalisations of Māori and non-Māori non-Pacific (NMNP) under-25-year olds in Aotearoa New Zealand.

METHODS

Hospital discharge data for Māori and NMNP taitamariki aged under-25 years were extracted from the National Minimum Dataset for the period 2000-2019. Acute or arranged admissions to hospital were included where the primary diagnosis was for a medical condition. Age- and gender-standardised rates (per 1000, 0-24-year old) were calculated for both ethnic groups by area deprivation using the 2013 NZ census estimated resident population. For each ethnic group, inequity indices of socio-economic deprivation (Slope Index of Inequality and Relative Index of Inequality) were computed, using regression modelling, to quantify inequity of medical condition-related hospitalisations and its changes over time.

RESULTS

Hospitalisation rates for medical conditions were consistently higher for Māori than for NMNP under-25-year olds from 2000 to 2019. Māori taitamariki residing in the most deprived (quintile 5) areas were more likely than NMNP to be hospitalised for a medical condition at each time point. Deprivation inequities existed for both ethnic groups and were greater for Māori. Despite reducing deprivation inequities over time, ethnic differences persist on both absolute and relative scales.

CONCLUSION

Deprivation inequities in hospitalisation for medical conditions persist for Māori taitamariki compared with NMNP and highlights society's tolerance of enduring inequity in health outcomes.

Measuring Positive Childhood Experiences: Testing the Structural and Predictive Validity of the Health Outcomes From Positive Experiences (HOPE) Framework

OBJECTIVE

Positive childhood experiences (PCEs), that occur within secure and nurturing social environments, are fundamental to healthy physical, social-emotional, and cognitive development. However, reliable measures of these experiences are not yet widely available. We used data from the Longitudinal Study of Australian Children (LSAC) to empirically represent and psychometrically evaluate 3 primary domains of PCEs defined within the Health Outcomes from Positive Experiences (HOPE) framework, specifically: 1) nurturing and supportive relationships; 2) safe and protective environments and; 3) constructive social engagement and connectedness.

METHODS

LSAC is a nationally representative cohort that has followed young Australians from birth since 2004. LSAC data were used to represent the 3 primary HOPE-PCEs domains (birth to 11 years) across 4 inter-related PCEs constructs: 1) positive parenting, 2) trusting and supportive relationships, 3) supportive neighborhood and home learning environments, and 4) social engagement and enjoyment. Confirmatory factor analysis was used to test the proposed 4-factor structure. Predictive validity was examined through associations with mental health problems and academic difficulties at 14 to 15 years.

RESULTS

The 4-factor structure was supported by empirical data at each time point. Higher exposure to PCEs across each domain was associated with lower reporting of mental health problems (β = -0.20 to -2.05) and academic difficulties (β = -0.01 to -0.13) in adolescence.

CONCLUSIONS

The 4 LSAC-based HOPE-PCEs have sufficient internal coherence and predictive validity to offer a potentially useful way of conceptualizing and measuring PCEs in future cohort studies and intervention trials aiming to enhance the understanding of, and mitigate the negative impacts of, adverse childhood experiences.

Prevalence and predictors of developmental health difficulties within New Zealand preschool-aged children: a latent profile analysis

New Zealand research on inequities in children's developmental health outcomes is sparse. We aimed to describe the prevalence, clustering, and socio-environmental associations of developmental health in preschool-aged children. A latent profile analysis was performed using data from child participants of Growing Up in New Zealand at age 4.5-years to identify profiles of developmental health status. Seven measures were included in the latent profile analysis, representing four domains of developmental health: 'physical', 'motor', 'socioemotional and behavioural', and 'communication and learning'. Multinominal logistic regression was used to investigate socio-environmental associations of latent profile membership. Six latent profiles were identified (N = 6109), including three healthy/flourishing profiles: 'healthy' (52.6% of the sample), 'early social skills flourishing' (14.5%), and 'early learning skills flourishing' (4.0%); and three suboptimal profiles: 'early learning skills difficulties' (19.5%), 'physical health difficulties' (5.6%), and 'developmental difficulties cluster' (3.7%). Children experiencing socioeconomic disadvantage, of Māori or Pacific ethnicity, and with unmet healthcare needs had increased odds of being classified to suboptimal developmental health profiles. In this large, diverse cohort, one-in-four children were classified as having suboptimal developmental health. Addressing inequities in developmental health is crucial to improving health over the life course.

Towards health equity: core components of an extended home visiting intervention in disadvantaged areas of Sweden

BACKGROUND

Understanding the mechanisms of implementation of public health interventions in community settings is a key aspect of programme assessments. To determine core components and establish a programme theory are important tools to improve functioning and support dissemination of programme models to new locations. An extended early childhood home visiting intervention has been developed on-site in a socioeconomically disadvantaged area of Sweden since 2013 with the aim of reducing persisting health inequities in the population. This study aimed at investigating the core programme components and how the intervention was perceived to contribute towards health equity from early childhood.

METHODS

Qualitative framework method was applied in a document analysis and subsequent semi-structured interviews with 15 key actors involved in the programme.

RESULTS

The intervention was found to be constituted of five core components centred around the situation-based, parental strengthening work method delivered by a qualified team of child health care nurse and social worker. The programme theory foresaw positive effects on child and parental health, responsive parenting practices, families' use of welfare services according to need and increased integration and participation in society. The principles of Proportionate Universalism were recognised in the programme theory and the intervention was perceived as an important contribution to creating conditions for improved health equity for the families. Still, barriers to health equity were identified on the structural level which limit the potential impact of the programme.

CONCLUSIONS

The core components of the Extended home visiting programme in Rinkeby correspond well to those of similar evidence-based home visiting interventions. Combining focus on early childhood development and responsive parenting with promoting access to the universal welfare services and integration into society are considered important steppingstones towards health equity. However, a favourable macro-political environment is required in the endeavour to balance the structural determinants' influence on health inequities. Improved availability and accessibility to welfare services that respond to the needs of the families regarding housing, education and employment are priorities.

TRIAL REGISTRATION

The study was retrospectively registered on 11/08/2016 in the ISRCTN registry ( ISRCTN11832097 ).

Timing and Persistence of Material Hardship Among Children in the United States

Objective

Screening for social determinants of health (SDH) has been widely adopted to identify child health risks associated with exposure to material hardship. Whereas SDH screening typically addresses a 12-month span, we sought to compare the prevalence of exposure to present (within the past year) as compared to recent (2–4 years ago) hardship among children in the United States.

Methods

We analyzed the 2014 Survey of Income and Program Participation, a nationally representative survey that interviewed participating households annually between 2014 and 2017. We included data from households with children in all waves. As of 2017, households were categorized as (1) experiencing present hardship (within the last year); (2) experiencing recent but not present hardship (any year between 2014 and 2016); and (3) experiencing no hardship over the 4-year period.

Results

Of 2422 households, 27% experienced present hardship and 29% experienced recent but not present hardship. Households presently experiencing hardship were more likely to have Medicaid insurance, less likely to be married, and had more children than families who had experienced recent hardship. However, these groups were similar on caregivers’ educational attainment, race/ethnicity, language spoken in the home, and age of the youngest child.

Conclusions

Our results suggest that clinical screening tools for SDH that use a 12-month time frame risk missing many children who have recently (within the past 4 years) experienced material hardship and may benefit from interventions to improve social support; a longer time frame could provide clinicians with valuable information for understanding social factors that impact child health and development.

Data to Decisions: Methods to Create Neighbourhood Built Environment Indicators Relevant for Early Childhood Development

Healthy development in the early years lays the foundations for children’s ongoing physical, emotional, and social development. Children develop in multiple contexts, including their local neighbourhood. Neighbourhood-built environment characteristics, such as housing, walkability, traffic exposure, availability of services, facilities, and parks, are associated with a range of health and wellbeing outcomes across the life course, but evidence with early years’ outcomes is still emerging. Data linkage techniques were used to assemble a dataset of spatial (objectively-measured) neighbourhood-built environment (BE) measures linked to participant addresses in the 2015 Australian Early Development Census (AEDC) for children living in the 21 most populous urban and regional Australian cities (n = 235,655) to help address this gap. This paper describes the methods used to develop this dataset. This linked dataset (AEDC-BE) is the first of its kind worldwide, enabling opportunities for identifying which features of the built environment are associated with ECD across Australia at scale, allow comparisons between diverse contexts, and the identification of where best to intervene. National data coverage provides statistical power to model real-world complexities, such as differences by city, state/territory, and remoteness. The neighbourhood-built environment can be modified by policy and practice at scale, and has been identified as a way to help reduce inequitable early childhood development outcomes.

Developmental relationships between socio-economic disadvantage and mental health across the first 30 years of life

Understanding of how socio-economic disadvantage experienced over the life course relates to mental health outcomes in young adulthood has been limited by a lack of long-term, prospective studies. Here we address this limitation by drawing on data from a large Australian population cohort study that has followed the development of more than 2,000 Australians (and their families) from infancy to young adulthood since 1983. Associations were examined between prospective assessments of socio-economic position (SEP) from 4-8 months to 27-28 years and mental health problems (depression, anxiety, stress) and competence (civic engagement, emotional maturity, secure intimate relationship) at 27-28 years. The odds of being socio-economically disadvantaged in young adulthood were elevated eight- to tenfold in those who had experienced disadvantage in the family of origin, compared with those who had not (OR 8.1, 95% CI 4.5-14.5 to 10.1, 95% CI 5.2-19.5). Only concurrent SEP was associated with young adult mental health problems, and this effect was limited to anxiety symptoms (OR 2.0, 95% CI 1.1-3.9). In contrast, SEP had more pervasive impacts on young adult competence, particularly in the civic domain where effects were evident even from early infancy (OR 0.46, 95% CI 0.26-0.81). Findings suggest that one potentially important mechanism through which disadvantage compromises mental health is through limiting the development and consolidation of key psychosocial competencies needed for health and well-being in adulthood.

Can social risks in early life predict children’s health and academic outcomes? An analysis of the Longitudinal Study of Australian Children

Exposure to social risk in early life negatively impacts the health and wellbeing of children. While screening for social determinants of health is recommended, there is little evidence that identifying social risk early in life predicts longer-term poorer outcomes. The purpose of this study is to examine the extent to which assessing social risk using a standardized tool in young children up to age 6 years might predict poor health and academic performance at 10–11 years old. The social risk domains studied were housing instability, food insecurity, financial strain, transport problems, safety, lack of support and unemployment. The predictive validity of these social risk domains measured at 0–5 years was examined using data from the Longitudinal Study of Australian Children. Outcomes at 10–11 years included ongoing diseases and mental health conditions, hospitalization, injury, dental problems, overweight or obesity and academic achievement. Financial strain and inability to access support were the most sensitive measures of poor outcomes. Across all social risks, the positive predictive value was highest for academic outcomes. Across all domains, there was higher sensitivity for children with 2 or more social risks. Items in the social risk screening tool were moderate predictors of academic outcomes, but weak predictors of health outcomes at 10–11 years. This data will be useful for informing screening for social determinants of health.

•

Social risks from 0 to 5 y were moderate predictors of 8-year-old school assessments.

•

Financial strain and a lack of social support had modest sensitivity.

•

Sensitivity is increased by applying a threshold of 2 or more social risks.

•

The positive predictive value of social needs was highest for academic outcomes.

The Impact of Nurse Home Visiting on the Use, Dose and Quality of Formal Childcare: 3-Year Follow-Up of a Randomized Trial

OBJECTIVE

We investigated whether nurse home visiting (NHV) affects the uptake and quality of formal early childhood education and care (ECEC) at child ages 2 and 3 years, and reasons for using ECEC at 3 years.

METHODS

Design: Secondary analysis of the "right@home" randomized trial of NHV.

PARTICIPANTS

722 pregnant Australian, English-speaking women experiencing adversity recruited from antenatal clinics across 2 states.

INTERVENTION

25 nurse home visits to 2 years; Control: universal well-child nursing service.

MEASURES

Parents reported formal ECEC use (government approved and subsidized), comprising long or family day care (LDC), and reasons for use. ECEC quality was classified using the Australian government's national ratings. Eighty-three percent of parents provided data at 2 years (306 intervention/290 control); and 69% at 3 years (255 intervention/240 control).

ANALYSIS

Intention-to-treat analyses were conducted using adjusted regression models, addressing missing data using multiple imputation and inverse probability weighting.

RESULTS

There was no evidence of group differences in ECEC uptake or quality, although control families may have used more LDC at 3 years (mean difference 2.8 hours, 95% confidence interval, -0.2 to 5.8 hours). Intervention parents reported using ECEC to support their children's social development more frequently than controls (48% vs 33%) but less for work/study (39% vs 46%).

CONCLUSIONS

The right@home NHV program did not impact ECEC uptake or quality, although it may influence parents' reasons for using ECEC. If supported by policy and provision, there is an opportunity for NHV programs to promote the transition to high-quality ECEC and evaluate the synergistic benefit on children's development.

Neighbourhood-level income and Zika virus infection during pregnancy in Recife, Pernambuco, Brazil: an ecological perspective, 2015-2017

Zika virus (ZIKV) infections during pregnancy can lead to adverse neurodevelopmental and clinical outcomes in congenitally infected offspring. As the city of Recife in Pernambuco State, Brazil—the epicentre of the Brazilian microcephaly epidemic—has considerable disparities in living conditions, this study used an ecological approach to investigate the association between income at the neighbourhood level and the risk of ZIKV infections in pregnant individuals between December 2015 and April 2017. The spatial distribution of pregnant individuals with ZIKV infection was plotted on a map of Recife stratified into four categories based on mean monthly income of household heads. Additionally, a Poisson regression model with robust variance was fitted to compare proportions of ZIKV infections among pregnant individuals in relation to the mean monthly income of household heads, based on the 2010 census data, across 94 neighbourhoods in Recife. The results provide evidence that the risk of ZIKV infection to pregnant individuals was higher among those residing in lower-income neighbourhoods: relative to neighbourhoods that had a mean monthly income of ≥5 times minimum wage, neighbourhoods with <1 and 1 to <2 times minimum wage had more than four times the risk (incidence rate ratio, 95% CI 4.08, 1.88 to 8.85 and 4.30, 2.00 to 9.20, respectively). This study provides evidence of a strong association between neighbourhood-level income and ZIKV infection risks in the pregnant population of Recife. In settings prone to arboviral outbreaks, locally targeted interventions to improve living conditions, sanitation, and mosquito control should be a key focus of governmental interventions to reduce risks associated with ZIKV infections during pregnancy.

When Families Do Not Request Help: Assessing a Social Determinants of Health Screening Tool in Practice

INTRODUCTION

Using pediatric social determinants of health screening data from a large medical system, we explored social needs dislosures and identified which needs were associated with resource connection requests.

METHOD

Data came from records of outpatient pediatric patients (0-18 years) seen between October 2018 and March 2020 (39,251 encounters). We assessed percent of encounters where families (1) indicated a social need, and (2) requested a resource connection. We conducted multivariable logistic regression to identify which needs were associated with resource connection requests.

RESULTS

Among all encounters, 8% indicated a need and 2% requested a resource connection. Among families indicating a need, needs associated with resource requests included: housing (odds ratio [OR], 3.49 [2.42-5.03]), employment (OR, 3.15 [2.21-4.50]), food (OR, 1.89 [1.41-2.52]), and transportation (OR, 1.82 [1.30-2.56]).

DISCUSSION

Families seldom requested resource connections to address social needs. Better understanding families' interests in receiving assistance is an important next step in pediatric social determinants of health screening system development.

A Novel 3-Part Approach to Tackle the Problem of Health Inequities in Early Childhood

The first 5 years of a child's life are crucial in laying the foundation for their health and developmental trajectory into adulthood. These early years are especially influenced by the surrounding environments in which children live and grow. A large international body of evidence demonstrates that children who experience disadvantage tend to fall increasingly behind over time. At the societal level, these inequities can cause substantial social burdens and significant costs across health, education, and welfare budgets. A contributing factor is that children experiencing adversity are less likely to have access to the environmental conditions that support them to thrive. Many of these factors are modifiable at the community or place level. We argue for three key-though not exhaustive-ideas that collectively could achieve more equitable outcomes for children facing disadvantage and experiencing adversity:We conclude that if adopted, these 3 ideas could contribute to the ability of local communities and networks to identify and respond to factors that address early childhood inequalities.

Vulnerable learners in the age of COVID-19: A scoping review

This scoping review provides an overview of COVID-19 approaches to managing unanticipated school closures and available literature related to young people learning outside-of-school. A range of material has been drawn upon to highlight educational issues of this learning context, including psychosocial and emotional repercussions. Globally, while some countries opted for a mass school shut-down, many schools remained open for students from disadvantaged backgrounds. This partial closure not only enabled learning in smaller targeted groups but also offered a safe sanctuary for those who needed a regulated and secure environment. In Australia, if full school closures were to be enforced over a long period, a significant proportion of students from more vulnerable backgrounds would likely experience persistent disadvantage through a range of barriers: long-term educational disengagement, digital exclusion, poor technology management, and increased psychosocial challenges. This scoping review combines research on technology availability and learning, with analysis of the long-term educational impacts of navigating the COVID-19 disruption.

Examining the Association of Socioeconomic Position with Microcephaly and Delayed Childhood Neurodevelopment among Children with Prenatal Zika Virus Exposure

Increased rates of Zika virus have been identified in economically deprived areas in Brazil at the population level; yet, the implications of the interaction between socioeconomic position and prenatal Zika virus exposure on adverse neurodevelopmental outcomes remains insufficiently evaluated at the individual level. Using data collected between September 2015 and September 2019 from 163 children with qRT-PCR and/or IgM-confirmed prenatal exposure to Zika virus participating in a prospective cohort study in Rio de Janeiro, Brazil (NCT03255369), this study evaluated the relationships of socioeconomic indicators with microcephaly at birth and Bayley-III neurodevelopmental scores during the early life course. Adjusted logistic regression models indicated increased odds of microcephaly in children born to families with lower household income (OR, 95% CI: 3.85, 1.43 to 10.37) and higher household crowding (OR, 95% CI: 1.83, 1.16 to 2.91), while maternal secondary and higher education appeared to have a protective effect for microcephaly compared to primary education (OR, 95% CI: 0.33, 0.11 to 0.98 and 0.10, 0.03 to 0.36, respectively). Consistent with these findings, adjusted linear regression models indicated lower composite language (−10.78, 95% CI: −19.87 to −1.69), motor (−10.45, 95% CI: −19.22 to −1.69), and cognitive (−17.20, 95% CI: −26.13 to −8.28) scores in children whose families participated in the Bolsa Família social protection programme. As such, the results from this investigation further emphasise the detrimental effects of childhood disadvantage on human health and development by providing novel evidence on the link between individual level socioeconomic indicators and microcephaly and delayed early life neurodevelopment following prenatal Zika virus exposure.

Driving Precision Policy Responses to Child Health and Developmental Inequities

The growing evidence base on the extent of and opportunities to reduce inequities in children's health and development still lacks the specificity to inform clear policy decisions. A new phase of research is needed that builds on contemporary directions in precision medicine to develop precision policy making; with the aim to redress child inequities. This would include identifying effective interventions and their ideal time point(s), duration, and intensity to maximize impact. Drawing on existing data sources and innovations in epidemiology and biostatistics would be key. The economic and social gains that could be achieved from reducing child inequities are immense.

Does Place Matter? An International Comparison of Early Childhood Development Outcomes between the Metropolitan Areas of Melbourne, Australia and Montreal, Canada

There is strong consensus about the importance of early childhood development (ECD) for improving population health and closing the health inequity gap. Environmental features and public policies across sectors and jurisdictions are known to influence ECD. International comparisons provide valuable opportunities to better understand the impact of these ecological determinants on ECD. This study compared ECD outcomes between metropolitan Melbourne (Australia) and Montreal (Canada), and contrasted disparities across demographic and socioeconomic characteristics. Methods: Population wide surveys using the Early Development Instrument (EDI) were conducted among 4–6 years-old children in both Montreal and Melbourne in 2012, measuring five domains of ECD: 1-Physical Health/Well-Being (PHYS); 2-Social Competence (SOC); 3-Emotional Maturity (EMOT); 4-Language/Cognitive Development (COGN); and 5-Communication Skills/General Knowledge (COMM). Descriptive analyses of summary EDI indicators and domain indicators (including median scores and interquartile ranges) were compared between metropolitan areas, using their respective 95% confident intervals (CIs). Analyses were performed using Stata software (v14). Results: The proportion of children developmentally vulnerable in at least one domain of ECD was 26.8% (95% CIs: 26.2, 27.3) in Montreal vs. 19.2% (95% CIs: 18.8, 19.5) in Melbourne. The Melbourne advantage was greatest for EMOT and COGN (11.5% vs. 6.9%; 13.0% vs. 5.8%). In both Montreal and Melbourne, boys, immigrants, children not speaking the language of the majority at home, and those living in the most deprived areas were at greater risk of being developmentally vulnerable. Relative risks as a function of home language and area-level deprivation subgroups were smaller in Montreal than in Melbourne. Conclusion: This study shows that Melbourne’s children globally experience better ECD outcomes than Montreal’s children, but that inequity gaps are greater in Melbourne for language and area-level deprivation subgroups. Further research is warranted to identify the environmental factors, policies, and programs that account for these observed differences.

Local Housing Characteristics Associated with Early Childhood Development Outcomes in Australian Disadvantaged Communities

Disadvantaged communities tend to have poorer early childhood development outcomes. Access to safe, secure, and stable housing is a well-known social determinant of health but there is a need to examine key features of neighbourhood housing that reduce early childhood development inequities. The 2012 Australian Early Development Census (AEDC), a population-wide measure of early childhood development, and the Australian Bureau of Statistics Socio-economic Index for Areas Index of Relative Socio-economic Disadvantage were used to select fourteen disadvantaged local communities in five Australian states and territories based on those performing better (off-diagonal), or as expected (on-diagonal) on the AEDC relative to their socio-economic profile. Between 2015-2017, qualitative and quantitative housing data were collected in the local communities. In total, 87 interviews with stakeholders, 30 focus groups with local service providers and parents, and Australian Census dwelling information were analysed. A comparative case study approach was used to examine differences in housing characteristics (e.g., public housing, density, affordability, and tenure) between disadvantaged local communities performing 'better than expected' and 'as expected' on early childhood development. Perceived better housing affordability, objectively measured housing tenure (ownership) and perceived and objectively measured lower-density public housing were housing characteristics that emerged as points of difference for disadvantaged local communities where children had relatively better early childhood development outcomes. These characteristics are potential modifiable and policy sensitive housing levers for reducing early childhood development inequities.

More than a snapshot in time: pathways of disadvantage over childhood

Background

Disadvantage rarely manifests as a single event, but rather is the enduring context in which a child's development unfolds. We aimed to characterize patterns of stability and change in multiple aspects of disadvantage over the childhood period, in order to inform more precise and nuanced policy development.

Methods

Participants were from the Longitudinal Study of Australian Children birth cohort (n = 5107). Four lenses of disadvantage (sociodemographic, geographic environment, health conditions and risk factors), and a composite of these representing average exposure across all lenses, were assessed longitudinally from 0 to 9 years of age. Trajectory models identified groups of children with similar patterns of disadvantage over time for each of these lenses and for composite disadvantage. Concurrent validity of these trajectory groups was examined through associations with academic performance at 10-11 years.

Results

We found four distinct trajectories of children's exposure to composite disadvantage, which showed high levels of stability over time. In regard to the individual lenses of disadvantage, three exhibited notable change over time (the sociodemographic lens was the exception). Over a third of children (36.3%) were exposed to the 'most disadvantaged' trajectory in at least one lens. Trajectories of disadvantage were associated with academic performance, providing evidence of concurrent validity.

Conclusions

Children's overall level of composite disadvantage was stable over time, whereas geographic environments, health conditions and risk factors changed over time for some children. Measuring disadvantage as uni-dimensional, at a single time point, is likely to understate the true extent and persistence of disadvantage.

Assessing community readiness for early intervention programmes to promote social and emotional health in children

Objective

Evidence for early intervention and prevention‐based approaches for improving social and emotional health in young children is robust. However, rates of participation in programmes are low. We explored the dynamics which affect levels of community readiness to address the issues of social and emotional health for pregnant women, young children (0‐4 years) and their mothers.

Setting

A deprived inner‐city housing estate in the north of England. The estate falls within the catchment area of a project that has been awarded long‐term funding to address social and emotional health during pregnancy and early childhood.

Methods

We interviewed key respondents using the Community Readiness Model. This approach applies a mixed methodology, incorporating readiness scores and qualitative data. A mean community readiness score was calculated enabling the placement of the community in one of nine possible stages of readiness. Interview transcripts were analysed using a qualitative framework approach to generate contextual information to augment the numerical scores.

Results

An overall score consistent with vague awareness was achieved, indicating a low level of community readiness for social and emotional health interventions. This score suggests that there will be a low likelihood of participation in programmes that address these issues.

Conclusion

Gauging community readiness offers a way of predicting how willing and prepared a community is to address an issue. Modifying implementation plans so that they first address community readiness may improve participation rates.

Paths to language development in at risk children: a qualitative comparative analysis (QCA)

Background

Childhood language development is related to long term educational, employment, health and social outcomes. Previous research identifies a complex range of risk and protective factors which result in good and poor language outcomes for children, however children at risk are an underrepresented group in these studies. Our aim is to investigate the combinations of factors (paths) that result in good and poor language outcomes for a group of 5 year old children of mothers experiencing adversity.

Methods

This mixed methods study utilised longitudinal data from a randomised control trial of sustained home visiting (MECSH) to determine the language outcomes in at risk children. Mothers were randomly assigned to a comparison group at entry to the study (prior to child’s birth). Their children who were retained at entry to school completed language assessments (n = 41) and were participants in this study. Influence of 13 key factors derived from the extant literature that impact language development were explored. Regression was used to determine the six key factors of influence and these were used in the Qualitative Comparative Analysis (QCA). QCA was employed to examine the necessary and sufficient conditions and paths affecting language development linked to good and poor language outcomes. A post hoc analysis of the risk and protective paths to good and poor language outcomes was also conducted.

Results

Thirteen distinct pathways led to good language outcomes and four paths to poor language outcomes in five year old at risk children. A variety of condition combinations resulted in these outcomes, with maternal responsivity, toddler development and number of children in the home being key. High and low maternal education influenced both good and poor language development.

Conclusions

The paths to good and poor language outcomes were different and complex. Most paths to a good language outcome involved protective factors, though not always. In addition, paths to poor language more often involved risk factors. The varied patterns of risk and protective factors point to the need for interventions across the first five years of life in both health and education for families which can respond to these risk and protective patterns.

Trial registration

The original RCT was retrospectively registered in the ANCTR: ACTRN12608000473369.

Electronic supplementary material

The online version of this article (10.1186/s12887-019-1449-z) contains supplementary material, which is available to authorized users.

Multiple risk exposures for reading achievement in childhood and adolescence

Background

Literacy is championed as a pathway out of poverty, yet it is vulnerable to the risk circumstances it seeks to mitigate. This study explored the developmental circumstances that gave rise to stark inequalities in reading achievement in Australian children across 6 years of school.

Methods

We used data from Growing up in Australia: the Longitudinal Study of Australian Children linked to Australia’s National Assessment Program-Literacy and Numeracy across school years 3, 5, 7 and 9. Latent class analysis and growth curve modelling (n=4983) were used to identify risk profiles for reading achievement for children (ages 8.2–15.2).

Results

Four distinct profiles were identified: developmentally enabled profile (62% of children); sociodemographic risk profile (25% of children); child development risk profile (11% of children); and sociodemographic and child development (double disadvantage) risk profile (2% of children). Children with a developmentally enabled profile achieved the expected rate of growth of 1.0 year per year of school across years 3, 5, 7 and 9. By comparison, children with sociodemographic and/or child development risk profiles started behind their developmentally enabled peers, and lost ground over time.

Discussion

Across 6 years of school, multiple risk-exposed children lagged behind low risk-exposed children in the order of years of lost gains in reading achievement. The results point to the complex contexts of educational disadvantage and the need for cross-cutting social, health and education policies and coordinated multiagency intervention efforts to break the cycle of educational disadvantage.

Nurse Home Visiting for Families Experiencing Adversity: A Randomized Trial

OBJECTIVES

Nurse home visiting (NHV) may redress inequities in children's health and development evident by school entry. We tested the effectiveness of an Australian NHV program (right@home), offered to pregnant women experiencing adversity, hypothesizing improvements in (1) parent care, (2) responsivity, and (3) the home learning environment at child age 2 years.

METHODS

A randomized controlled trial of NHV delivered via universal child and family health services was conducted. Pregnant women experiencing adversity (≥2 of 10 risk factors) with sufficient English proficiency were recruited from antenatal clinics at 10 hospitals across 2 states. The intervention comprised 25 nurse visits to child age 2 years. Researchers blinded to randomization assessed 13 primary outcomes, including Home Observation of the Environment (HOME) Inventory (6 subscales) and 25 secondary outcomes.

REULTS

Of 1427 eligible women, 722 (50.6%) were randomly assigned; 306 of 363 (84%) women in the intervention and 290 of 359 (81%) women in the control group provided 2-year data. Compared with women in the control group, those in the intervention reported more regular child bedtimes (adjusted odds ratio 1.76; 95% confidence interval [CI] 1.25 to 2.48), increased safety (adjusted mean difference [AMD] 0.22; 95% CI 0.07 to 0.37), increased warm parenting (AMD 0.09; 95% CI 0.02 to 0.16), less hostile parenting (reverse scored; AMD 0.29; 95% CI 0.16 to 0.41), increased HOME parental involvement (AMD 0.26; 95% CI 0.14 to 0.38), and increased HOME variety in experience (AMD 0.20; 95% CI 0.07 to 0.34).

CONCLUSIONS

The right@home program improved parenting and home environment determinants of children's health and development. With replicability possible at scale, it could be integrated into Australian child and family health services or trialed in countries with similar child health services.