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Exploring Infant Health. Conroy S, Smith M. (Pp 184, A4; £7.50.) London: Foundation for the Study of Infant Deaths.
The relation between social disadvantage and infant health is at the core of this topical and comprehensive book comprising three extensive literature reviews. It is timely in view of the recent publication of the Acheson report into health inequalities (Inequalities in health: report of an independent inquiry. London: HMSO 1998).
Parental smoking is a known risk factor for a range of adverse infancy and childhood outcomes. Socioeconomic status is a risk factor for the same adverse outcomes. The review presents unequivocal evidence for the link between increasing social disadvantage and parental smoking. The problems of disentangling the influence of these related factors on sudden unexpected death of infants (SUDI) and other adverse outcomes are considered, and the authors conclude that the extent to which smoking acts as a marker for socially disadvantaging factors and the extent to which it is a contributory or causal factor in the aetiology of SUDI is uncertain.
Parenting has been correlated with infant health outcomes. There is less clarity, however, in the association between specific aspects of parenting and specific health outcomes, with the possible exception of child abuse and neglect, and in the association between parenting and social disadvantage. The review concludes that, while there are significant differences in behaviour towards children and attitudes to child care associated with social variables, there is rather less evidence about differences in parenting knowledge and health beliefs. Further, the authors conclude that, with the exception of response to risk reduction recommendations, the mechanism by which any of the differences highlighted in the review may be related to SUDI is not clear.
The parenting review is helpful in that it focuses on the association of social disadvantage with specific aspects of parenting, and makes useful recommendations for future research; however, there are some glaring omissions. The major research programme into cycles of disadvantage in the 1970s by Brown and Madge is missing as is the work in the USA by Elder et al and others, which document the direct effects of economic hardship on parenting. Brown and Madge concluded that multiple deprivation and its effects on children were based on structural and material factors and not on family psychopathology.
Within the narrow context which the authors set themselves, their methodological review will be of great value to future researchers. They address the problems associated with studying parenting among families living in socially disadvantaged environments with a particular focus on the multiply disadvantaged. They consider in detail the complex, innovative, and challenging research strategies required to overcome the difficulties of engaging such families in research, and ensure their representation in population based studies.
A fundamental difficulty with methodological review is the narrow focus on multiply disadvantaged families as the main “problem”. This arises from the findings of the Confidential Enquiry into Sudden Infant Death (CESDI) study that, following the “Back to sleep” campaign, SUDI deaths are concentrated in the most disadvantaged families. Although an important observation, SUDI, in common with other adverse infant, child, and adult health outcomes, shows a finely graded social patterning, also shown in the CESDI study. Focusing on the extreme group fails to address the true nature of the social gradient in infant and child health. Why, for example, are infants born to parents with incomes above £200 per week at less risk than those with incomes between £100 and £199 per week? These fundamental questions cannot be addressed by studying the most disadvantaged.
These reviews are refreshing and rewarding in that they treat social disadvantage as a serious risk factor rather than focusing exclusively on the attributes and behaviour of individual parents outside the social context of that behaviour; they should be of particular value to those with a serious commitment to promoting infant and child health.