The social determinants of child health and inequalities in child health

Social factors have a profound impact on child health – they are the “causes of the causes”, creating social gradients and inequalities in almost all morbidities. The social determinants of health are complex and intertwined, and in the UK child health inequalities are entrenched and intractable. We describe how longitudinal research on children's health and life course trajectories gives us insights into the ways in which the social determinants interact to affect children, and how these insights can shape policy and practice to improve child health. We also touch on three major contemporary issues in child health: adverse childhood experiences, the Covid-19 pandemic and climate change. We explore how paediatricians can engage with the social determinants of child health and be agents for change, and share examples of innovative practice.     

Child and youth mental health: Integrated health care using contemporary competency-based teams

Mental health teams have long been the foundation for mental health services provided to children and youth. Changes in professional practices, the emergence of evidence-based care, the importance of integrating mental health into primary health care delivery, the decrease in professional ‘ownership’ of mental health care competencies and other factors now challenge the traditional structure and function of these teams. New and novel frameworks will be needed to address mental health care needs for problems that do not require ‘traditional’ mental health service interventions, to enable integration of mental health care into usual health services, to promote specialist mental health care delivery for those in need, and to facilitate the development and translation of mental health research into practice. In all of these new team structures, the active participation of young people and their families will be necessary.     

Baby swimming and respiratory health

AIM: To estimate the effect of baby swimming in the first 6 months of life on respiratory diseases from 6 to 18 months. METHODS: We used data from The Norwegian Mother and Child Cohort Study (MoBa) conducted by the Norwegian Institute of Public Health in children born between 1999 and 2005 followed from birth to the age of 18 months (n = 30,870). Health outcomes: lower respiratory tract infections (LRTI), wheeze and otitis media between 6 and 18 months of age. Exposure: baby swimming at the age of 6 months. The effect of baby swimming was estimated by logistic regression analysis adjusting for potential confounders. RESULTS: About 25% of the children participated in baby swimming. The prevalence of LRTI was 13.3%, wheeze 40.0% and otitis media 30.4%. Children who were baby swimming were not more likely to have LRTI, to wheeze or to have otitis media. However, children with atopic mothers who attended baby swimming had an increased risk of wheeze, adjusted odds ratios (aOR) 1.24 (95% CI 1.11, 1.39), but not LRTI or otitis media. This was also the case for children without respiratory diseases before 6 months aOR 1.08 (95%CI 1.02-1.15). CONCLUSION: Baby swimming may be related to later wheeze. However, these findings warrant further investigation.     

Higher-income countries and global child health

Social and economic factors, acting via communities and households, impact child health. These are the social determinants of health. An array of international forces can affect the availability of these health determinants; this is especially important in lower-income countries. Government revenue is critical to funding the public services which provide child health determinants, such as water, sanitation, healthcare, and education. Global actors play a significant role in the availability of resources to provide these services and, thus, global child health. Important global actors: upper-middle and high-income countries, multinational corporations, and international organisations (such as the International Monetary Fund and other banks), impact policies and the availability of government revenue within lower-income countries. This short review considers the potential impacts of these actors. Understanding these dynamics is essential for advocacy, and paediatricians and healthcare professionals have a critical role. Child health advocates could critically analyse the impact of global actors and use these to advocate for children's right to health.     

Evaluating and providing quality health information for adolescents and young adults with cancer

Adolescents and young adults (AYAs, 15‐39 years old) are an ideal population to benefit from the ever‐expanding number and variety of cancer information and health resources available via the Internet and other digital platforms. However, the ability of individual AYAs to fully utilize such resources depends on their degree of health literacy. Across the trajectory of cancer care, an important role for the oncology clinician is assisting AYAs and caregivers in accessing quality health information consistent with their level of health literacy. Working from the premise that all AYAs with cancer and their caregivers deserve to be empowered with maximal knowledge about their condition, this review provides information to assist oncology clinicians in (1) understanding the variety of contemporary online resources that are currently available, including their strengths and limitations; (2) evaluating the quality of health information; and (3) recommending specific health information resources to their AYA patients.     

Trends in maternal health/healthcare in low-income countries and the implications on neonatal health

Maternal health in low-income countries has received increasing attention over the last 15-20 years. Maternal mortality ratios in these countries are mainly still modelled estimates and one cannot discern trends. The introduction of registration systems-giving reliable causes of death-is essential both for monitoring maternal health and fuelling action. Countries with documented success in reducing maternal mortality have used systematic, incremental approaches, often tied to multi-sectoral efforts, including roads, communication links, education, water and sanitation. Improving maternal health requires a reasonably well-functioning health system and this typically requires the reduction of poverty and consistent investment in the health system. Increasingly, policies to improve maternal and newborn health are being implemented, but in the poorest countries the impact is still not discernible. New clinical interventions, such as effective treatment of (pre)eclampsia and post-partum haemorrhage, are often beyond reach of the majority in low-income countries. In summary, progress in maternal health, and the intimately linked perinatal and newborn health, is too slow and requires urgent efforts in poverty reduction and health system strengthening in low-income countries.     

Adolescent male health

Although adolescent males have as many health issues and concerns as adolescent females, they are much less likely to be seen in a clinical setting. This is related to both individual factors and the health care system itself, which is not always encouraging and set up to provide comprehensive male health care. Working with adolescent boys involves gaining the knowledge and skills to address concerns such as puberty and sexuality, substance use, violence, risk-taking behaviours and mental health issues. The ability to engage the young male patient is critical, and the professional must be comfortable in initiating conversation about a wide array of topics with the teen boy, who may be reluctant to discuss his concerns. It is important to take every opportunity with adolescent boys to talk about issues beyond the presenting complain, and let them know about confidential care. The physician can educate teens about the importance of regular checkups, and that they are welcome to contact the physician if they are experiencing any concerns about their health or well-being. Parents of preadolescent and adolescent boys should be educated on the value of regular health maintenance visits for their sons beginning in their early teen years.     

Parental perception of the use and usefulness of a parent-held child health record

Abstract This study surveyed 313 parents to investigate how frequently parents used a parent-held child health record, and whether they saw the record as useful. Since 1981, The Child, Adolescent and Family Health Service has distributed a Personal Health Record (PHR) to the parents of all children in South Australia. The PHR has provided each family with an ongoing record that has been consistently used for immunization, child health checks and child health screening. However, little is known about how parents view the PHR, its usefulness, and how frequently the record is used. Previous studies, generally conducted prior to, or shortly after, a parent-held child health record was introduced, have shown a poor understanding of the uses of the PHR on the part of parents and a low level of use by health professionals such as general practitioners. In contrast, the results of this study show high levels of understanding of the health record on the part of parents, and an increase in the use of the health record by general practitioners over the 10 years since the record was introduced. Although moderated by the age of the child, the sections of the PHR seen as most useful (and the most frequently used) by parents were immunization, growth charts, progress notes and health checks.     

Parenting and health: a call for action

Paediatricians and healthcare professionals working with children are well placed to observe parents and see a wide range of parenting from the exceptional to the abusive. Parenting has important short, medium and long term effects on child physical and mental health. Understanding these effects more fully helps paediatricians to comment on parenting, offer advice or refer to parenting programmes. This article outlines advances in neuroscience and attachment theory as well as contemporary issues that underpin the case for parenting intervention. It also discusses the rationale and evidence base for particular programmes, the UK policy context, and makes some suggestions on how paediatricians may wish to support better parenting.     

Sleep problems in young infants and maternal mental and physical health

AIM: Sleep problems in the second 6 months of life are common and associated with maternal depression. This paper extends previous research to (i) establish the prevalence of sleep problems in younger infants from a broader socio-economic spectrum, (ii) examine the relationship between infant sleep problems and maternal physical, as well as mental, health, and (iii) explore mothers' sleep quality as a potential mediator of this relationship. METHODS: Design: Cross-sectional, community survey in Melbourne, Australia. Sample: Mothers of 3- to 6-month-old infants (mean 4.6 months) recruited from well-child clinics in six sociodemographically diverse metropolitan local government areas. Outcome measures: Maternal mental and physical health; standardised questionnaire on infant sleep patterns; maternal report of an infant sleep problem (yes/no). RESULTS: The survey was completed by 692 mothers; 237 (34%) reported an infant sleep problem, of whom 73 (31%) rated the problem as severe. Sleep patterns characterising a problem included the infant waking seven nights per week, nursing the infant to sleep at the beginning of the night, the infant sleeping in the parent's room, and parental disagreement regarding managing infant sleep. There was no relationship between sleep problems and socio-economic levels. Mothers reporting infant sleep problems had poorer mental and physical health compared with those not reporting sleep problems. CONCLUSION: Sleep problems are common in early infancy across metropolitan socio-economic levels and are associated with poorer maternal health and well-being. Preventive strategies for infant sleep problems need to begin early in primary care to improve mothers' health.     

Inequalities in children's health in the UK

Health outcomes for children in the United Kingdom vary depending on socioeconomic risk factors. This article explores the evidence for this association including data on child mortality, developmental progress, educational outcomes and obesity. Fair Society, Healthy Lives was a 2010 report chaired by Professor Marmot and this article describes the framework proposed in the Marmot report to understand how health inequalities occur and what policy objectives could reduce the gap between outcomes for the wealthy and the poor in British society.     

Self-perceived health among adolescents: the role of gender and psychosocial factors

Since adolescents’ psychosocial health problems may have major implications for adult morbidity and mortality, investigating their self-perceived health deserves priority. In the lack of limiting illness, psychosocial health variables, e.g., psychosomatic health complaints or health behaviors, play a decisive role in determining adolescents’ self-perceived health. Using data on adolescents from Szeged, Hungary (n = 1,114), we examined the relationship between adolescents’ self-perceived health and a set of psychosocial health status measurements. Findings show that psychosomatic and depressive symptoms contributed significantly to adolescents’ poor/fair perceptions of health. Findings also support the relationship between health behaviors and adolescents’ self-perceived health. Among boys, drug use and the lack of physical activity are significant predictors. Among girls, smoking may act in a similar way. Diet control is significant in both cases. Besides academic achievement, SES self-assessment and non-intact family status are strong contributes to health perception. Overall, findings show that psychosocial health variables are important influences on adolescents’ self-perceived health.     

Barriers and facilitators to growth monitoring and promotion in Nepal: Household,health worker and female community health volunteer perceptions

Growth monitoring and promotion (GMP) is both a service for diagnosing inadequate child growth in its earliest stages and a delivery platform for nutrition counselling. The widespread use of GMP services in developing countries has the potential to substantially reduce persistent child undernutrition through early diagnosis and by linking caregivers and their children to key health and nutrition services. However, researchers have questioned the effectiveness of GMP services, which are frequently undermined by underdeveloped health systems and inconsistent implementation. This analysis examined both supply‐ and demand‐side factors for GMP utility in Nepal from the perspectives of beneficiaries and service providers, particularly focusing on three components of GMP: growth assessment, analysis of growth status and counselling. The most common factors influencing GMP uptake included beneficiaries' perceptions of the relative importance of GMP and the knowledge and skill of frontline workers. Both providers and beneficiaries viewed GMP as a secondary health and nutrition activity and therefore less important than curative services. We found deficits in GMP‐related knowledge and skills among providers (i.e. health workers and female community health volunteers), as well as indications of poor training quality and coverage. Furthermore, we found variation in GMP utilization by maternal age, education and residency (alone, nuclear or extended), as well as household socio‐economic well‐being and rurality. This study is the first to assess factors influencing both beneficiaries and service providers for GMP utilization. Further research is needed to explore the implementation of improved GMP protocols and to evaluate facility‐level implementation barriers.     

Maternal relationship style, paediatric health care use and infant health

OBJECTIVE:

The aim of the current exploratory study was to examine the relationships between maternal relationship style, paediatric health care use and infant health variables in a sample of middle-class and ethnically diverse mother-infant dyads.

METHODS:

An initial cross-sectional cohort study obtained demographic and self-report data on mothers’ relationship styles. As an extension of the original study, infants’ patient files were reviewed for the year following initial recruitment to obtain data regarding the use of paediatric health care services and infant health. The final sample included 64 mothers and their infants.

RESULTS:

Correlational analyses revealed that mothers’ higher endorsement of a dismissive relationship style were associated with fewer acute care visits and fewer reported infant illnesses.

CONCLUSIONS:

Compared with other relationship styles, mothers who highly endorsed a dismissive relationship style tended to use fewer acute paediatric health care services and reported fewer infant health problems. However, further longitudinal research is needed to clarify these relationships.     

The enigma of the welfare state: excellent child health prerequisites – poor subjective health

The rate of subjective health complaints among Swedish children is increasing by age and over time, and more so than among children in other Scandinavian countries. In contrast, the somatic health and prerequisites for wellbeing are excellent. This paradoxical situation, The Enigma of the Welfare State, is the focus of this viewpoint. We argue that one important background factor may be late adverse effects of the welfare society itself and some of its inherent values. We have identified several possible pathways. We have given them names of diseases – on the society level – like health obsession, stress panic, welfare apathy and hyper‐individualism. Together with other factors such as a dysfunctional school and an unsatisfactory labour market for youth, these diseases are involved in an interplay that is constantly inducing anxiety and low self‐esteem. Conclusion: The gradually deteriorating self‐reported health among Swedish youth may, to some degree, be explained as a late adverse effect of the welfare society itself and its inherent values.     

Household food insecurity and child health

Food insecurity, the lack of consistent access to sufficient quality and quantity of food, affects an estimated 800 million people around the world. Although household food insecurity is generally associated with poor child nutrition and health in the USA, we know less about household food insecurity and child health in developing countries. Particularly lacking is research assessing how associations between household food insecurity and children's health outcomes may differ by child age and among children beyond age 5 years in low‐income settings. We use data from a population‐based sample of households with children ages 3–11 years (N = 431) in León, Nicaragua to consider how household food insecurity is associated with three measures of child health: illness, anaemia and low height‐for‐age. Our results provide new evidence that even mild household food insecurity is detrimental to children's health; and that child age conditions the associations between household food insecurity and child health. We find that food insecurity is especially harmful to health during early childhood, but continues to have significant associations with health into middle childhood (up to ages 7–8 years). We discuss the potential implications of these results for future child health research and policies in low‐income countries. © 2016 John Wiley & Sons Ltd     

Unmet education and training needs in adolescent health of health professionals in a UK children's hospital

Aim: To determine the perceived education and training needs in adolescent health of health professionals. Design: Cross-sectional survey Setting and subjects: Hospital staff in a UK children's hospital. Outcome measures: perceived barriers, confidence, knowledge, skill and prior teaching in key adolescent health subject areas. Results: The hospital survey was completed by 159/1400 professionals representing a completion rate of 11%. Doctors and staff from 'Professions allied to medicine' rated 'lack of training', 'lack of teaching materials' and ' lack of community resources' as the main barriers to providing developmentally appropriate care. Sixty per cent of hospital respondents had received no prior specific training in adolescent health. All but four topics were perceived to be of very high or high importance by the majority of respondents (54-90%). Low scores in perceived knowledge, confidence and/or skill were reported in nine key subject areas (including adolescent mental health and substance use). Differences between doctors and professions allied to medicine were observed in a minority of areas.

Conclusion: Unmet education and training needs of a range of professionals working in a paediatric setting were identified in key areas of adolescent health and they provide useful directions for the development of future multidisciplinary training programmes.