Cumulative inequality in child health and academic achievement

Ambulance service recognition of health inequalities and activities for reduction: An evidence and gap map of the published literature

Background

Emergency medical services (EMS) are often patients' first point of contact for urgent and emergency care needs. Patients are triaged over the phone and may receive an ambulance response, with potential conveyance to the hospital. A recent scoping review suggested disparities in EMS patient care in the United States. However, it is unknown how health inequalities impact EMS care in other developed countries and how inequalities are being addressed.

Objectives

This rapid evidence map of published literature aims to map known health inequalities in EMS patients and describe interventions reducing health inequalities in EMS patient care.

Methods

The search strategy consisted of EMS synonyms and health inequality synonyms. The MEDLINE/PubMed database was searched from 1 January 2010 to 26 July 2022. Studies were included if they described empirical research exploring health inequalities within ambulance service patient care. Studies were mapped on to the EMS care interventions framework and Core20PLUS5 framework. Studies evaluating interventions were synthesised using the United Kingdom Allied Health Professions Public Health Strategic Framework.

Results

The search strategy yielded 771 articles, excluding duplicates, with two more studies added from hand searches. One hundred studies met the inclusion criteria after full-text review. Inequalities in EMS patient care were predominantly situated in assessment, treatment and conveyance, although triage and response performance were also represented. Studies mostly explored EMS health inequalities within ethnic minority populations, populations with protected characteristics and the core issue of social deprivation. Studies evaluating interventions reducing health inequalities (n = 5) were from outside the United Kingdom and focused on older patients, ethnic minorities and those with limited English proficiency. Interventions included community paramedics, awareness campaigns, dedicated language lines and changes to EMS protocols.

Conclusions

Further UK-based research exploring health inequalities of EMS patients would support ambulance service policy and intervention development to reduce health inequality in urgent and emergency care delivery.

Socioeconomic Position and Health Among Children and Adolescents With CKD Across the Life-Course

Children and adolescents in families of lower socioeconomic position (SEP) experience an inequitable burden of reduced access to healthcare and poorer health. For children living with chronic kidney disease (CKD), disadvantaged SEP may exacerbate their considerable disease burden. Across the life-course, CKD may also compromise the SEP of families and young people, leading to accumulating health and socioeconomic disadvantage. This narrative review summarizes the current evidence on relationships of SEP with kidney care and health among children and adolescents with CKD from a life-course approach, including impacts of family SEP on kidney care and health, and bidirectional impacts of CKD on SEP. It highlights relevant conceptual models from social epidemiology, current evidence, clinical and policy implications, and provides directions for future research. Reflecting the balance of available evidence, we focus primarily on high-income countries (HICs), with an overview of key issues in low- and middle-income countries (LMICs). Overall, a growing body of evidence indicates sobering socioeconomic inequities in health and kidney care among children and adolescents with CKD, and adverse socioeconomic impacts of CKD. Dedicated efforts to tackle inequities are critical to ensuring that all young people with CKD have the opportunity to live long and flourishing lives. To prevent accumulating disadvantage, the global nephrology community must advocate for local government action on upstream social determinants of health; and adopt a life-course approach to kidney care that proactively identifies and addresses unmet social needs, targets intervening factors between SEP and health, and minimizes adverse socioeconomic outcomes across financial, educational and vocational domains.

Do immigrants benefit from selection? Migrant educational selectivity and its association with social networks, skills and health

Recent scholarship suggests that immigrant selectivity - the degree to which immigrants differ from non-migrants in their sending countries - can help us understand their labour market outcomes in the receiving country. The selectivity hypothesis rests on three assumptions: first, that immigrants differ from non-migrants in their observed characteristics, such as education; second, that there is an association between such observed selection and (usually) unobserved characteristics, and third that this association drives positive relationships between observed selection and immigrant outcomes. While there is some evidence for a relationship between the degree of immigrants' selectivity and their children's outcomes, a comprehensive assessment of these assumptions for immigrants' own labour market outcomes remains lacking. We use high-quality, nationally representative data for the UK, with large numbers of immigrants from a wide range of different origins and with a rich set of measures of networks, traits and characteristics, as well as economic outcomes, not typically found in surveys of immigrants. This enables us to conduct a comprehensive assessment of the selectivity hypothesis and its assumptions. We find that immigrants to the UK are on average positively selected on educational attainment. However, counter to theoretical assumptions, educational selection has little association with labour market outcomes: it is not or negatively associated with employment; and it is only associated with pay for those with tertiary qualifications and with occupational position for women. We show that the general lack of economic benefits from selection is consistent with an absence of association between educational selectivity and (typically unobserved) mechanisms assumed to link selection and labour market outcomes: social networks, cognitive and non-cognitive skills, and mental and physical health. We contextualise our findings with heterogeneity analysis by migration regime, sending country characteristics, level of absolute education and location of credential.

A Chronic Disease in Adolescence and Selection to an Educational Path-A Longitudinal Study

Chronic disease may affect adolescents' educational success. We study whether adolescents with a somatic chronic condition have lower school performance, lower odds for academic education, and a delayed start of upper-secondary studies. Seventh graders and ninth graders in the Helsinki Metropolitan Region, Finland, were invited to participate in a school survey in 2011 and 2014, respectively. The respondents (2011, N = 8960; 2014, N = 7394) were followed using a national application registry until 2017. The chronic conditions were asthma, diabetes, and epilepsy. Outcomes were grade point average (GPA), study place in an academic school, and delayed start of secondary education. Adolescents with a chronic disease needing medication had lower GPAs in both grades. Chronic disease with medication in the seventh grade predicted higher odds for the non-academic track (OR = 1.3) and the delayed start (OR = 1.4). In the ninth grade, chronic disease predicted non-academic studies univariately (OR = 1.2) and was not associated with the delayed start. The somatic chronic condition with medication, particularly epilepsy, slightly lowers students' school performance, which is a mediator between the chronic condition and selection into educational paths. Compared to gender and parents' education, and particularly to GPA, the role of chronic conditions on educational outcomes is small.

Adverse childhood experiences: Examining latent classes and associations with physical, psychological, and risk-related outcomes in adulthood

BACKGROUND

Adverse childhood experiences (ACEs) are a public health crisis, affecting nearly half of children in the United States. Long-term effects of ACEs on psychological well-being, engagement in risk behaviors, and physical health have been observed. Moreover, many individuals exposed to ACEs are also affected by an accumulation of stressors due to broader structural inequities.

OBJECTIVE

The current study examined heterogeneity in patterns of ACEs, explored how these patterns varied based on race/ethnicity, biological sex, and socioeconomic status, and assessed how ACE patterns were associated with physical health, mental health, and risk-related outcomes in adulthood.

PARTICIPANTS

Drawing on the Add Health dataset, survey data from Waves I, III, IV (n = 12,288) were analyzed. Mean age of participants was 28.3 (SD = 1.9), more than half were female (54.4%), and a little less than half identified as youth of color (46.7%).

METHOD

Multigroup latent class analysis explored heterogeneity in ACE exposure and variations based on structural inequities. Latent class regression assessed associations between ACE classes and outcomes.

RESULTS

A four-class solution was identified. Class sizes and latent structures differed by biological sex. Among males and females, the low adversity class had more positive physical health, mental health, and risk-related outcomes compared to all classes, while the childhood maltreatment and high adversity/community violence classes engaged in more risk-related behaviors. Very small to medium effects were observed.

CONCLUSION

Findings highlight the importance of examining heterogeneity in ACE exposure, and how patterns of ACEs may differentially affect outcomes in adulthood.

Special health care needs during childhood and academic achievement in secondary school

BACKGROUND

Secondary education has lifelong implications for wellbeing. We evaluated associations between the duration and timing of special health care needs (SHCN) across childhood and academic achievement in secondary school.

METHODS

Cohort design. The structured modelling approach was used to evaluate life-course models for associations between the duration and timing of SHCN (measured using a two-item SHCN screener across ages 4-5, 6-7, 8-9 and 10-11 years) and Grade 7 (median age 12.5 years) reading and numeracy achievement. Linear regressions were fitted for each life-course model: four critical period models (each including SHCN exposure in one period), one sensitive period model (including SHCN exposure in all periods) and two strict accumulation models (including the duration of SHCN exposure in linear form then categorical form). Interactions of SHCN with child sex and family socio-economic status (SES) were examined.

RESULTS

Of 3734 children, 1845 were female. The number of children with SHCN was 434 (11.7%), 458 (12.9%), 534 (14.7%), 551 (15.4%) at 4-5, 6-7, 8-9 and 10-11 years respectively. For both outcomes, the linear strict accumulation model fitted best, and interactions of SHCN with sex and SES were non-significant. The average decrease in school achievement z score (95% confidence interval) per period of having SHCN was 0.04 (-0.07 to -0.02) for reading and 0.08 (-0.11 to -0.05) for numeracy.

CONCLUSIONS

A longer duration of SHCN from age 4-11 years has small-sized cumulative associations with poorer Grade 7 reading and numeracy achievement. Each period of SHCN between 4 and 5 and 10-11 years was associated with nearly 0.05 and 0.1 of a standard deviation reduction in Grade 7 reading and numeracy scores respectively, and these associations did not appear to differ across sex or SES. These findings suggest that children with persistent SHCN are at risk of academic deficits and should receive focused interventions.

Evaluating the Role of Parental Education and Adolescent Health Problems in Educational Attainment

This article reconsiders the role of social origin in health selection by examining whether parental education moderates the association between early health and educational attainment and whether health problems mediate the intergenerational transmission of education. We used longitudinal register data on Finns born in 1986–1991 (n = 352,899). We measured the completion of secondary and tertiary education until age 27 and used data on hospital care and medication reimbursements to assess chronic somatic conditions, frequent infections, and mental disorders at ages 10–16. We employed linear probability models to estimate the associations between different types of health problems and educational outcomes and to examine moderation by parental education, both overall in the population and comparing siblings with and without health problems. Finally, we performed a mediation analysis with g-computation to simulate whether a hypothetical eradication of health problems would weaken the association between parental and offspring education. All types of health problems reduced the likelihood of secondary education, but mental disorders were associated with the largest reductions. Among those with secondary education, there was further evidence of selection to tertiary education. High parental education buffered against the negative impact of mental disorders on completing secondary education but exacerbated it in the case of tertiary education. The simulated eradication of health problems slightly reduced disparities by parental education in secondary education (up to 10%) but increased disparities in tertiary education (up to 2%). Adolescent health problems and parental education are strong but chiefly independent predictors of educational attainment.

Is there a social gradient in how youth with mental disorder perform academically? Findings from a Swedish longitudinal register-based study

Background

It is well established that academic achievement and other school-related outcomes are associated with mental health status in children and youths. However, few studies have examined the influence of socioeconomic background on the relationship between poor childhood/adolescent mental health and school performance. From an equity perspective, it is important to explore how school-related outcomes are affected for young people with mental disorder and if these outcomes differ depending on gender and socioeconomic background. This study aimed to investigate social gradients in the prospective association between childhood/adolescent mental disorder and academic achievement.

Methods

This register based study used data from the Umeå SIMSAM Lab of linked Swedish registers on all children born between 1990 and 1994 and their parents (N = 642 558). The outcome was school grades achieved upon compulsory school graduation (age 15/16). Mental disorder was indicated by number of hospitalisations due to ICD classified mental disorders and prescription of psychoanaleptic drugs. Indicators of socioeconomic position were parental level of education and family income in four categories respectively. Parental history of mental disorder was controlled for. Linear regressions, including interaction analyses, were performed.

Results

Mental disorder in childhood/adolescence was related to lower grades, particularly in boys. The drop in academic achievement among youth with mental disorder was more pronounced among girls in mid SEP categories than among their less and more advantaged peers. A less clear interaction pattern was identified in boys.

Conclusions

Based on theory and existing research we expected a typical social gradient in the strength of the association between mental disorder and academic achievement. However, we identified a U-shaped social gradient among girls. Analyses of the links between mental health and academic outcomes need to take both gender and social position into account. More research is needed to investigate these patterns further.

Performance, Achievement, and Success in Psychological Research: Towards a More Transparent Use of the Still Ambiguous Terminology

The present study focused on the terms performance, achievement, and success that have often been used in an ambiguous manner in psychological research. The way in which the meaning of the domain-specific constructs referred to with the terms was established for measurement purposes was investigated on a sample of 262 articles that stemmed from 35 randomly selected journals covering the full range of psychological research. The operational definitions of the constructs referred to with the terms performance, achievement, and success were analysed and compared in both inter- and intra-domain fashion. Additionally, we assessed the match among the observed operational definitions and general conceptual definitions available in the extant literature. The results revealed terminology-related issues in educational and occupational research. Within these domains, lack of adherence to the multidimensionality of the constructs of academic performance, academic achievement, academic success, job performance, and career success was identified as a general issue. Further, the tendency to measure job performance via indicators based on self-rating was considered inadequate given the objective nature of the term performance. In educational research, the overlap of the academic performance, academic achievement, and academic success constructs was confirmed, resulting from the tendency to use GPA as a universal indicator of academic outcomes. Based on the present findings, we provided several recommendations in order to encourage future research towards a more transparent way of dealing with the particular constructs referred to with the terms performance, achievement, and success. We suppose the present study may help researchers in the full range of psychological disciplines to add clarity to their own research.

Children's visual impairment and visual care related to socioeconomic status in Catalonia (Spain)

BACKGROUND

The objective of this study is to assess the prevalence of visual impairment and visual care practices and its association with socioeconomic conditions in the infant population in Catalonia.

METHODS

The Catalan Institute of Statistics provided a random sample of 0 to 14-year-old non-institutionalized children whose parents were interviewed in a continuous health survey from 2011 to 2015 in Catalonia. A multistage stratified and random sampling procedure considering age, sex, county and town was followed. All results have been weighted according to the sample design and are presented as the proportion of the condition with its 95% confidence limits. Chi-square tests were performed to evaluate the association between categorical variables. To study the association of visual care with independent variables, a multiple logistic regression model was used.

RESULTS

In 0 to 14-year-old children, a 12.9% (95% confidence interval [CI] [11.8-13.9]) prevalence of correctable visual impairment was observed. The prevalence of non-correctable visual impairment was 0.9% (95% CI [0.6-1.2]). Non-correctable visual impairment was more prevalent in families with lower education levels, manual professions or unemployed. Of children without visual impairment, 13,5% (95% CI:12.3-14.6) visited a visual care professional in the last 12 months while this proportion was 67.4% (95% CI [63.3-71.5]) among those with correctable visual impairment. When parents have a university degree or non-manual professions, a higher level of visual care was observed. In children with correctable visual impairment, visual reviews were more frequent when parents are employed in a non-manual profession.

CONCLUSIONS

For the first time, indicators related to visual impairment in children in Catalonia have been recorded. There is an association between lower socioeconomic status and having non-correctable visual impairment, and conversely, having correctable visual impairment was significantly associated with employed parents. More visual care is associated with higher socioeconomic status.

Putting cumulative (dis)advantages in context: Comparing the role of educational inequality in later-life functional health trajectories in England and Germany

BACKGROUND

The cumulative (dis)advantage (CAD) perspective more and more is examined in a comparative way, to highlight the role of context in generating inequality over the life course. This study adds to this field of research by examining trajectories of activities of daily living (ADL) in later life by educational level in a country comparison of England and Germany, emphasizing differing institutional conditions.

METHOD

Data used are the English Longitudinal Study of Ageing (ELSA; 11,352 individuals) and the German subsample of the Survey of Health and Retirement in Europe (SHARE; 5,573 individuals). Using population averaged Poisson panel regression models, 12-year trajectories of six birth cohorts are investigated, covering the age range of 50 to 90 years.

RESULTS

Respondents in England have a higher level of limitations at age 50, and more limited increases over age than in Germany. An educational gradient exists in both countries at age 50. Notably, the educational gradient increases for more recently born cohorts, but declines with increasing age in England, while in Germany educational differences increase for more recently born cohort only.

DISCUSSION

The current study indicates that CAD processes between educational groups are context sensitive. While England showed convergence of disparities with increasing age, in Germany no differential development was found.

The Higher Educational Trajectories of Undocumented Youth in the United States

Despite growth in the number of Latino students enrolled in U.S. colleges, foreign-born Latinos are less likely than both native-born Latinos and other immigrant groups to graduate. However, it is difficult to understand the lower educational attainment of Latino immigrants without considering variation in enrollment by legal status. After all, until recently, undocumented immigrants have been blocked from higher education in the United States. Drawing upon the education and immigrant illegality literature, as well as longitudinal administrative data on 35,400 college students, we examine the association between students' legal status and their educational achievement, or GPA-an important predictor of educational attainment. We find that, despite high achievement in high school and upon first enrolling in college, undocumented students do not experience upward achievement over time, otherwise known in the education literature as educational progression. Rather, their growth is flat, and their level of achievement declines slightly, what we call an educational regression, relative to their documented and foreign-born citizen Latino peers. We identify several individual- and structural-level factors that help explain the pattern and timing of undocumented student regression. The results have implications for studies of immigrant inequality, incorporation, and immigration law in the U.S. and globally.

The scars of the past? Childhood health and health differentials in later life

This study estimates multilevel mixed effects models of three retrospective measures of childhood health – self-rated childhood health, exposure to parental smoking growing up, and missing school for 30 or more consecutive days due to a health event – on levels and changes in physical functioning at age 50 and beyond. Using data from 15 waves of the Household, Income and Labour Dynamics in Australia survey, the results show that variation in the level of later-life physical functioning is associated with childhood health. Poor childhood health however is not associated with the rate of physical functioning decline. Respondents who reported poor childhood health and were migrants to Australia from a non-English speaking country reported better physical functioning in later life, compared with non-Indigenous Australian-born respondents who reported poor childhood health. In contrast, women who reported poor self-rated childhood health reported worse physical functioning compared with men who reported poor self-rated childhood health. These findings are robust to the inclusion of a range of measures of childhood and adult characteristics and circumstances. These results suggest that Australia, with arguably a strong and supportive health care system as compared with the U.S., may mitigate the accumulation of disadvantages to those who reported poor childhood health. We note that though functional health differences due to childhood health are not exacerbated in later life, neither are they eliminated.

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Poor childhood health is associated with worse physical functioning in later life.

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This association is stronger for women, as compared with men.

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Association weaker for migrants non-English speaking countries, vs. native-born.

The impact of health on economic and social outcomes in the United Kingdom: A scoping literature review

This is the first review of the evidence, based on longitudinal studies in the United Kingdom, on the association of ill health at any life stage and later social and economic outcomes. The review included a wide range of physical and mental health exposures, both self-reported and objectively measured, as well as social (e.g. life satisfaction) and economic (e.g. employment) outcomes. We searched the Web of Science, key longitudinal datasets based in the UK, major economic journals, Google Scholar and reference lists of relevant publications. The review includes 80 studies. There was strong evidence for the association between early mental health, mainly attention deficit hyperactivity disorder, and lifetime educational, occupational and various social outcomes. Also, both poor physical and mental health in early and middle adulthood, tended to be associated with unemployment and lower socioeconomic status. Among older adults, the evidence quite consistently indicated an association between mental health, chronic conditions, disability/functional limitations, self-rated general health and quality of life, life satisfaction and early retirement. Overall, mental health was consistently found to be associated with a range of social and economic outcomes throughout the lifespan. The evidence for the association between physical health and later outcomes is more inconsistent. A number of methodological challenges need to be addressed, particularly related to causal inference, to produce robust evidence with potential to inform public health policy.

Accumulation, Timing, and Duration of Early Childhood Adversity and Behavior Problems at Age 9

We utilized a life course framework to examine associations between the accumulation, timing, and duration of adverse childhood experiences (ACEs) across early childhood (ages 1-5 years) and internalizing and externalizing behavior problems at age 9. The sample included 1,789 children from the Fragile Families and Child Wellbeing Study, a birth cohort study of children born between 1998 and 2000. Primary caregivers reported on seven ACEs at child ages 1, 3, 5, and 9. We created 2 summary measures of early childhood ACEs to capture (a) accumulation and (b) timing and duration. We derived indicators of caregiver-reported internalizing and externalizing problems at ages 5 and 9. Logistic regression was used to estimate associations between early childhood ACEs and behavior problems at age 9, sequentially adjusting for sociodemographic covariates, age 9 ACEs, and age 5 behavior problems. In fully adjusted models, children exposed to 6 or more ACEs in early childhood faced 3 times the odds of age 9 behavior problems, compared to children exposed to 0-1 ACE. Intermittent adversity was associated with the greatest increase in odds of age 9 behavior problems, relative to other early childhood timing/duration categories. Categories of high early and high late adversity were also associated with age 9 behavior problems. Chronic adversity was not associated with age 9 behaviors in final models that adjusted for age 5 problems. These results demonstrate the importance of a developmental perspective for understanding the role of childhood adversity in the etiology of child psychopathology.

Gender Differences in Biological Function in Young Adulthood: An Intragenerational Perspective

Sex/gender differences in health are a function of social and biological factors, and their interplay over the life course. Despite a large body of research documenting sex/gender as a determinant of health behavior and outcomes, far less scholarship examines how these differences are reflected in physiologic function-an important mediator through which social experiences "get under the skin"-in young adulthood. Using nationally representative, longitudinal data from the National Longitudinal Study of Adolescent to Adult Health (Add Health), we examine the relationship between gender and biological function (inflammation and immunosuppression) in young adulthood. Second, we examine the contribution of social and economic circumstances in childhood and early adulthood to gender differences in health. The findings reveal strong gender differences in physiologic function, which are robust to the inclusion of many indicators of the social environment, in both inflammation and immune function.

The Simultaneous Effects of Socioeconomic Disadvantage and Child Health on Children's Cognitive Development

Family socioeconomic status (SES) and child health are so strongly related that scholars have speculated child health to be an important pathway through which a cycle of poverty is reproduced across generations. Despite increasing recognition that SES and health work reciprocally and dynamically over the life course to produce inequality, research has yet to address how these two pathways simultaneously shape children's development. Using longitudinal data from the Fragile Families and Child Wellbeing Study and marginal structural models, we ask three questions: (1) how does the reciprocal relationship between socioeconomic disadvantage and child health affect estimates of each circumstance on children's cognitive development?; (2) how do their respective effects vary with age?; and (3) do family SES and child health have differential effects on cognitive development across population subgroups? The results show that the negative effects of socioeconomic disadvantage and poor health are insensitive to their reciprocal relationships over time. We find divergent effects of socioeconomic disadvantage and poor health on children's cognitive trajectories, with a widening pattern for family SES effects and a leveling-off pattern for child health effects. Finally, the effects of socioeconomic disadvantage are similar across all racial/ethnic groups, while the effects of child health are largely driven by white children. We discuss theoretical and policy implications of these findings for future research.