Social inequalities in access to child healthcare services : an international comparative perspective

Universal access to child healthcare services is of greatest importance and a common goal of many countries in Europe and elsewhere. Thus, every child should be able to receive the healthcare they need, irrespective of their socio-economic circumstances and national origin. To what degree this is the case is the subject of this thesis. This thesis examines social patterns of access to child healthcare services and, furthermore, evaluates social inequalities in relation to structural and organizational differences in child healthcare systems at national levels. In particular, the studies use different indicators of access to child healthcare services, focusing on the three levels of preventive care: primary, secondary, and tertiary. The thesis draws on national register data from several countries and uses an international comparative perspective on social inequalities in child healthcare services.

Studies I, II, and III analyzed primary-level prevention, focusing on the social distribution of Measles-Mumps-Rubella (MMR) and/or Diphtheria-Tetanus-Pertussis (DTP) vaccination uptake among children. The results from Study I, a systematic review, revealed different levels of inequalities across European countries and Australia. A comparison of healthcare systems showed that countries that have well-baby clinics and have a hierarchical primary healthcare service structure tend to be more equitable. The results from Study II supported the findings about well-baby clinics in Study I. A comparison between four Nordic countries revealed the lowest vaccination levels and the highest social inequalities in Denmark. Considering that the healthcare systems among these Nordic countries are very similar, the absence of well-baby clinics stands out as a possible explanation for the observed difference in inequalities. Study III examined trends in the social distribution of MMR vaccination coverage in two Australian states (New South Wales and Western Australia). The results showed increasing inequalities among children with a migrant background in both states and persisting but diminishing inequalities for Aboriginal children, especially in Western Australia. Ambitious immunization policies and strategic interventions towards the Aboriginal population could plausibly explain the decreasing inequalities in New South Wales. Study IV analyzed secondary prevention, focusing on the social distribution of the timing of orchidopexy (surgery for undescended testicles) among children before and after new European guidelines recommending the surgery to be performed before the age of 1. Based on a comparison between five jurisdictions, the results showed both absolute and relative increases in overall inequalities in surgeries before the age of 1. Study V looked at the social distribution of ADHD medication uptake among children in Sweden. A comparison between children of parents with a migrant background and children of Swedish-born parents showed lower ADHD medication uptake among children of parents from low- and middle-income non-European countries.

In summary, using an international comparative perspective and combining a systematic review with empirical registry studies, the thesis shows persisting inequalities in the uptake of child healthcare services. Furthermore, the magnitude of social inequalities vary between countries with different structure and organization of child healthcare services. These findings indicate the potential of a more equitable healthcare system and points to the need to reform child healthcare services in welfare states.

List of scientific papers

I. Arat A, Burström B, Östberg V, Hjern A. Social inequities in vaccination coverage among infants and pre-school children in Europe and Australia – a systematic review. BMC Public Health. 2019, 19:290.
https://doi.org/10.1186/s12889-019-6597-4

II. Arat A, Norredam M, Baum U, Jónsson SF, Gunlaugsson G, Wallby T, Hjern A. Organisation of preventive child health services: Key to socio-economic equity in vaccine uptake? Scandinavian Journal of Public Health. 2019.
https://doi.org/10.1177/1403494819850430

III. Arat A, Moore H, Goldfeld S, Östberg V, Vicky Sheppeard, Hjern A and Gidding H. Childhood immunization coverage in Australia: An equity perspective. [Manuscript]

IV. Jay MA, Arat A, Wijlaars L, Ajetunmobi O, Fitzpatrick T, Lu H, Lei S, Skerritt C, Goldfeld S, Gissler M, Gunnlaugsson G, Jónsson SF, Hjern A, Guttmann A, Gilbert R. Timing of paediatric orchidopexy in universal healthcare systems: an international administrative data cohort study. [Submitted]

V. Arat A, Östberg V, Burström B, Hjern A. ADHD medication in offspring of immigrants - does the income level of the country of parental origin matter? BMC Psychiatry. 2018, 18:3.
https://doi.org/10.1186/s12888-017-1572-z