Supporting child development to reduce child health inequalities in Belgium: a realist evaluation

Abstract

Abstract Background Reducing social inequalities in child health is a major challenge in Belgium. In Brussels, 40% of children are born in a household below the poverty line. The most efficient way to reduce social inequalities in health is to address them on a structural level, via public policies that improve families’ income. But it is also proven that direct support of child development can reduce the risk of poverty in adulthood. Therefore, this study focuses on fields projects working directly with families living in poverty and aims to understand how, for whom and in which circumstances their actions can have effects on child’s development. Methods We conducted a realist evaluation of 30 field projects funded as part of the fight against child poverty and offering parenting support from prenatal period to the age of 6. Firstly, focus groups with the projects’ workers were conducted to identify the underlying mechanisms in their interventions and the contexts facilitating or hindering these mechanisms to achieve the desired effects. Secondly, these Context-Mechanisms-Outcomes (CMO) configurations are validated with project beneficiaries through semi-directed interviews, using picture telling. Results Despite the diversity of the actions carried out, common and transversal mechanisms are highlighted within 6 different CMOs that allow us to understand how and for whom those 30 projects work. Certain contexts - e.g. the characteristics of families, their feeling of freedom regarding the project, the density of projects network - can activate or hinder the mechanisms. We also note that workers tend to adjust their actions to support very vulnerable families for whom certain common mechanisms aren’t working. Conclusions This study, co-constructed through the collaboration of researchers and actors, could help workers to better understand and improve the mechanisms induced by their interventions, and stakeholders to recognise which projects are best suited to certain contexts. Key messages This realist evaluation enables to understand how for whom and in which circumstances field projects actions can have effects on child’s development and therefore take part in child poverty reduction. The realist approach used in this study, through the parallel evaluation of 30 different field projects, allows to refine hypothesis from one project to another, ensuring transferability of results.