Category Archives: Health

Children’s Neighborhoods, Homes, and Health

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One of my favorite things to do is explore cities on foot. Of course, I like some cities more than others—New York City being among my favorites. Until recently, I hadn’t quite articulated what makes a city attractive and appealing to me. Then I came across a video by the School of Life, an organization based out of London. According to the video, some of the things people tend to enjoy about cities include order and variety in physical structures, visible life such as street-level businesses with large windows, and a sense of mystery about places to discover.

These are things that adults might think about when exploring or moving to a new neighborhood, but what about children? What do they need and how does their housing and neighborhood affect their health and wellbeing? In the Future of Children, Ingrid Gould Ellen and Sherry Glied summarize what we know from research. One thing is clear—poor children tend to live in more disadvantaged environments.

For instance, poor children are more likely to live in inadequate housing. The U.S. Census Bureau considers a unit inadequate for reasons such as not having hot and cold running water, no bathtub or shower, no flushing toilet, and having exposed wiring. Recent estimates indicate that 11% of poor households with children and 5.9% of all households with children were physically inadequate, respectively. Thankfully, these figures have been cut in half since the 1970s. Nevertheless, children living in these circumstances probably experience greater emotional and behavioral problems and may perform worse in school.

The physical condition of children’s neighborhoods and what happens in them is also important. For example, when violent crime occurs close to where a child lives, that child is likely to perform poorer on cognitive tests within the next week. Car pollution is associated with asthma and even premature birth. As for the physical condition of things, poorly maintained playgrounds, crumbling sidewalks, and littered glass may result in physical injury or less outdoor activity. We should keep in mind that injuries and homicide are among the leading causes of death among children.

What can we do to make children’s homes and neighborhoods healthier and safer?

Speed bumps and safe walking/biking paths can reduce rates of child pedestrian injuries.

Installing window bars on apartment buildings can reduce fall-related deaths among children.

Introducing the E-ZPass at toll booths can reduce pollution in nearby residential areas. This strategy has been shown to reduce the incidence of preterm births in these neighborhoods.

There are many things we can do to make the homes and neighborhoods of children safe and healthy. However, Ellen and Glied caution that improvements to housing and neighborhoods can increase costs, thereby driving out low-income families. While subsidies can offset these costs for some families, the authors suggest that policymakers experiment with offering subsides to more families while reducing the size of the subsidy available per family. To learn more, see the Future of Children issue, “Policies to Promote Child Health.”

Child Health and Health Care Access

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Many celebrated outside the Supreme Court two weeks ago following SCOTUS’s decision to allow health care subsidies through the Affordable Care Act (ACA). I was among those who breathed a sigh of relief at home after reading that our coverage through the Marketplace would be continued. Now as life returns to normal and we no longer have to worry for the time being, let’s not forget the importance of health care access, especially for children, and the fact that there are still children who don’t have it. Exactly how important is health care access? Lindsey Leininger and Helen Levy joined forces in the latest Future of Children issue to tell us about the influence access has on child health.

Research on this question has had varying results, but Leininger and Levy argue that, overall, access to care does improve child health and that the influence is often more significant for those who are marginalized. The classic RAND Health Insurance Experiment, for instance, suggested that in the population as a whole, the generosity of insurance coverage did not significantly determine overall health. However for high-risk (meaning low-income) children, generosity of coverage did affect health.

Studies on Medicaid eligibility show further evidence: in the year after implementation, mortality fell among nonwhite infants, and this effect persisted for at least 10 years. Also, among children in low-income families, those who experienced more years of Medicaid eligibility were in better health. A variety of other studies have associated expansions of Medicaid eligibility with reductions in child mortality. With regard to Medicaid enrollment, positive effects have also been seen, such as increased enrollment leading to decreases in hospital admissions for conditions that could be well-managed by primary care.

Leininger’s own research has shown that lack of coverage can be a strong detriment to child health. Her study showed that each additional month without coverage was associated with a small, statistically significant decline in the probably of a child seeing a doctor for a well-visit or any other visit. A four-month spell of being uninsured, for example, resulted in a 4 percent decrease in the likelihood of any visit and a 9 percent decrease in the likelihood of a well-visit.

So insurance coverage is good for child health, especially for marginalized children. But according to our authors, although “the ACA builds on the earlier successes of Medicaid expansion and CHIP to promote children’s access to care… challenges remain.” Access to care improves child health, but it is not the only factor. For example one study cited by Leininger and Levy estimates that lack of access to medical care explains only about 10% of early mortality in the population as a whole; less than genetics (30%), social circumstances (15%), and behavioral factors (40%). To improve children’s health overall and consider policies that may do so, we must also consider the larger picture. To learn more about other factors that influence children’s health, read the full Future of Children issue on Child Health.

Child and Public Health in a Libertarian Legal Framework

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Earlier this year the West Coast saw a measles outbreak, another recurrence in a string of previously eradicated childhood illnesses. Stories of parents’ various objections to vaccination quickly flooded the news, underscoring the main question: who is responsible for these public health crises, families or the state? While some people may have been surprised or confused to see such illnesses return, Clare Huntington and Elizabeth Scott’s explanation of children’s health in a legal framework for The Future of Children provides valuable context.

The U.S. legal system, say Huntington and Scott, “gives parents the authority and responsibility to make decisions about their children’s health care, and favors parental rights over society’s collective responsibility to provide for children’s welfare” or, in the case of vaccination, overall public health. They call this a libertarian legal framework as a way to describe the legal context in which parents are permitted to make their own decisions about child health. There are exceptions, such as when a child’s life is in danger or when a child is in juvenile justice custody; however, since parental rights are constitutionally protected, a high standard of harm must be met before intervention can occur.

In public health cases such as vaccination, where can the line of “harm” be drawn? Currently, all healthy children are required to receive vaccinations in order to attend school. However, almost all states offer exemptions for religious beliefs and many also offer them for other philosophical convictions. The balance between the libertarian argument and public health theoretically rests on the understanding that those with strong beliefs both deserve their right to decide and are a small enough segment of the population that the overall public interest of immunity is still met. However the return of some childhood illnesses shows that this balance is no longer being maintained.

Now many states are tightening their exemption policies. For example, California (origin of the measles outbreak) is on the verge of eliminating philosophical exemptions. For some states, making these adjustments may be more difficult. As Huntingdon and Scott put it, “without an affirmative legal obligation to promote children’s [or public] health, governmental investment is optional.” In this context, public health policy is often reactive rather than proactive or preventative.

Recent shifts in both cultural and legal views of vaccination deliver an immediate and crucial example of the libertarian legal context for child health policy and its limits. To read further on current issues in children’s health, see our latest issue of The Future of Children, “Policies to Promote Child Health.”

Defragmenting Child Mental Health

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If you’re ready for a crash course in mental health, read Alison Cuellar’s article in the new volume of Future of Children “Policies to Promote Child Health.” She introduces us to internalizing and externalizing conditions that children experience, as well as the trajectories and outcomes that can accompany them. She also describes prevention programs, and interventions from academic, juvenile justice, and medical and social service angles.

Unfortunately, well intended programs and interventions often come with an unintended consequence. Cuellar argues that due, in part, to differing funding structures of schools, health care providers, and juvenile justice programs, there is an inherent lack of integration among treatment providers; thus, children sometimes fall through the cracks. For example, health insurance might not pay for anything beyond direct professional services provided to a child; whereas parent education or family treatment might be necessary but not be covered. Another example would be programs funded by the Substance Abuse and Mental Health Services Administration—while there might be more flexible funding available for intervention and prevention initiatives through this funder than health insurance, funding is limited to particular communities and settings; thus excluding children not found in these areas.

I’ll be frank in saying that there isn’t an easy method to defragment a complicated system of service delivery. Cuellar concludes that we need to identify ways to overcome fragmentation between services. Volume editors Currie and Reichman call on governments to follow the lead of businesses and make use of the vast amount of data available to them to “create an integrated portrait of child health or to target policies to those who have the most to gain from them.”

In a blog post last year, I wrote about how the Affordable Care Act was a step in the right direction to allow for a more integrated health care system and that there were existing initiatives, such as the patient-centered medical home model, that encourage coordination among providers. Perhaps future policies and practices will encourage coordination among mental health services, thereby improving child mental health.

Childhood Food Insecurity: Especially Vulnerable Populations

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If you’ve read our recent posts, you now know that a number of factors besides household income influence childhood food insecurity, including caretakers’ mental and physical health, parents’ marital status, and childcare arrangements. However, even when these factors are taken into account, children of immigrant parents and children of incarcerated parents remain especially at risk for childhood food insecurity, according to the Future of Children‘s Fall 2014 research report.

For example, writes John Cook, after controlling for other risk factors, “children of foreign-born mothers were three times as likely to experience very low food security as were children of U.S.-born mothers.” And a study by Kelly Balistreri found that 40 percent of children experiencing very low food security are children of immigrants, even though they constitute less than 25 percent of all children in the US.

When children have one or more parents incarcerated, this factor also decreases food security, however the reasons for the effect of incarceration are unclear. The research report highlights several theoretical explanations, but none have been thoroughly investigated. For example, incarcerating a parent might theoretically improve a household’s food security because of decreased demands on resources or by removing a negative influence in the household. On the other hand, incarceration might reduce food security because that parent’s financial, child care, and other contributions are removed. Given these conflicting theories, you might think that other factors correlated with incarceration, such as drug use or mental illness (which I discussed in a previous blog), are causing the effects we see. However, Wallace and Cox found that children with an incarcerated parent are more likely to be food insecure even after controlling for correlated factors.

We need to better understand exactly how these populations are affected, but it’s clear from the research report that children of immigrant or incarcerated parents may need additional support to obtain stable nutrition. Given that these are often two difficult-to-reach populations, policy makers should consider how to best serve these children within existing programs or with new possibilities. For more information about these vulnerable populations, see the Future of Children‘s Fall 2014 research report. For more about children of immigrants in the U.S., see Volume 21 on Immigrant Children.

Food Insecurity and Marital Status

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So far, in our blog series on the Gunderson and Ziliak Future of Children research report, we’ve outlined how 1 in 5 children in America are food insecure and how there are more reasons for this besides low household income. For example, caregivers’ mental and physical health, as well as child care arrangements, are contributing factors. Another piece of the puzzle is family structure.

I’ll start with some basic statistics. This table from childstats.gov shows the differences in the percentage of food-insecure households with children by family structure in 2011. Without taking any other contributing factors into account, female-headed households with no spouse present are more than twice as likely to be food-insecure than households headed by married couples (40 vs. 15 percent). Households headed by a father with no spouse present have a 28% prevalence of food insecurity, in between married couples and single mothers.

These differences aren’t surprising. But there’s more to the story.

Gunderson and Ziliak summarize several studies that give us clues about how marital status is related to food insecurity. For example, Balistreri found that children living with a single parent or with an unmarried parent in a more complex family (such as when the mother is cohabiting with a partner and there’s also a grandparent in the household) are at greater risk of food insecurity than children living with two biological parents or in a stepfamily. Also, Neeraj Kaushal and colleagues found that children living with their biological parents, whether married or cohabiting, have a lower risk of food insecurity. In contrast, Miller and colleagues found no substantive differences across family types after controlling for socioeconomic status and demographic characteristics. Regarding unmarried families, Nepomnyaschy and colleagues have shown that nonresident fathers’ consistent support, whether in cash or in kind, is associated with lower food insecurity; interestingly, inconsistent support was worse than no support at all.

Based on these findings, it’s important not to jump to conclusions about marital status and food insecurity. While married-couple households seem to be at least risk, this doesn’t mean a marriage certificate solves food insecurity, and that we should rush people into marriage. Family complexity, socioeconomic status, and nonresident fathers’ support also play a contributing role.

The Fragile Families Study and the work of Sara McLanahan, editor-in-chief of the Future of Children offer potential policy implications. In a recent article about unmarried parents, McLanahan and Jencks concluded that to prevent the negative outcomes associated with having children outside of marriage, women with lower socioeconomic status can be encouraged to postpone having children, giving them time to mature and increase their education and earnings. By extension, since women aren’t likely to marry men with poor earning capacity, men need to increase their capacity to provide for a family. Initiatives such as the promotion of effective birth control and education access seem promising. For currently unmarried families, Nepomnyaschy’s article underscores the importance of consistent child support in reducing the risk of childhood food insecurity.

Food insecurity and child care for low-income families

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So far, we’ve written several blogs about how characteristics of children’s parents can influence food security. As the authors of our Fall 2014 research report remind us, however, three-quarters of children spend some portion of their preschool years in the care of people other than their parents, so we need to look at how child-care arrangements may also influence food insecurity among children. This is especially important given that children in center-based care may receive a majority of their nutritional needs at their center rather than in the home.

The research report highlights a study by Heflin, Arteaga, and Gable that compared child care by parents to child care by someone else, among low-income families. Specifically, they examined five types of child-care arrangements: child-care by parents, by a relative, by someone unrelated to the child in a home care setting, in a child-care center, and in Head Start. They found that compared with children cared for exclusively by their parents, low-income preschoolers attending a child-care center had lower levels of both food insecurity in general and of very low food security. Children cared for by a relative were less likely to experience food insecurity in general but equally likely to experience very low food security and children cared for by an unrelated adult were more likely to experience very low food security.

The finding that low-income preschoolers attending child-care centers had lower levels of food insecurity and very low food security compared to those cared for by their parents has several theoretical explanations. First, parents of these children may be better able to work while their children attend the center, which increases household income. Second, these children may receive some of their nutritional needs directly through the child-care center.

While school-based nutrition programs have proven to help alleviate food insecurity for some children, this research reminds us that preschool children must also be considered in policy discussions. Improving access to child-care services for low-income parents of preschool children may improve food security within this age group.

Rising from a Culture of Violence to a Culture of Health

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Sara McLanahan, Editor-in-Chief of Future of Children, along with several colleagues, recently prepared a policy report published by the Robert Wood Johnson Foundation (RWJF) that describes children’s exposure to violence in the Fragile Families Study (see the Future of Children Fall 2010 volume to learn more about Fragile Families). The report examines neighborhood violence, intimate partner violence, and harsh parenting, and finds that these types of violence are endemic and interrelated. An implication of these findings is that we need to tackle all these kinds of violence simultaneously, rather than in isolation. The authors point out, for instance, that reducing harsh parenting practices of mothers who experience domestic violence and are worried about their child’s safety won’t be as effective as reducing harsh parenting while also taking on the other problems.

What’s preventing us from achieving this vision?

Part of the problem, as the policy report points out, is that our efforts to combat violence could be more holistic. In other words, there might be a number of specialized programs working on different types of violence within the same community, and yet there can be a disconnect in communication and coordination between these well-meaning efforts. This disconnect warrants consideration.

To gather ideas from stakeholders on how to “break down the silos” between specialized efforts, RWJF has provided a discussion forum led by Senior Program Officer Martha Davis, along with a dialogue on RWJF’s LinkedIn Leadership Network. In the discussion threads, a common theme I noticed from several community leaders was that we should use common needs as a way to build relationships that cross program boundaries. The proposition that all stakeholders–such as prevention, intervention, community services and government–should come together, trust one another, share information and resources, and work together on objectives seems promising.

As a social worker, I often wonder how ideas and research can make a meaningful difference in people’s lives. With this in mind, I recently connected with Martha and discussed the bigger picture. What I learned from our conversation was that we can all catch RWJF’s vision of a culture of health in our communities–part of which is that all children will be able to grow up in safe and nurturing environments at home, in the neighborhood, and at school. And that all children will have a real chance from the very beginning to develop to their full potential as individuals. Risa Lavizzo-Mourey, the President of RWJF, describes this vision in her 2014 President’s Message. I’m excited by the challenge to promote a culture of health.

I would like to invite you to join the conversation. Read the policy report and comment below to share your ideas. Tell us about any programs or policies you believe are making a difference that we can learn from, how you think we can move from a culture of violence to a culture of health, or anything else you think can be part of the solution for improving environments for children and their families.

Health of Caregivers and Childhood Food Insecurity

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We often assume that low household income causes children’s food insecurity. But the Future of Children’s recent research report highlights a number of additional factors that contribute to food insecurity. One notable risk factor is a caregiver who faces mental or physical health problems.

The latest research shows that even when we account for income level, caregivers’ health is still central to children’s food security. For example, a recent paper in the Journal of Children and Poverty found that mothers in food-secure families had better overall health and were less likely to report substance use compared with mothers in food-insecure households. Craig Gunderson and James Ziliak‘s Future of Children report cites a number of health factors that can contribute to children’s food insecurity, including parental depression, parental drug use, or living with an adult with a disability.

What can we do to help children in these situations? The authors point out that the effect of caregiver’s mental and physical health on family food security raises concerns about families’ ability to navigate the welfare system. A caregiver’s health problems may also be exacerbated by lack of access to services. While the authors argue that improved access to services could improve food security, they also state that we need further research on how policy makers can create more accessible systems. The authors offer one suggestion to address the risk factor of substance use: ensuring that mothers who seek substance use treatment are enrolled in SNAP and WIC, if they are eligible. Perhaps a similar idea could be implemented in other contexts where caregivers receive medical or mental health treatment.

As more researchers explore the relationship between food security and health, new policy possibilities may come to light. However, the research highlighted in the Future of Children report makes us aware that health contributes to food security, and low income is not the only indicator of risk. In following blog posts, we will explore additional factors that influence food security. To learn more about health and food insecurity, see the Future of Children‘s Fall 2014 research report.

Childhood Food Insecurity in America

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This past year, lighthearted quizzes have been popular to share and discuss on social media. They’ve allowed to me to find out everything from what U.S. state I actually belong in to which Disney princess I would be if I existed in the cartoon realm, simply by answering odd and seemingly unrelated questions about my personality and preferences. The researcher in me feels a little annoyed at how unscientific these assessments are, but at the same time they are sometimes too fun to pass up–and somehow the results can feel so valid. I’m definitely not opposed to the idea of living in New York as Mulan.

As fun as it can be to spend free time taking and sharing these quizzes, one quiz that ought to go viral is the Hunger Quiz from the Feeding America charity. While it won’t tell you which vegetable you are, it will inform you of some of the surprising facts about hunger in America, and possibly some of your misconceptions about food insecurity. A take-home message is that hunger is a significant problem in America that can alleviated. But what can we do about it?

In a new Future of Children research report, professors Craig Gunderson of the University of Illinois and James Ziliak of the University of Kentucky use the latest research to describe childhood food insecurity in the U.S. They write that the government defines food insecurity as “a household-level economic and social condition of limited access to food” and surprisingly, in 2012, over 1 in 5 children met this criterion. This is disheartening, especially since the government spent over $100 billion in fiscal year 2012 on federal food-assistance programs.

The authors argue that one reason food insecurity rates remain stubbornly high is that we don’t fully understand what causes food insecurity or how programs help alleviate it. The research in the report helps fill this gap and can contribute to policy initiatives that could result in powerful improvements in the health and wellbeing of children.

In upcoming blog posts, we’ll be exploring factors that contribute to food insecurity and what policies are worth consideration in light of these factors. To learn more about food insecurity in America, see the Fall 2014 research report in the Future of Children.