Children living in disadvantaged communities have substantially increased risk for deleterious health and developmental outcomes. A considerable proportion of developmental delay is avoidable; ...however if children do not receive appropriate treatment within this critical period, damage can be irreparable. Community paediatric clinics provide medical and developmental assessment; deliver health promotion services, counselling, and advice to caregivers; and referral to services. The aim of this study was to systematically search, appraise, and synthesise the literature exploring the role of community paediatric clinics in supporting developmental outcomes and services for children living in disadvantaged communities. Electronic databases were searched using a carefully developed search strategy. Validated tools and appropriate guidelines assessed quality and confidence in evidence. Data analysis and mixed-methods synthesis was guided by the Segregated Framework for Mixed-Method Systematic Reviews. Eighteen studies were selected for inclusion. Areas of emphasis in the literature include the identification and monitoring of developmental delay; engagement of vulnerable families; relational working with children, families, and local services; referral to early intervention services; parental empowerment, practitioner capacity building; and tackling barriers to healthcare access. Through use of a child and family-centred model of care, community paediatric clinics can better meet the needs of vulnerable populations.
In the UK, school nurses play a crucial role in promoting the health and wellbeing of children and young people, giving them the best start in life and supporting them to sustain optimal health. They ...have a vital and unique link between education settings, home and the community. Their key role is within the public health arena, they are an important part of the primary health care team and a key link for acute and community paediatric teams and therapies. The onset of school nursing came in the Victorian era with a focus on improving the health of children living in poverty, this coincided with a report from the British army at the time which highlighted that young men joining the service were unfit for purpose. Now, in the 21st century, we are faced with widening health inequalities, shocking levels of poverty and increases in the number of people living with major illness and mental health problems. It is argued that the school nurse has never been more essential in supporting the health and well-being of children and young people which includes their integral role in safeguarding. In this article we will explore why this might be the case, the difficulties and opportunities and, importantly, how, alongside our paediatric colleagues in both community and acute settings, we can best garner our combined efforts to rise above and beyond the escalating challenges.
Biological embodiment is a concept derived from Engel’s biopsychosocial model to health, theorized as the process by which adverse social exposures trigger neuroendocrine and immune responses, ...leading to disease and/or increased disease susceptibility. This critical review discusses the biopsychosocial model as applied to oral health and its relevance to oral health policy while deciphering some of the pathobiological processes underlying social adversity. In periodontal disease, for example, such processes can occur via the activation of the hypothalamic-pituitary-adrenal axis and the consequent release of the chronic stress hormone cortisol. The latter contributes to a proinflammatory immune state that increases the risk for periodontal inflammation. Recent research shows that cortisol relates to an elevated oral inflammatory load, demonstrated as hyperactive neutrophils that are pivotal to periodontal tissue damage. Consistent with the biopsychosocial model, this relationship is amplified in those of lower income and higher financial stress. Similarly, among children from lower socioeconomic backgrounds, cortisol is linked to a higher cariogenic bacterial load. Such findings implicate the stress pathway as key in the oral pathogenic process, particularly under social/socioeconomic adversity. Collectively, this work emphasizes the importance of addressing social factors in alleviating oral disease burden and reducing the social gaps therein.
Background
With advances in technology, there is an emerging concern that inequalities exist in provision and diabetes outcomes in areas of greater deprivation. We assess the relationship between ...socio‐economic status and deprivation with access to diabetes technology and their outcomes in adults with type 1 diabetes.
Methods
Retrospective, observational analysis of adults attending a tertiary centre, comprising three urban hospitals in the UK. Socio‐economic deprivation was assessed by the English Indices of Deprivation 2019. Data analysis was performed using one‐way ANOVAs and chi‐squared tests.
Results
In total, 1631 adults aged 44 ± 15 years and 758 (47%) women were included, with 391 (24%) using continuous subcutaneous insulin infusion, 312 (19%) using real‐time continuous glucose monitoring and 558 (34%) using intermittently scanned continuous glucose monitoring. The highest use of diabetes technology was in the least deprived quintile compared to the most deprived quintile (67% vs. 45%, respectively; p < 0.001). HbA1c outcomes were available in 400 participants; no association with deprivation was observed (p = 0.872). Participation in structured education was almost twice as high from the most deprived to the least deprived groups (23% vs. 43%; p < 0.001). Adults with white or mixed ethnicity were more likely to use technology compared to black ethnicity (60% vs. 40%; p < 0.001).
Conclusions
Adults living in the most deprived quintile had less technology use. Irrespective of socio‐economic status or ethnicity, glycaemia was positively affected in all groups. It is imperative that health disparities are further addressed.
BackgroundBoth adverse childhood experiences (ACEs) and adverse childhood socioeconomic conditions (SECs) in early life are associated with poor outcomes across the life course. However, the complex ...interrelationships between childhood SECs and ACEs are unclear, as are the consequences for health outcomes beyond childhood. We therefore assessed the extent to which early-life ACEs mediate the relationship between SECs and socioemotional behavioural problems, cognitive disability and overweight/obesity in adolescence.MethodsWe used longitudinal data from the UK Millennium Cohort Study (MSC). Outcomes assessed at age 14 were socioemotional behavioural problems, cognitive disability and overweight/obesity. SECs at birth were measured by maternal education. Potentially mediating ACEs measured up to 5 years were verbal and physical maltreatment, parental drug use, domestic violence, parental divorce, maternal mental illness and high frequency of parental alcohol use. We used counterfactual mediation analysis to assess the extent to which ACEs mediate the association between SECs at birth and behavioural, cognitive and physical outcomes at age 14, estimating total (TE), natural direct and indirect effects, and mediated proportions.ResultsChildren with disadvantaged SECs were more likely to have socioemotional behavioural problems (relative risk (RR) 3.85, 95% CI 2.48 to 5.97), cognitive disability (RR 3.87, 95% CI 2.33 to 6.43) and overweight/obesity (RR 1.61, 95% CI 1.32 to 1.95), compared to those with more advantaged SECs. Overall, 18% of the TE of SECs on socioemotional behavioural problems was mediated through all ACEs investigated. For cognitive disability and overweight/obese, the proportions mediated were 13% and 19%, respectively.ConclusionACEs measured up to age 5 years in the MCS explained about one-sixth of inequalities in adolescents behavioural, cognitive and physical outcomes.
Homelessness is associated with enormous health inequalities, including shorter life expectancy, higher morbidity and greater usage of acute hospital services. Viewed through the lens of social ...determinants, homelessness is a key driver of poor health, but homelessness itself results from accumulated adverse social and economic conditions. Indeed, in people who are homeless, the social determinants of homelessness and health inequities are often intertwined, and long term homelessness further exacerbates poor health. Aggregated health service data can mask this, and case histories thus provide important insights.
This paper presents three case histories of homeless patients seen at an inner city public hospital in Perth, Western Australia. The case histories draw on several data sources: hospital data, information collected from rough sleepers and clinical observations. Estimates of the cost to the health system of the observed hospital usage by the three patients are included.
The case histories illustrate the interplay of social determinants of health in homelessness that help explain the high level of hospital usage by rough sleepers. The cumulative healthcare costs for the three individuals over a 33 months period were substantial. Hospital attendance plummeted even in the short term when housing needs were addressed.
Treating homelessness as a combined health and social issue is critical to improving the abysmal health outcomes of people experiencing homelessness. In addition, the enormous economic costs of hospital care for people who are homeless can be reduced when housing and other social determinants are taken into account.
As intuitive and inviting as it may appear, the concept of patient-centered care has been difficult to conceptualize, institutionalize and operationalize. Informed by Bourdieu's concepts of cultural ...capital and habitus, we employ the framework of cultural health capital to uncover the ways in which both patients' and providers' cultural resources, assets, and interactional styles influence their abilities to mutually achieve patient-centered care. Cultural health capital is defined as a specialized collection of cultural skills, attitudes, behaviors and interactional styles that are valued, leveraged, and exchanged by both patients and providers during clinical interactions. In this paper, we report the findings of a qualitative study conducted from 2010 to 2011 in the Western United States. We investigated the various elements of cultural health capital, how patients and providers used cultural health capital to engage with each other, and how this process shaped the patient-centeredness of interactions. We find that the accomplishment of patient-centered care is highly dependent upon habitus and the cultural health capital that both patients and providers bring to health care interactions. Not only are some cultural resources more highly valued than others, their differential mobilization can facilitate or impede engagement and communication between patients and their providers. The focus of cultural health capital on the ways fundamental social inequalities are manifest in clinical interactions enables providers, patients, and health care organizations to consider how such inequalities can confound patient-centered care.
•Patient-centered care (PCC) is difficult to achieve in practice.•Cultural health capital (CHC) helps explain the challenges of providing PCC.•CHC are cultural skills and resources that facilitate patient–provider engagement.•Our qualitative study shows the presence or lack of CHC promotes or impedes PCC.•PCC models must attend to the clinical interaction complexities highlighted by CHC.
A number of studies have shown an association between health-related quality of life (HRQL) and socioeconomic status (SES). Indicators of SES usually serve as potential confounders; associations ...between SES and HRQL are rarely discussed in their own right. Also, few studies assess the association between HRQL and SES among those with a chronic disease. The study focuses on the question of whether people with the same state of health judge their HRQL differently according to their SES, and whether a bias could be introduced by ignoring these differences.
The analyses were based on a representative sample of the adult population in Germany (n = 11,177). HRQL was assessed by the EQ-5D-3 L, i.e. the five domains (e.g. 'moderate or severe problems' concerning mobility) and the Visual Analog Scale (VAS). SES was primarily assessed by educational level; age, sex and family status were included as potential confounders. Six chronic diseases were selected, each having a prevalence of at least 1% (e.g. diabetes mellitus). Multivariate analyses were conducted by logistic and linear regression.
Among adults with a chronic disease, most 'moderate or severe problems' are reported more often in the low (compared with the high) educational group. The same social differences are seen for VAS values, also in subgroups characterized by 'moderate or severe problems'. Gender-specific analyses show that for women the associations with VAS values can just be seen in the total sample. For men, however, they are also present in subgroups defined by 'moderate or severe problems' or by the presence of a chronic disease; some of these differences exceed 10 points on the VAS scale.
Low SES groups seem to be faced with a double burden: first, increased levels of health impairments and, second, lower levels of valuated HRQL once health is impaired. These associations should be analysed and discussed in their own right, based on interdisciplinary co-operation. Social epidemiologists could include measures of HRQL in their studies more often, for example, and health economists could consider assessing whether recommendations based on HRQL scales might include a social bias.
Purpose
Poor mental health has been consistently linked with the experience of financial hardship and poverty. However, the temporal association between these factors must be clarified before ...hardship alleviation can be considered as an effective mental health promotion and prevention strategy. We examined whether the longitudinal associations between financial hardship and mental health problems are best explained by an individual’s current or prior experience of hardship, or their underlying vulnerability.
Methods
We analysed nine waves (years: 2001–2010) of nationally representative panel data from the Household, Income, and Labour Dynamics in Australia survey (
n
= 11,134). Two components of financial hardship (deprivation and cash-flow problems) and income poverty were coded into time-varying and time-invariant variables reflecting the contemporaneous experience of hardship (i.e., current), the prior experience of hardship (lagged/12 months), and any experience of hardship during the study period (vulnerability). Multilevel, mixed-effect logistic regression models tested the associations between these measures and mental health.
Results
Respondents who reported deprivation and cash-flow problems had greater risk of mental health problems than those who did not. Individuals vulnerable to hardship had greater risk of mental health problems, even at the times they did not report hardship. However, their risk of mental health problems was greater on occasions when they did experience hardship.
Conclusions
The results are consistent with the argument that economic and social programmes that address and prevent hardship may promote community mental health.
Socio-economic inequalities in mental health problems are found in measures covering prevalence, treatment utilisation, and treatment helpfulness. However, whether these inequalities exist globally ...and what factors explain between-country variation is unclear. We use a nationally representative individual-level survey dataset (Wellcome Global Monitor, 2020) in 111 countries (N = 117,088) to test if socio-economic factors (household income, education), psycho-social factors (stigma perception, trust in health professionals) and country-level factors (GDP, Gini, health expenditure) predict (1) self-reported lifetime prevalence of anxiety and depression symptomology, (2) treatment utilisation and (3) perceived treatment helpfulness talking to a mental health professional and taking prescribed medication. Multi-level logistic regression models were used. Across both HICs and LMICs, being in the richest income quintile within each country is associated with a lower probability of experiencing symptoms of anxiety and depression compared to the poorest quintile (OR = 0.67 CI0.64-0.70), as well as a higher probability of talking to a mental health professional (OR = 1.251.14-1.36), and of perceiving this treatment as very helpful (OR = 1.231.07-1.40). However, being among the richest income quintile is not associated with taking prescribed medication (OR = 0.970.89-1.06) and its perceived helpfulness (OR = 1.060.94-1.21) across all countries. Trust in health practitioners is associated with higher mental health professional utilisation (OR = 1.101.06-1.14) and helpfulness (OR = 1.321.25-1.40). This analysis reveals a global 'triple inequality in mental health', whereby disadvantages of lower SES individuals persist in three outcomes (lifetime prevalence, treatment utilisation and helpfulness). Treatment utilisation and helpfulness also vary by trust in healthcare professionals and treatment type. Policymakers must address all three inequalities and their fundamental causes.
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