Driving Precision Policy Responses to Child Health and Developmental Inequities

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.

Promoting Child Health Equity through Health Literacy

Every child has the right to a fulfilling and thriving life [...].

Models, theoretical design and formal evaluation of integrated specialist community health service provision for the first 2000 days: a scoping review

OBJECTIVE

This scoping review identifies evidence for design, models and evaluation of integrated care service provision for families and children in the first 2000 days, in the context of community-based specialised health, education and welfare services.

DESIGN

Scoping review following the Joanna Briggs scoping review method.

DATA SOURCES

Medline, CINAHL, Cochrane and PsycINFO. Grey literature used a manual search of original articles, and snowball technique to identify government and policy documents relevant to Australia.

ELIGIBILITY CRITERIA FOR SELECTING STUDIES

Inclusion criteria were 'population' of prebirth to age 5; 'concept' of design, models and delivery of integrated specialist care for children and families; and 'context' of community-based specialised health, education and welfare services. Medical Subject Heading (MeSH) and free text searches were conducted in electronic database sources. Limits January 2010 to October 2022, full text, English language, human.

DATA EXTRACTION AND SYNTHESIS

Data were extracted independently by two authors using a piloted data extraction table and presented in table and narrative form.

RESULTS

Full text of 11 articles were reviewed, domains were coded using four domains of a framework identified in one reviewed article to maintain consistency of reporting; 'governance,' 'leadership,' 'organisational culture and ethos,' and 'front-line interdisciplinary practice.' A fifth domain was identified, 'access.'

CONCLUSIONS

Services providing integrated care for families in the early years will ideally be based on values generated through codesign with families and the community. Considerations include sound governance and leadership, shared vision, and commitment to providing accessible and culturally safe family-centred care.

Reflections on oral health inequalities: Theories, pathways and next steps for research priorities

Health inequalities, including those in oral health, are a critical problem of social injustice worldwide, while the COVID-19 pandemic has magnified previously existing inequalities and created new ones. This commentary offers a summary of the main frameworks used in the literature of oral health inequalities, reviews the evidence and discusses the potential role of different pathways/mechanisms to explain inequalities. Research in this area needs now to move from documenting oral health inequalities, towards explaining them, understanding the complex mechanisms underlying their production and reproduction and looking at interventions to tackle them. In particular, the importance of interdisciplinary theory-driven research, intersectionality frameworks and the use of the best available analytical methodologies including qualitative research is discussed. Further research on understanding the role of structural determinants on creating and shaping inequalities in oral health is needed, such as a focus on political economy analysis. The co-design of interventions to reduce oral health inequalities is an area of priority and can highlight the critical role of context and inform decision-making. The evaluation of such interventions needs to consider their public health impact and employ the wider range of methodological tools available rather than focus entirely on the traditional approach, based primarily on randomized controlled trials. Civil society engagement and various advocacy strategies are also necessary to make progress in the field.

Nurse home visiting to improve child and maternal outcomes: 5-year follow-up of an Australian randomised controlled trial

OBJECTIVES

Nurse home visiting (NHV) is widely implemented to address inequities in child and maternal health. However, few studies have examined longer-term effectiveness or delivery within universal healthcare systems. We evaluated the benefits of an Australian NHV program ("right@home") in promoting children's language and learning, general and mental health, maternal mental health and wellbeing, parenting and family relationships, at child ages 4 and 5 years.

SETTING AND PARTICIPANTS

Randomised controlled trial of NHV delivered via universal, child and family health services (the comparator). Pregnant women experiencing adversity (≥2 of 10 risk factors) were recruited from 10 antenatal clinics across 2 states (Victoria, Tasmania) in Australia.

INTERVENTION

Mothers in the intervention arm were offered 25 nurse home visits (mean 23·2 home visits [SD 7·4, range 1-43] received) of 60-90 minutes, commencing antenatally and continuing until children's second birthdays.

PRIMARY AND SECONDARY OUTCOMES MEASURED

At 4 and 5 years, outcomes were assessed via parent interview and direct assessment of children's language and learning (receptive and expressive language, phonological awareness, attention, and executive function). Outcomes were compared between intervention and usual care arms (intention to treat) using adjusted regression with robust estimation to account for nurse/site. Missing data were addressed using multiple imputation and inverse probability weighting.

RESULTS

Of 722 women enrolled in the trial, 225 of 363 (62%) intervention and 201 of 359 (56%) usual care women provided data at 5 years. Estimated group differences showed an overall pattern favouring the intervention. Statistical evidence of benefits was found across child and maternal mental health and wellbeing, parenting and family relationships with effect sizes ranging 0·01-0·27.

CONCLUSION

An Australian NHV program promoted longer-term family functioning and wellbeing for women experiencing adversity. NHV can offer an important component of a proportionate universal system that delivers support and intervention relative to need.

TRIAL REGISTRATION

2013-2016, registration ISRCTN89962120.

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.

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.

Identification of models, theoretical design and formal evaluation of integrated specialist community health service provision for the first 2000 days: a protocol for a scoping review

INTRODUCTION

The first 2000 days of a child's life (during pregnancy up to age 5 years) represent a critical period, in which early interventions reduce risk associated with developmental delay, disability and intergenerational disadvantage. The risk is exacerbated by barriers to specialised early intervention for children and families. This scoping review seeks to contribute to the evidence for sustaining integrated community-based specialist care in these earliest years of a child's life.

METHODS AND ANALYSIS

The Joanna Briggs Institute scoping review framework will be followed. Inclusion and exclusion criteria for screening of literature is predefined, guided by the criteria of population, concept and context. The review will identify models of care delivery, and will identify quality of care outcomes that have been measured, including evidence of reliability and validity. Sources of evidence will include CINAHL, Cochrane databases, Medline, PsycINFO and Scopus.

ETHICS AND DISSEMINATION

In a three-part study, evidence synthesis from the scoping review of the literature; mapping of existing specialist early years services in one community and a consumer consultation (Curtin University Human Research Ethics approval HRE2021-0546) in the same community will inform a model of integrated care that accounts for the context of the community it seeks to serve. Results will be disseminated by peer-reviewed publications and conference presentations, contributing to the evidence base for delivering sustainable community-based integrated care in the context of the first 2000 days. This protocol is specific to the scoping review.

Inequality and child health: dynamic population health interventions

PURPOSE OF REVIEW

Established social gradients across a wide range of child health issues including obesity, anxiety, infectious diseases, injuries, prematurity and low birth weight suggest that much illness is avoidable and there is an imperative to intervene in this whole of society issue. This review examines recent advances in understanding of the pathways to health and health inequalities and their application to interventions to improve health equity.

RECENT FINDINGS

Children's health develops over the life course in ways that are profoundly influenced by their entire developmental ecosystem including individual, family, community and system-level factors. Interventions to address child health inequalities must include action on the structural determinants of health, a greater focus on family and community health development, and attention to the acquisition of developmental capabilities. Nascent dynamic population health initiatives that address whole developmental ecosystems such as All Children Thrive, Better Start Bradford and Generation V, hold real promise for achieving child health equity.

SUMMARY

Pathways to health inequalities are driven by social and structural determinants of health. Interventions to address inequalities need to be driven less by older biomedical models, and more by prevailing ecological and complex systems models incorporating a life course health development approach.

Inequities in Children's Reading Skills: The Role of Home Reading and Preschool Attendance

OBJECTIVE

Children from socioeconomically disadvantaged backgrounds have poorer learning outcomes. These inequities are a significant public health issue, tracking forward to adverse health outcomes in adulthood. We examined the potential to reduce socioeconomic gaps in children's reading skills through increasing home reading and preschool attendance among disadvantaged children.

METHODS

We drew on data from the nationally representative birth cohort of the Longitudinal Study of Australian Children (N = 5107) to examine the impact of socioeconomic disadvantage (0-1 year) on children's reading skills (8-9 years). An interventional effects approach was applied to estimate the extent to which improving the levels of home reading (2-5 years) and preschool attendance (4-5 years) of socioeconomically disadvantaged children to be commensurate with their advantaged peers, could potentially reduce socioeconomic gaps in children's reading skills.

RESULTS

Socioeconomically disadvantaged children had a higher risk of poor reading outcomes compared to more advantaged peers: absolute risk difference = 20.1% (95% confidence interval [CI]: 16.0%-24.2%). Results suggest that improving disadvantaged children's home reading and preschool attendance to the level of their advantaged peers could eliminate 6.5% and 2.1% of socioeconomic gaps in reading skills, respectively. However, large socioeconomic gaps would remain, with disadvantaged children maintaining an 18.3% (95% CI: 14.0%-22.7%) higher risk of poor reading outcomes in absolute terms.

CONCLUSION

There are clear socioeconomic disparities in children's reading skills by late childhood. Findings suggest that interventions that improve home reading and preschool attendance may contribute to reducing these inequities, but alone are unlikely to be sufficient to close the equity gap.

Socioeconomic inequalities in co-morbidity of overweight, obesity and mental ill-health from adolescence to mid-adulthood in two national birth cohort studies

AIM

To examine socioeconomic inequalities in comorbidity risk for overweight (including obesity) and mental ill-health in two national cohorts. We investigated independent effects of childhood and adulthood socioeconomic disadvantage on comorbidity from childhood to mid-adulthood, and differences by sex and cohort.

METHODS

Data were from 1958 National Child Development Study (NCDS58) and 1970 British Cohort Study (BCS70) [total N=30,868, 51% males] assessed at ages 10, 16, 23/26, 34 and 42 years. Socioeconomic indicators included childhood and adulthood social class and educational level. Risk for i. having healthy BMI and mental ill-health, ii. overweight and good mental health, and iii. overweight and mental ill-health was analysed using multinomial logistic regression.

FINDINGS

Socioeconomic disadvantage was consistently associated with greater risk for overweight-mental ill-health comorbidity at all ages (RRR 1.43, 2.04, 2.38, 1.64 and 1.71 at ages 10, 16, 23, 34 and 42 respectively for unskilled/skilled vs. professional/managerial class). The observed inequalities in co-morbidity were greater than those observed for either condition alone (overweight; RRR 1.39 and 1.25, mental ill-health; 1.36 and 1.22 at ages 16 and 42 respectively, for unskilled/skilled vs. professional/managerial class). In adulthood, both childhood and adulthood socioeconomic disadvantage were independently associated with comorbid overweight-mental ill-health, with a clear inverse gradient between educational level and risk for comorbidity. For instance, for the no education group (compared to university education) the RRR is 6.11 (95% CI 4.31-8.65) at age 34 and 4.42 (3.28-5.96) at age 42. There were no differences observed in the extent of inequalities by sex and differences between cohorts were limited.

INTERPRETATION

While socioeconomic disadvantage in childhood and adulthood are consistently and independently associated with greater risk for mental ill-health and being overweight separately, these associations are even larger for their comorbidity across the lifecourse. These findings are significant given the increasing global prevalence of obesity and mental ill-health, and their implications for lifelong health and mortality.

FUNDING

This research was supported by grants from the Wellcome Trust (ISSF3/ H17RCO/NG1) and Medical Research Council (MRC) [MC_UU_00019/3].

Moving Health Literacy Research and Practice towards a Vision of Equity, Precision and Transparency

Over the past two decades, health literacy research has gained increasing attention in global health initiatives to reduce health disparities. While it is well-documented that health literacy is associated with health outcomes, most findings are generated from cross-sectional data. Along with the increasing importance of health literacy in policy, there is a lack of specificity and transparency about how to improve health literacy in practice. In this study, we are calling for a shift of current research paradigms from judging health literacy levels towards observing how health literacy skills are developed over the life course and practised in the real world. This includes using a life-course approach, integrating the rationale of precision public health, applying open science practice, and promoting actionable knowledge translation strategies. We show how a greater appreciation for these paradigms promises to advance health literacy research and practice towards an equitable, precise, transparent, and actionable vision.

The Effect of Different Treatment Regimens and Multiple Risk Factors on Adverse Pregnancy Outcomes among Syphilis-Seropositive Women in Guangzhou: A Retrospective Cohort Study

Background

To eliminate mother-to-child transmission of syphilis, the Chinese government recommends a treatment regimen that slightly differs from the World Health Organization- (WHO-) recommended treatment. However, little is known about their difference in efficacy. This study is aimed at comparing the effect of China-recommended and WHO-recommend treatment regimens on adverse pregnancy outcomes (APOs) and at examining associated risk factors of APOs among syphilis-seropositive women.

Methods

Using the syphilis registry data, we retrospectively collected data from 4488 syphilis-infected pregnant women in Guangzhou during 2011-2018. Multivariate analyses were used to investigate the association between treatment regimens and APOs (ectopic pregnancy, spontaneous abortion, stillbirth, preterm birth or low birth weight, newborn smaller than gestational age, congenital syphilis, and infant death) and the association between risk factors and APOs.

Results

Of 3474 participants, 27.3% had at least one APO. Compared to those receiving WHO-recommended treatment, women who received China-recommended treatment were less likely to have APOs (odds ratio (OR) 0.47, 95% confidence interval (CI) 0.38-0.57), whereas those who received no treatment had 1.6 times higher odds of experiencing APOs. One common risk factor across different APOs was high levels of log₂-transformed toluidine red unheated serum test (TRUST) titers before treatment (OR 1.14, 95% CI 1.10-1.19). China-recommended treatment was effective in reducing APOs for those with TRUST ≥ 1 : 8 (OR 0.21, 95% CI 0.14-0.29) and those with TRUST < 1 : 8 (OR 0.62, 95% CI 0.50-0.77).

Conclusions

Syphilis-seropositive women receiving China-recommended treatment had lower odds of APOs, especially when TRUST titers before treatment were high. Findings can be used to guide health professionals to reduce APOs among syphilis-infected mothers and promote nationwide use of China-recommended treatment.