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Podcast series from the MRC/CSO Social and Public Health Sciences Unit, University of Glasgow.
Anna Pearce:
Welcome to the latest edition of 15 Minutes on Health Inequalities. Today we are talking to Ronan McCabe about some work that he's carried out during his PhD, which has considered the impacts of baby boxes on infant health. I’m Anna Pearce at the MRC/CSO Social and Public Health Sciences Unit and with me is
Alastair Leyland:
Alastair Leyland, also from the Social and Public Health Sciences Unit at Glasgow University and today we're talking to
Ronan McCabe:
Ronan McCabe. I am a Research Assistant based here at the Unit as well. Prior to that I did a PhD here.
Anna Pearce:
Thanks for joining us, Ronan. So, can we start out for those who aren't familiar with what a baby box is by just talking us through what they are?
Ronan McCabe:
Of course. So, baby boxes were the focus of my PhD and I was interested in that because the Scottish Government introduced a baby box in 2017. And what that is is essentially a cardboard box filled with items used for childcare, and the box itself also provides sleeping space for the child. So yeah, this concept originated in Finland in the 20th century, which I can speak about a bit later, but the Scottish Government introduced one, and it's a universal policy available to all mothers in Scotland, or all parents in Scotland. And yeah, provides a box full of items and information.
Anna Pearce:
Great, thanks. Can you just give us a couple of examples of the items in there?
Ronan McCabe:
So, it has various things. It has a leaflet with information about certain health behaviours. It has items like thermometers, clothing, that sort of thing. It is valued, I think, at approximately £250, so it's worth a fair bit of money. And that's where sort of the interest on its impact on health alongside the information contained within it.
Alastair Leyland:
As you said, Finland was the first country to introduce a baby box. You said the 20th century, but I think it's fairly early in the 20th century and that was a long time ago. So, what made you decide to evaluate it? Hadn’t there already been some kind of evaluation?
Ronan McCabe:
So, there was no evaluation of the Finnish baby box. It was introduced in its initial form in 1938. At the time it wasn't actually a box and it was just, I think, various items for the parents and later became a box. And it was universalised to the whole Finnish population in 1949. But the interest in evaluating it came from the insistence from the Scottish Government that it had an effect on infant mortality. There has been some interest in infant mortality rates in Finland because in relative terms, relative to Europe, they had quite high infant mortality at the start of the 20th century and it fell gradually over that time and it's now one of the lowest in the world. So, I think people are interested in why that occurred. And yeah, the baby box. The Finnish baby box has been linked by some people to this, but up to this point, has not been properly evaluated.
Alastair Leyland:
So what did you find then?
Ronan McCabe:
The main finding is that it's complicated and almost too complicated to know actually what the relationship between the Finnish baby box and infant mortality is because infant mortality rates were, yeah, far higher and a lot more unstable at the point at which it was introduced. And there was also the co-occurrence of lots of events and, probably most notably the Second World War, likely had an effect on infant mortality, so the impact of the box is obscured by these other events and we don't actually know it's effect, and that was the sort of conclusion.
Anna Pearce:
So, infant mortality changed after the introduction of the Finnish baby box. Do you think that does tell us anything about the effectiveness?
Ronan McCabe:
No, because we can't rule out other factors that might have contributed to that decline. There are obviously, yeah, quite a few medical changes occurring and also social changes occurring at this point in time. In Finland. there's this idea that compared to the other Nordic countries, Finland was quite a latecomer to, sort of, the industrial revolution or industrial development and, sort of, catching up at this time. There were a lot of changes there like improved sanitation in urban areas, the introduction of antibacterial agents and antibiotics, and the introduction of immunisations and stuff like that. So, there's a lot of things that probably contributed to the fall in infant mortality and it's very hard, especially with the sort of lack of granularity when it comes to data.
Anna Pearce:
When you went into the evaluation of the Scottish baby box did you have, sort of, any prior feeling about what you might see?
Ronan McCabe:
On the basis of that sort of research, I mean, probably not. So, like I think one thing to note is even though it is, yeah, separated by a century or wee bit less, the context in which baby boxes are now introduced differs quite dramatically from the context in which the Finnish box was introduced, not least in terms of infant mortality. Infant mortality is now quite low in Scotland and most of Europe. So, I think it's been, well, it's not been unchanging, it has sort of changed in the last few years, perhaps for other reasons, but I didn't really expect it to do much. I didn't focus on infant mortality for that reason, because it is so small, it would be hard to detect changes but I focused on other health outcomes.
Alastair Leyland:
OK. And the Scottish evaluation did seem to show slightly more positive findings.
Ronan McCabe:
It did. So, I didn't anticipate these. So, we looked at a range of outcomes and these were decided based on an evaluability assessment that was conducted by the Scottish Government, which provided a logic model or a theory of change of how the box would affect infant and maternal health. So, we selected our outcomes, the aspects of health that we wanted to focus on from this, which included things like breastfeeding and infant tobacco smoke exposure and immunisation uptake and that sort of thing. And yeah, we did observe some small positive effects which was on infant tobacco smoke exposure, which decreased slightly and also exclusive breastfeeding, which increased amongst young mothers, and these changes were associated with the introduction of the box, so occurred immediately after it. Although they didn't necessarily last that long into, sort of, the post-natal period.
Alastair Leyland:
For both of these evaluations you chose to use interrupted time series. What are the advantages of that?
Ronan McCabe:
So interrupted time series is in essence, a sort of pre post comparison that compares a trend and data or trend and outcome you're interested in after an event with the trend and that same outcome that occurred prior to the event. And it essentially uses the pre-event trends to model what would be expected on the basis of that trend to occur after it and then compares what actually occurred after it to what you would expect. And the difference between those two things gives an indication of the impact of that event. It, sort of, relies on they're not being other, sort of, events occurring at the same time that would similarly affect the thing you’re interested in.
Anna Pearce:
So, this might be a bit of a tricky question to answer, but I'm going to ask you anyway, Ronan. So, based on those two studies that you've carried out, would you say that baby boxes are a good investment for supporting child and maternal health?
Ronan McCabe:
I don't know because I didn't conduct a cost benefit analysis or anything. But I am aware that the changes that did occur, even though they are small, these things are quite hard to change. So, it maybe is notable in that sense that the box was able to have an effect on these things, but whether it's a worthy investment, I'm not sure I can say, or whether, yeah, the money that goes into baby boxes is better spent on other things. But I think it's also important to note that, yeah, the box is not just a health intervention and it obviously could have benefits that are not on health that might still be worth having. And obviously the box is perceived by most parents to be quite a positive thing and be good. So yeah, that's not necessarily a bad thing.
Anna Pearce:
Yeah, I think something that supports breastfeeding and immunisations and so forth is a real positive, like you say.
Ronan McCabe:
Yeah.
Anna Pearce:
And supporting children's health. To go back a little bit slightly, we've seen effects on the, I guess, more proximal outcomes that say, so, as you noted infant mortality is quite an extreme way of looking at health. Do you think if you'd been able to look at those, sort o,f health behaviours, had the data been available in Finland, do you think you might have seen something? Do you think the null findings more or less are just because it was too extreme?
Ronan McCabe:
I'm not too sure. I mean in the hypothetical world where the war didn't happen and, yeah, the other sort of major events didn't happen, if you could bracket the effect of those things on infant mortality, like maybe it would have. I don't know. It is possible, at that time, that receiving the care package or I would assume that it would have more of an impact than it maybe does now but because it's not necessary the case.
Alastair Leyland:
Thanks. We like to finish these podcasts by asking about the implications of research for health inequalities. Were you able to consider the impacts of baby boxes on inequalities?
Ronan McCabe:
We did, yeah. We looked at how the box affected different groups in society and that's by age,
maternal age and then also area level deprivation. So, we did look at that and yeah, look to see if any effects we did observe were different by these, sort of, different groups or if they were present within certain groups and not within others. And there was some indication that infant exposure to secondhand smoke that the effect was stronger amongst the most deprived in society.
Alastair Leyland:
So a big decrease in exposure.
Ronan McCabe:
Yeah, a bigger decrease in exposure. So, we did see that but we probably didn't go into that as much as I would have liked.
Anna Pearce:
OK, well, I think we're out of time now. Thank you, Ronan, for talking to us today. And thanks to our listeners. So, you can find out more about Ronan's research, which has been published in two separate journal articles, in the podcast notes, as well as details of all of us talking on this podcast today.