Integrating Health Care Strategies to Prevent Poverty-Related Disparities in Development and Growth: Addressing Core Outcomes of Early Childhood

Abstract

Poverty-related disparities appear early in life in cognitive, language, and social-emotional development, and in growth, especially obesity, and have long-term consequences across the life course. It is essential to develop effective strategies to promote healthy behaviors in pregnancy and the early years of parenthood that can mitigate disparities. Primary preventive interventions within the pediatric primary care setting offer universal access, high engagement, and population-level impact at low cost. While many families in poverty or with low income would benefit from preventive services related to both development and growth, most successful interventions have tended to focus on only one of these domains. In this manuscript, we suggest that it may be possible to address both development and growth simultaneously and effectively. In particular, current theoretical models suggest alignment in mechanisms by which poverty can create barriers to parent-child early relational health (i.e., parenting practices, creating structure, and parent-child relationship quality), constituting a final common pathway for both domains. Based on these models and related empirical data, we propose a strength-based, whole child approach to target common antecedents through positive parenting and prevent disparities in both development and growth; we believe this approach has the potential to transform policy and practice. Achieving these goals will require new payment systems that make scaling of primary prevention in health care feasible, research funding to assess efficacy/effectiveness and inform implementation, and collaboration among early childhood stakeholders, including clinicians across specialties, scientists across academic disciplines, and policy makers.

Introduction

The damaging effects of poverty on the development and growth of young children have been extensively documented.^1,2 Poverty-related disparities appear early in life in cognitive, language, and social-emotional development (and subsequent school readiness),³ and in physical growth, especially obesity,⁴ with consequences for trajectories across the life course. Parent-child early relational health represents a common link between child development and growth in the context of poverty. Primary prevention evidence-based interventions (EBIs), particularly those that promote relational health beginning in early childhood before problems arise, offer potentially far-reaching benefits.²

Multiple methodologies have documented pathways by which poverty affects development and growth. Correlational studies show that parental income is related to cognitive development and behavior before child age 5 years, both directly and indirectly through parents’ ability to invest in a cognitively-stimulating environment and through stress and mental health.^5,6 Similarly, cohort studies have shown that overweight and obesity are more common in children whose families had limited or declining income. In addition, experimental studies have linked income to academic achievement and attainment in school-age children.² Impacts of poverty and low income on children’s early cognitive, social-emotional development and physical growth are partially due to toxic stress.⁷ Increased or prolonged activation of the hypothalamic-pituitary-adrenal axis, in the absence of buffering, responsive relationships, may have detrimental effects on the development of the brain and body. For instance, poverty-related family stress has been shown to disrupt children’s emotional regulation, with implications for both cognitive and social-emotional skills as well as for increased obesogenic eating practices, such as eating in the absence of hunger.⁸

Longstanding systemic injustices have contributed greatly to child poverty in the United States.¹ Programs supporting families with children such as universal health insurance, paid parental leave, extended sick leave, fair living wage, and housing support are not widely available. Structural racism has resulted in inequality of opportunities in education, housing, and employment. Therefore, a significant expansion of programs and policies, which support improved economic circumstances for families with children, and buffer the impacts of structural racism, is essential to address disparities, which persist across the life course.

In conjunction with such policy changes, pediatric health care represents a system with a unique and underutilized potential to prevent or ameliorate poverty-related disparities in child development and growth through primary prevention. Pediatric primary care includes thirteen or more routine visits during the first three years of life, with trusted providers within an existing infrastructure – the medical home, and a health insurance system that covers most children.⁹ Indeed, a core component of primary care is anticipatory guidance designed for primary prevention related to development and growth. However, data suggesting that such guidance is sufficient on its own are limited, and there has been a sustained focus on adding EBIs to support primary prevention related to development and growth in primary care.

Implementation of preventive EBIs within pediatric primary care, to provide equitable parenting supports and resources, offer potential for universal access, high engagement, and population-level impact at low cost, and can complement initiatives in other settings such as home visiting.^9,10 However, there are significant barriers to delivering primary prevention within health care focused on both development and growth, despite interest and buy-in documented in community needs assessments. The most clear-cut barrier is practical – families generally do not have either the time or bandwidth to engage in separate programs. Further, systems-level changes to date (e.g., team-based care) have not typically focused on primary prevention, and have not necessarily been designed to support universal delivery across these two domains.

We suggest that it may be possible to support development and growth simultaneously and more effectively in primary health care. In particular, theoretical models and related empirical data suggest alignment in mechanisms by which poverty affects both development and growth. Further, they suggest that parent-child early relational health¹¹—the patterns of early emotional connection and relationships, including responsive parenting and positive practices— is an important source of resilience that can buffer families’ adverse experiences due to poverty and racism. Promoting relational health in primary care can thereby result in enhanced outcomes in these two central domains, channeling support through a system already used by the vast majority of families with young children across the racial, ethnic, and socioeconomic spectrum.

Poverty and disparities in development and growth

Approximately half of children living in poor and low-income families have delays in school readiness at kindergarten entry,³ which is linked to low reading proficiency in the third grade. More than a quarter will not finish high school,¹² leading to long-term disparities in adult economic achievement and human capital, and in health and mental health. Such risks are further exacerbated by impacts of poverty on children’s social-emotional development, including increased internalizing and externalizing behaviors, and reduced self-regulation.²

Similarly, child obesity is significantly more prevalent among low-income, racial, and ethnic minority children in the United States.⁴ Onset of disparities in obesity is apparent in early infancy, well before school entry, with implications for long-term weight trajectories,¹³ and development of comorbidities, including diabetes, cardiovascular disease, joint disease, and cancers.

These lines of evidence highlight that disparities in development and growth both begin in infancy, within a multilevel, ecological context related to society, community, family, and the child,^14,15 with significant heterogeneity of assets and vulnerabilities within low-income families. Effective strategies to promote healthy behaviors in pregnancy and the early years of parenting offer an opportunity to intervene early and improve outcomes across the life course.¹⁶

Poverty, early relational health, and early child development and growth

Early relational health,¹¹ conceptualized here as positive parenting practices, creating structure, and strong parent-child relationships, represents a common pathway to build family resilience and thereby mitigate poverty-related disparities in early childhood development (cognitive/language and social-emotional) and growth.^1,17 As shown in Figure 1, the three components of relational health are interrelated and represent common antecedents for both development and growth.

Figure 1.

Models and mechanisms by which poverty influences both child development and growth through early relational health

First, positive parenting practices supporting development, such as shared reading and pretend play, have been demonstrated to facilitate both verbal and affective interactions that enhance parent-child relationship quality.¹⁸ Similarly, positive parenting practices supporting growth, including exclusive breastfeeding, provision of healthy foods, and opportunities for physical activity, are linked with healthier growth trajectories.¹⁹ Interactions between parents and children are central within both domains.

Second, similarities exist across domains with regard to creating structure by establishing daily routines for positive activities related to development, such as reading, play, and teaching,²⁰ or routines related to growth, such as feeding, mealtimes, physical activity, and sleep. Simultaneously, both domains are supported by appropriate limit setting, particularly in relation to consistent, non-reinforcing discipline strategies for behavioral challenges and maintaining appropriate limits on sweetened beverage and processed food consumption, excessive bottle use, and screen time.

Third, aspects of parent-child relationship quality across both domains align, with general authoritative parenting styles (e.g., contingent, sensitive/responsive to developmental/behavioral cues)²¹ supporting development, and responsive feeding styles (e.g., responding to hunger and satiety cues, and appropriate limit setting with regard to quality of food consumed)²² supporting growth. Non-responsive parenting, including harsh, controlling, coercive, intrusive, and punitive approaches, is adversely associated with outcomes across the two domains.

Conceptualization within an integrated framework

Early relational health and child development and health outcomes can be conceptualized within a transactional/ecological, developmental systems framework,^7,14,23,24 in which poverty and racism dynamically affect the broad family context. Two complementary explanatory models (Parental Investment Model, Family Stress Model,^5,6 Fig. 1) build upon this framework to explain these processes. According to these models, social determinants of health, including limitations in family resources (e.g., financial capital, human capital, and community resources) and stressors both within the family (e.g., chaos, discord) and extending beyond (e.g., trauma, low social support, discrimination), represent distal ecological factors that affect early relational health aligned most proximally to the core outcomes. Importantly, the same broad contextual factors are associated with both development and growth. Therefore, these factors represent targets for population-level approaches that combat poverty and systemic racism, and provide context for individual-level strategies.

Intermediate factors that compensate for or potentiate the effects of distal ecological factors on early relational health include parenting assets, aligned across development and growth with respect to knowledge, interactional skills, resources, and self-efficacy. There are also parenting vulnerabilities, such as parenting stress and depressive and anxiety symptoms that are common to disparities in both domains.

Consideration of the broader context is especially urgent in the context of COVID-19, which has disproportionately affected low-income, racial, and ethnic minority families. One mechanism by which the pandemic is anticipated to exacerbate disparities in both early childhood development and growth is by compounding the stresses which act negatively in the pathways described in these models, harming early relational health.²⁵

An important limitation of this framework is that it accounts for racism only within pathways aligned with those of poverty. For example, structural racism acts through disparities in employment and housing with consequent reduced resources, and interpersonal racism acts through bias and discrimination, affecting mental health and parenting stress. However, the effects of racism are pervasive across socioeconomic status,²⁶ extending well beyond poverty. Refer to the supplement manuscript focused on equity.

To summarize, poverty-related contextual factors adversely affect early childhood development and growth through common mechanisms acting through aligned parenting assets and vulnerabilities, and aligned proximal early relational health practices, structure and quality. This framework therefore can provide a theoretical foundation for integrated strategies to prevent disparities in both development and growth by supporting proximal early relational health to target common antecedents. To date, few if any programs have sought to promote optimal development and growth through intentionally building on the commonalities described here.

Empirical rationale for integrating primary prevention of development and growth in the pediatric setting

Current strategies seeking to prevent disparities in development and growth individually target common pathways within this conceptual framework

Only limited pediatric primary prevention programs targeting development (cognitive/language and social-emotional) and growth have evidence of impact demonstrated in rigorous clinical trials. Table 1 shows exemplar programs with strong evidence, in various stages of scaling. Table 1 does not include programs that: 1) primarily focus on health care delivery/redesign [e.g., AAP Bright Futures, Centering Parenting, Touchpoints]; 2) are primarily community/messaging/app-based [e.g., VROOM, Talking is Teaching:, 5,2,1,0 Pediatric Obesity]; 3) primarily focus on social determinants of health [e.g., Help Me Grow]; 4) have been designed/studied primarily for treatment [e.g., Incredible Years, Triple P Positive Parenting Program, AAP Obesity Treatment Guidelines]; 5) have not yet had large scale studies published or significant scaling [e.g., Thirty Million Words, Sit Down and Play, First Steps for Mommy and Me, Ounce of Prevention]); or 6) are primary prevention outside health care (e.g., WIC, Early Head Start, Head Start, home-visiting).

Table 1.

Exemplar primary care-based, primary prevention models

Interventions	Description and Core Components	Efficacy of Interventions	Target/Mechanism of Action within Conceptual Framework
Developmental Focus
Reach Out and Read (ROR)27 Provider-delivered at well-child visits	Developmentally-appropriate books given (age, language); guidance and modeling of reading during health care visits to coach parents on effective ways to read aloud together.	Higher: reading/book sharing, child receptive language scores, well-child visits; Benefits greater for higher risk (lower education/Latinx) families; Clinics: higher morale, satisfaction, patient-doctor relations.	Increases parenting assets (knowledge, interactional skills, books) → improved relational health (increases reading, interactions, routines).
Video Interaction Project (VIP)29 Co-located 1:1 parenting coach	Video recording of parent and child for 3-5 minutes playing/reading with a toy/book at each well-child visit, review of video with parent to facilitate self-reflection and identify/reinforce strengths.	Increased reading aloud, play, responsivity sustained 1.5 years after completion; Enhanced social-emotional and language development; Decreased: maternal depressive symptoms, parenting stress, harsh discipline.	Increases parenting assets (knowledge, interactional skills, book/toys, self-efficacy) and reduces vulnerabilities (parenting stress, depressive symptoms) → improved relational health (increases verbal interaction, reading/play, routines, limit setting; reduces harsh discipline).
HealthySteps (HS)30 Co-located psychologist/social worker	HealthySteps Specialist (HSS) support via 3 tiers: 1) universal screening for mental health, social determinants of health (SDH) and parenting risk; 2) HSS services for acute challenges; and 3) HSS services for chronic needs.	HS clinics had: increased referral for mental health evaluation/treatment, receipt of information on community resources; reduced depressive symptoms; increased visit attendance; higher vaccine + screening rates; more continuity of well child care.	Addresses SDH (mental health care, social services), increases parenting assets (knowledge, interactional skills, self-efficacy), reduces vulnerabilities (depressive symptoms) → improved relational health (increases routines, limit setting; reduces harsh discipline).
Healthy Growth Focus
Greenlight (GL)28 Provider-delivered at well-child visits	Health literacy-informed toolkit: 1) age-specific low-literacy booklets given with tangible tools to reinforce behaviors; 2) health communication curriculum for providers (teach-back, goal setting).	Improved: feeding practices (e.g., reduced juice, transition from bottle to cup); responsive feeding styles (less pressuring); Lower adjusted mean child BMI-z score at age 6, 12, and 18 months. Providers: more goal setting.	Increases parenting assets (knowledge, feeding resources, self-efficacy) → improved relational health (increases healthy feeding practices and diet quality, routines, limit setting; reduces pressuring).
Starting Early Program (StEP)31,32 Co-located dietitian-led groups	1) Groups with demos, peer modeling, social support; 2) Individual nutrition counseling (motivational interviewing, goal setting, lactation support); 3) Plain language handouts and videos.	Improved: feeding practices (breastfeeding, reduced juice/early introduction to solid/excess milk); infant tummy time; responsive feeding styles; Lower child standardized weight at 18 and 24 months old in trajectory and cross-sectional models.	Addresses parenting assets (knowledge, interactional skills, feeding resources, self-efficacy), reduces vulnerabilities (increases social support) → improved relational health (increases healthy feeding practices and diet quality, routines, limit setting; reduces controlling, indulgent and laissez faire feeding styles).

Some of the exemplar programs (Reach Out and Read [ROR],²⁷ Greenlight [GL]²⁸) are provider delivered and very low cost. For ROR, this has led to implementation at 6100 sites, and 4.5 million children reached annually. Other programs require co-located staff (Video Interaction Project [VIP],²⁹ HealthySteps [HS],³⁰ Starting Early Program [StEP]^31,32); although cost is somewhat increased, these programs have greater impacts in many domains and are still very low cost compared to other settings. Most relevant here, each of the programs is strengths-based and acts by targeting early relational health practices, structure and parenting quality, and by addressing antecedent parenting assets, while varying in targets and strategies. Two programs (HS, and an integrated adaptation of VIP [Smart Beginnings,³³ which adds a home visiting program, Family Check Up [FCU],³⁴ for families with identified risks]) also address social determinants of health.

Models targeting development and growth separately have shown cross-over effects

Emerging data suggests that models targeting developmental preventive interventions focused on general parent-child relationships and child self-regulation may also have impacts on feeding styles, practices and/or early child obesity. HS is associated with healthy responsive feeding styles and weight status at kindergarten entry, especially in children with poor social-emotional development.³⁵ VIP is associated with reduced negative feeding attitudes mediated by changes in the parent-child relationship, and reduced controlling feeding styles.³⁶ Minding the Baby, a prenatal/infant-toddler home-visiting program focused on development, was associated with reduced early obesity.³⁷ FCU, which focuses on supportive parenting in the context of social determinants, had impacts on child weight, mediated by changes in diet, in families with parenting challenges and children with behavior problems.³⁸ ParentCorps, a preschool-based program that includes parenting workshops together with teacher support, also had beneficial impacts on obesity for children with lower self-regulation.³⁹ INSIGHT, an obesity prevention home-visiting program which promotes responsivity, had impacts on both child self-regulation and child weight.⁴⁰ These studies provide preliminary empirical support for alignment in pathways related to early childhood development and growth.

Multiple program enrollment is challenging for families at risk

Enrollment in prevention programs is relatively low even for programs addressing child development and growth separately.⁴¹ Continued engagement is also difficult, with less than half of families having weekly Early Head Start visits, and more than half of families dropping out of Nurse-Family Partnership.⁴²

Participation and engagement are particularly challenging for multiple or complex interventions, because the most salient barriers for families are situational or practical factors. These include limited transportation, lack of childcare, scheduling conflicts, language mismatch, and work and other family obligations.⁴³ In addition, low levels of literacy, health literacy, and education affect participation because of their influence on parenting knowledge and beliefs.⁴¹ Barriers to participation in individual programs therefore underscore the importance of designing programs that can address development and growth simultaneously.

Implications and recommendations

We have sought to provide a rationale for design and implementation of strategies that simultaneously prevent disparities in early childhood development and growth through promotion of early relational health. Supporting parenting skills and strengths has the potential to enhance both healthy development - cognitive and social-emotional - and everyday aspects of family routines and behaviors, such as meals, food practices, and physical activity. Further, we have delineated alignment in pathways by which poverty affects both development and growth within an underlying conceptual framework related to early relational health that builds on foundational ecological and developmental systems models. Integration of pathways within this common framework can support the design and implementation of primary prevention interventions to support early relational health built into the health care visits that already fit into families’ lives.

While alignment of parenting related to development and growth within this framework is grounded within theory and empirical data, there are some limitations. First, challenges in development and healthy weight are common across the socioeconomic spectrum; however, the model focuses on pathways related to poverty. Second, systemic racism, a major contributor to adverse childhood outcomes in both domains regardless of income status, is not comprehensively addressed other than within pathways aligned with those of poverty. Third, the framework does not account for biologic mechanisms (e.g., epigenetics, toxin exposures) by which poverty and related factors affect children’s neurodevelopment, stress-reactivity, and self-regulation.

There has been some progress in development of primary care preventive models seeking to address development and growth together. For example, StEP is piloting integration of VIP video feedback into its group sessions, to reduce parenting stress and enhance child social-emotional development and self-regulation, with the goal of enhancing nutrition and growth-related impacts while simultaneously reducing developmental disparities. ROR initiatives have offered children’s books focused on healthy eating to support parent provision of and child interest in healthy foods. HealthySteps has piloted components related to lactation support and healthy feeding. To date, however, these initiatives have primarily brought together specific components of existing interventions rather than developing new comprehensive, integrated models targeting relational health.

As programs addressing development and growth are refined and scaled, a key question will be the degree to which programs should be delivered universally or targeted to those at increased risk. Primary care programs with very low cost and provider-led delivery, such as ROR and GL, are the most straightforward to implement at population-level. At the same time, there would be significant benefits to universal delivery of primary care programs with co-located providers, such as VIP, HS, and StEP, which are far lower in cost than programs in other settings. Such programs are likely to benefit all but the most highly resourced families, and universal delivery can reduce stigma while increasing engagement and impact for those at higher risk.⁴⁴ As new models emerge addressing development and growth through support for early relational health, additional study of costs and benefits together with considerations of equity will be needed to inform policy. It will also be critical to address reimbursement challenges, in the context of a long timeline for return on investment.

Primary prevention at its best would include rectifying disparities in neighborhoods, childcare, schools, and health services, while building supports and resources. Closer involvement by the child’s primary health care provider and medical home is clearly necessary, but not sufficient, and we put forward the idea of primary prevention interventions based in health care in the hope of supporting resiliency, but with the clear acknowledgment that many underlying issues of poverty and systemic racism need to be elucidated and addressed.

Moving forward, we recommend:

1. Recognizing a central role for health care-based primary prevention, in conjunction with systemic policy changes addressing poverty and racism to ameliorate disparities in early childhood development and growth, as critical sources of inequity across the life course.

2. Engaging in full partnerships with communities and families to identify respectful, nonjudgmental, culturally aligned intervention strategies that build upon community and family needs and priorities.

3. Designing and implementing integrated strengths-based models, which acknowledge the strong foundational role of early relational health and the complex interweaving of development and growth in early childhood.

4. Utilizing payment systems that make scaling of primary prevention interventions in health care feasible through both domain-specific and integrated models.

5. Funding research to assess intervention efficacy/effectiveness and inform implementation.

6. Encouraging collaboration between early childhood stakeholders, including clinicians across specialties, scientists across academic disciplines, and policy makers, to more effectively promote comprehensive prevention across both domains.

7. Acting with urgency, given the importance and lifelong consequences of poverty and racism, together with the disproportionate impacts of the COVID-19 pandemic for low-income, racial, and ethnic minority families.