Intersectional inequalities in social-emotional problems among three-year-old children in Sweden: a population-based...

Social-emotional development is an important part of early childhood development and appears to have a socioeconomic gradient. Going beyond conventional approaches, this study aimed to examine intersectional inequalities in social-emotional problems in three-year-old children in relation to their parents' income, education and place of birth and to consider the implications for public health.

A cross-sectional design was used in this population-based study in Västerbotten County of Sweden with an effective sample of 8,823 children. Social-emotional problems were assessed using the parent/caregiver-report Ages and Stages Questionnaires: Social-Emotional (ASQ: SE) 36-month interval in Child Health Services over the years of 2014-2018 and linked to parents' sociodemographic characteristics obtained from national population registers. An analysis of individual heterogeneity and discriminatory accuracy (AIHDA) approach was combined with additive binomial regression, estimating risk differences for social-emotional problems across 27 intersectional categories.

In the intersectional categories where multiple dimensions of social disadvantage overlapped, average risk differences generally increased. For instance, when comparing with the most advantaged category a risk difference as high as 25.4% (95% CI 13.7 to 37.0%) was found for the children whose parents' income was in the lowest tercile, only one parent had a higher educational level and whose parents were both born outside of Sweden. Discriminatory accuracy was estimated as moderate for the three included regression models, although it improved slightly for the model including dimensions of social disadvantage. The addition of intersectional categories provided no further significant improvement.

The intersectional approach used in this study improves our understanding of complex social inequalities in social-emotional problems in preschool children in northern Sweden. Consistent with the concept of proportionate universalism, the results of this study indicate that universal public health policies are needed when addressing this issue in addition to policies targeting disadvantaged groups. Research that considers individual heterogeneity and discriminatory accuracy has the potential to advance our knowledge of health inequities and increase the effectiveness of public health policy.