Inequalities in COVID-19 impact on preschool mental health in India: key moderators of adverse outcome

Sharp, Helen ORCID: https://orcid.org/0000-0002-0988-8718, Wright, Nicky ORCID: https://orcid.org/0000-0002-3285-2051, Bozicevic, Laura ORCID: https://orcid.org/0000-0001-8629-1723, Supraja, Thirumalai Ananthanpillai ORCID: https://orcid.org/0000-0003-1128-7935, Pickles, Andrew ORCID: https://orcid.org/0000-0003-1283-0346, Hill, Jonathan ORCID: https://orcid.org/0000-0003-2801-0449 and Chandra, Prabha S. (2024) Inequalities in COVID-19 impact on preschool mental health in India: key moderators of adverse outcome. BMJ Public Health, 2 (2). e001209. ISSN 2753-4294

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Abstract

Introduction: Worldwide research suggests that the COVID-19 pandemic had little to no overall effect on preschool children’s mental health, but that the impact is variable depending on pre-existing and COVID-19-related inequalities. Evidence from low- and middle-income country settings is sparse, yet effects may be more variable due to greater inequalities. We provide the first empirical evidence for the impact of the pandemic on emotional and behavioural problems in Indian preschool children, after accounting for normative age-related change, and test whether the impact varied depending on COVID-19-related inequalities. Methods: Families participating in an Indian-based prospective longitudinal birth cohort (Bangalore Child Health and Development Study) provided data at age 2 years (before COVID-19) and again during COVID-19 (n=528). Mothers reported child emotional and behavioural problems and a range of COVID-19-related adverse experiences. Results: There was a small overall pandemic effect on emotional (rate ratio (RR)=1.31, p=0.040), but not behavioural problems, after adjusting for age-related change. However, compared with the lowest risk level, emotional and behavioural problems rose higher compared with whole sample age-expected rates in families who reported the highest levels of perceived negative impact of COVID-19-related adversities (moderation p<0.001, RR=2.43 and p<0.001, RR=1.32), COVID-19 life events (p<0.001, RR=3.28, and p<0.001, RR=1.26) and time the child spent playing alone (p<0.001, RR=2.49). Emotional problems rose higher with high perceived COVID-19 maternal stress (p=0.013, RR=1.57) and with increased child mobile phone use (p<0.001, RR 1.48). Secondary analyses controlling for variation in age trends within moderator subgroups revealed these to be rarely significant. Where significant and accounted for, having more children living at home emerged as protective, whereas living below the poverty line emerged as a risk for adverse pandemic impact on child mental health. Conclusion: A small overall increase in preschool mental health problems was evident. However, this masked substantial worsening of such problems in families with elevated COVID-19 adversities in India. These findings can inform the targeting of policy and practice initiatives to better mitigate adverse longer-term mental health outcomes arising from the pandemic response.