Clare Blackburn

Access to health care for Roma children in Central and Eastern Europe: findings from a qualitative study in Bulgaria

BackgroundDespite the attention the situation of the Roma in Central and Eastern Europe has received in the context of European Union enlargement, research on their access to health services is very limited, in particular with regard to child health services.Methods50 qualitative in-depth interviews with users, providers and policy-makers concerned with child health services in Bulgaria, conducted in two villages, one town of 70,000 inhabitants, and the capital Sofia.ResultsOur findings provide important empirical evidence on the range of barriers Roma children face when accessing health services. Among the most important barriers are poverty, administrative and geographical obstacles, low levels of parental education, and lack of ways to accommodate the cultural, linguistic and religious specifics of this population group.ConclusionOur research illustrates the complexity of the problems the Roma face. Access to health care cannot be discussed in isolation from other problems this population group experiences, such as poverty, restricted access to education, and social exclusion.

Parent reported home smoking bans and toddler (18–30 month) smoke exposure: a cross-sectional survey

Aims: To study the relation between the use of parent reported home smoking bans and smoke exposure among children aged 18–30 months. Methods: A total of 309 smoking households with children aged 18–30 months, who were part of the Coventry Cohort study, consented to participate in this cross-sectional survey. Results: Although parents in almost 88% of smoking households reported using harm reduction strategies to protect their toddlers from smoke exposure, only 13.9% reported smoking bans in the house. Mean log urinary cotinine:creatinine ratio was significantly lower for those children whose parents reported no smoking in the house (1.11, 95% CI 0.64 to 1.49) compared with none/less strict strategies (1.87, 95% CI 1.64 to 2.10). In linear regression models fitted on log cotinine:creatinine ratio, no smoking in the house was independently associated with a significant reduction in cotinine:creatinine ratio (B = −0.55, 95% CI −0.89 to −0.20) after adjusting for mother’s and partner’s average daily cigarette consumption, housing tenure, and overcrowding. The final model accounted for 44.3% of the variance. Conclusions: Not smoking in the house was associated with a reduction in mean urinary cotinine:creatinine ratio in children aged 18–30 months; the relation persisted after adjustment for levels of mother’s and partner’s daily cigarette consumption and sociodemographic factors. Results suggest that home smoking bans in this age group have a small but significant effect on smoke exposure independent of levels of parental tobacco consumption.

The Socio‐economic Patterning of Health and Smoking Behaviour among Mothers with Young Children on Income Support

The paper is set against the backdrop of the increase in the number of households in the UK in receipt of means-tested benefits. Focusing on women in households with children, it examines two issues : the limitations of conventional measures of socio-economic position and the contribution that alternative measures can make to the analysis of socio-economic variations in health in claimant households. These issues are illustrated by a British survey of mothers caring for young children on income support. The data point to relative disadvantage within this low-income group and the difficulties of capturing its range and degree within conventional socio-economic measures. Analyses examine the contribution which conventional and alternative indicators of socio-economic position make to predicting the odds of poor health and cigarette smoking among mothers in the survey. They conclude that the use of conventional measures may result in an underestimation of the strength of the association between relative disadvantage, poorer health and smoking behaviour within claimant groups, and that alternative measures need to be developed if the scale and health-impact of disadvantage is to be accurately reflected in surveys of health and lifestyles

Impact of health reforms on child health services in Europe: the case of Bulgaria.

BACKGROUND In the last two decades, all countries in Europe have embarked on substantial health reforms, introducing new models of financing and provision of health services. Using Bulgaria as a case study, this article examines the impact of the reforms on child health services. METHODS This is the first of a series of papers drawing on a broader research on inequalities in access to child health services, using Bulgaria as a case study. Multiple methods and data sources were used, including a review of the literature and existing epidemiological data, 50 qualitative in-depth interviews and an analysis of regulatory documents. This article presents the findings of the documentary analysis. RESULTS Primary health services for children are now provided by general practitioners. Children are exempted from health insurance contributions and user fees and are formally entitled to free health care. During the first years of the reform general practitioners still had insufficient training in child health. Restrictions on the number of referrals to paediatricians and discontinuation of community services at a time when general practice was not well established, undermined access to quality care. CONCLUSION While many of these issues have been subsequently addressed, the reform process was far from linear. Challenges remain in ensuring access to quality child health services to the rural population and marginalized groups, such as the Roma minority and children with disabilities. Throughout Europe, health reforms need to be based on solid evidence of what works best for improving quality of and access to child health services.

Is the onset of disabling chronic conditions in later childhood associated with exposure to social disadvantage in earlier childhood? a prospective cohort study using the ONS Longitudinal Study for England and Wales

BackgroundThe aetiology of disabling chronic conditions in childhood in high income countries is not fully understood, particularly the association with socio-economic status (SES). Very few studies have used longitudinal datasets to examine whether exposure to social disadvantage in early childhood increases the risk of developing chronic conditions in later childhood. Here we examine this association, and its temporal ordering, with onset of all-cause disabling chronic later childhood in children reported as free from disability in early childhood.MethodsThe study comprised a prospective cohort study, using data from the Office for National Statistics Longitudinal Study (ONSLS) for England and Wales. The study sample included 52,839 children with complete data born between 1981–1991 with no disabling chronic condition/s in 1991. Index cases were children with disability recorded in 2001. Comparison cases were children with no recorded disability in 1991. A socio-economic disadvantage index (SDI) was constructed from data on social class, housing tenure and car/van access. Associations were explored with logistic regression modelling controlling sequentially for potentially confounding factors; age, gender, ethnicity and lone parenthood.ResultsBy 2001, 2049 (4%) had at least one disability. Socio-economic disadvantage, age, gender and lone parenthood but not ethnicity were significantly associated with onset of disabling chronic conditions. The SDI showed a finely graded association with onset of disabling chronic conditions in the index group (most disadvantaged OR 2·11 [CI 1·76 to 2·53]; disadvantaged in two domains OR 1·45 [CI 1·20 to 1·75]; disadvantaged in one domain OR 1·14 [CI 0·93 to 1·39] that was unaffected by age, gender and ethnicity and slightly attenuated by lone parenthood.ConclusionTo our knowledge, this is the first study to identify socio-economic disadvantage in earlier childhood as a predisposing factor for onset of all-cause disabling chronic conditions in later childhood. Temporal ordering and gradation of the response indicate socio-economic disadvantage may play a causal role. This suggests that targeting preventative efforts to reduce socio-economic disadvantage in early childhood is likely to be an important public health strategy to decease health inequalities in later childhood and early adulthood.

Issues of Gender, Reflexivity and Positionality in the Field of Disability: Researching Visual Impairment in an Arab Society

This article examines how the social and cultural context influence the way in which field research methods are utilized. Research methods need to be modified to meet the sensibilities and sensitivities of particular social groups and settings. Through a reflexive analysis of a research study on the lives of visually impaired young people and adults in Bahrain, this article discusses how gender, religion and culture need to be taken account of. It also discusses how the research process needed to take account of the participants’ disabilities. It examines the issues of research access, informed consent, researcher’s dress, confidentiality, research location, and time. It highlights how the gender of the researcher was constraining in some gender segregated educational settings in a Muslim society. The article engages with the researcher’s positionality through reflexive discussion.

Disabling chronic conditions in childhood and socioeconomic disadvantage: a systematic review and meta-analyses of observational studies

Objective To determine the association of socioeconomic disadvantage with the prevalence of childhood disabling chronic conditions in high-income countries. Study design Systematic review and meta-analyses. Data sources 6 electronic databases, relevant websites, reference lists and experts in the field. Study selection 160 observational studies conducted in high-income countries with data on socioeconomic status and disabling chronic conditions in childhood, published between 1 January 1991 and 31 December 2013. Data extraction and synthesis Abstracts were reviewed, full papers obtained, and papers identified for inclusion by 2 independent reviewers. Inclusion decisions were checked by a third reviewer. Where reported, ORs were extracted for low versus high socioeconomic status. For studies reporting raw data but not ORs, ORs were calculated. Narrative analysis was undertaken for studies without data suitable for meta-analysis. Results 126 studies had data suitable for meta-analysis. ORs for risk estimates were: all-cause disabling chronic conditions 1.72 (95% CI 1.48 to 2.01); psychological disorders 1.88 (95% CI 1.68 to 2.10); intellectual disability 2.41 (95% CI 2.03 to 2.86); activity-limiting asthma 2.20 (95% CI 1.87 to 2.85); cerebral palsy 1.42 (95% CI 1.26 to 1.61); congenital abnormalities 1.41 (95% CI 1.24 to 1.61); epilepsy 1.38 (95% CI 1.20 to 1.59); sensory impairment 1.70 (95% CI 1.39 to 2.07). Heterogeneity was high across most estimates (I2>75%). Of the 34 studies without data suitable for meta-analysis, 26 reported results consistent with increased risk associated with low socioeconomic status. Conclusions The findings indicate that, in high-income countries, childhood disabling chronic conditions are associated with social disadvantage. Although evidence of an association is consistent across different countries, the review provides limited evidence to explain the association; future research, using longitudinal data, will be required to distinguish low socioeconomic status as the cause or consequence of childhood disabling chronic conditions and the aetiological pathways and mechanisms.

Childhood disability and socio-economic circumstances in low and middle income countries: systematic review

BackgroundThe majority of children with disability live in low and middle income (LAMI) countries. Although a number of important reviews of childhood disability in LAMI countries have been published, these have not, to our knowledge, addressed the association between childhood disability and the home socio-economic circumstances (SEC). The objective of this study is to establish the current state of knowledge on the SECs of children with disability and their households in LAMI countries through a systematic review and quality assessment of existing research.MethodsElectronic databases (MEDLINE; EMBASE; PUBMED; Web of Knowledge; PsycInfo; ASSIA; Virtual Health Library; POPLINE; Google scholar) were searched using terms specific to childhood disability and SECs in LAMI countries. Publications from organisations including the World Bank, UNICEF, International Monetary Fund were searched for. Primary studies and reviews from 1990 onwards were included. Studies were assessed for inclusion, categorisation and quality by 2 researchers.Results24 primary studies and 13 reviews were identified. Evidence from the available literature on the association between childhood disability and SECs was inconsistent and inconclusive. Potential mechanisms by which poverty and low household SEC may be both a cause and consequence of disability are outlined in the reviews and the qualitative studies. The association of poor SECs with learning disability and behaviour problems was the most consistent finding and these studies had low/medium risk of bias. Where overall disability was the outcome of interest, findings were divergent and many studies had a high/medium risk of bias. Qualitative studies were methodologically weak.ConclusionsThis review indicates that, despite socially and biologically plausible mechanisms underlying the association of low household SEC with childhood disability in LAMI countries, the empirical evidence from quantitative studies is inconsistent and contradictory. There is evidence for a bidirectional association of low household SEC and disability and longitudinal data is needed to clarify the nature of this association.

Prevalence and social patterning of limiting long‐term illness/disability in children and young people under the age of 20 years in 2001: UK census‐based cross‐sectional study

Uses research data from the UK 2001 Population Census to look at the prevalence rates of limiting long-term illness/disability in children and young people aged 0-19 years. Finds that almost one in 20 children and young people had a parent-reported LLTI/disability. Discusses findings on age and gender; the impact of social policy and social inequalities; the impact on service provision; and in relation to other research findings.

Disabled children in the UK: a quality assessment of quantitative data sources

BACKGROUND The limitations of reliable and accessible UK national and local quantitative data on the prevalence of childhood disability and the characteristics and circumstances of disabled children and their households have been recognized for some time. This paper reports the findings from a study that scoped and quality-assessed existing quantitative UK national and regional data sets on disabled children and their families. METHODS A comprehensive search of relevant data sources with information on disabled children was undertaken. Data sources were evaluated with reference to: disability definitions and questions; potential to generate nationally representative prevalence estimates of disabled children; study design; population coverage; sampling issues; social and demographic data; appropriateness for identifying childhood as opposed to adult disability. RESULTS Thirty-seven data sources with information on childhood disability were identified, of which 30 met the inclusion criteria: nine cross-sectional surveys, nine longitudinal and panel studies, seven administrative data sets, four specific condition databases and one was another type. Definitions and questions varied across data sources. Long-standing illness and limiting long-standing illness were the most consistently used definitions. Repeated cross-sectional surveys were found to be most appropriate for estimating overall prevalence but, with the exception of the Population Census, sample sizes were too small to study prevalence and characteristics by some population sub-groups such, including age by year, minority ethnic status and socio-economic position. Few data sources included questions appropriate for identifying childhood as opposed to adult disability or collected information from disabled children themselves. CONCLUSIONS Our findings summarize the currently available quantitative data sources on childhood disability and highlight the limitations. We make recommendations for the future development of more robust childhood disability data and issues requiring further research. To assist policy makers and service providers to make use of current data sources we have produced a brief online guide based on our findings.