Health outcomes of experiencing poverty in the early years: evidence review

Executive summary

Introduction

This report presents findings from an evidence review on child health outcomes and impacts of experiencing poverty in the early years, defined in this report as the period between ages 0-3. However, it also looks at preconception and pregnancy for adults and the connections between parent and child health.

Poverty and health are deeply interconnected, forming a cycle where poor health exacerbates poverty and poverty makes achieving good health more challenging. The early years are a critical developmental period, marked by heightened sensitivity to environmental influences, including poverty-related stress and deprivation, and increased vulnerability to disruptions in how the genetic code is expressed. Given this context, preconception, pregnancy, and early childhood represent a critical window for action. Furthermore, investing in primary prevention – addressing issues before they arise – delivers significant economic and health benefits across the life course and across generations and is an approach encouraged throughout the literature to change health outcomes.

Efforts to tackle child poverty in Scotland operate within the legal framework of the Child Poverty (2017) Act. Achieving poverty reduction targets and improving child health outcomes cannot be achieved in isolation; it requires a coordinated, long-term approach that addresses the broader social determinants of health – poverty being one of them – through preventive, system-change, place-based, intersectional, and life-course initiatives.

This evidence review forms part of a wider evidence base developed by Scottish Government to understand and tackle child poverty and the factors affecting the health and wellbeing of children and families.

Research questions

The research questions that guided this review are:

What are the key indicators of health/ill health in the early years that might capture the impacts of poverty?

What are the short/medium term outcomes of the experience of poverty in the early years for children’s physical and mental health?

Methods

Evidence was gathered through an initial rapid search to scope the area; two searches conducted by the Scottish Government library service; and a final search for broader, qualitative and grey literature. The review prioritised recent publications using Scottish data (2018-2024), with older and international studies included where relevant.

Structured around key statistical health indicators and related literature, the report examines the impact of early-years poverty on child health while incorporating broader insights (Chapter 4: Moving forward: overarching evidence) that go beyond the indicators themselves.

The process of selecting these indicators (described in more detail in Chapter 2) led to the inclusion of nine indicators:

• Parental nutrition, weight and supplement use
• Infant-feeding practices, nutrition and weight
• Parental tobacco, alcohol and drug use
• Access to healthcare in the perinatal period
• Parental mental health
• Infant mental health
• Infant oral health
• Infant vaccination uptake
• Infant mortality

The review presents evidence on child poverty and draws on analyses using the Scottish Index of Multiple Deprivation (SIMD) (see Introduction). SIMD was used as a proxy measurement for children in poverty, as direct measurement of health outcomes was limited with available datasets. Other measurements and key terms are explained in the main report.

Several gaps in the evidence base were identified. These include limited data on paternal influences on child health, maternal supplementation during pregnancy, infant mental health, oral health for children under five and infant mortality rates disaggregated by deprivation. Additionally, children's voices are underrepresented in the current evidence base. Furthermore, the literature provides limited coverage of the specifics regarding the implementation and evaluation of initiatives.

The health outcomes of experiencing poverty in the early years

Good health in childhood not only shapes developmental trajectories but is also intrinsically valuable for children’s present wellbeing, learning, and development. Addressing child poverty and prioritising good child health in the early years is therefore important for the health and wellbeing of children both now and into the future.

Research indicates that children growing up in poverty and living in more deprived areas face a heightened risk of health challenges from infancy through to adulthood. The health of children begins with the health of their parents, and addressing the transgenerational transmission of health risks requires systemic action within and beyond traditional early childhood systems.

Key findings include:

• Parental nutrition, weight and supplement use: Maintaining a healthy weight and nutrient intake during pregnancy is particularly challenging for families experiencing poverty and living in more deprived areas. Pregnant women in more deprived areas experience a higher likelihood of poor nutrient intake and a higher risk of diabetes and obesity.

Improving diet and weight-related outcomes requires community and system change, making healthier food choices more accessible for all, and particularly for low-income families. Suggested actions include mandatory healthiness targets for large retailers, advertising restrictions, improved food labelling, expanded access to treatment, and mandated data collection of sales and nutritional information for large businesses. Integrating preconception health into services and enhancing training for health professionals can improve support before, during and after pregnancy. Addressing inequalities also requires tackling climate-related food disruptions and the affordability challenges of lower-emission diets.

• Infant-feeding practices, nutrition and weight: Supporting children’s nutritional needs from infancy helps build a foundation for lifelong health. This includes both breastfeeding – widely recognised for its significant health benefits for both parent and child, but not always a practical choice for families for a range of reasons – and the introduction of solid foods as infants grow. Differences in breastfeeding rates by deprivation continue to exist in Scotland, though the gap has narrowed over the last decade.

Beyond breastfeeding, there was evidence of diet-related inequalities among children. In more deprived areas, children were more likely to have diets higher in energy density, saturated fat, free sugars, and salt, and lower in fibre, fruit, vegetables, and oily fish. By age five, children in more deprived areas were at a higher risk of obesity.

Children in poverty are less likely to have high food security, increasing risks of hospital admissions, malnutrition, developmental delays, anaemia, and asthma. However, the impact of food insecurity is not always evenly felt within a household, often because of parents’ strategies to protect their children’s nutrition, sometimes at the cost of their own wellbeing.

To address these concerns, all parents and caregivers need to be supported in providing safe and sustainable nutrition for infants and children. The specific barriers posed by poverty and deprivation also need to be considered. Other key considerations include strengthening legislative protections for mothers, providing robust workplace support for women returning to employment, tackling food insecurity and its financial drivers and focusing on measures to increase spending on healthy foods.

• Parental tobacco, alcohol and drug use: The periods before, during, and after pregnancy are particularly vulnerable, and tobacco, alcohol, and drug use at these stages can pose significant health risks for both parents and children. Evidence indicates that adults living in more deprived areas are disproportionately affected by these harms.

Prioritising pre-conception care is key to prevention, especially for women facing poverty and deprivation-related challenges. Risk identification can be integrated into booking appointments, with evaluations considering substance use and its impact on daily life. Early interventions by non-specialist primary care providers and stronger cross-service collaboration – through improved communication, continuity of care, and multi-agency safeguarding arrangements – can further support preventive efforts.

Policies such as Minimum Unit Pricing, tobacco taxation, and education on health risks to support informed decision-making – many of which are in place in Scotland – are also highlighted in the literature as significant to making progress. Addressing broader environmental and systemic factors – such as limited access to support services and the high density of tobacco and alcohol retail outlets in close proximity in more deprived areas – is also important.

• Access to healthcare in the perinatal period: Access to pregnancy planning services during the antenatal period, as well as healthcare in the perinatal and postnatal periods, is essential to ensuring women enter pregnancy in good health and to protecting the health of children and families.

Pregnant women in Scotland’s most deprived areas were less likely to access maternity services on time or at all and this inequality has widened over time. Key barriers to healthcare access for families facing poverty include fewer or lower-quality services in deprived areas and the high costs associated with travelling to healthcare facilities.

Limited access or lack of access to healthcare can contribute to poorer health outcomes for both parents and children throughout the life course, including ineffective management of conditions that impact pregnancy and unmet medical needs.

Addressing these inequalities requires a strong focus on the preconception period, raising awareness of the benefits of good health at conception and the risks of poor parental health for children. Making the system easier to navigate for families is essential, which includes integrating services and decentralising care. Implementing place-based approaches – already in practice in Scotland – is key to tackling health and poverty-related challenges through locally tailored solutions.

• Parental mental health: Parent and child mental health are closely linked, with each influencing the other and persistent childhood poverty negatively affecting both.

Adults in Scotland’s most deprived areas were more likely to report experiencing higher levels of psychosocial stress and mental ill health. Poverty was identified as the single biggest driver of poor maternal mental health, with women living in deprived areas being particularly vulnerable to perinatal mental health issues. The unique mental health challenges faced by parents in poverty may not be fully represented in the literature as data was not consistently available for this specific group.

A holistic approach should address both parental and infant mental health from the earliest stages of life, with targeted support through maternity and health visitor services, enhanced training for midwifery professionals and action on the wider social determinants of health. Strengthening protective factors – i.e., social networks, education, and financial stability – can further promote parental well-being, while inclusive services and targeted resources for fathers can help create a more supportive environment for family mental health.

• Infant mental health: Adult mental health, especially pre- and post-pregnancy, is crucial to infants’ mental health and development. Prolonged exposure to maternal distress increased the risk of child mental health problems by age 3. Children born into poverty scored lower on cognitive tests at ages 3, 5, and 7, with effects accumulating over time. Early risk factors, measured by age 3, accounted for about two-thirds of the social inequality in adolescent mental health. Persistent poverty was linked to the greatest increase in the probability of behavioural problems at age 11 and anti-social behaviour at age 12, emphasising the need for early intervention.

Raising awareness of infant mental health, expanding infant mental health services – which is already implemented in Scotland – and embedding infant mental health into broader mental health strategies can help ensure children’s mental health needs are considered on a consistent basis. Participatory approaches in research can strengthen family voices, while professional training, safeguarding, and addressing gaps for children in deprived areas are also important areas to focus on to reduce inequalities. Furthermore, maximising household income is key to improving the mental health of adults and children in poverty.

• Infant oral health: Evidence on oral health for children under 3 was limited, but there was evidence suggesting oral health inequalities at age 5, with children in more deprived areas experiencing an increased likelihood of having decayed teeth and cavities. Children in Scotland’s most deprived areas were more likely to be registered with a dentist, however they were less likely to visit a dentist compared to children in the least deprived areas.

Families experiencing poverty encounter substantial challenges in accessing adequate oral healthcare. Key barriers include limited access to online services to make appointments and financial constraints such as travel expenses to healthcare facilities. Poverty-related stigma also requires further exploration in this context.

Oral health and nutrition are closely linked, therefore tackling food insecurity and diet-related inequalities are also important in addressing poor oral health. Making healthy food more accessible, educating parents and children on oral hygiene, and ensuring children receive routine dental care can help lower risks and improve long-term outcomes.

• Infant vaccination uptake: Childhood immunisation is essential for protecting children from infectious diseases. Despite overall high immunisation uptake in Scotland, vaccination rates remain lower in the most deprived areas compared to the least deprived. Children living in more deprived areas were found to face personal, interpersonal and structural barriers to accessing vaccinations at the recommended intervals.

Universal access to vaccination is key to health outcomes. Expanding coverage in more deprived areas requires promotion of the health benefits of vaccination, tackling misinformation, and improving accessibility and location planning. Mobile units, flexible hours and improved messaging – through social media, schools, and collaboration between health professionals and the press – can encourage uptake.

• Infant mortality: Infant and neonatal mortality rates in Scotland have fluctuated in recent years, with stillbirth rates showing improvement. While infant mortality data by deprivation is limited in Scotland, UK-wide data indicate that deprivation influences health outcomes, including stillbirth and neonatal mortality. The gap in neonatal mortality between the most and least deprived areas has widened, and maternal mental health remains a key factor in this infant health risk.

Strengthening reproductive healthcare, preconception support and pregnancy planning can foster nurturing care before birth. Better data is key to identifying vulnerable populations, while holistic risk assessments – considering overlapping adversities such as financial difficulties and mental health issues – are also important for early intervention.

Moving forward: overarching evidence

The evidence base highlighted the disproportionate impacts of poverty in the early years on parental and child health in relation to the nine selected indicators, and related suggested actions. It also provided some indication on broader actions – overarching to the health indicators that shaped this report – that could be taken to create preventive change for children, families and their health outcomes. This evidence is summarised below:

Universal versus targeted support: The evidence highlighted universal support as a foundational measure for all families, while acknowledging that families in poverty and more deprived areas may face additional barriers to accessing services, requiring targeted action. While evaluating individual initiatives is important, successful interventions across various contexts often share key characteristics: they strengthen caregiver skills; reduce major stressors; support parental health and nutrition; improve the caregiving environment; and implement structured, age-appropriate programmes. These actions should tackle structural inequalities to have large-scale impact.

Coordinated approach: To improve child health outcomes for those experiencing poverty and living in more deprived areas, service providers must work together across silos to ensure a coordinated approach to responding to the needs of children and families. Ensuring that children’s health outcomes are considered holistically across sectors requires a ‘health for all policies’ approach – one that moves beyond integrating health considerations into policies and instead positions health outcomes as the driving force in shaping and guiding decisions.

Children in all policies: The adoption of a ‘children in all policies’ approach is advocated to ensure children’s needs are integrated into all policy development also, and that the complexity and interrelated nature of the needs of children experiencing poverty and living in deprived areas can be better understood and taken into account. This approach aligns with rights-based principles, including the incorporation of the United Nations Convention on the Rights of the Child (UNCRC) in Scotland, and is supported by the evidence as important for tackling poverty and improving health outcomes.

Frameworks to support children and families: The legal framework in which children and families live is important to the quality of services provided and the access, experience, and outcomes of children requiring health or other services. Scotland has the Child Poverty (Scotland) Act (2017), and the system is responding to the targets within it. Adopting a rights-based approach within any legal framework is important to ensuring children’s needs are prioritised, including within budget and resource allocation processes. Changes such as these are intended to set not only the legal framework itself, but to encourage sustained, system-wide and coordinated action, creating a culture focused on the wellbeing of children and families and the reduction of inequalities.

Representation of children’s voices and the voices of children’s organisations: Children’s voices are often underrepresented in decisions that affect their lives, particularly in maternal and newborn care. Involving children and families with lived experience in decisions related to service design and provision can create opportunities for their input to shape improvements. Children’s services and advocacy groups can also support the design of policy and services.

Budgets and resourcing: Budgets are highlighted as important to ensuring quality and effective services that can improve children’s health outcomes. The literature notes work here should include prioritising participatory and rights-based approaches to budget and ensuring sufficient funding allocation for children’s services and funding for collaboration and co-design. Efforts should remain focused on addressing the effects of austerity and its broad impacts on low-income households. Other key priorities include setting short-term goals within a longer-term preventive framework, embedding prevention into the spending framework, and prioritising ongoing evaluation to assess the impact of initiatives.

Addressing the social determinants of health: The wider social determinants of health are critical to health outcomes; poverty itself is a determinant. Key actions to address inequalities and improve health outcomes include: enhancing the income and financial stability of families; implementing supportive employment and social security policies; providing accessible, quality childcare, to enable return to work; supporting safe and affordable housing; strengthening digital connectivity; ensuring affordable transport; and strengthening strong social networks.

The healthcare system: The healthcare system plays a vital role in addressing inequalities by ensuring universal, high-quality support for all families while prioritising specialist care for those with complex needs. Targeted measures include enhanced health services in high-need areas and flexible care models. Continuity of support throughout life should be a priority, enabled by strong professional collaboration and staff training to ensure children and families receive appropriate care.

Monitoring and evaluation: Robust data is essential for improving child and family care, especially for those in poverty and more deprived areas. Ensuring children's visibility in national surveys across life stages is crucial, as is clearly defining parental health data during the early years to better understand their experiences.

Priority areas for improving data collection and understanding children’s health and wellbeing include focusing research efforts on the antenatal and perinatal periods, developing tools to assess cumulative risk, enhancing data collection and linkage processes and ensuring diverse perspectives are included. Frequent monitoring of children’s NHS and health experiences (to a similar extent as adults), improving quality measures, and addressing remote and rural health data gaps are also important to strengthen the evidence base needed to build effective and equitable support systems.