Impact of the 2008 Economic and Financial Crisis on Child Health: A Systematic Review

1. Introduction

2. Methods

3. Results

Figure 1. Flow chart of the study selection process.

3.1. Study Characteristics

Nineteen quantitative studies, two qualitative studies and one study with mixed quantitative and qualitative methods were included in the review. Thirteen quantitative studies analysed trends over time [24,25,26,27,28,29,30,31,32,33,34,35,36] and four of them showed a low risk of bias (Table 1) [25,31,32,36]. Six were cross-sectional studies [37,38,39,40,41,42] three of which showed a low risk of bias [38,39,41]. Two qualitative studies were included: one was carried out in developing countries [43,44,45], and one in the UK [46]. All except one qualitative sub-study [45] showed low risk of bias on the EPICURE assessment. The study with mixed methods [47] showed moderate risk of bias on its quantitative approach and low risk of bias on qualitative approach.

Table 1. Characteristics of included studies.

Table 1. Characteristics of included studies.

First Author	Countries	Type of Study	Year(s)	Population/Sample	Source of Data (n)	Outcome Measure (s)	Risk of Bias (Score) "
Quantitative studies: trends over time
Ariizumi [24]	Canada	Mortality trends	1977–2009	All ages	Canadian Vital Statistics Data	Under 15 year mortality	15
Friedman [25]	30 Sub-Saharan African countries	Infant mortality trend modelisation	2007–2009	<1 year /Women 15–49 years old	Demographic Health Survey. Data from 260,000 women and 640,000 live births	Infant mortality	16
Simó [26]	Greece, Spain, OECD "" countries	Infant, neonatal, and perinatal mortality trends	1990–2010	<1 year	OECD "" data on mortality	Infant, perinatal and neonatal	7.5
Vlachadis [27]	Greece	Descriptive time-trends	1966–2010	All recorded live births and fetal deaths	Helenic Statistical Authority	Stillbirths per 1000 women	7.5
Gordon [28]	UK	Cross-sectional survey and time trends description	Surveys conducted in 1982, 1990, 1999, 2012	Children (ages not specified)	Necessities of Life survey (N = 2462 adults). Living standard survey (N = 5193 households)	Basic needs (30 items for children). Multiple deprivation	14.5
Department for Environment Food and Rural Affairs (DEFRA) [29]	UK	Trends based on cross-sectional repeated surveys	2007– 2011	General population of households with children (ages not specified)	Family Food Survey (N = approximately 6000 households a year)	Household spending on food, and comparisons with healthy diet	12.5
Sulaiman [30]	Bangladesh	Longitudinal rural panel and 2 urban cross sectional samples	2006, 2008	Children 0–59 months in 2006/24–82 months in 2008	Nutritional project 2006. In 2008: subsample of 1163 rural households, and 435 urban households	Weight-for-height Z score in children. Changes of food consumption.	12.5
Berger [31]	U.S.	Comparison before-during the recession	2004–2007/December 2007–June 2009	<5 year Population of 74 counties in 3 areas.	Incidence of AHT ‡ in children under 5 year. Hospital discharge records (N = 422)	Changes in rates of hospitalisation due to AHT	20
Huang [32]	OH, U.S.	Incidence rates over time	2001–November 2007/December 2007–June 2010	<2 year	Incidence of injuries and AHT ‡. Hospital discharge records (N = 639). Study from 1 hospital	Changes in rates of hospitalisation due to AHT ‡	18
Brooks-Gunn [33]	U.S.	Prospective cohort study	May 2007–February 2010	9 year-old children	Wave of Fragile Families Child Well-being Study. 5000 families of 20 large cities from 15 States	Frequency of maternal spanking	16
Cui [34]	U.S.	Trends based on repeated cross-sectional surveys	2001–2010 U.S. general population sample	12–17 year	National Health and Nutrition Examination Survey (NHAMES)	Self-rated health, unhealthy days and activity limitation days	16
Millet [35]	U.S.	Before-after approach	2001–2010	Child under 18 year	Public available administrative data for 7 States	Child abuse and maltreatment reported to social services	10
Rajmil [36]	Catalonia, Spain	Before-after approach	2006–2010/2012	0–14 year General population	Catalan Health interview Survey 2006 (N = 2200) and Continuous health survey 2010–2012 (N = 1967)	Health behaviors, obesity, mental health and perceived heatlh and quality of life	17
Quantitative studies: cross sectional
Catalonian ombudsman [37]	Catalonia, Spain	Cross-sectional	2013	<16 year General population from Catalonia	European Union Statistics on Income and Living Conditions (EU-SILC) and other sources	Reported food consumption. Multiple deprivation	5.5
Samuels [47]	Nigeria	Cross sectional	2009	Households with children	National household surveys	Reported food consumption	10
Bruening [38]	MN, U.S.	Cross-sectional	2009–2010 Population-based study	Adolescents	Household Food Insecurity questionnaire (Families and Eating Activity Among Teens study) (N = 2095 parents)	Family food security status	17
Jackson [39]	U.S.	Comparison of two cross-sectional studies	2008–2010	<18 year children with asthma and their parents	Behavioural Risk Factor Surveillance System phone interview (2008 N = 4133/2010 N =3492 parents)	Parental smoking behavior	16
Pearlman [40]	U.S.	Cross-sectional	2007–2009	2–17 year children with asthma	U.S. national Child Asthma Call-Back survey. Parents of children with asthma (N = 5138)	Level of asthma control	13.5
Tarantino [41]	U.S.	Cross-sectional survey	2009–2010	<26 year Patients with haemophilia and their caregivers (where <26 year, average age = 11.2 year) Hematologists	Survey designed ad hoc (N = 70 caregivers of <26 year with Hemophilia A, and adult patients, N = 64)	Changes in treatment decision-making after downturn. Attitude towards healthcare reform	16
Anagnostopoulos [42]	Greece	Descriptive cross sectional study	2000–2011	Child and adolescent population attending psychiatric services	National Action Plan Psychargos on mental healthcare services	Changes on the distribution of mental health diagnoses among users	6
Qualitative studies
Heltberg [43] Hossain [44] Hossain [45]	Developing countries 17 in 2008, 6 in 2009, 4 in 2011	Focus groups and interviews	2008–2011	Children (ages not specified. Respondents selected that represent groups exposed to economic shock)	To study perceptions and behaviors of people as live crisis impact and major coping responses used by poor and vulnerable people and households		EPICURe, EPICURe and epicURe respectively
Samuels [47]	Nigeria	Key informants interviews, focus groups and in-depth interviews	2009	Children (ages not specified) 6 Nigerian zones that reflect demographic and socioeconomic heterogeneity	To analyse the impact of 3F † crisis on vulnerable social groups (women and children) and coping strategies undertaken by households during the period of food, fuel and financial crisis		EPICURe
Halls [46]	UK	Semi-structured interviews and participant observation (Ethnographic approach)	December 2011 and January 2012	Theoretically driven sample of 11 families with children (ages not specified) with different social status over 5 visits	To analyse the lived experience of families against a backdrop of austerity. Impact of austerity on family life and family food choices		ePIcURE

Notes: * The risk of bias was assessed using the STROBE criteria for quantitative studies (range 0–22 points); for qualitative studies the uppercase and lowercase indicate compliance or non-compliance (or absence) of a given item from the 7 items of the (see methods section for more information); ** OECD: Organisation for Economic Cooperation and Development; ^‡ AHT Abussive head trauma; ^† 3F crisis: food, fuel and financial shock.

3.1.1. Infant and Child Mortality

Four studies reported mortality outcomes. One modelling study estimated an excess of 28,000–50,000 infant deaths in the year 2009 in sub-Saharan African countries based on interviews with a random sample of 260,000 mothers (Table 2) [25]. National vital statistics in Greece reported an increase of 32% in stillbirths between 2008 and 2010, and also increases in infant, perinatal and neonatal mortality [27], while no influence was found on infant mortality in Spain [26], or under 15 year mortality in Canada [24].

Table 2. Impact of the 2008 economic crisis on infant and child mortality.

Table 2. Impact of the 2008 economic crisis on infant and child mortality.

Countries	Results	Study
30 Sub Saharan Africa Countries	Excess of 28,000–50,000 infant deaths in 2009, most of them girls (compared to period 1977–2008). There are 3 million infant deaths a year in these countries (infant mortality rate was 90/1000 in 2005).	Friedman J. [25]
Greece, Spain	Perinatal, neonatal and infant mortality all increased by 20% to 30% from 2008 to 2010 in Greece. No changes were found for Spain.	Simó J. [26]
Greece	Stillbirth rate increased from 3.31/1000 in 2008 to 4.28/1000 in 2009 and 4.36/1000 in 2010 (a 32% increase over 2 years).	Vlachadis N. [27]
Canada	No influence of parental unemployment on mortality in children under 15 year when comparing the period 1977–2008 to 2009.	Ariizumi H. [24]

3.1.2. Food Habits and Nutrition

Four quantitative studies reported on the food habits and one on nutritional status, and there were three qualitative studies exploring food habits and nutrition (Table 3). Studies in Europe (Spain [37] and UK [29]), U.S. [38] and Bangladesh [30] all demonstrated a significant adverse effect of the economic crisis on food intake by children, and specifically in vulnerable children. In particular the study in the UK by DEFRA [29] showed a social gradient with children from low income families eating less fruit and vegetables between 2007 and 2011. A study in Bangladesh showed an increase in the number of children who were underweight [30].

Qualitative studies found similar and consistent results both in developed and developing countries [43,44,45,46,47]. The increase in food prices was associated to diminishing the number and quality of meals and buying cheaper food. A gender effect was noted since the results showed that more women were affected by the crisis compared to men. Poor children from urban areas in developing countries were affected the most [47]. The usual strategy followed by families was shown to be to reducing costs by giving foods based more on carbohydrates in developed and developing countries and fast food offered an easy solution according to the UK study [46].

3.1.3. Health Behaviours, Non-accidental Injuries, Mental Health and Health-related Quality of Life

Twelve studies reported on health behaviours, child maltreatment, mental health and health-related quality of life (see Table 4). Higher probability of smoking for unemployed parents in families having children with asthma was found in the U.S. in 2010, but this association was not found in 2008 [39].

Table 3. Impact of the 2008economic crisis on food and nutrition.

Table 3. Impact of the 2008economic crisis on food and nutrition.

Country	Results	Study
Quantitative Findings
U.S.	39% of parents experienced food insecurity in 2009/2010 and 13% had very low food security. Food insecure parents were more likely to be non-white, single parent, low education level, unemployed and with low income.	Bruening M. [38]
UK	In 2012 500,000 children (4%) in the UK live in families who cannot afford to feed them properly.	Gordon D. [28]
UK	Households purchased 4.2% less food in 2011 than in 2007 while spending 12% more. Low income decile households have bought less fruits and vegetables.	Department for Environment Food and Rural Affairs (DEFRA) [29]
Spain	9.8% of families with children under the age of 16 years could not afford regular fish or meat on alternate days. This figure had risen from 1.7% in 2008.	Catalonian Ombudsman [37]
Bangladesh	The weight-for-height Z score in 2008 was below the trend line for >30–59 months old children at baseline. More affected groups were 30–59 months and 0-6 months old. In the rural sample wasting and underweight was 5.5%, and this figure was 6.7% for the urban sample comparing with 2006.	Sulaiman M. [30]
Qualitative Findings
UK	Food was often the first area to be cut in the family budget. Families get this buying in cheaper supermarkets, less fresh fruit and vegetables and more frozen. Trading down was a common strategy lowering the quality. Another way to reduce costs for families on lower incomes is buying food that would fill children up (more rice or pasta or samosas with chips). Fast food offers also an easy solution.	Halls S. [46]
Data from 17 developing countries	Food insecurity emerged as the most severe impact of the crisis. It was more pronounced in Central African Republic and Kenya, and was also common in Bangladesh and Zambia. Reducing the quality of food and the number of meals was the most common behaviour-based coping response to crises. Problem of sending children to school on an empty stomach was widely cited.	Heltberg R. [43] Hossain N. [44] Hossain N. [45]
Nigeria	Families reduced consumption of food in terms of quality and quantity in Nigeria. Urban poor are more adversely affected because the rural poor have their own food production. Informants identified children and women from poor families as bearing the brunt of rising costs of food.	Samuels F. [47]

Table 4. Summary of the impact of the 2008 economic crisis on health behaviors, non-accidental injuries, mental health and health-related quality of life.

Table 4. Summary of the impact of the 2008 economic crisis on health behaviors, non-accidental injuries, mental health and health-related quality of life.

Country	Results	Study
Quantitative Findings
U.S.	Comparing 2007 and 2010, unemployed parents showed higher probabilities to be current smokers only in 2010 OR = 1.8 (1.24–2.61). Lower level of education, and mental distress were other associated factors in both surveys.	Jackson T.L. [39]
U.S.	Increasing incidence rates of AHT " was observed from 8.9/100,000 in 2004–2007 to 14.7/100,000 in 2007–2010 (1.30 to 1.7) for AHT " during the recession period in 3 different areas from the U.S. compared to the previous period. No association was found on this outcome when adujusting for unemployment rates.	Berger R.P. [31]
U.S.	Increasing incidence rates on AHT ", from 0.7/month to 1.4/month from the non-recession to the recession period. Unemployment rates in Ohio have risen after the increase in AHT.	Huang M.I. [32]
U.S.	A Relative risk = 1.06 (p < 0.05) was found for high frequency of spanking in periods of worse consumarer confidence (Consumer Sentiment Index). No significant changes were observed when taking into account the rest of variables in the model (unemployment rates and home foreclosure).	Brooks-Gunn J. [33]
U.S.	No clear association was found between pre-recession and post recession period on different types of child maltreatment measures in seven U.S. States.	Millet L. [35]
Greece	Prevalence of psychosocial problems have risen by 40%, conduct disorders by 28%, school leaves by 25%, bullying by 22%, suicide attempts 20%, illegal and additive substances have risen by 19%, and family conflicts by 51%.	Anagnostopoulos D.C. [42]
U.S.	Self-rated health and reported mental health declined significantly, specially among adolescents in low-income families, at the end of the decade analyzed.	Cui W. [34]
Spain	A mixture impact on health was found: some health behaviors have improved as an average in the whole population (i.e., time spent on screen) while inequalities in health-related quality of life appeared according to the level of education, inequalities in mental health remained, and obesity showed an important increase.	Rajmil L. [36]
UK	The number of children who are multiple deprivated (at least two basic needs uncovered regarding food, clothing crowded houses, and social participation) was 2 million in 1999 and 4 million in 2012. Multiple-deprived housesholds in Britain have increased from 14% in 1983 to 33% in 2012.	Gordon D. [31]
Spain	Families suffering severe material deprivation (at least 4 items from a list of minimum 9 items) was 5.8% in 2011 and 1.6% in 2008.	Ombudsman C. [37]
Qualitative Findings
17 developing countries	Stressed women took their frustrations out on children. Children were often left alone as all adult family members had to work long hours away from home. Tensions within households we fairly clear and well-established, even in absence of domestic violence or abuse. Criminalisation and/or substance abuse among young people was directly attributed to the pressure of the crisis. In some countries young women, and even men, were reported to be increasingly entering sex work (Kenya, Zambia, Dhaka, Lusaka, Nairobi).	Heltberg R. [43] Hossain N. [44] Hossain N. [45]
Nigeria	Mothers reported worsening mental health and changes in the amount of child care and protection. Children are adopting harmful coping mechanismes like illegal livelihoods, sex work, early marriage of girls, exploitative child labour, distress sale.	Samuels F. [47]

Note: * AHT: abussive head trauma.

An increase in the incidence rates in the U.S. for abusive head trauma (AHT) and child maltreatment was found in three studies [31,32,33], while no influence of the downturn period was found in one study [35]. In Greece, an increase was reported for child and adolescent patients in hospital care for various psychosocial problems from 2007 to 2011 [42].

Self-rated health declined and mentally unhealthy days increased in adolescents from the U.S., mainly among those in low-income families [34], and inequalities in health-related quality of life in children 6–14 year according to maternal level of education appeared after the start of the crisis in Catalonia, Spain [36]. Qualitative studies in developing countries highlight increased family tension and substance abuse among young people attributed to the pressure of the crisis [43,44,45,46,47].

3.1.4. Chronic Conditions

Two studies reported on children with chronic conditions from the U.S. (see Table 5). A gap in health insurance coverage in the previous year was associated to a lower asthma control in children when comparing before and during the current crisis [40].

Fifty four percent of hemophiliac patients or their caregivers reported negative impact on the management of the condition after starting the current crisis [41].

Table 5. Summary of the impact of the 2008 economic crisis on chronic conditions.

Table 5. Summary of the impact of the 2008 economic crisis on chronic conditions.

Country	Results	Study
U.S.	Lack in health insurance coverage (OR = 1.74; 1.07–2.83) was the main factor associated to poorly controlled asthma during the period 2007–2009, together with intermediate-low income level. Higher levels of unemployment were not associated with asthma control.	Pearlman D.N. [40]
U.S.	54% reported negative impact on the management of the Hemophilia in the period 2009/2010 than previously: delayed or cancelled appointments, reduced or skipped doses, skipped filling prescription, delayed bleeding related urgent care visit. 22% anticipated positive influence of healthcare reform.	Tarantino M.D. [41]

4. Discussion

5. Conclusions

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