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People in disadvantaged areas face extra challenges when dealing with a child’s stomach bug. New research compared the difficulties faced by people in a disadvantaged area with those in a wealthier area. Poorer parents were more likely not to receive sick pay; staying at home to look after a sick child could mean having less money that month. It was also harder for them to isolate the child within the same house, to prevent the spread of infection.

Around a quarter of people in the UK develop a stomach bug (gastrointestinal infection) each year.
Bugs can cause vomiting and diarrhoea and the NHS advises that stomach bugs should be managed at home. They usually resolve without medical treatment, and current public health messages focus on individual behaviours such as hygiene and isolation.

In this study, researchers investigated inequalities by speaking with parents from two areas and spending time in those areas. One area was economically advantaged; the other disadvantaged. The parents had children under 5 who had had a gastrointestinal infection within the last 12 months.

Children typically had vomiting and diarrhoea when they were ill, and the paper describes the work involved in cleaning up and looking after them. Parents’ effort and workload were similar in both areas. But the practical difficulties were greater for people in disadvantaged areas. Children in these areas were also more likely to have other medical conditions, such as asthma; there was therefore more concern that the stomach bug would worsen existing conditions.

Children's illnesses can increase existing inequalities, the research found. It concluded that policies need to look beyond advice on behaviour, and take into account different lived experiences, if they are to address these inequalities.

Further information on diarrhoea and vomiting is available on the NHS website.

What’s the issue?

Gastrointestinal infections are caught through contaminated water or food, or contact with animals or with another person who is ill.

The infections typically cause vomiting, diarrhoea, stomach pain and fever. Symptoms usually resolve within 2 days and the NHS advises that people should stay at home until 48 hours after their symptoms resolve.

Symptoms are distressing, both for the person with the infection and for those caring for them. For some older and very young people, or those with other health conditions, these infections can be dangerous; symptoms can lead to dehydration and even death.

Previous research has shown that children in disadvantaged areas have an increased risk of gastrointestinal infections. Both children and adults in these areas have more chance of severe infection and are more likely to need time off school or work (than those in wealthier areas).

Current advice targets individual behaviours to prevent these illnesses spreading. It includes regular handwashing, isolating the sick person, and staying away from school or work for 48 hours after the last symptom.

Few studies have explored how members of the public manage their health day-to-day. With that in mind, the research team explored people’s experiences of gastrointestinal infections. They wanted to see how those in different areas coped with these infections.

What’s new?

The study compared two urban areas in the Northwest of England. One of the areas was disadvantaged in terms of life expectancy, deprivation, income and health. People in this area had more long-term conditions, such as diabetes and anxiety. The other area was more advantaged. The terms 'advantaged' and 'disadvantaged' are used to distinguish the two areas; they not necessarily accepted by the people living in them.

Over 10 months, the researchers spent 150 hours observing the everyday activities, and the family and social lives of people living in the study areas. They had informal conversations and more structured interviews with 23 people from both areas. Participants all had children under 5 who had had a gastrointestinal infection in the previous 12 months.

The team found inequalities in 3 main areas.

  1. Cleaning and preventing the spread of infection

Vomiting and diarrhoea created extra work and cleaning. People in the advantaged area had more access to dishwashers and carpet cleaners. Isolating ill people was easier because their houses were larger, and some had separate bathrooms.

In disadvantaged areas, strategies for limiting mess, such as use of carpet cleaners, were less available because of the cost. These households were more likely not to have a functioning washing machine.

  1. Anxiety

Parents in both communities were anxious that the bug would make an existing illness worse. For example, it can be difficult for people with diabetes to control their blood sugar when they have a stomach bug. More people in the disadvantaged area had long-term conditions, and they therefore experienced more anxiety around managing infections.

  1. The financial impact

Having a child home from nursery or school meant a parent taking time off work to look after them. In the advantaged area, people were more likely to have flexible working (for instance working from home or being able to change working hours) and sick pay. This made taking time off easier.

People in the disadvantaged area tended to have less flexible jobs or less secure work. They were less likely to be paid when having time off work. Taking time off was especially difficult for drivers, shop workers or care workers. Paying for replacement clothes, medications or additional nappies was more difficult for families in this area.

Why is this important?

Public health messages tend to target individual behaviours, such as hygiene and isolation, in the management of gastrointestinal infections. To some extent, these messages blame people for their own ill health.

Furthermore, messages that describe gastrointestinal infections as ‘self-limiting’ downplay both the work required to manage them, and the consequences for people in disadvantaged areas.

Guidelines on managing infections need to be realistic for all households, regardless of income. Guidance needs to reflect people’s living and working conditions. These conditions, rather than a lack of knowledge, can constrain individual ‘choices’ around behaviours. People know how to care for their child, but may lack the means to isolate their sick child, or to take time off work.

What’s next?

This study concludes that public health agencies need to consider the wider social, economic and policy contexts. Policies need to be sensitive to the lived experience of many in society. Making sick pay universally available, for example, and other financial changes, would reduce some inequalities.

The findings are especially relevant because of the COVID-19 pandemic. It is more difficult to self-isolate in a small or crowded house. Research and policy in acute infection need to account for the differing lives and resources households have.

Vaccinations policies could be influenced by this research. For example, an oral vaccine is given to babies to protect against an infection that causes diarrhoea (rotavirus). The researchers say that future vaccination programmes against gastrointestinal infections should prioritise the groups of people who suffered most from gastrointestinal illness in this study. This includes families with young children who either have pre-existing medical conditions, or are living in disadvantaged circumstances.

You may be interested to read

This Alert is based on: Rotheram S, and others. How are inequalities generated in the management and consequences of gastrointestinal infections in the UK? An ethnographic study. Social Science & Medicine 2021;282:114131

Further research on gastrointestinal infections from the same group:

McGarrol S and others. Disgusting disruptions: capturing the everyday experience and burden of managing gastrointestinal infections in the home. Health and Social Care in the Community 2021;29:284–293

Rotheram S, and others. What is the qualitative evidence concerning the risk, diagnosis, management and consequences of gastrointestinal infections in the UK? A systematic review and meta-ethnography. PLoS One 2020;15:e0227630

Another paper showing the inequalities in managing stomach bugs in developed countries: Adams NL, and others. Relationship between socioeconomic status and gastrointestinal infections in developed countries: a systematic review and meta-analysis. PLoS ONE 2018;13:e0191633

 

Funding: The research was funded by the NIHR Health Protection Research Unit in Gastrointestinal Infections at University of Liverpool in partnership with Public Health England, University of East Anglia, University of Oxford and the Quadram Institute.

Conflicts of Interest: The study authors declare no conflicts of interest.

Disclaimer: NIHR Alerts are not a substitute for professional medical advice. They provide information about research which is funded or supported by the NIHR. Please note that views expressed in NIHR Alerts are those of the author(s) and reviewer(s) and not necessarily those of the NHS, the NIHR or the Department of Health and Social Care.


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Comments

Study author

We hope our work helps professionals think about the way they label infections. Saying that it’s ‘just’ a gastrointestinal infection doesn’t capture the impact on families.

Policy makers need to think about individual behaviours in managing these infections, but also the wider context. These infections mean time off work for parents looking after children; these groups of people might not have the luxury of sick pay.

Research, legislation and interventions must address the consequences of infectious diseases. Otherwise, inequalities widen and communities are blamed.

Our findings are specific to gastrointestinal infections, but they also resonate with other infectious diseases such as COVID-19.  Public health responses have aimed to reduce the spread of infection through individual behaviours, such as hand hygiene and social isolation. Our study shows that while this approach is clearly important, it is not the only consideration. Those concerned with reducing inequalities in acute infectious diseases will have to think more broadly.

Suzie Rotheram, Research Fellow, University of Liverpool 

Association for Young People’s Health 

The findings from this study provide a very concrete illustration of the ways in which health inequalities are formed and experienced in childhood. The data are really helpful in showing very clearly how living in a disadvantaged area shapes your ability to cope and respond. Without a doubt these pressures continue throughout adolescence too. It is critical that health inequalities are not just considered the result of a lack of knowledge and skills, but are understood to be about resources and context. The paper concentrates on economic disadvantage, which is a huge factor, but we have also looked in our own work at the ways in which other life experiences such as being brought up in care also create an environment that exacerbates health inequalities.

The research highlights a real need for policies and interventions targeted at families and young people from disadvantaged areas. In our own health inequalities conceptual model we have begun the process of identifying where the levers and intervention points might be, including ensuring services are equally accessible to all.

Ann Hagell, Research Lead, Association for Young People’s Health 

Clinician

This paper holds important messages for policy makers, public health professionals and environmental health professionals, among others. It contributes insightful approaches to supporting populations in more deprived areas, and with lower incomes.

The paper contributes to the national evidence base showing how social policy such as tax credits and universal credit are crucial in maintaining the health and wellbeing of working families with low incomes. It highlights the knock-on effect of losing work when a child or children are sick.

Young families experience the inequalities because children under 5 years (and older) are unable to look after themselves. It raises several questions. Does staying home from work impact on families’ ability to pay their rent or mortgage? How quickly do children recover? In other words, is the inequality temporary, given that most children recover from a gastrointestinal infection? And does the inequality change when children are older?

I lead work on the social determinants of health and health inequalities. I am interested in how issues, such as gastrointestinal illness, are due to structural, behavioural and health inequalities. The impact on employment, housing, and finance are all relevant to understanding the common themes in health inequalities.

Chimeme Egbutah, Public Health Service Manager, Luton Borough Council  

Researcher 

This study will help me generate ideas for conducting such ethnographic studies. It will encourage other healthcare researchers to perform similar studies in relation to different diseases. The paper will help frame and implement related policies. There should be more focus on eradication of inequalities in management of disease.

Ankit Sharma, Assistant Professor, Uttaranchal Institute of Pharmaceutical Sciences, Uttaranchal University, India 

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