Introduction
The peer-reviewed literature on the developmental origins of health and development underscores the profound influence of household income and parental mental health on children’s lifelong outcomes.Reference Shonkoff, Boyce and McEwen1–Reference Heckman and Masterov3 Increasing household income benefits children directly through better food, stable housing and healthcare (known as the ‘investment’ pathway), as well as indirectly through improved caregiver mental health and capacity (known as the ‘family stress’ pathway).Reference Cooper and Stewart4–Reference Conger and Donnellan8 For reasons including limited access to resources, increased exposure to stress and reduced opportunities for enriching activities, children raised in households with low incomes face increased risks of psychological or socioemotional difficulties, behavioural problems, educational difficulties and poor mental health as they grow.Reference Saunders, Bedford, Brown, Naidoo and Adamson9,10 Parental mental health is also a critical determinant, with numerous studies showing that children of parents with mental health issues face higher risks of emotional and behavioural problems.Reference Scarlett, Moirangthem and van der Waerden11 The interplay between low income and poor parental mental health creates a compounding effect, exacerbating the challenges faced by children.Reference Shonkoff, Boyce and McEwen1,Reference Heckman and Masterov3,Reference Conger and Donnellan8
In 2020–21, the COVID-19 pandemic lockdowns generated enormous global financial disruption and, during the post-lockdown periods of 2022–23, cost of living and inflation rapidly increased, continuing after the end of pandemic was declared in May 2023.12–14 The early pandemic literature hypothesised an exacerbation of health and developmental inequities for children,Reference Lange, Altrock, Gossmann, Fegert and Jud15–Reference Zima17 and emerging data are substantiating these concerns. A meta-analysis of studies conducted during 2020–22 across 15 countries that investigated impacts on children’s learning found an overall learning deficit (effect size d = −0.14) that arose early in the pandemic and persisted.Reference Betthäuser, Bach-Mortensen and Engzell18 The deficit increased with increasing socio-economic disadvantage and was higher in lower-income than high-income countries.Reference Betthäuser, Bach-Mortensen and Engzell18
It is still early to measure the impacts of the pandemic, which will also be affected over time by new global events and national policies. What can be measured now are the mechanisms underlying emerging inequities; that is, the financial experiences of families and how they related to the mental health of caregivers and children throughout the pandemic. As the translation of adverse experiences into later disorder or disease can take decades,Reference Shonkoff, Boyce and McEwen1 it is important to understand how if and how these mechanisms changed during the pandemic period, to consider how impacts may be offset in the future.
Studies during the lockdown periods of 2020–2021 typically examined socio-economic inequities using measures such as education, income and financial stress. While large studies in high-income countries such as Norway (n = 58,982 parents)Reference Worn, Reme and Skirbekk19 and the United Kingdom (UK, n = 2,710 young adults)Reference Smith, Herbert, Hughes, Northstone and Howe20 showed that negative financial and employment consequences in 2020 were more common for individuals experiencing lower socio-economic status, the mental health impacts were comparable. Similar patterns for children and young people were reported by a Finish study of adolescent mental health from 2019 to 2021 (n = 87,283 14–16-year- olds),Reference Kaltiala, Aalto-Setala and Kiviruusu21 and a German repeated cross-sectional study of 800 preschoolers from 2018 to 2022.Reference Weyers and Rigo22
Other research reports a more complex interplay. In an early childhood study from the United States (n = 372 parents surveyed in 2020), families’ wealth was associated with a reduction in the number of stressful life events, including financial events, during the pandemic.Reference Thomas, Osbourne, Appelhans, Roisman, Booth‐LaForce and Bleil23 A European longitudinal birth cohort (n = 4,575 children aged 8–9 years in 2020) found that lower pre-pandemic socio-economic status was associated with a higher risk of emotional symptoms only for children whose families experienced a decline in income during the pandemic. A UK survey of young adults in 2021 (n > 2000 16– 25-year-olds) also found that the relationship between socio-economic factors and mental health was partially mediated through financial strain and psychosocial factors such as optimism, self-efficacy and social support.Reference Schoon and Henseke24
In Australia, the federal and state governments established temporary economic supports to counter the negative financial impacts of the country’s extensive lockdowns, which briefly offset poverty in 2020–2021.25,Reference Price, Contreras-Suárez and Zhu26 Our earlier analyses of data from the Royal Children’s Hospital National Child Health Poll, which is Australia’s only representative, repeated, cross-sectional survey collected from families from June 2020 to April 2023 (n = 12,408 caregivers of 20,339 0–17-year-olds), showed a peak in poor caregiver and child mental health associated with Australia’s lockdowns in 2021, followed by a substantial recovery in 2022–2023.14,25–Reference Price, Measey, Hoq, Rhodes and Goldfeld28 Throughout the pandemic, poor caregiver mental health (Kessler-6) was similar between female and male genders but more common for sole-caregivers, those with a home language other than English and lower education.Reference Price, Measey, Hoq, Rhodes and Goldfeld28 Perceived negative impacts were more common for female caregivers and more socially advantaged caregivers. Poor child mental health (a single 5-point item reported by caregivers) was similar between female and male children and increased with child age.Reference Price, Measey, Hoq, Rhodes and Goldfeld28
While poverty is the traditional measure of financial hardship, it is indirect, calculated based on household income.Reference Mack29 ‘Deprivation’ offers a more direct measure by considering whether a family can afford the material basics that are essential for health, such as food, housing and healthcare.Reference Saunders, Bedford, Brown, Naidoo and Adamson9,Reference Mack29–Reference Sollis31 There is limited research into the experiences of deprivation during the pandemic period. In a Canadian, repeated, cross-sectional survey (n = 12,091 from May 2020 to December 2021), more than one in seven adults reported stress or worry about having enough food to meet their household’s basic needs in the previous two weeks.Reference Daly, Black, McAuliffe and Jenkins32 A similar study with adults in Nevada, United States (US, n = 2,002 in 2020 and 2021), found that food insecurity reduced while housing insecurity increased over time, and both were related to age, disability and certain categories of race/ethnicity and income.Reference Coughenour, Chien and Gakh33 In a survey across five US cities, one-third of n = 1,395 caregivers of young children reported household food insecurity and two in five reported being behind on rent, with disparities also differing relative to ethnicity.Reference Le-Scherban, Ettinger de Cuba and Bovell-Ammon34 A Japanese longitudinal study of over 700 adolescents in 2019 and 2021 revealed a widening of economic disparities related to physical activity before and during the pandemic, but a narrowing of disparities related to the proportion of children eating breakfast almost every day (although whether this assessed choice or deprivation was unstated).Reference Kyan and Takakura35
Despite the abundance of pandemic research, published population-representative data on the financial hardship and mental health of families and children are limited, and we could find none that spanned the three years of the pandemic.Reference Price, Measey, Hoq, Rhodes and Goldfeld28 To address this evidence gap, this study drew on the data from the aforementioned Australian RCH National Child Health Poll, and aimed to (1) describe household experiences of low income and deprivation (the investment pathway) overall and by demographic characteristics and (2) investigate the relationship of the two financial hardship measures (low income and deprivation) with caregiver and child mental health (the family stress pathway).
Methods
Design and procedure
The Royal Children’s Hospital (RCH) National Child Health Poll comprises periodic cross-sectional surveys of approximately 2,000 Australian caregivers of children aged 0–17 years. To achieve high response rates and population representativeness, the surveys are intentionally brief and ask simple questions. Data collection was contracted to the Online Research Unit which obtains written informed consent and draws a nationally representative sample of caregivers using stratified random sampling from their panel of over 350,000 adults aged 18 years or older, composed of over 30% caregivers to children aged less than 18 years, who live in Australia and have internet access. Surveys are administered in English, with a reading level equivalent to sixth grade (the end of primary/elementary school). Responses are anonymous and respondents are remunerated with points exchangeable for department store gift vouchers.
The questions analysed in this study, about deprivation and mental health, were introduced after the COVID-19 pandemic began and collected in the six surveys conducted during the pandemic period. The first three surveys occurred during the ‘lockdown period’, when stay-at-home orders varied by jurisdiction and were the primary method to prevent virus spread: (1) 15–23 June 2020, after a first national lockdown (March–May 2020) eased; (2) 15–29 September 2020, when only metropolitan residents of Victoria were in a second, stricter lockdown (July–November 2020); (3) 20–29 July 2021, when multiple states/territories were in and out of lockdown (June to October 2021). The next three surveys occurred in the post-lockdown period of the pandemic: (4) 14–22 April 2022; (5) 19 September to 4 October 2022 and (6) 11–21 April 2023.
Patient and public involvement
The research questions and design were informed by previous RCH Poll surveys, which asked caregivers to identify child health issues of most concern and topics of future surveys. At the end of each survey, participants were informed of the study website where all research reports are accessible to the public. Respondents were not directly involved in the recruitment or conduct of each survey.
Measures
Table 1 describes the measures and demographic characteristics. Caregivers reported two measures of financial hardship, low household income and experience of material deprivation; their mental health with the Kessler-6 (K6);Reference Furukawa, Kessler, Slade and Andrews36 and the mental health of each child in their care with the Self-Rated Mental Health (SRMH) item.Reference Ahmad, Jhajj, Stewart, Burghardt and Bierman37 Table 1 describes the binary cut-points for analysis. Not all measures were collected at all six waves; these are described in Table 1 and denoted with a dash (-) in the Results Tables.
Table 1. Financial, demographic, and mental health measures
Analysis
Descriptive statistics (frequencies, weighted proportions and 95% confidence intervals) were used to describe the two financial hardship measures overall and by demographic characteristics and the mental health measures overall. To reduce effects of non-response and non-coverage and therefore approximate population distributions, caregiver measures were weighted using national population estimates for caregiver age, gender, family structure (sole-caregiving, number of children and proportions of families with children aged less than 5 years), regionality, state/territory and SEIFA. Child measures were weighted using the national population distributions of children aged less than 18 years for children’s age, sex and state/territory.
We used binary logistic regression models to investigate whether the two financial hardship measures were associated with caregiver and child poor mental health over time, after adjusting for caregiver gender, sole caregiver status, education, home language other than English, regionality and SEIFA (Table 1). The child models were additionally adjusted for child age, sex, poor caregiver mental health (Kessler-6) and clustering at the level of family. The regression models were used to estimate marginal probabilities of the two mental health outcomes, by low income and any deprivation (yes versus no), at the six survey timepoints. The Results section describe the overall patterns of the sample estimates and evidence for group differences according to the 95% confidence intervals (CIs). Data were analysed using Stata/IC v18 (Stata, College Station, TX, USA).
Results
Participant characteristics
Across the six survey waves, a total of 17,099 caregivers were approached, and 12,408 (72.5%) provided data for themselves and 20,339 children. Supplementary Table S1 describes the sample sizes and characteristics for each survey. Overall, caregiver mean age was 42.5 years (standard deviation (SD) 9.8 years), ranging 18 to 92 years and 51.4% (n = 6,191/12,048) were female. Respondents cared for a median of 2 children, range 1–6. Just under a quarter (n = 2,922) were sole caregivers and 22.0% (n = 2,648) spoke a language other than English at home. Seventeen percent (n = 2,082) lived in regional/remote areas. No data were available to compare respondents and non-respondents. However, the socio-economic characteristics suggested a strong response bias towards more advantaged groups with 32.3% (n = 3,890) in the highest SEIFA quintile compared with 11.6% (n = 1,402) in the lowest. Overall, children’s mean age was 9.6 years (SD 5.1 years) and 47.8% (n = 9,721/20,339) were female. The proportions of respondents in lockdown at the time of survey completion were 33.0% (n = 473/1434) in Wave 2 (September 2020) and 56.5% (n = 1416/2508) in Wave 3 (July 2021) and zero for Waves 1 and 4–6 (not tabulated). Supplementary Table S1 shows that there were differences between surveys in demographic characteristics, supporting the use of sample weights in analyses to adjust for these differences between surveys and the Australian population.
Financial hardship overall and by demographic characteristics (Aim 1)
Table 2 and Supplementary Fig. S1 show that low income and deprivation were common for Australian families and had different trajectories over time. Weighted proportions of low income were highest in September 2020 (44.7, 95% CI 40.9 to 48.6) and lowest in September 2022 (25.3, 95% CI 21.4 to 29.7%). In contrast, weighted proportions of caregivers experiencing any deprivation were lowest in September 2020 (27.4%, 24.2 to 30.9) and highest in April 2023 (34.5, 95% CI 31.5, 37.6). Of the eight deprivation items, food and utilities were the most commonly missed items throughout the pandemic. Food insecurity increased the most, from 17.2% (95% CI 14.8, 19.9) in June 2020 to 23.7% (95% CI 21.0, 26.6) in April 2023.
Table 2. Financial hardship and poor mental health measures described with the number of respondents and weighted proportions (95% confidence intervals (CIs))
N: Number, K6: Kessler 6 (dichotomized as suboptimal for total score 19+ versus not for score < 19), SRMH: self-rated mental health (dichotomized at poor/fair versus good/very good/excellent). Proportions and 95% CIs for the caregiver were weighted using national population distributions for caregiver age, gender, family structure (sole-caregiving, number of children and any under 5 years), regionality, state/territory and socio-economic indexes for areas index of relative disadvantage. Dash (-) denotes that measure was not collected in that survey wave. n = 1500 (12.5%) caregivers preferred not to report income. Note, the mental health data are previously published.Reference Price, Measey, Hoq, Rhodes and Goldfeld28
Supplementary Tables S2 and S3 present the weighted proportions of families experiencing low income and any deprivation by demographic characteristics, respectively. Low income and deprivation followed a socio-economic gradient and were more common for female caregivers, sole caregivers, those with lower education, living in rural and remote regions and lower SEIFA. The two financial hardship measures were similar between states and child sex and more common for families with younger children.
The cross tabulation of income and deprivation variables was similar across waves so Supplementary Table S4 presents the frequencies and weighted proportions for the total cohort. Overall, 56.8% of families experienced neither financial hardship; 14.9% experienced both; 16.6% reported deprivation but not low income and 11.8% reported low income without deprivation.
Financial hardship and mental health (Aim 2)
Table 1 shows that poor caregiver and child mental health peaked in July 2021, the survey that most closely corresponded with the peak of Australia’s lockdown length, before recovering. This has previously been published in detail.Reference Price, Measey, Hoq, Rhodes and Goldfeld28 Briefly, the weighted proportions and 95% CIs of poor caregiver mental health (K6) were higher in the lockdown periods of 2020–2021 (estimated weighted proportions ranging 17–20%) than post-lockdown in 2022–2023 (estimated weighted proportions ranging 12–14%). Child poor/fair SRMH doubled from June 2020 to July 2021 (6 to 13%) before reducing to 6% in April 2023.
Table 3 and Figure 1 present the estimated probabilities of poor caregiver mental health (Kessler-6) by low income and any deprivation. For the low income measure, estimated probabilities were most similar in June 2020, experienced by 18.8% (95% CI 13.4 to 24.2) of caregivers reporting low income and 15.8% (95% CI 12.5 to 19.2) of caregivers above the low income threshold. Differences increased over time and were greatest in April 2023, when poor mental health had persisted and was estimated at 20.9% (95% CI 16.0 to 25.7) of caregivers with low income, compared with a reduction for caregivers above the threshold to 9.9% (95% CI 7.4 to 12.4).
Figure 1. Adjusted* estimated probabilities of caregiver and child poor mental health over time, by survey, by financial hardship (a) caregiver poor mental health (Kessler-6) by low income, (b) caregiver poor mental health (Kessler-6) by any deprivation, (c) child poor/fair mental health (SRMH) by income, (d) child poor/fair mental health (SRMH) by any deprivation. N: Number, K6: Kessler 6 (dichotomized as suboptimal for total score 19+ versus not for score < 19), SRMH: Self-rated mental health (dichotomized at poor/fair versus good/very good/excellent). *All models were adjusted for caregiver gender, sole caregiver status, education, home language other than English, regionality, socio-economic indexes for areas and state as a proxy for lockdown. Child models were additionally adjusted for child age, sex, poor caregiver mental health (Kessler-6) and clustering at the level of family. n = 1500 (12.5%) caregivers preferred not to report income.
Table 3. Mental health measures by survey and by financial hardship measure, described with number of respondents and adjusted* estimated probabilities (95% confidence intervals (CIs))
N: Number, K6: Kessler 6 (dichotomized as suboptimal for total score 19+ versus not for score < 19), SRMH: Self-rated mental health (dichotomized at poor/fair versus good/very good/excellent).
* All models were adjusted for caregiver gender, sole caregiver status, education, home language other than English, regionality, socio-economic indexes for areas and state as a proxy for lockdown. Child models were additionally adjusted for child age, sex, poor caregiver mental health (Kessler-6) and clustering at the level of family. Dash (-) denotes that measure was not collected in that survey wave. n = 1500 (12.5%) caregivers preferred not to report income.
Table 3 and Figure 1 show substantial differences in the estimated probabilities of caregivers experiencing poor mental health by deprivation status throughout the pandemic. The relative increase in poor mental health during the lockdown periods was greater for caregivers who were not experiencing deprivation, from 9.3% (95% CI 6.7 to 12.0) in June 2020 to 12.7% (95% CI 10.5 to 14.9) in July 2021, compared with caregivers who reported any deprivation, from 31.8% (26.2 to 37.4) in June 2020 to 34.1% (95% CI 29.7 to 38.5) in July 2021. However, like low income, the relative recovery in poor caregiver mental health was greater for those who did not report deprivation, more than halving to 5.0% (95% CI: 3.3 to 6.6) by April 2023. In contrast, the estimated probabilities had reduced by a third for caregivers who were experiencing deprivation, to 25.6% (95% CI: 21.0 to 30.3).
Table 3 and Figure 1 shows that, overall, the estimated probabilities of children’s poor/fair mental health (SRMH) were slightly higher for families experiencing low income or any deprivation in 2021–2022. However, the distributions (95% confidence intervals) were similar, and estimates were mostly equivalent in June 2020 and again by April 2023, ranging 6–8%.
Discussion
This study investigated the financial hardship and related mental health experiences of Australian families during 3 years of the COVID-19 pandemic. These were captured with Australia’s only nationally representative, repeated cross-sectional survey about families conducted during this period. Low income and deprivation (financial hardship) were common, experienced by between one-fifth and two-thirds of all caregivers depending on demographic subgroup. Low household income declined over the three-year period, whereas deprivation increased. Poor mental health was common for caregivers with low income and even more so for those experiencing deprivation. After a collective peak in poor mental health with lockdowns during the July 2021 survey, there was substantial recovery by April 2023 for caregivers who were not experiencing financial hardship. In contrast, poor mental health was more persistent for caregivers experiencing low income or deprivation, suggesting a widening of mental health disparities over time. Children in households with low income or deprivation were more likely to have poorer caregiver-reported mental health during 2021–2022 but distributions were similar, and mostly equivalent in June 2020 and April 2023.
The finding that low income increased while deprivation increased was somewhat counter-intuitive. It is likely that wage growth during the pandemic period outpaced the increase in the Australian government’s low-income threshold, which was used to calculate the low income variable in this study. The base rate for the government threshold for a household with one child has varied with indexation and the pandemic income supplements.38 However, payments for additional children have remained the same over time and not increased with inflation or wage growth. Alternatively, the finding that low income decreased over time may be a by-product of the measurement used. The income variable was relatively crude, collected using 11 categories (see Table 1), and the low-income variable was calculated according to the best fit of the income category to the low income threshold. This study shows the added value of measuring the lived experience of money (i.e. deprivation) and not just a measure of poverty or low income. The two measures of financial hardship followed different patterns over time, with deprivation experienced by a broader cross-section of the population than low income.
In our study, food insecurity and utility bills were the most common deprivations, consistent with other Australian data collected from adultsReference Botha, Gamara and Payne39 and parentsReference Price, White and Burley40 during the pandemic period. In a nationally representative Canadian study of adults in four survey rounds in 2020–2021, more than one in seven participants reported stress or worry related to having enough food for their household, and this was higher for subgroups including those with children or financial concerns. By December 2021, however, less than four percent reported accessing a food bank. A qualitative study of 24 Australians in 2020, who were using income support before the COVID-19 pandemic, found that food was often more insecure because it was deemed a flexible priority compared with housing, employment and education.Reference Zorbas, Browne and Chung41 In our study, as is well-established across the literature, low income and deprivation followed social gradients. Our findings are also consistent with representative, longitudinal Australian data that show that high levels of poverty are disproportionately experienced by sole caregivers, and there are substantial drops in household income associated with the first five years of parenting, which are predominately borne by women.Reference Gamara and Price42
In our earlier analysis of mental health experiences,Reference Price, Measey, Hoq, Rhodes and Goldfeld28 the recovery in poor mental health (Kessler-6) during the post-lockdown periods was apparent across demographic subgroups including caregiver gender, home language, regionality and university educated and multi-caregiving households.Reference Price, Measey, Hoq, Rhodes and Goldfeld28 While poor mental health reduced overall for sole caregivers from 36% in June 2020 to 25% in September 2022, it had increased to 29% by April 2023.Reference Price, Measey, Hoq, Rhodes and Goldfeld28 This is similar to the trajectory for low income in the current study and may reflect the high proportion of sole parents who experience poverty relative to multi-caregiver households.25,Reference Gamara and Price42 Unfortunately, deprivation was not collected by the RCH Poll in September 2022 to enable the same comparison. In our earlier analysis,Reference Price, Measey, Hoq, Rhodes and Goldfeld28 poor mental health increased for caregivers with high school education or less, from 16% in June 2020 to 26% in April 2023. When considered collectively with the current study, these findings highlight important subgroups such as sole caregivers, caregivers of younger children and those with lower education, who are experiencing the cumulative adversities of financial hardship and poor mental health.43 Notably, the cut-point for suboptimal caregiver mental health on the Kessler-6 (19 or more) was higher than many international studies of adults.Reference Prochaska, Sung, Max, Shi and Ong44 While our scoring aligned with Australian normative data and previous studies using the same dataset,Reference Price, Measey, Hoq, Rhodes and Goldfeld28,Reference Furukawa, Kessler, Slade and Andrews36 this high scoring may mean the findings represent the most severe forms of distress, and that other relationships would be evident for lesser, but still important, levels of poor mental health.Reference Prochaska, Sung, Max, Shi and Ong44
Strengths of this study included the large cross-sectional and nationally representative surveys, which employed a robust methodology (surveys piloted and included the validated Kessler-6); collected data on caregiver and child mental health; surveyed female and male caregivers and achieved good response proportions. The study also had limitations. There were no pre-pandemic data to evaluate changes in financial hardship and mental health from before to during the pandemic. In our study, poor caregiver K6 was higher in April 2023 (13%) than representative Australian adult data collected pre-pandemic (8% in 2017) or during the first national lockdown (11%),Reference Biddle, Edwards, Gray and Sollis45 which suggests that child rearing was associated with poorer mental health during the pandemic. Other studies demonstrated that, compared with pre-pandemic levels, there were reductions in financial hardship25 and improvements in well-being for low-income householdsReference Lycett, Frkyberg, Crowe and Capic46 related to the temporary income supports in 2020–2021, but rebounds in hardship subsequently. We could find no study that investigated whether the caregiver mental health disparities associated with financial hardship were increasing before the pandemic, to understand whether our findings were specific to the pandemic period, or whether the data collection period shone a light on a pre-existing pattern. The number of surveys was insufficient to conduct a time-series analysis, so future polls are necessary for evaluating whether mental health disparities related to financial hardship continue to increase in the post-pandemic period, and whether these translate into effects on children’s health and development outcomes.
Further limitations included the reliance on caregiver-report, from only one caregiver per household, which means the child rating may be biased by caregiver perception. The RCH Poll eligibility criteria and sampling approach mean the findings are unlikely to generalise to caregivers without final-year primary/elementary school English, internet access or who are younger than 18, and 12.5% of families did not report income. However, the similarities in pandemic mental health experiences and increasing cost of living across high-income countries mean our findings are likely to generalise to families raising children in similar settings.
Inequities in children’s learning and development existed before the pandemic in Australia,47 and our study suggests that the pandemic exacerbated the causal pathways. We found a strong and persistent relationship between financial hardship and mental health for caregivers, over and above the mental health impacts of the pandemic. In Australia, the recent increase in cost of living has been met with increasing use of and pressure on social services and supports, such as financial counselling and hardship concessions, as well as reduced household savings.48 It is important to consider whether addressing financial hardship can decrease the need for mental health services and explore policy opportunities for testing this, such as income supplements, and the integration of financial support into universal platforms such as primary healthcare.Reference Goldfeld, Price and Al-Yaman30,48 This study has important implications for post-pandemic recovery including finding ways to accelerate prevention and early intervention pathways for addressing the contemporary issues of increasing cost of living and limited mental health supports and services.12,43,Reference Hall49
Supplementary material
The supplementary material for this article can be found at https://doi.org/10.1017/S2040174424000321.
Acknowledgements
We thank all families who took part in the Royal Children’s Hospital National Child Health Poll.
Financial support
The National Child Health Polls are funded by The Royal Children’s Hospital Foundation. Research at the Murdoch Children’s Research Institute (MCRI) is supported by the Victorian Government’s Operational Infrastructure Support Program. Dr Price was supported by The Erdi Foundation Child Health Equity (COVID-19) Scholarship and an MCRI Emerging Leadership Award. Prof Goldfeld was supported by a NHMRC Practitioner Fellowship (#1155290). The other authors received no additional funding. The Murdoch Children’s Research Institute (MCRI) administered research grants for the work and provided infrastructural support (as study sponsor) to its staff but played no role in the conduct or analysis of the research.
Competing interests
None.
Ethical standard
The authors assert that all procedures contributing to this work comply with the ethical standards of the National Statement on Ethical Conduct in Human Research (2023) in accordance with the National Health and Medical Research Council Act 1992 and with the Helsinki Declaration of 1975, as revised in 2008. This study was approved by The Royal Children’s Hospital Human Research Ethics Committee (#35254).
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