Family Income and Child Depression: The Chain Mediating Effect of Parental Involvement, Children's Self-Esteem, and Group Differences

Family income is an important factor that affects depression in children and can indirectly be associated with children's development through family and individual factors. However, few studies have examined the mechanism of multiple risk factors. Therefore, this study focused on the relationship between family income and child depression, as well as the chain mediating the roles of parental involvement and children's self-esteem both in single-parent families and intact families. A total of 1355 primary school students completed questionnaires that assessed family income, parental involvement, children's self-esteem, and depression. The results showed that family income influenced child depression through both the mediating roles of parental involvement and children's self-esteem and the chain mediating role of parental involvement and children's self-esteem. Meanwhile, family income only influenced child depression through chain mediation in single-parent families. The group differences in the mechanism of depression provide a reference for empirical research on depression intervention in children from different family structures.

Family Income Level, Income Structure, and Dietary Imbalance of Elderly Households in Rural China

In rural areas, the aging of households is becoming increasingly severe, and the issue of dietary imbalance among the elderly is becoming increasingly prominent. Using data from the China Health and Nutrition Survey (CHNS), the negative binomial regression method was used to investigate the impact of household income level on dietary imbalance among rural elderly people, and to explore the heterogeneity of household income structure and its role in the relationship between the two. Research has found that an increase in total household income significantly improves the dietary quality of rural elderly people, and the income structure variable enhances its negative pulling effect on dietary imbalance. For elderly people with moderate dietary imbalance, the effect of increased family income is most significant. In different income groups, the impact of total household income on dietary imbalance in the high-income group is greater than that in the low-income group, and there is also a significant difference in the role played by the proportion of net income from agricultural operations. Therefore, it is necessary to increase the non working income of the elderly, strengthen social responsibility for elderly care, and alleviate the problem of dietary imbalance among rural elderly people.

Mediators of the Relation of Family Income with Adolescent Behavior Problems and Cognitive Achievement: Material Hardship, Parent Distress and Parent Support

Structural equation modeling (SEM) with longitudinal survey data was used to test a proposed developmental model of the association of family income (with children aged 6-9) to parent behaviors (for children at 10 years of age) and adolescent cognitive achievement and behavior problems (at age 15). Data from the Child Development Supplement (CDS) and Panel Study of Income Dynamics (PSID) provided a representative US sample (n = 953). The SEM measurement model of parent behaviors showed two robust latent variables representing parent distress (based on two measures) and parent support (composed of four measures of parent investment, cognitive stimulation, emotional warmth, and educational expectations for the child). The SEM structural model indicated that the relation between average family income between 1998 and 2001 for young children (ages 6-9) and adolescent cognitive achievement and behavior problems in 2007 (age 15) was almost entirely mediated by parent distress, parent support and material hardship, all measured in 2002. Results suggested that the structural model was strongest (RMSEA = .08) when all three mediating variables were included. These results provide a clearer picture of the developmental mechanisms by which family income becomes associated with adolescent cognitive achievement and behavior problems over time.

Age, income and sleep duration were associated with outcomes in children participating in weight management

Aim

To explore associations between baseline factors and weight‐related outcomes among participants enrolled in a paediatric obesity trial.

Methods

We included children aged 6–12 years participating in a 2‐year multidisciplinary family programme who attended a postintervention follow‐up 36 months from baseline (n = 62). Outcome measures were change in body mass index standard deviation score (BMI SDS), reduction in BMI SDS ≥0.25 and change in waist circumference (WC). Independent variables included in linear and logistic regression models were age, sex, household income, parents' education, sleep duration, screen time and physical activity.

Results

Altogether, 26 children (42%) attained a reduction of BMI SDS ≥0.25. Higher family income and longer sleep duration were associated with greater change in BMI SDS (−0.05 per 100.000 NOK, p = 0.02, and −0.24 per hour, p = 0.02, respectively). Higher age was associated with greater change in WC (−2.1 cm per year, p = 0.01) but lower odds of attaining a reduction in BMI SDS ≥0.25 (OR per year 0.70, p = 0.04). There was a borderline statistically significant trend towards greater increase in WC with longer daily screen time (p = 0.05).

Conclusion

Age, family income and sleep duration at baseline were associated with weight‐related outcomes 1‐year postintervention.

Changes in Cognitive Outcomes in Early Childhood: The Role of Family Income and Volatility

Associations between family income and child developmental outcomes are well documented. However, family income is not static but changes over time. Although this volatility represents income shocks that are likely to affect children’s lives, very few studies have so far examined its effect on early cognitive development. This study investigated associations between family income, volatility, and changes in cognitive outcomes in early childhood and examined whether these associations are dependent on a family’s overall income position. Data for the study spanned five waves of the Growing Up in Scotland longitudinal survey (N = 3,621). Findings indicate that income volatility was more prevalent among disadvantaged sociodemographic groups. In addition to average income, short-term volatility was associated with changes in child cognitive outcomes from ages 3 to 5. While upward volatility was associated with gains in expressive vocabulary, downward and fluctuating volatility were associated with declines in child problem-solving abilities. The association between volatility and changes in cognitive outcomes was similar for both children living in poverty and those from medium–high-income households. Our results suggest that policies aiming to cushion all families from negative income shocks, boost family income to ensure stability, and take low-income families out of poverty will have a significant impact on children’s cognitive development. Additionally, a more nuanced conceptualization of income is needed to understand its multidimensional impact on developmental outcomes.

Family Income, Parental Education and Chinese Preschoolers' Cognitive School Readiness: Authoritative Parenting and Parental Involvement as Chain Mediators

This study examined the associations of family income and parental education with Chinese preschool children's cognitive school readiness and the sequential mediating role of parenting style (i.e., authoritative parenting) and parental involvement in these relations. A total of 307 5-6 years old kindergarten children from Shanghai, China and their parents participated in the study. Using structural equation modeling method, the results indicated that parental education was directly related to children's cognitive school readiness, while no direct relationship was found for family income. The link of parents' education with children's cognitive school readiness was sequentially mediated by authoritative parenting and home-based parental involvement. Authoritative parenting and parental involvement at home can be targeted by government administrators to effectively improve children's cognitive school readiness skills. The theoretical and practical implications were discussed.

Nutrient and Food Group Intakes among U.S. Children (2-5 Years) Differ by Family Income to Poverty Ratio, NHANES 2011-2018

Family income may influence nutrient and food group intakes among preschool children, thus increasing risk of nutrient deficiencies. This study compared nutrient and food group intakes and diet quality among a U.S. sample of children 2–5 years of age by family income to poverty ratio (PIR) based on National Health and Nutrition Examination Survey (2011–2018) data (n = 2249). Regression analyses were used to compare dietary intakes based on proxy-reported 24-h dietary recalls and Healthy Eating Index-2015 total scores by low PIR versus mid-high PIR levels adjusted for covariates. PIR levels varied by child race/ethnicity and household reference person’s sex, marital status, and education. More than half of the children in the low PIR group (56%) were reported to have received WIC benefits in the past year. Marginally lower calcium (p = 0.008) and lower fiber intakes, lower total HEI-2015 scores, and lower intakes of fruits and whole grain foods (all p < 0.007) were observed among children in low PIR households compared to mid-high PIR households. However, iron intakes were higher (p = 0.0003) among children in low PIR households compared to mid-high PIR households. Lack of other differences in nutrient and food group intakes may be attributable to WIC benefits.

No causal associations between childhood family income and subsequent psychiatric disorders, substance misuse and violent crime arrests: a nationwide Finnish study of >650 000 individuals and their siblings

BACKGROUND

Childhood family income has been shown to be associated with later psychiatric disorders, substance misuse and violent crime, but the consistency, strength and causal nature of these associations remain unclear.

METHODS

We conducted a nationwide cohort and co-sibling study of 650 680 individuals (426 886 siblings) born in Finland between 1986 and 1996 to re-examine these associations by accounting for unmeasured confounders shared between siblings. The participants were followed up from their 15th birthday until they either migrated, died, met criteria for the outcome of interest or reached the end of the study period (31 December 2017 or 31 December 2018 for substance misuse). The associations were adjusted for sex, birth year and birth order, and expressed as adjusted hazard ratios (aHRs). The outcomes included a diagnosis of a severe mental illness (schizophrenia-spectrum disorders or bipolar disorder), depression and anxiety. Substance misuse (e.g. medication prescription, hospitalization or death due to a substance use disorder or arrest for drug-related crime) and violent crime arrests were also examined. Stratified Cox regression models accounted for unmeasured confounders shared between differentially exposed siblings.

RESULTS

For each $15 000 increase in family income at age 15 years, the risks of the outcomes were reduced by between 9% in severe mental illness (aHR = 0.91; 95% confidence interval: 0.90-0.92) and 23% in violent crime arrests (aHR = 0.77; 0.76-0.78). These associations were fully attenuated in the sibling-comparison models (aHR range: 0.99-1.00). Sensitivity analyses confirmed the latter findings.

CONCLUSIONS

Associations between childhood family income and subsequent risks for psychiatric disorders, substance misuse and violent crime arrest were not consistent with a causal interpretation.

The Impact of Family Income on Body Mass Index and Self-Rated Health of Illiterate and Non-illiterate Rural Elderly in China: Evidence From a Fixed Effect Approach

Background: Rural communities worldwide are experiencing the most significant levels of aging. Most rural elderly have no stable pension, and leading family income plays an indispensable role in the life security of rural elderly. This study aims to investigate whether the association between annual family income per capita and body mass index (BMI) and self-rated health (SRH) in rural elderly is moderated by education during fast economic development.

Methods: We chose the fixed-effects model to analyze the impact of the annual family income per capita change on BMI and SRH based on a large, nationally representative longitudinal dataset of rural respondents aged above 60 of the China Family Panel Studies (CFPS) from 2010 to 2018.

Results: Six hundred and fifty-eight were eligible for inclusion in our analysis in CFPS. The median age of participants was 65 years in 2010, and 379 (57.60%) participants were male. Self-rated health increased with higher the logarithmized family income per capita among the rural illiterate elderly (β = 0.0770; 95% CI = 0.0065–0.1473). Body mass index increased with higher the logarithmized family income per capita among the rural elderly (β = 0.1614, 95% CI: 0.0325–0.2903), and it was more evident among the illiterate elderly (β = 0.2462, 95% CI: 0.05519–0.4372).

Conclusion: Family income has an impact on BMI and SRH moderated by education level among rural elderly in China. These results contribute to developing more targeted strategies in the context of a developing country. In addition, it also reminds us to consider the differences in the educational level of the elderly in rural areas when examining the relationship between family income and health.

Epidemiology of Sports-Related Eye Injuries Among Athletes in Tianjin, China

Purpose: To investigate the incidence, characteristics, and risk factors of sports-related eye injuries among athletes in Tianjin, China.

Methods: A cross-sectional study was carried out from March 2018 to October 2018. In this study, the athletes from Tianjin University of Sports, Tianjin Vocational College of Sports, and Tianjin provincial sports teams were selected for general investigation. In total, 1,673 athletes were invited and 1,413 participated in the study (response rate of 84.5%).

Results: In total, 1,413 athletes were enrolled; 151 had suffered from sports-related eye injuries, with an incidence of 10.7% (95% CI: 9.1–12.0%). Handball (38.5%) was the sport with the highest incidence of eye injuries, followed by water polo (36.4%) and diving (26.7%). Overall, 42.4% of the athletes were injured by ball and 22.5% of injuries came from teammates. The eye injuries usually occurred during training (64.2%) and competitions (14.6%). Adnexa wound (51.7%) was the most common type of injury. About 11.9% of the athletes with eye injuries had the impaired vision; 66.7% failed to see doctors on time. The athletes <18 years of age had a higher risk of eye injuries (odds ratio [OR] =1.60, 95% CI: 1.06–2.40). The athletes with lower family income (<1,000 RMB) were at risk population for sports-related eye injuries (OR = 3.91, 95% CI: 2.24–6.82). Training >4 h a day increased the risk of eye injuries (OR = 2.21, 95% CI: 1.42–3.43).

Conclusion: The incidence of sports-related eye injuries among athletes was 10.7% in Tianjin, China. Handball, water polo, and diving were the most common activities of injury. Age, family income, and training time were the risk factors for sports-related eye injuries.

The impact of low income on long-term mortality of myocardial infarction patients: results from the Brazilian Heart Study

BACKGROUND

Low socioeconomic status has for long been considered an important modifiable risk factor for developing cardiovascular disease, plausibly by lower access to healthcare, lower therapeutic adhesion, and overlapping of other known risk factors. Nevertheless, whether family income and social isolation of poor communities seen in Brazil impact outcomes following ST-segment elevation myocardial infarction (STEMI) remain scarcely understood.

METHODS

STEMI diagnosed patients were consecutively enrolled from the Brazilian Heart Study (ClinicalTrials.gov Identifier: NCT02062554) and categorized according to median family income (US$350), address-based human development index (HDI), and distance between communities and a tertiary hospital (DCTH). Incidence of death after 48 months was compared by using adjusted Cox regressions. p-alues < .05 were considered significant.

RESULTS

Among 542 subjects, there were 69 deaths (13.2%) after a median follow-up time of 611 d (IQR = 724). The low-income group had a higher incidence of all-cause mortality compared to high income (18.4 vs. 7.1%; p = .001), with an adjusted HR of 2.16 (95%CI: 1.25-3.75; p = .006). Compared to high-income, low-income individuals had the worst clinical presentation of myocardial infarction and less frequently received dual antiplatelet therapy and statins at hospital discharge. The population attributable risk of low income was 44.8%. HDI and DCTH did not influence the delay to reperfusion therapy nor the risk of death.

CONCLUSIONS

Low income was independently associated with a higher long-term mortality rate, lower prescription of guidelines-recommended therapy, and worst clinical presentation of myocardial infarction in STEMI patients.

White Matter Microstructure in the Young Adult Brain Varies with Neighborhood Disadvantage in Adolescence

Neighborhood disadvantage and community violence are common in poor, urban communities and are risk factors for emotional dysfunction. Emotional processes are supported by neural circuitry that includes the prefrontal cortex (PFC), hippocampus, amygdala, and hypothalamus. These brain regions are connected by white matter pathways that include the cingulum bundle, uncinate fasciculus, stria terminalis, and fornix. Emotional function varies with the microstructure of these white matter pathways. However, it is not clear whether the microstructure of these pathways varies with risk factors for emotional dysfunction (e.g., neighborhood disadvantage and violence exposure). Therefore, determining the relationships between neighborhood disadvantage, violence exposure, and white matter microstructure may offer insight into the neural mechanisms by which adverse life experiences alter developing neural systems. The current study investigated the association that exposure to neighborhood disadvantage and violence have with the quantitative anisotropy (QA), a measure of the amount of directional water diffusion, of the cingulum bundle, uncinate fasciculus, stria terminalis, and fornix. Neighborhood disadvantage (M_age = 11.20) and violence exposure (M_W1age = 11.20; M_W2age = 13.05; M_W3age = 16.20; M_W4age = 19.25) were assessed during adolescence and participants returned for magnetic resonance imaging as young adults (N = 303; M_age = 20.25, SD = 1.55), during which diffusion weighted brain images were collected. The QA of the cingulum bundle, uncinate fasciculus, and stria terminalis/fornix varied negatively with neighborhood disadvantage such that the QA of these white matter tracts decreased as neighborhood disadvantage increased. Violence exposure was not related to QA in any tract (i.e., cingulum bundle, uncinate fasciculus, and stria terminalis/fornix) after correction for multiple comparisons. These results suggest that an adolescent's neighborhood may play an important role in the microstructure (i.e., QA) of white matter pathways that connect brain regions that support emotional function.

Associations of Age, Gender, and Family Income with Quality of Life in Children With Advanced Cancer

Background: Children with cancer often experience decreased quality of life (QOL) throughout the illness trajectory. The purpose of this study was to explore the associations of demographic characteristics with QOL in children with advanced cancer. Methods: This secondary analysis was part of a larger randomized clinical trial that evaluated the efficacy of a legacy intervention for children (7-17 years) with relapsed/refractory cancer and their primary parent caregivers. Assessments included child self-reports on the Pediatric Quality of Life Inventory (PedsQL) Cancer Module. Researchers used descriptive and linear regression statistical methods. Results: Children (n = 128) averaged 10.9 years (SD = 3.0). The majority were female (n = 68, 53%), white (n = 107, 84%), had a hematologic malignancy (n = 67, 52%), with family incomes of $50,000 or less (n = 81, 63.3%). Statistically significant positive associations of both age and income level with PedsQL scores were observed (p < .05) but not gender (p > .05). The strongest correlations for age were with the procedural anxiety (beta = 0.42), treatment anxiety (beta = 0.26), and total (beta = 0.28) scores (all p < .01). In general, there was a positive correlation between family income levels and PedsQL scores (p < .05). The strongest correlations for income were with nausea (R = 0.49), appearance (R = 0.44), pain, and treatment anxiety (both R = 0.42) (all p < .01). Associations adjusted for age remained essentially the same (all p < .01). Discussion: Children with advanced cancer with lower family income and younger age are at high risk for poorer QOL. Oncology nurses should seek to identify families who may benefit from additional resources to promote QOL.

American Children's Screen Time: Diminished Returns of Household Income in Black Families

While increased household income is associated with overall decreased screen time for children, less is known about the effect of racial variation on this association. According to Minorities' Diminished Returns (MDRs) theory, family income and other economic resources show weaker association with children's developmental, behavioral, and health outcomes for racialized groups such as black families, due to the effect of racism and social stratification. In this study, we investigated the association, by race, between family income and children's screen time, as a proxy of screen time. This longitudinal study followed 15,022 American children aged 9-11 over a 1-year period. The data came from the baseline of the Adolescent Brain Cognitive Development (ABCD) study. The independent variable was family income, and it was categorized as a three-level nominal variable. The dependent variable, screen time, was a continuous variable. Ethnicity, gender, parental education, and marital status were the covariates. The results showed that family income was inversely associated with children's screen time. However, there was a weaker inverse association seen in black families when compared with white families. This was documented by a significant statistical interaction between race and family income on children's screen time. Diminished association between family income and children's screen time for black families, compared with white families, is similar to MDRs and reflects a health risk to high-income black children. In a society where race and skin color determine opportunities and treatment by society, children from middle class black families remain at risk across multiple domains. We should not assume that income similarly promotes the health of all racial and ethnic groups. Addressing health and behavioral inequalities requires interventions that go beyond equalizing socioeconomic resources for black families. Marginalization, racism, and poverty interfere with the normal family income-related development of American children.

Family Income and Children's Emotional Wellbeing: the Mediational Role of Parents' Life Satisfaction and Emotional Wellbeing in China

Utilizing the Chinese Family Panel Studies (CFPS) dataset and the structural equation model, this paper examines the direct and indirect influences of family income on children’s emotional wellbeing as a function of parents’ life satisfaction and parents’ emotional wellbeing. Firstly, the empirical analysis of this paper shows that family income exerts a positive influence on children’s emotional wellbeing outcomes, including depressed, hopeless, helpless, and meaningless feelings. Secondly, the findings show that family income is significantly associated with parents’ emotional wellbeing, through which children’s wellbeing is affected. The intergenerational emotional transmission mechanism is validated. The ability to control personal emotions is an important skill, related not only to personal health but also to children’s health and wellbeing. Furthermore, parents’ life satisfaction serves as the mediator between family income and parents’ emotional wellbeing. If parents are more satisfied with their own lives, they are less likely to experience emotional problems. Policy implications are discussed in the end.

Prospective associations, longitudinal patterns of childhood socioeconomic status, and white matter organization in adulthood

The association between childhood socioeconomic status (SES) and brain development is an emerging area of research. The primary focus to date has been on SES and variations in gray matter structure with much less known about the relation between childhood SES and white matter structure. Using a longitudinal study of SES, with measures of income-to-needs ratio (INR) at age 9, 13, 17, and 24, we examined the prospective relationship between childhood SES (age 9 INR) and white matter organization in adulthood using diffusion tensor imaging. We also examined how changes in INR from childhood through young adulthood are associated with white matter organization in adult using a latent growth mixture model. Using tract-based spatial statistics (TBSS) we found that there is a significant prospective positive association between childhood INR and white matter organization in the bilateral uncinate fasciculus, bilateral cingulum bundle, bilateral superior longitudinal fasciculus, and corpus callosum (p < .05, FWE corrected). The probability that an individual was in the high-increasing INR profile across development compared with the low-increasing INR profile was positively associated with white matter organization in the bilateral uncinate fasciculus, left cingulum, and bilateral superior longitudinal fasciculus. The results of the current study have potential implications for interventions given that early childhood poverty may have long-lasting associations with white matter structure. Furthermore, trajectories of socioeconomic status during childhood are important-with individuals that belong to the latent profile that had high increases in INR having greater regional white matter organization in adulthood.

Childhood Obesity: Is the Built Environment More Important Than the Food Environment?

Obesity continues to be a health burden to society and new efforts may be needed to combat this epidemic. This study aims to investigate the contribution of parents education and level of income, food environment (grocery stores and fast food restaurants), and built environment (perceived safety, availability/quantity of parks) on childhood obesity. This cross-sectional observational study explored whether parents education and income level, built environment, and food environment can affect children with obesity. Participants were selected from 3 separate elementary schools located in an urban community with higher risk to have children with obesity in Montclair, California. Children living in families with low incomes have 2.31 times greater odds to be affected by obesity than children living in higher income homes. Children whose parents did not feel safe in their neighborhoods had odds of obesity 2.23 times greater than those who reported their neighborhoods as safe. Age also appeared to be a risk factor, and the odds of children affected by obesity among children 8 to 9 years was 0.79, and the odds of being affected by obesity among children 10 to 11 years of age was 0.36, when compared to children 6 to 7 years old. Findings suggest that low family income, perceptions of neighborhoods as unsafe, and young age are associated with higher body mass index (BMI) percentiles among children living in poor neighborhoods in Montclair, California.

Testing If Primal World Beliefs Reflect Experiences-Or at Least Some Experiences Identified ad hoc

Do negative primal world beliefs reflect experiences such as trauma, crime, or low socio-economic status? Clifton and colleagues recently suggested that primals-defined as beliefs about the general character of the world as a whole, such as the belief that the world is safe (vs. dangerous) and abundant (vs. barren)-may shape many of the most-studied variables in psychology. Yet researchers do not yet know why individuals adopt their primals nor the role of experience in shaping primals. Many theories can be called retrospective theories; these theories suggest that past experiences lead to the adoption of primals that reflect those experiences. For example, trauma increases the belief that the world is dangerous and growing up poor increases the belief that the world is barren. Alternatively, interpretive theories hold that primals function primarily as lenses on experiences while being themselves largely unaffected by them. This article identifies twelve empirical tests where each theory makes different predictions and hypothesizes that retrospective theories are typically less accurate than interpretive theories. I end noting that, even if retrospective theories are typically inaccurate, that does not imply experiences do not shape primals. I end by offering a conceptual architecture-the Cube Framework-for exploring the full range of human experience and suggest that, though psychologists have historically focused on negative, externally imposed experiences of short-duration (e.g., trauma), positive, internally driven, and longer-term experiences are also worth considering.

Socioeconomic and Familial Factors Associated with Gross Motor Skills among US Children Aged 3-5 Years: The 2012 NHANES National Youth Fitness Survey

The first aim of this study was to examine the prevalence of below average gross motor skills in a representative sample of US children aged 3 to 5 years. The second aim was to identify socioeconomic and familial characteristics that are associated with below average gross motor skills. Secondary analysis was conducted using the datasets from the 2012 National Health and Examination Survey National Youth Fitness Survey (NNYFS). The NNYFS assessed gross motor skills among 329 children aged 3-5 years, using the Test of Gross Motor Development-Second Edition (TGMD-2). Socioeconomic and familial characteristics of interest, such as family income and family structure, were asked in an in-person interview. This study estimated that one in three US children age 3 to 5 years old (33.9%) scored below average for gross motor quotient. In the gross motor subsets, one in four (24.4%) scored below average for locomotion and two in five (39.9%) scored below average for object control. Children living below the poverty threshold were more likely to have a higher gross motor quotient (odds ratio, OR = 2.76; 95% confidence interval, CI = 1.09-7.00). Girls were more likely to have a higher locomotor score (OR = 2.17; 95% CI = 1.10-4.25). Those living with other child(ren) aged ≤5 years were more likely to have a higher locomotor score (OR = 2.36; 95% CI = 1.01-5.54), while those living with child(ren) aged 6-17 years were more likely to have a higher object control score (OR = 1.83; 95% CI = 1.24-2.69). This study revealed risk factors associated with poor gross motor development, furthering our understanding of gross motor development in early childhood.

Family Income Gradients in Adolescent Obesity, Overweight and Adiposity Persist in Extremely Deprived and Extremely Affluent Neighbourhoods but Not in Middle-Class Neighbourhoods: Evidence from the UK Millennium Cohort Study

We investigated whether family income gradients in obesity, overweight, and adiposity persist at geographic-level deprivation quintiles using a nationally representative cohort of UK adolescents. Data from 11,714 eligible adolescents from the sixth sweep of the Millennium Cohort Study (14 years old) were analysed in this study. The International Obesity Task Force age- and sex-specific thresholds were used to define obesity and overweight. Self-reported family income was standardized using the Organisation for Economic Co-operation and Development (OECD)'s equivalised income scale. Geographic-level deprivation was defined by the index of multiple deprivation 2004. Results showed that the prevalence of obesity and overweight was 8.0% and 27.2%, respectively. Mean percentage body fat was 16.9% (standard error, SE = 0.2%) in male and 27.3% (SE = 0.1%) in female adolescents. Risk of obesity, overweight, and adiposity increased with decreasing family income quintiles (p for trend <0.001). After stratifying by geographic-level deprivation quintiles, a U-shaped association emerged, whereby family income gradients in the risk of adolescent obesity and adiposity persisted in extremely affluent and extremely deprived neighbourhoods but attenuated to non-significance in middle-class neighbourhoods. These results focus on the findings from England. Recognition of the persistence of inequalities in the risk of obesity in the most deprived and affluent neighbourhoods may be necessary in planning public health resources and interventions.

Influence of family income and medical insurance coverage on health-related quality of life and optimism in cancer patients at a Hong Kong private hospital: A cross-sectional study

OBJECTIVE

Health-related quality of life (HRQL) and optimism are important health domains that express the physical, emotional, and psychological well-being of cancer patients. Previous studies have explored income and medical insurance coverage as predictors of their well-being with the aim to better understand their financial needs. The primary objective of this study was to examine the associations in the private health sector in Hong Kong.

METHODS

The study was conducted cross-sectionally with a structured questionnaire in traditional Chinese. HRQL was assessed with the RAND 12-item Health Survey, and optimism was assessed with the Life Orientation Test. The two primary predictors were family income and medical insurance coverage. The associations were tested using logistic regression, controlling for other sociodemographic and clinical covariates.

RESULTS

A total of 428 questionnaires were used in the regression model. After adjusting for other covariates, no significant association was observed with family income as the predictor. Medical insurance coverage was a significant and positive predictor of optimism with odds ratio of 2.30 and 95% confidence interval of 1.30 to 4.05 for the group with the most coverage with little to no coverage as the reference group.

CONCLUSIONS

The significant association between medical insurance coverage and optimism might be an indication that the medical cost was a financial burden to many cancer patients in Hong Kong. In addition to their medical needs, cancer support organization and health care practitioners must be able to recognize and assist with the financial needs of the cancer patients.

Why Does Parental Divorce Lower Children's Educational Attainment? A Causal Mediation Analysis

Mechanisms explaining the negative effects of parental divorce on children's attainment have long been conjectured and assessed. Yet few studies of parental divorce have carefully attended to the assumptions and methods necessary to estimate causal mediation effects. Applying a causal framework to linked U.S. panel data, we assess the degree to which parental divorce limits children's education among whites and nonwhites and whether observed lower levels of educational attainment are explained by postdivorce family conditions and children's skills. Our analyses yield three key findings. First, the negative effect of divorce on educational attainment, particularly college, is substantial for white children; by contrast, divorce does not lower the educational attainment of nonwhite children. Second, declines in family income explain as much as one- to two-thirds of the negative effect of parental divorce on white children's education. Family instability also helps explain the effect, particularly when divorce occurs in early childhood. Children's psychosocial skills explain about one-fifth of the effect, whereas children's cognitive skills play a minimal role. Third, among nonwhites, the minimal total effect on education is explained by the offsetting influence of postdivorce declines in family income and stability alongside increases in children's psychosocial and cognitive skills.

The Effects of Family Socioeconomic Status on Psychological and Neural Mechanisms as Well as Their Sex Differences

Family socioeconomic status (SES) is an important factor that affects an individual’s neural and cognitive development. The two novel aims of this study were to reveal (a) the effects of family SES on mean diffusivity (MD) using diffusion tensor imaging given the characteristic property of MD to reflect neural plasticity and development and (b) the sex differences in SES effects. In a study cohort of 1,216 normal young adults, we failed to find significant main effects of family SES on MD; however, previously observed main effects of family SES on regional gray matter volume and fractional anisotropy (FA) were partly replicated. We found a significant effect of the interaction between sex and family income on MD in the thalamus as well as significant effects of the interaction between sex and parents’ educational qualification (year’s of education) on MD and FA in the body of the corpus callosum as well as white matter areas between the anterior cingulate cortex and lateral prefrontal cortex. These results suggest the sex-specific associations of family SES with neural and/or cognitive mechanisms particularly in neural tissues in brain areas that play key roles in basic information processing and higher-order cognitive processes in a way females with greater family SES level show imaging outcome measures that have been associated with more neural tissues (such as greater FA and lower MD) and males showed opposite.

Long-term impacts of early-life exposure to malaria: Evidence from Taiwan's Eradication Campaign in the 1950s

This paper utilizes the eradication campaign in Taiwan in the 1950s to estimate the long-term impacts of early-life (in utero and postnatal) exposure to malaria. Matching adults in the 1992-2012 Taiwan Social Change Survey to the malaria intensity in their individual place and year of birth, difference-in-difference estimation shows strong evidence that the eradication increased men's own educational attainment as well as their family income in adulthood. We also use the 1980 census data to show there was a sharp education increase after the eradication. Furthermore, the eradication increased the educational attainment of married men's spouses. Finally, quantile regressions show that the effect concentrated on the lower percentile of the income distribution. Overall, our results suggest negative effects of early-life exposure to malaria.

The dynamic relationships between economic status and health measures among working-age adults in the United States

We examine the dynamic relationships between economic status and health measures using data from 8 waves of the Panel Study of Income Dynamics from 1999 to 2013. Health measures are self-rated health (SRH) and functional limitations; economic status measures are labor income (earnings), family income, and net wealth. We use 3 different types of models: (a) ordinary least squares regression, (b) first-difference, and (c) system-generalized method of moment (GMM). Using ordinary least squares regression and first difference models, we find that higher levels of economic status are associated with better SRH and functional status among both men and women, although declines in income and wealth are associated with a decline in health for men only. Using system-GMM estimators, we find evidence of a causal link from labor income to SRH and functional status for both genders. Among men only, system-GMM results indicate that there is a causal link from net wealth to SRH and functional status. Results overall highlight the need for integrated economic and health policies, and for policies that mitigate the potential adverse health effects of short-term changes in economic status.

How Will Higher Minimum Wages Affect Family Life and Children's Well-Being?

In recent years, new national and regional minimum wage laws have been passed in the United States and other countries. The laws assume that benefits flow not only to workers but also to their children. Adolescent workers will most likely be affected directly given their concentration in low-paying jobs, but younger children may be affected indirectly by changes in parents' work conditions, family income, and the quality of nonparental child care. Research on minimum wages suggests modest and mixed economic effects: Decreases in employment can offset, partly or fully, wage increases, and modest reductions in poverty rates may fade over time. Few studies have examined the effects of minimum wage increases on the well-being of families, adults, and children. In this article, we use theoretical frameworks and empirical evidence concerning the effects on children of parental work and family income to suggest hypotheses about the effects of minimum wage increases on family life and children's well-being.

Gender Differences in How Family Income and Parental Education Relate to Reading Achievement in China: The Mediating Role of Parental Expectation and Parental Involvement

The impact of social economic status (SES) on children's academic outcomes has been well documented. However, the mechanisms underlying this relationship remain poorly understood. Furthermore, the process by which SES relates to academic achievement needs to be studied separately for boys and girls. Using a sample of 598 Chinese children (299 boys, 299 girls) in grades 4 to 6 and their parents, this study examined the process of how family SES, specifically family income and parental education, indirectly relates to children's reading achievement through parental expectation and parental involvement and whether this process differs between boys and girls. The results revealed that parental expectation and specific parental involvement behaviors played critical mediating roles between family SES and reading achievement. Moreover, the exact nature of these links differed by the gender of children. For boys, both the effect of parental education and the effect of family income were partially mediated by parental expectation and parent-child communication orderly. For girls, the effect of parental education was partially mediated by three separate pathways: (1) home monitoring; (2) parent-child communication; and (3) parental expectation followed by parent-child communication, while the effect of family income was fully mediated by parent-child communication. These findings suggest a process through which SES factors are related to children's academic development and identify a context under which these associations may differ. The practical implications of these findings are discussed, along with possible future research directions.

Family Income, Cumulative Risk Exposure, and White Matter Structure in Middle Childhood

Family income is associated with gray matter morphometry in children, but little is known about the relationship between family income and white matter structure. In this paper, using Tract-Based Spatial Statistics, a whole brain, voxel-wise approach, we examined the relationship between family income (assessed by income-to-needs ratio) and white matter organization in middle childhood (N = 27, M = 8.66 years). Results from a non-parametric, voxel-wise, multiple regression (threshold-free cluster enhancement, p < 0.05 FWE corrected) indicated that lower family income was associated with lower white matter organization [assessed by fractional anisotropy (FA)] for several clusters in white matter tracts involved in cognitive and emotional functions including fronto-limbic circuitry (uncinate fasciculus and cingulum bundle), association fibers (inferior longitudinal fasciculus, superior longitudinal fasciculus), and corticospinal tracts. Further, we examined the possibility that cumulative risk (CR) exposure might function as one of the potential pathways by which family income influences neural outcomes. Using multiple regressions, we found lower FA in portions of these tracts, including those found in the left cingulum bundle and left superior longitudinal fasciculus, was significantly related to greater exposure to CR (β = -0.47, p < 0.05 and β = -0.45, p < 0.05).

The impacts of minimum alcohol pricing on alcohol attributable morbidity in regions of British Colombia, Canada with low, medium and high mean family income

BACKGROUND AND AIMS

Previous research indicates that minimum alcohol pricing (MAP) is associated negatively with alcohol-attributable (AA) hospitalizations. Modeling studies predict that this association will be stronger for people on lower incomes. The objective of this study was to test whether the association between MAP and AA hospitalizations is greater in low-income regions.

DESIGN

Cross-sectional versus time-series analysis using multivariate multi-level effect models.

SETTING

All 89 Local Health Areas in British Columbia (BC), Canada, 2002-13 (48 quarters).

PARTICIPANTS

BC population.

MEASUREMENTS

Quarterly rates of AA hospital admissions, mean consumer price index-adjusted minimum dollars per standard alcoholic drink and socio-demographic covariates.

FINDINGS

Family income was related inversely to the effect of minimum prices on rates of some types of AA morbidity. A 1% price increase was associated with reductions of 3.547% [95% confidence interval (CI) = -5.719, -1.377; P < 0.01] in low family-income regions and 1.64% (95% CI = -2.765, -0.519; P < 0.01) across all income regions for 100% acute AA hospital admissions. Delayed (lagged) effects on chronic AA morbidity were found 2-3 years after minimum price increases for low income regions and all regions combined; a 1% increase in minimum price was associated with reductions of 2.242% (95% CI = -4.097, -0.388; P < 0.05) for 100% chronic AA and 2.474% (95% CI = -3.937, -1.011; P < 0.01) for partially chronic AA admissions for low-income regions.

CONCLUSION

In Canada, minimum price increases for alcohol are associated with reductions in alcohol attributable hospitalizations, especially for populations with lower income, both for immediate effects on acute hospitalizations and delayed effects on chronic hospitalizations.

Family support and gains in school readiness: A longitudinal study

BACKGROUND

Traditional measures of school readiness are labour-intensive and do not assess family support.

AIMS

The current study used the newly developed Brief Early Skills and Support Index (BESSI: Hughes, Daly, Foley, White and Devine 2015) to examine 6-month longitudinal stability and change in teachers' ratings of young children's school readiness and investigate the role of family support as a predictor of school readiness.

SAMPLE

Five hundred and seventy-eight children (270 boys; 74.2% White British) were included at Time 1 aged 2.58-5.84 years (M_age  = 3.98 years, SD = 0.66).

METHOD

Teachers and nursery workers completed BESSI questionnaires for each participant on two occasions separated by 6 months.

RESULTS

The four latent factors of the BESSI (i.e., Behavioural Adjustment, Language and Cognition, Daily Living Skills and Family Support) exhibited longitudinal measurement invariance and individual differences in ratings on each factor showed strong stability over time. BESSI ratings were also sensitive to improvements over time. Auto-regressive models showed that family support and family income (as measured by eligibility for pupil premium support) at Time 1 each uniquely predicted child outcomes at Time 2.

CONCLUSIONS

These findings highlight the importance of family contexts for children's school readiness.

Poverty and Internalizing Symptoms: The Indirect Effect of Middle Childhood Poverty on Internalizing Symptoms via an Emotional Response Inhibition Pathway

Childhood poverty is a pervasive problem that can alter mental health outcomes. Children from impoverished circumstances are more likely than their middle-income counterparts to develop internalizing problems such as depression and anxiety. To date, however, the emotional-cognitive control processes that link childhood poverty and internalizing symptoms remain largely unexplored. Using the Emotion Go/NoGo paradigm, we examined the association between poverty and emotional response inhibition in middle childhood. We further examined the role of emotional response inhibition in the link between middle childhood poverty and internalizing symptoms. Lower income was associated with emotional response inhibition difficulties (indexed by greater false alarm rates in the context of task irrelevant angry and sad faces). Furthermore, emotional response inhibition deficits in the context of angry and sad distracters were further associated with child-report internalizing problems. The results of the current study demonstrate the significance of understanding the emotional-cognitive control vulnerabilities of children raised in poverty and their association with mental health outcomes.

The financial burden of sickle cell disease on households in Ekiti, Southwest Nigeria

Background

Studies on economic impact of sickle cell disease (SCD) are scanty despite its being common among children in developing countries who are mostly Africans.

Objective

To determine the financial burden of SCD on households in Ado Ekiti, Southwest Nigeria.

Methods

A longitudinal and descriptive study of household expenditures on care of 111 children with SCD managed at the pediatric hematology unit of the Ekiti State University Teaching Hospital was conducted between January and December 2014.

Results

There were 64 male and 47 female children involved, aged between 15 and 180 months. They were from 111 households, out of which only eight (7.2%) were enrolled under the National Health Insurance Scheme. The number of admissions and outpatients’ consultations ranged from 1 to 5 and 1 to 10 per child, respectively. Malaria, vaso-occlusive crisis, and severe anemia were the leading comorbidities. The monthly household income ranged between ₦12,500 and ₦330,000 (US$76 and US$2,000) with a median of ₦55,000 (US$333), and health expenditure ranged between ₦2,500 and ₦215,000 (US$15 and US$1,303) with a mean of ₦39,554±35,479 (US$240±215). Parents of 63 children lost between 1 and 48 working days due to their children’s ill health. Parents of 23 children took loans ranging between ₦6,500 and ₦150,000 (US$39 and US$909) to offset hospital bills. The percentage of family income spent as health expenditure on each child ranged from 0.38 to 34.4. Catastrophic health expenditure (when the health expenditure >10% of family income) occurred in 23 (20.7%) households. Parents who took loan to offset hospital bills, low social class, and patients who took ill during the study period significantly had higher odds for catastrophic health expenditure (95% confidence interval [CI] 5.399–87.176, P=0.000; 95% CI 2.322–47.310, P=0.002; and 95% CI 1.128–29.694, P=0.035, respectively).

Conclusion

SCD poses enormous financial burden on parents and households.

The implications of selective attrition for estimates of intergenerational elasticity of family income

Numerous studies have estimated a high intergenerational correlation in economic status. Such studies do not typically attend to potential biases that may arise due to survey attrition. Using the Panel Study of Income Dynamics - the data source most commonly used in prior studies - we demonstrate that attrition is particularly high for low-income adult children with low-income parents and particularly low for high-income adult children with high-income parents. Because of this pattern of attrition, intergenerational upward mobility has been overstated for low-income families and downward mobility has been understated for high-income families. The bias among low-income families is greater than the bias among high-income families implying that intergenerational elasticity in family income is higher than previous estimates with the Panel Study of Income Dynamics would suggest.

Sociodemographic differences in parental satisfaction with an autism spectrum disorder diagnosis

BACKGROUND

The diagnostic process for autism spectrum disorder (ASD) can be difficult for families. Growing evidence suggests that the diagnostic process may vary as a function of sociodemographic factors, such as socioeconomic status. The purpose of this study was to extend findings related to families' experiences obtaining a diagnosis and accessing services for their young child with ASD.

METHOD

A mixed methods approach was used in this study, in which 46 families with children with ASD participated. A chi-square analysis compared ratings of parental satisfaction with the diagnostic process and current services between sociodemographic groups, and this was supplemented by thematic analysis of relevant open-ended questions.

RESULTS

Results indicated that satisfaction ratings varied significantly by maternal education and family income levels. Ratings of satisfaction with the child's paediatrician also differed by family income. Major themes from the open-ended questions are discussed.

CONCLUSIONS

Results support assessing satisfaction and barriers in families seeking healthcare and school-based services to facilitate access to services.

Longitudinal changes in health-related quality of life scores in Brazilian incident peritoneal dialysis patients (BRAZPD): socio-economic status not a barrier

BACKGROUND AND OBJECTIVES

A large proportion of the patients on peritoneal dialysis (PD) in Brazil have low levels of education and family income. The present study assessed whether education level and family income are associated with baseline and longitudinal changes in health-related quality of life (HRQOL) scores during the first year of PD therapy.

METHODS

We evaluated 1624 incident patients from the Brazilian Peritoneal Dialysis Multicenter Study (BRAZPD) at baseline, and 486 of them after 12 months. The SF-36 was used to determine HRQOL and the Karnofsky index (KI), physical performance.

RESULTS

At baseline, patients received high KI scores compared with scores on the SF-36. The means of the mental and physical components at baseline and after 12 months were 39.9 ± 10.5 compared with 38.7 ± 11.7 and 41.8 ± 9.6 compared with 40.7 ± 9.8 respectively, which were not statistically different. A multivariate regression analysis showed that age, sex, diabetes, and cardiovascular disease were predictors of the mental component (respectively, β = 0.12, p < 0.001; β = 0.11, p < 0.001; β = -0.08, β = 0.007; and β = -0.07, p = 0.007) and that age, sex, diabetes, cardiovascular disease, hemoglobin, glucose, and creatinine were predictors of the physical component (respectively, β = -0.28, p < 0.001; β = 0.06, p = 0.009; β = -0.09, p = 0.002; β = -0.09, p = 0.001; β = 0.07, p = 0.004; β = -0.05, p = 0.040; and β = 0.05, p = 0.040). Education level and family income were not significantly associated with HRQOL (mental and physical components) in the multivariate regression.

CONCLUSIONS

The results indicate that, as predictors, family income and education level have no impact on HRQOL, supporting the idea that socio-economic status should not be a barrier to the selection of PD as a treatment modality in Brazil.

Family income in early childhood and subsequent attention deficit/hyperactivity disorder: a quasi-experimental study

BACKGROUND

Studies have found negative associations between socioeconomic position and attention deficit/hyperactivity disorder (ADHD), but it remains unclear if this association is causal. The aim of this study was to determine the extent to which the association between family income in early childhood and subsequent ADHD depends on measured and unmeasured selection factors.

METHODS

A total of 811,803 individuals born in Sweden between 1992 and 2000 were included in this nationwide population-based cohort study. Diagnosis of ADHD was assessed via the Swedish national Patient Register and the Swedish Prescribed Drug Register. Annual family income during offspring's first 5 years in life was collected prospectively from the Swedish Integrated Database for Labour Market Research and divided into quartiles by (lower) family disposable income. We predicted ADHD from family income while controlling for covariates and also comparing differently exposed cousins and siblings to control for unmeasured familial confounding.

RESULTS

The crude analyses suggested that children exposed to lower income levels were at increased risk for ADHD (HRQ uartile1  = 2.52; 95% CI, 2.42-2.63; HRQ uartile2  = 1.52; 95% CI, 1.45-1.58; HRQ uartile3  = 1.20; 95% CI, 1.14-1.15). This dose-dependent association decreased after adjustment for measured covariates (HRQ uartile1  = 2.09; 95% CI, 2.00-2.19; HRQ uartile2  = 1.36; 95% CI, 1.30-1.42; HRQ uartile3  = 1.13; 95% CI, 1.08-1.18). Although the association was attenuated in cousin comparisons (HRQ uartile1  = 1.61; 95% CI, 1.40-1.84; HRQ uartile2  = 1.28; 95% CI, 1.12-1.45; HRQ uartile3  = 1.14; 95% CI, 1.01-1.28) and sibling comparison models (HRQ uartile1  = 1.37; 95% CI, 1.07-1.75; HRQ uartile2  = 1.37; 95% CI, 1.12-1.68; HRQ uartile3  = 1.23; 95% CI, 1.04-1.45), it remained statistically significant across all levels of decreased disposable family income.

CONCLUSIONS

Our results indicated that low family income in early childhood was associated with increased likelihood of ADHD. The link remained even after controlling for unmeasured selection factors, highlighting family income in early childhood as a marker of causal factors for ADHD.

Individual differences in attention deficit hyperactivity disorder symptoms and associated executive dysfunction and traits: sex, ethnicity, and family income

The goal of the present investigation was to investigate sex, ethnic, and socioeconomic status (SES) influences on attention deficit hyperactivity disorder (ADHD) symptoms and risk markers, including executive dysfunction and temperament traits. Participants were 109 children who were 3 to 6 years old (64% male; 36% ethnic minority) and their primary caregivers and teachers who completed a multistage, multi-informant screening, and diagnostic procedure. Parents completed a diagnostic interview and diagnostic and temperament questionnaires, teachers completed questionnaires, and children completed cognitive control tasks. Because of targeted overrecruitment of clinical cases, 56% of children in the sample were diagnosed with ADHD. Results suggested minimal sex differences, but prominent ethnic differences, in ADHD symptoms and temperament and executive function risk markers. Further, low family income was associated with increased ADHD symptoms and more temperament and executive function risk markers, and low family income explained many ethnic differences in ADHD symptoms and these risk markers. There were prominent interactions among child sex, ethnicity, and family income. Thus, study results suggest that children with multiple individual difference demographic risk factors (e.g., such as being male and ethnic minority) are at highly increased risk of ADHD symptoms and associated risk markers in the temperament and executive function domains.

Trends in the Family Income Distribution by Race/Ethnicity and Income Source, 1988-2009

The recent dramatic rise in U.S. income inequality has prompted a great deal of research on trends in overall family income and changes in sources of family income, especially among the highest income earners. However, less is known about changes in sources of income among the bottom 99% or about racial/ethnic differences in those trends. The present research contributes to the literatures on income trends and racial economic inequality by using family-level data from the 1988-2009 Current Population Survey to examine changes in overall family income and the proportion of income coming from employment, property/assets, and transfers across five different levels of family income for white-, black, and Hispanic-headed families. We find that at all income levels above the 25^th percentile, employment income is by far the largest contributor to family income for all racial/ethnic groups. Employment income trended upward over the period in both real dollars and as a percentage of total family income. In this respect, white, black and Hispanic families are remarkably similar. The racial gap in total family income has remained fairly stable over the period, but this trend conceals a narrowing of racial differences in property income, mostly as a function of the decline in property income among whites, a widening of racial differences in transfer income among the bottom 25%, and a widening of racial differences in employment income, particularly at the top of the family income distribution. Income accrued from wealth is a very small component of overall family income for all three racial groups, even for the highest-income families (top 1%).

Parental occupation and risk of small-for-gestational-age births: a nationwide epidemiological study in Sweden

BACKGROUND

Although evidence suggests that some occupations may be a risk factor for small-for-gestational age (SGA) birth, associations between a wide range of maternal and paternal occupations and risk of SGA births remain unclear. Our objective was to analyze the risk of SGA births by parental occupation, including the entire Swedish population of mothers (> or =20 years) and fathers.

METHODS

We linked nationwide data (1990-2004) on singletons born to employed mothers to nationwide data on maternal and paternal occupation and other individual-level variables. Information on parental occupations was obtained from the 1990 census. Approximately 95% of SGA births (calculated using normative data) were defined on the basis of ultrasound. Odds ratios of SGA birth were calculated with 95% confidence intervals. Women and men were analyzed separately.

RESULTS

There were 816,310 first singleton live births during the study period, of which 29,603 were SGA events. Families with low incomes had an increased risk of SGA births. After accounting for maternal age at the infant's birth, period of birth, family income, region of residence, marital status and smoking habits, several maternal occupational groups (including 'mechanics and iron and metalware workers' and 'packers, loaders and warehouse workers') had a significantly higher risk of SGA birth than the reference group (all women in the study population). Among paternal occupational groups, only waiters had an increased risk of SGA birth.

CONCLUSIONS

This large-scale follow-up study shows that maternal occupation affects risk of SGA birth, whereas paternal occupation does not seem to have an impact on SGA birth. Further studies are required to examine the specific agents in those maternal occupations that are associated with an increased risk of SGA birth.