The health of Canada's children. Part II: Health mechanisms and pathways

Social Determinants of Health and Pediatric Emergency Department Outcomes: A Systematic Review and Meta-Analysis of Observational Studies

STUDY OBJECTIVE

Social determinants of health contribute to disparities in pediatric health and health care. Our objective was to synthesize and evaluate the evidence on the association between social determinants of health and emergency department (ED) outcomes in pediatric populations.

METHODS

This review was conducted in accordance with Preferred Reporting Items for Systematic Reviews and Meta-Analyses-Equity Extension guidelines. Observational epidemiological studies were included if they examined at least 1 social determinant of health from the PROGRESS-Plus framework in relation to ED outcomes among children <18 years old. Effect direction plots were used for narrative results and pooled odds ratios (pOR) with 95% confidence intervals (CI) for meta-analyses.

RESULTS

Fifty-eight studies were included, involving 17,275,090 children and 103,296,839 ED visits. Race/ethnicity and socioeconomic status were the most reported social determinants of health (71% each). Black children had 3 times the odds of utilizing the ED (pOR 3.16, 95% CI 2.46 to 4.08), whereas visits by Indigenous children increased the odds of departure prior to completion of care (pOR 1.58, 95% CI 1.39 to 1.80) compared to White children. Public insurance, low income, neighborhood deprivation, and proximity to an ED were also predictors of ED utilization. Children whose caregivers had a preferred language other than English had longer length of stay and increased hospital admission.

CONCLUSION

Social determinants of health, particularly race, socioeconomic deprivation, proximity to an ED, and language, play important roles in ED care-seeking patterns of children and families. Increased utilization of ED services by children from racial minority and lower socioeconomic status groups may reflect barriers to health insurance and access to health care, including primary and subspecialty care, and/or poorer overall health, necessitating ED care. An intersectional approach is needed to better understand the trajectories of disparities in pediatric ED outcomes and to develop, implement, and evaluate future policies.

Geographic Inequalities of Respiratory Health Services Utilization during Childhood in Edmonton and Calgary, Canada: A Tale of Two Cities

Young children are susceptible to respiratory diseases. Inequalities exist across socioeconomic groups for paediatric respiratory health services utilization in Alberta. However, the geographic distribution of those inequalities has not been fully explored. The aim of this study was to identify geographic inequalities in respiratory health services utilization in early childhood in Calgary and Edmonton, two major urban centres in Western Canada. We conducted a geographic analysis of data from a retrospective cohort of all singleton live births occurred between 2005 and 2010. We aggregated at area-level the total number of episodes of respiratory care (hospitalizations and emergency department visits) that occurred during the first five years of life for bronchiolitis, pneumonia, lower/upper respiratory tract infections, influenza, and asthma-wheezing. We used spatial filters to identify geographic inequalities in the prevalence of acute paediatric respiratory health services utilization in Calgary and Edmonton. The average health gap between areas with the highest and the lowest prevalence of respiratory health services utilization was 1.5-fold in Calgary and 1.4-fold in Edmonton. Geographic inequalities were not completely explained by the spatial distribution of socioeconomic status, suggesting that other unmeasured factors at the neighbourhood level may explain local variability in the use of acute respiratory health services in early childhood.

Inequality, Familial Aggregation, and Risk Prediction of Caries in Siblings

INTRODUCTION

Social and family conditions are likely of great importance to dental health; however, limited evidence of familial aggregation of caries among adolescent siblings exists. Moreover, social and family-level factors have never been evaluated as isolated caries predictors at the individual level.

OBJECTIVES

The objectives were to evaluate socioeconomic patterning of caries among siblings, assess sibling-specific aggregation of caries within families, and examine if such aggregation differed by parental socioeconomic position (SEP). We also evaluated the discriminant ability of sibling caries, SEP, and other social and familial factors in predicting caries in cosiblings.

METHODS

This nationwide register-based study included all 15-y-olds in Denmark in 2003 (index siblings) and their biological siblings born within ±3 y (cosiblings). Clinical and sociodemographic data for each subject were compiled from Danish national dental, social, and population registers. Caries was measured by the decayed, missing, and filled tooth surfaces (DMFS) index. Predictors included SEP (parental education, income, and occupational social class), gender, birth order, immigration status, and household type. Adjusted SEP-caries associations were estimated using negative binomial regression. Familial aggregation was evaluated using adjusted pairwise odds ratios from alternating logistic regressions. Caries prediction was based on classification and regression tree (CART) analyses.

RESULTS

The study included 23,847 sibling pairs (n = 47,694). Socioeconomic patterning of caries was similar among the index and cosiblings with significant graded SEP-caries associations. Significant sibling-specific aggregation of caries was observed; cosiblings of caries-affected index siblings had odds of having caries 3.9 times (95% confidence interval: 3.65-4.18) as high as that of cosiblings with caries-free index siblings. This sibling similarity was stronger in socioeconomically disadvantaged families (adjusted pairwise odds ratios: 3.08-5.47). CART revealed index sibling caries as the single most important caries predictor, with caries predicted in ≥84% of cosiblings of adolescents with ≥3 carious tooth surfaces.

CONCLUSIONS

Caries in a sibling should prompt preventive family-based approaches targeting cosiblings.

KNOWLEDGE TRANSFER STATEMENT

This study revealed significant socioeconomic patterning of caries in adolescent siblings. Prediction modeling indicated that the single most important caries predictor among cosiblings was index sibling caries. Information on sibling caries level should be routinely combined with clinical evaluation to identify children at risk. Moreover, information on social and family conditions should be used to target prevention and health promotion at the school or municipal level. These approaches could possibly contribute to reducing the existing caries inequalities.

Gender and education differences in sedentary behaviour in Canada: an analysis of national cross-sectional surveys

Background

Canadians spend the majority of their days sedentary. Gender and education are important social determinants of health that impact health behaviours. There is evidence that gender and educational differences in sedentary behaviour exist. In Canada, while general trends suggest that leisure sedentary activities have changed; there has been no comprehensive assessment examining whether historical changes in sedentary behaviour differ by gender and education level. Our objective was to examine whether gender and educational differences in accelerometer-measured sedentary time and self-reported sedentary behaviours exist among Canadians and if differences are consistent across age groups, over time and across multiple survey sources.

Methods

We summarize amounts of total accelerometer-measured sedentary time and self-reported sedentary activities (e.g., passive travel, television, computer, video games, screen, reading) by age (i.e. children: 6–11 years, youth: 12–17 years, adults: 18–34 years, 45–49 years, 50–64 years, and older adults: ≥ 65 years), gender (girls/women, boys/men) and household education level (< post-secondary vs. ≥ post-secondary) over time in the Canadian Community Health Survey, Canadian Health Measures Survey, General Social Survey, and the Health Behaviour in School-Aged Children study. Gender and education level differences are examined using independent sample t-tests or chi-square analyses.

Results

While few differences were found for total accelerometer-measured sedentary time, gender and education differences in self-reported, type-specific sedentary behaviour were identified. Among youth, data from all surveys consistently identified that boys engaged in more video/computer game play (e.g., boys: 0.35–2.68 vs. girls: 0.09–2.15 h/day), while girls engaged in more leisure reading (e.g., boys: 0.45–0.65 vs. girls: 0.71–0.99 h/day). Those with a higher education or household education often reported more leisure reading and passive travel. Education level differences in screen time were often age dependent, with leisure computer use greater in higher education groups in adults only and leisure television watching generally higher in lower education groups in children and adults, but not youth.

Conclusions

This information is valuable as it helps to identify segments of the population which may be at greater risk for engaging in higher volumes of sedentary behaviour. In turn, this information can identify target audiences and behaviours for policies and interventions. Future work is needed to further understand factors contributing to these differences (e.g., preferences, occupation, family structure).

Conceptualising paediatric health disparities: a metanarrative systematic review and unified conceptual framework

OBJECTIVE

There exists a paucity of work in the development and testing of theoretical models specific to childhood health disparities even though they have been linked to the prevalence of adult health disparities including high rates of chronic disease. We conducted a systematic review and thematic analysis of existing models of health disparities specific to children to inform development of a unified conceptual framework.

METHODS

We systematically reviewed articles reporting theoretical or explanatory models of disparities on a range of outcomes related to child health. We searched Ovid Medline In-Process & Other Non-Indexed Citations, Ovid MEDLINE, Ovid Embase, Ovid Cochrane Central Register of Controlled Trials, Ovid Cochrane Database of Systematic Reviews, and Scopus (database inception to 9 July 2015). A metanarrative approach guided the analysis process.

RESULTS

A total of 48 studies presenting 48 models were included. This systematic review found multiple models but no consensus on one approach. However, we did discover a fair amount of overlap, such that the 48 models reviewed converged into the unified conceptual framework. The majority of models included factors in three domains: individual characteristics and behaviours (88%), healthcare providers and systems (63%), and environment/community (56%), . Only 38% of models included factors in the health and public policies domain.

CONCLUSIONS

A disease-agnostic unified conceptual framework may inform integration of existing knowledge of child health disparities and guide future research. This multilevel framework can focus attention among clinical, basic and social science research on the relationships between policy, social factors, health systems and the physical environment that impact children's health outcomes.

Connecting the Dots: An Ecological Lens to Preventive Measures for Adverse Childhood Experiences

Adversity in early childhood may have a profound impact on physical and mental health as well as general well-being later in life. Despite increasing research evidence on the lifelong impact of adverse experiences, one of the key questions that motivated this research was how to translate this knowledge into preventive measures. This article presents data from an exploratory study aimed to explore strategies and effective practices to prevent adverse experiences in early childhood. An ecological framework organized participants' suggested actions, highlighting the importance of proactive, multifaceted approaches and interventions that connect the child to the background environment where adversity takes place.

Youth health care utilization in Nova Scotia: what is the role of age, sex and socio-economic status?

OBJECTIVE

Youth have distinct health care needs that are not always met within a framework designed for children or adults. In Canada, little attention has been given to how youth utilize health care services and limited data are available. The aim of this study was to identify whether age, sex, socio-economic status (SES) and geographic location were significant mediators of youth health care utilization in Nova Scotia.

METHODS

The NSYOUTHS database comprises health care utilization information for all youth aged 12 to 24 years, resident in Nova Scotia between 1997 and 2007. We calculated health care utilization rates by provider, stratified by sex, age, SES, urban/rural residence and year. Negative binomial regression was used to model the variation in health care utilization by sex, SES and urban/rural location.

RESULTS

Health care utilization declined over time and varied by age. Females were more frequent users of services. Youth from lower SES areas had fewer family physician contacts but more outpatient, emergency and inpatient contacts compared to those from higher SES areas. Rural residents had fewer family physician and emergency contacts but more outpatient contacts than youth from urban areas. Ten percent of the youth were responsible for 32% of all health care contacts, whereas 11% had no health care contacts.

CONCLUSION

Specific subgroups, including youth from rural areas and of lower SES, utilize health care services differently than other youth. The challenge is to provide health care that is responsive to the needs of this heterogeneous population. Meeting this challenge requires accurate information on youth health care utilization.

Adolescence as a gateway to adult health outcomes

Adolescence has long been regarded as a transition from childhood to adulthood. More recently it is become a concern of those wishing to avoid adverse health outcomes during middle and late adulthood. Most of this effort has been focused on behavioural risk factors such as tobacco and excessive alcohol use, physical exercise habits, dietary habits, as well as sexual and injury-related behaviours. The concern is that these habits are established during adolescence, continue into adulthood, and come to constitute ongoing risk factors for adverse health outcomes during middle and late adulthood. There is good reason to criticize this approach. These behaviours are themselves shaped by adolescents' living and working conditions and even then constitute a small proportion of the variance predicting adverse health outcomes during adulthood. More complex models of how adolescence serves as a gateway to adult health outcomes are presented. These are the socio-environmental, public policy, and political economy approaches. The argument is made that adolescence is a period during which public policy plays an especially important role in predicting future health outcomes. Yet, these public policies influence health all across the life span with adolescence providing only one of many important periods during which public policy shapes health prospects during middle and later adulthood. Ultimately one should consider a range of approaches ranging from the behavioural to the political to examine how adolescence serves as a gateway towards future adult prospects. An Adolescent Gateway Towards Adult Health Model is provided to assist in this process.

Exploring interpretation of complexity and typicality in narratives and statistical images about the social determinants of health

This article explores public responses to narratives and statistical images, predominantly graphs and maps, designed to raise awareness of social determinants of health and health disparities. We focus particular attention on respondents' interpretation of the complexity of health causality and the typicality of the situations described. We conducted 24 focus groups with liberal and conservative adults (n = 180 participants) living in a large U.S. northeastern state. Although some narratives showed potential for communicating the complex causality connecting social determinants of health (SDH) to health outcomes, contextual details sometimes disrupted generalization to a broader thematic message. Statistical images often prompted useful speculation about how the factors portrayed might be related, but tended to be regarded with suspicion and criticized for oversimplifying what were perceived to be extremely complex issues. These findings lend theoretical insight to narrative and visual persuasion in the context of social issues with complex causation. We discuss practical implications for those seeking to communicate about the social determinants of health.

Poverty in childhood and adverse health outcomes in adulthood

The experience of poverty during childhood is a potent predictor of a variety of adverse health outcomes during middle and late adulthood. Children who live in poverty are more likely as adults than their peers to develop and die earlier from a range of diseases. These effects are especially strong for cardiovascular disease and type II diabetes. Most disturbingly, these effects appear in large part to be biologically embedded such that later improved life circumstances have only a modest ameliorative effect. Considering these findings and the relatively high rates of child poverty in nations such as Canada, UK, and USA, those concerned with improving the health of citizens should focus their attention on advocating for public policy that will reduce the incidence of child poverty.