Children’s health-related quality of life in early childhood education and care

ABSTRACT

Studies focusing on young children’s self-reported health-related quality of life (HRQoL) are scarce. More research is needed on the reliability and validity of the methods as well as how self-reported HRQoL in early childhood is linked to other well-being factors. Using the Kiddy-KINDL questionnaire in interviews with 245 3- to 6-year-old children this study investigated how children view their quality of life in Swedish speaking early childhood education and care in Finland, how reliably it can be assessed, and how it relates to age, gender, parent-reported socioeconomic background, and teacher-reported psychological well-being. The results showed that only the social-emotional scale consisting of eight items was a reliable index of HRQoL. The correlation over time in the 12-week follow-up was significant, but small, which may reflect children’s here and now thinking. Children’s poorer self-reported social-emotional well-being was associated with externalizing problems as reported by the teachers. Older children and children from highly educated families reported better social-emotional well-being.

KEYWORDS:

• Children’s self-report
• early childhood education and care
• health-related quality of life
• psychological well-being
• socioeconomic status

Introduction

Health-related quality of life (HRQoL) captures the individual’s perspective on well-being within the physical, psychological, and social domains of life (The WHOQOL Group 1995). Concentrating on self-reported HRQoL is valuable in better understanding the individual’s perspective on their health and well-being as well as individual effects of treatments and interventions that may differ from normative expectations (Coghill et al. 2009). This is especially important regarding children, whose own experiences of their wellbeing are often overlooked, despite the importance of children’s participation as emphasized in the UN Convention on the Rights of the Child (UN Committee on the Rights of the Child 2009).

In 2022 89% of 3–5-year-olds attended early childhood education and care (ECEC) in Finland (Statistics Finland 2022), this makes ECEC an influential environment for the well-being of most Finnish children from varying socioeconomic backgrounds. It would be valuable to understand how children in Finnish ECEC themselves evaluate their HRQoL. However, studies focusing on self-reported HRQoL regarding young children are scarce. Research often focuses primarily on reports from caregivers disregarding the children’s perspective (Dey, Landolt, and Mohler-Kuo 2012).

To address children’s perspective to HRQoL in ECEC adequately, more research is needed on the reliability and validity of the methods in early childhood as well as how HRQoL is linked to other well-being factors. This study provided a unique opportunity to investigate research questions that have not been focused on in earlier studies from the perspective of young children. We interviewed 3- to 6-year-old children about their quality of life using the Kiddy-KINDL questionnaire (Ravens-Sieberer and Bullinger 2000) at two time points, and examined how it related to age, gender, socioeconomic background, and psychological well-being. Parent reports were used to gather information on socioeconomic background (parental education) and teacher reports were used to gather information about the teachers’ view on the children’s psychological well-being.

The KINDL health related quality of life questionnaires

There are few generic self-report HRQoL measures available intended for under 5-year-old children (Solans et al. 2008). The KINDL questionnaires are a set of HRQoL measures for children at different ages: Kiddy-KINDL (12 items presented in an interview form) is originally for 4- to 6-year-olds, but it has been reported reliable even among 3-year-olds (Villalonga-Olives et al. 2015), Kid-KINDL (24 item questionnaire) is for 7- to 13-year-olds, and Kiddo-KINDL (24 item questionnaire) is for 14- to 17-year-olds (Ravens-Sieberer and Bullinger 1998). The originally German language KINDL questionnaires have been translated into Swedish and Finnish (Korpilahti et al. 2015).

The KINDL questionnaires encompass six quality of life dimensions (physical well-being, emotional well-being, self-esteem, family, friends, and everyday functioning at school or nursery school). However, the creators of the questionnaire recommend that rather than six separate dimensions, only a total HRQoL score should be used regarding the 12-item Kiddy-KINDL questionnaire, since only two items per dimension are available (Ravens-Sieberer and Bullinger 2000).

The questionnaires for older children (Kid-KINDL and Kiddo-KINDL) have been reported to be valid and reliable in various studies (Bullinger et al. 2008; Erhart et al. 2009; Ravens-Sieberer and Bullinger 2000; Ravens-Sieberer and Bullinger 1998; Jozefiak, Larsson, and Wichstrøm 2009; Jozefiak et al. 2008). However, to our knowledge, only one study, by Villalonga-Olives and colleagues (2015) has previously investigated the psychometric properties and factor structure of the Kiddy-KINDL. In their study, the age-range of participants was extended to include 3-year-olds. Their findings recommended a two-factor structure for the Kiddy-KINDL including a physical (two items) and a social-emotional dimension (eight items, including questions on self-esteem, family and friend relations, and everyday functioning) and discarding the emotional dimension of the questionnaire (two items), both dimensions were found to be internally consistent.

It is important to acknowledge that the reliability of self-reported HRQoL measures is more uncertain the younger the children are. Several factors may affect young children’s evaluations of their HRQoL including the development of emotion vocabulary (Grosse et al. 2021) and episodic memory (Ghetti and Angelini 2008). A review by Matza and colleagues (2004) concluded that 4-year-olds can report on tangible aspects on their HRQoL, but individual differences in language and cognitive skills may affect the reliability of their answers. Furthermore, the review by Coghill and colleagues (2009) pointed out that younger children also have limited capacity to reflect on their emotions and to remember events over a longer period. Some studies have confirmed the idea that the younger the person is, the more the person lives in the moment (Chen et al. 2016). Although studies on the time perspective of very young children are lacking, we assume that interviews with young children reflect their thinking here and now. That does not undermine the importance of interviewing children about their own well-being.

Children’s own evaluations of their HRQoL also differ from the evaluations of caregivers, with low to moderate correlations between child and caregiver reports (Jozefiak et al. 2008; Bullinger et al. 2008). This suggests that simply focusing on caregiver evaluations does not convey a complete picture of the child’s quality of life.

HRQoL and psychological well-being

Mental health problems and neurodevelopmental disorders are known to affect HRQoL. A systematic review of 16 studies (from different countries and cultures) focusing on children’s mental health and HRQoL reported that especially the psychosocial and family dimensions of HRQoL are negatively affected by mental health problems. Failure to use self-reports in many of the studies was seen as a major limitation (Dey, Landolt, and Mohler-Kuo 2012).

The associations between HRQoL and psychological well-being differ when HRQoL is measured from the parent’s perspective as compared to the children’s perspective. For example, a review by Danckaerts and colleagues (2010) showed that ADHD has a clear negative association with parental reports on their child’s quality of life, whereas children with ADHD themselves do not always report their own quality of life more negatively than other children. Dancaerts and colleagues review included 36 studies from different countries, but only seven of these included children’s self-ratings of their quality of life. The authors concluded that more effort needs to be invested in investigating children’s self-reported quality of life.

In a later study from Germany, children’s self-reported internalizing problems (such as worrying or withdrawal) were associated with lower quality of life in the psychological, social support, and school environment dimensions, whereas externalizing problems (such as fighting and disobedience) were associated with poorer parent relations and autonomy. In parent reports, internalizing was negatively associated with the psychological dimension of HRQoL, whereas externalizing was negatively associated with the school environment dimension (Weitkamp et al. 2013). It could be hypothesized that internalizing problems have a more negative influence on well-being as observed by the children themselves whereas the conflicts created by externalizing problems may be more problematic from the viewpoint of parents and teachers.

Altogether, these findings indicate that mental health and neurodevelopmental problems clearly affect children’s HRQoL but parents and children experience this process from different perspectives. Also, the type of problems the children are facing influences how they evaluate HRQoL. The child’s individual experience cannot be fully grasped without focusing on the self-reported HRQoL as well. Further research on psychological well-being and self-reported HRQoL especially in early childhood, is warranted.

HRQoL in the context of socioeconomic status, age, and gender

Socioeconomic inequalities in health among adults are well documented (Mackenbach et al. 2008) and other studies have examined the links between socioeconomic status (SES) and health among children in Finland. Data from the 1987 Finnish Birth Cohort study show that exposure to poverty during childhood increased the risk of health related and other problems during youth and young adulthood. Furthermore, economic disadvantage during early childhood (0–2 years) was found to be associated with the highest risk in comparison with exposure to poverty later in childhood (Ristikari, Merikukka, and Hakovirta 2018). In addition, despite high quality public health care and comprehensive social security, a Finnish study that investigated the influence of parental socioeconomic factors on childhood cancer mortality showed higher mortality in children with less educated parents and parents with lower incomes (Tolkkinen et al. 2018).

Research focusing directly on HRQoL and SES among children also exists. Low parental educational status (Von Rueden et al. 2006) and lower family affluence (Rajmil et al. 2014) have been associated with poorer self-reported HRQoL among children from several European countries. Also, lower SES (income, education, and occupational status) has been associated with poorer HRQoL in parent reports in a German study (Ravens-Sieberer et al. 2008). These results indicate that socioeconomic inequalities affect health and well-being from early on and HRQoL could be used as an index of equality in well-being. All the above-mentioned studies were conducted among school-aged children, thus more information focusing on younger children is still needed.

In addition to SES, age and gender have an influence on HRQoL. Previous studies have shown that HRQoL decreases by age and that gender differences start to appear at ages between 11 and 13 years showing a more noticeable decrease in HRQoL among girls in comparison to boys (Ravens-Sieberer et al. 2008; Bisegger et al. 2005). Also, contrasting findings related to gender differences exist: Weitkamp and colleagues (2013) found that adolescent boys reported poorer HRQoL related to autonomy and parent relations, whereas in the parent reports, no gender differences were found.

It has been suggested that the age-related decrease in HRQoL as well as increasing gender differences result from pressures relating to gender roles (Ravens-Sieberer et al. 2008), as well as from differing social demands and puberty-related changes in physical and mental well-being (Bisegger et al. 2005). To our knowledge age-related differences in self-reported HRQoL in early childhood have not been studied.

Research questions

As discussed in the earlier paragraphs, further research is needed on younger children’s evaluations on their HRQoL and the validity of these evaluations. In addition, age and gender related differences in self-reported HRQoL in early childhood have not been studied and further research on the links between psychological well-being, SES, and self-reported HRQoL, especially in early childhood, is warranted.

In this study we focus on how 3- to 6-year-olds evaluate their HRQoL in Swedish speaking ECEC centers in Finland using the Kiddy-KINDL questionnaire in interviews with the children.

Our research questions (RQs) are:

• (RQ1) What is the distribution of answers, internal consistency, and correlation over time (two measurement points, 12 weeks apart) of the Kiddy-KINDL?

• (RQ2) Are educators’ evaluations of the children’s psychological well-being associated with children’s self-reported HRQoL?

• (RQ3) What are the potential correlations between HRQoL and children’s age, gender, and SES?

Based on the previous findings, we hypothesize that teacher-reported internalizing and externalizing problems are negatively associated with the children’s self-reported HRQoL (Weitkamp et al. 2013; Dey, Landolt, and Mohler-Kuo 2012) and that SES is positively associated with HRQoL (Von Rueden et al. 2006; Rajmil et al. 2014; Ravens-Sieberer et al. 2008). We might not find age or gender-related differences in HRQoL, as these have been usually shown to emerge during adolescence (Von Rueden et al. 2006; Rajmil et al. 2014; Ravens-Sieberer et al. 2008; Bisegger et al. 2005). However, the effects of age and gender have not been studied among children this young, thus definite hypotheses cannot be made. In addition, we hypothesize that the correlation over time is not strong since children’s answers may emphasize here and now events.

Materials and methods

Participants

The participants came from a study assessing the effects of an intervention designed to support social-emotional development in Swedish speaking ECEC centers in Finland in 2020 (Kalland and Linnavalli 2023) and 2022 (Linnavalli et al. 2024). The participation was based on the interest of the ECEC centers. In 2020 The ECEC centers were from the greater Helsinki metropolitan area (Kalland and Linnavalli 2023). In 2021 the ECEC centers were from four cities in South-Western Finland. Most of the participating children were multilingual, and all attended daycare in Swedish (an official minority language in Finland).

Ninety children (45 girls) participated in the data collection in 2020 and 197 children (94 girls) in 2022. The 2020 data collection was interrupted due to COVID-19 and only baseline data for the intervention study were collected. All analyses except those related to whether HRQoL tracks over time were conducted on the baseline data.

Of the 287 participating children, 245 (85.4%) provided answers to at least eight of the 12 Kiddy-KINDL questions, the remaining 42 children were excluded from further analyses. The children excluded were significantly younger (mean difference 0.91 years) than those who were included t(284) = 6.97, p < 0.001. Those excluded did not differ in gender Χ² (1, N = 287) = 0.20, p = 0.65 or parental education Χ² (3, N = 262) = 4.45, p = 0.22.

Of the children who participated in the intervention study, 174 had valid data from the pre- and post-intervention measurements. Children assigned to the control and experimental groups did not differ from each other in age, parental education, or language background (Linnavalli et al. 2024).

Ethical considerations

Caregivers gave written informed consent for the children’s participation and children’s consent was obtained orally. The families were informed about the study by an information sheet and a data protection notice detailing the research protocol, data management, and participants’ rights following the General Data Protection Regulation of the EU. The families were provided with contact information to discuss any details of the study with the researcher. The caregivers were informed about their own and their children’s right to withdraw from the study at any point without any consequences (and that in this case all collected data from the participant would be deleted). The Kiddy-KINDL interviews were held during the daycare day by trained assistants, who verbally explained the study to the child and inquired about their willingness to participate before the interview. Researchers with training in clinical psychology and social work were available to consult the research assistants during the whole study.

The data were immediately pseudonymized using identification numbers during the data collection, the sheet linking the participants to their codes was stored in a locked space separate from all other data. The data were stored on a secured university server only accessible to the researchers of the study. Data containing personal identifiers (consent forms) were stored separately from all other data in a locked facility.

The study protocol was approved by the Research Ethics Committee in the Humanities and Social and Behavioral Sciences at the University of Helsinki.

Measures

Health-related quality of life. A trained research assistant interviewed each child using the Kiddy-KINDL questionnaire (Ravens-Sieberer and Bullinger 1998; Ravens-Sieberer and Bullinger 2000). The interviews we carried out in a separate calm space, where only the assistant and the participating child were present (see each question in Figure 1). The children were not familiar with the assistants prior to the interview. As discussed in the introduction, the Kiddy-KINDL was originally developed to measure HRQoL within six dimensions (two items per dimension): physical, emotional, self-esteem, family, friends, school/kindergarten. The questionnaire was modified for this study. Since the focus of our study was on children’s emotions and functioning at the ECEC environment, the questions regarding the psychological domain (Q2.1. ‘I had fun and laughed a lot’ and Q2.2. ‘I was bored’) were modified to inquire about the child’s experiences especially at ECEC (Q2.1. ‘I had fun and laughed a lot at kindergarten’ and Q2.2. ‘I was bored at kindergarten’). In addition, instead of asking them to rate their experiences within past two weeks, we asked the children about their experiences without a time limit (on a scale of rarely = 0, sometimes = 1, often = 2), since the concept of a week could still have been difficult for some (especially the younger) children. All questions were answered using this scale. Following Villalonga-Olives and colleagues’ study (Villalonga-Olives et al. 2015) we calculated two separate dimensions: physical (two items) and social-emotional (eight items).

Figure 1. Percentages of children’s item-specific answers.

Teacher-reported psychological well-being. The strengths and difficulties questionnaire (SDQ) was used to measure the children’s psychological well-being. The SDQ is a well-validated 25-item behavioral screening questionnaire (Ferreira et al. 2021; Goodman and Goodman 2011; Goodman and Goodman 2009) that includes the subscales of emotional problems, conduct problems, hyperactivity, peer problems, and prosocial behavior (five items each). In this study, the composite scales of internalizing (sum of emotional and peer problems) and externalizing problems (sum of conduct problems and hyperactivity), and the scale of prosocial behavior were used as recommended for community-based research (Goodman, Lamping, and Ploubidis 2010).

Background variables. The parents completed a brief questionnaire that included information on their educational level and the child’s language skills, gender, and age. Parental education level (highest of either parent) was used as an indicator of family SES.

Results

Descriptive statistics

Table 1 shows the descriptive statistics of the participants. Of the 245 participating children 120 (49%) were girls. Of the 229 children with valid background data, 54% had Swedish and 26% had Finnish as their strongest language, 18% spoke Swedish and Finnish equally well, and 1% had a language other than Finnish or Swedish as their strongest language. The participating families were highly educated, 28% and 66% had at least one parent with a bachelor’s or master’s degree, respectively.

Table 1. Descriptive statistics of the included participants.

Variable	n^a	%	M	SD
N total	245
Girls	120	49
Age (years)	245		4.8	0.8
Daycare start age (months)	226		21.8	10.6
Language background, n available	229
Strongest language Swedish	124	54
Strongest language Finnish	60	26
Equally strong Swedish and Finnish	42	18
Strongest language other than Swedish or Finnish	3	1
Parental education (highest of either parent), n available	229
Up to high school diploma or equivalent	14	6
Bachelor’s degree or equivalent	65	28
At least master’s degree or equivalent	150	66
SDQ
Internalizing (scale 0–20)	242		3.0	3.2
Externalizing (scale 0–20)	241		5.1	4.5
Prosocial behavior (scale 0–10)	244		6.8	2.5
Quality of life at time 1
Social-emotional dimension (scale 0–16)	245		12.7	2.8
Quality of life at time 2 (2022 data collection)
Social-emotional dimension (scale 0–16)	174		12.8	3.3

^a The number of cases available.

Children’s answers to each item of the questionnaire can be found in Figure 1. The answers to the health-related questions were most evenly distributed, 30% of the children felt ill rarely and 23% often. Also 27% rarely had tummy aches or headaches and 31% had them often. Most positive answers related to playing with friends (77% often), enjoying kindergarten (73% often), and feeling fine at home (73% often). Most negative answers related to self-esteem: 13% were rarely proud of themselves and 13% rarely felt pleased with themselves. Furthermore, 23% of the children reported that they were often bored at kindergarten (41% were bored sometimes, and 36% rarely). This is in contrast with only 6% reporting rarely enjoying kindergarten (21% sometimes, and 73% often). This discrepancy may relate to the difficulty of understanding the reversed question (‘I was bored at kindergarten’) for young children as discussed by Villalonga-Olives and colleagues (2015).

Internal consistency and correlation over time

Cronbach’s alpha was used as a measure of internal consistency of the KIDDY-Kindl scales. Cronbach’s α for the social-emotional (8 items) and physical dimensions (2 items) of the Kiddy-KINDL questionnaire were 0.69 and 0.27, respectively. The αs were lower than in the study by Villalonga-Olives and colleagues (2015), and especially low for the physical dimension. We further calculated the recommended Spearman-Brown reliability estimate for the 2-item physical dimension (Eisinga, Grotenhuis, and Pelzer 2013), which was also low (0.27).

We then analyzed whether children’s evaluations of HRQoL tracked over time in the 12-week follow-up of the children who participated in the intervention study by correlating the first and second measurements. Correlation over time in self-reported HRQoL was calculated using Spearman’s ρ since the HRQoL scales were not normally distributed. The Spearman’s ρ between the measurements was 0.382 and 0.433 (p-values < 0.001) for the social-emotional and physical scales, respectively, indicating a significant but low correlation between the time points.

Due to low internal consistency of the physical dimension, only the social-emotional dimension (8 items) of the Kiddy-KINDL was investigated in the further analyses reported below. The scale was dichotomized for these analyses: children scoring more than 1SD below the mean (sum scores below 10), were considered as having low self-reported social-emotional well-being. A similar approach was used in the study by Rajmil and colleagues (2014).

The potential associations of self-reported social-emotional well-being with child's gender and family SES were analyzed via Chi-squared tests. Mann–Whitney U-tests were used to analyze the associations between self-reported social-emotional well-being and child’s age and teacher-reported psychological well-being. Mann–Whitney U-test was chosen as age and teacher-reported psychological well-being were not normally distributed in the data.

Associations between HRQoL, children’s background, and teacher-reported psychological well-being

Table 2 shows the differences in the social-emotional dimension of HRQoL by the children’s gender and family SES. The child’s gender was not significantly associated with social-emotional well-being (p = 0.075), whereas a significant effect for parental education was found (p = 0.041). Children from highly educated families (at least a master’s degree or equivalent) had higher self-reported social-emotional well-being, the effect size for this result was medium (Cramer’s V = 0.17, df = 3).

Table 2. Differences in the social-emotional dimension of HRQoL by child’s gender and family SES (parental education).

	Social-emotional dimension ≥ −1 SD		Social-emotional dimension < −1 SD		p	Effect size, Cramer’s V
	N	%	N	%
Gender
Girl	106	88.3%	14	11.7%	0.075	0.114
Boy	100	80.0%	25	20.0%
Parental education (highest of either parent)
Up to high school diploma or equivalent	11	78.6%	3	21.4%	0.041	0.167
Bachelor’s degree or equivalent	49	75.4%	16	24.6%
At least master’s degree or equivalent	133	88.7%	17	11.3%

Note. Chi-squared test.

As Table 3 shows, younger children were significantly more likely to have low social-emotional well-being (p = 0.003), the effect size for this result was small (eta squared = 0.037). Children reporting low social-emotional well-being had more externalizing problems as reported by their teachers (p = 0.004) with a small effect size (eta squared = 0.034). Teacher-reported internalizing problems (p = 0.092) and prosocial behavior (p = 0.297) were not associated with social-emotional well-being.

Table 3. Differences in the social-emotional dimension of children’s self-reported HRQoL by child’s age and teacher-reported psychological well-being.

	Social-emotional dimension ≥ −1 SD		Social-emotional dimension < −1 SD		p	Effect size, eta squared
	M	SD	M	SD
Age (years)	4.9	0.8	4.5	0.7	0.003	0.037
SDQ
Internalizing problems	2.8	3.1	3.8	3.6	0.092	0.012
Externalizing problems	4.8	4.4	6.8	4.4	0.004	0.034
Prosocial behavior	6.9	2.5	6.5	2.2	0.297	0.004

Note. SDQ = Strengths and Difficulties Questionnaire, Mann-Whitney U-test.

Discussion

We studied 3- to 6-year-old’s self-reported HRQoL in Finnish ECEC centers using the Kiddy-KINDL questionnaire in interviews with the children. Our aim was to study how children’s answers are distributed in the ECEC environment and how they are associated with age, gender, psychological well-being, and socioeconomic background.

In general, 23% (‘I felt ill’) to 31% (‘I had a headache or tummy ache’) of the children reported often having physical symptoms. Most positive answers were related to peer interaction whereas most negative answers related to self-esteem. In line with earlier findings (Villalonga-Olives et al. 2015) the reversed questions seemed to be difficult for the children to comprehend. Since children’s item-specific answers to the questionnaire have not been published before it is difficult to draw conclusions about how the children’s answers in this study relate to children’s typical experiences at this age. However, these findings suggest that more research both in Finland and internationally should be directed to understanding children’s feelings of self-worth and self-esteem and how they may be supported.

As recommended by Villalonga-Olives and colleagues (2015) we calculated two dimensions from the 12 Kiddy-KINDL items: social-emotional (eight items) and physical (two items). The internal consistency (Cronbach’s α) for the social-emotional dimension was 0.69, which was lower than in the Villonga-Olives’ study (α = 0.76). The internal consistency of the physical dimension was poor (α = 0.27), and clearly lower than in the earlier study (α = 0.69). It is not clear why there was such a significant difference between the two studies regarding the physical dimension. It may be that the Swedish and Finnish translations do not convey exactly the same meanings to the children as the original German version did. The use of only two-item scales is to be considered problematic (Eisinga, Grotenhuis, and Pelzer 2013), and based on our findings the use of the two-item physical dimension of the Kiddy-KINDL questionnaire cannot be recommended.

In addition to internal consistency, we investigated whether the self-reported social-emotional well-being tracked over time in a 12-week follow-up. The correlation was significant, but small, indicating that short-term phenomena are likely to influence young children’s answers to the Kiddy-KINDL questions. As discussed by Matza and colleagues (2004) younger children may vary in their ability to reflect on more complex concepts related to HRQoL, and children may not remember things explicitly for longer time periods (Coghill et al. 2009), making their answers more temporary. Children tend to live in the moment, as suggested in our hypothesis.

The reliability and validity of the 24-item KINDL-questionnaires for older children have been found to be good in several earlier studies (Bullinger et al. 2008; Erhart et al. 2009; Ravens-Sieberer and Bullinger 2000; Ravens-Sieberer and Bullinger 1998; Jozefiak, Larsson, and Wichstrøm 2009; Jozefiak et al. 2008). However, our findings point out that younger children’s self-reported HRQoL should be interpreted with caution. Indeed, significantly larger number of younger children had to be excluded from this study for not providing enough valid answers, which indicates that answering questions related to HRQoL is more difficult the younger the children are. Future studies with more participants might further elaborate these findings.

Associations with teacher-reported psychological well-being

We analyzed the extent to which the teachers’ reports on psychological well-being were reflected in the children’s self-reported social-emotional dimension of HRQoL. The associations between psychological well-being and self-reported HRQoL have not been studied earlier among children this young.

We found a small, but significant, association between externalizing problems and poorer self-reported social emotional well-being. Internalizing problems were not associated with HRQoL. This finding is in contrast with an earlier study linking internalizing problems with poorer HRQoL (Weitkamp et al. 2013), however in the earlier study internalizing was measured using self and parent reports and not teacher reports as in our study.

It may be that externalizing problems are easier to detect for the ECEC personnel than internalizing problems, which can be seen in the lower mean score of internalizing problems (M = 3.0) when compared to externalizing problems (M = 5.1). Since large part of the data was from a cross-sectional setup and the time difference between the two measurement points (when available) was short, we cannot make inferences about causality of these findings. It is also likely that these associations are bidirectional: on one hand conflicts related to externalizing problems may decrease the children’s overall sense of well-being and on the other hand children with low social-emotional well-being may be more prone to develop externalizing problems. Longitudinal research is warranted to further investigate these suggestions.

The fact that only one weak association between HRQoL and externalizing problems was found in this study may result from several factors. First, young children may have difficulties in consistently evaluating their HRQoL, and their answers may be subject to change momentarily, as discussed earlier. This can lead to low correlations between self-reported HRQoL and teacher-reports of psychological well-being. Second, a teacher’s perspective on children’s behavior can differ from the child’s own point-of-view. Earlier, correlations between parent’s and children’s ratings of HRQoL have been found to be low to moderate (Jozefiak et al. 2008; Bullinger et al. 2008), and even though children’s psychiatric problems have been associated with parent’s evaluations of poorer HRQoL this is not always the case regarding self-ratings of HRQoL (Danckaerts et al. 2010; Dey, Landolt, and Mohler-Kuo 2012). A follow-up study collecting data from the same children as they grow older, as well as their teachers and parents, could help in better understanding these associations.

Associations with age and gender and SES

We investigated the associations between the self-reported social-emotional well-being, age, and gender. To our knowledge earlier studies have not been conducted among this age group. In line with earlier findings among pre-adolescent children (Bisegger et al. 2005; Ravens-Sieberer et al. 2008), we did not find a gender difference in social-emotional well-being. We found that older children reported better social-emotional well-being, whereas earlier studies have found that HRQoL decreases by age (Bisegger et al. 2005; Ravens-Sieberer et al. 2008; Weitkamp et al. 2013). However, these earlier studies have not included under 6-year-old children and based on Bisegger et al. ’ (2005) findings age-differences only arose starting from 12 years onwards. It is possible that the development and change over time in HRQoL is not linear: it may increase until preadolescence, showing highest values around the age of 8–12-years and decreasing thereafter. Further research is needed to investigate this suggestion.

Finally, we investigated whether social-emotional well-being was associated with the family’s SES as indicated by parental education. We found that children from highly educated families (at least one parent with an MA degree or equivalent) reported better social-emotional well-being than others. This finding is in line with previous research showing socioeconomic inequalities in HRQoL among children and adolescents. Lower family affluence (Rajmil et al. 2014), lower level of parental education (Von Rueden et al. 2006), and a combination of factors related to lower SES (income, education, and occupational status) (Ravens-Sieberer et al. 2008) have all been associated with poorer HRQoL.

As discussed by Bradley and Corwyn (2002), many factors are likely to explain the associations between SES and social-emotional development including stressful life events and poorer access to health care and other services, the developmental pathways are likely to be different from one individual to another. It is of note that although the participating families were overall well-educated, we still could find a significant difference in self-reported social-emotional well-being in children this young. Further investigation is warranted to better understand how these inequalities could be addressed in Finnish ECEC centers.

Strengths and limitations

This study has several strengths. It is, to our knowledge, only the second study focusing on children’s self-reported HRQoL using the Kiddy-KINDL interview. Although the reliability of interviews among young children may be compromised when compared to older children, it is important to investigate and evaluate the children’s own perspective to their well-being in addition to proxy reports.

The participants in this study came from Swedish-speaking ECEC centers, and thus the results may not be directly generalizable to Finnish-speaking ECEC centers, that often have larger numbers of children not speaking Swedish or Finnish as their first language. Elaborating these findings with a future study among Finnish-speaking ECEC centers could give a comprehensive picture of children’s well-being in Finnish ECEC centers overall.

Parental evaluations of HRQoL or psychological well-being were not included in this study. It would be important to investigate how children’s self-reports are linked to the parental reports of HRQoL, although the correlations are known to be low to moderate among older children. Furthermore, SES was only measured via parental education in this study. Including the factors of family income and occupational status could have given a more precise picture of the effects of SES on children’s self-reported social-emotional well-being.

It should also be noted that the Kiddy-KINLD questionnaire was modified for use in this study, as discussed in the methods. Thus, our findings on the reliability of the measure are not directly comparable with studies using the original version of the questionnaire.

Conclusions

Our findings contribute to the field of ECEC research by showing that HRQoL can be measured via self-reports even among 3-year-olds with some caution. Children’s reports are not necessarily stable and, in many cases, might relate to more temporal phenomena than among older children. Based on our results, children can respond reliably to interview questions about their quality of life from a social-emotional perspective (e.g. friend and family relations). We showed that older children and children from highly educated families gave more positive reports on the social-emotional aspects of their quality of life, while negative reports related to problem behaviors at kindergarten as observed by the teachers. These results demonstrate that socioeconomic inequalities exist in children’s self-reported quality of life, and they should be addressed early on before school-age. Children’s own perspective on their well-being is valuable and children’s right to express their own views should be respected when aiming to develop an equal ECEC environment for children from diverse backgrounds.

Acknowledgements

We would like to thank all the families and ECEC personnel investing their time in this study.

Disclosure statement

No potential conflict of interest was reported by the author(s).

Additional information

Funding

This work was supported by the Swedish Cultural Foundation in Finland [grant number 14738].