After completing this weeks reading assignments develop a short (500-750 word) posting

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MAMP 504: Ethics Morality and Social Justice in the Military MAMP 504: Ethics Morality and Social Justice in the Military

Adler School of Professional Psychology

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After completing this week’s reading assignments develop a short (500-750 word) posting. It should list at least four examples of inequality or social justice issues (past or present) and their impact upon the military or related governmental departments. Reference sources used. please use the same material that is provided below fro references and tie it with the previous one.

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Tackling the wider social determinants of health and health inequalities: evidence from systematic reviews C Bambra,1 M Gibson,2 A Sowden,3 K Wright,3 M Whitehead,4 M Petticrew5 < A supplementary appendix is published online only at http:// jech.bmj.com/content/vol64/ issue4 1 Department of Geography, Durham University, Durham, UK 2 MRC Social and Public Health Sciences Unit, Glasgow, UK 3 Centre for Reviews and Dissemination, University of York, York, UK 4 Division of Public Health, University of Liverpool, Liverpool, UK 5 Public and Environment Health Research Unit, London School of Hygiene and Tropical Medicine, London, UK Correspondence to Clare Bambra, Department of Geography, Wolfson Research Institute, Durham University Queen’s Campus, Stockton on Tees TS17 6BH, UK; clare.bambra@durham.ac.uk Accepted 3 June 2009 This paper is freely available online under the BMJ Journals unlocked scheme, see http:// jech.bmj.com/site/about/ unlocked.xhtml 284 ABSTRACT Background There is increasing pressure to tackle the wider social determinants of health through the implementation of appropriate interventions. However, turning these demands for better evidence about interventions around the social determinants of health into action requires identifying what we already know and highlighting areas for further development. Methods Systematic review methodology was used to identify systematic reviews (from 2000 to 2007, developed countries only) that described the health effects of any intervention based on the wider social determinants of health: water and sanitation, agriculture and food, access to health and social care services, unemployment and welfare, working conditions, housing and living environment, education, and transport. Results Thirty systematic reviews were identified. Generally, the effects of interventions on health inequalities were unclear. However, there is suggestive systematic review evidence that certain categories of intervention may impact positively on inequalities or on the health of specific disadvantaged groups, particularly interventions in the fields of housing and the work environment. Conclusion Intervention studies that address inequalities in health are a priority area for future public health research. It is well established that health follows a social gradient: better health with increasing socioeconomic position.1 The importance of the social (as opposed to biological or genetic) causes of this gradientdfor example, housing quality, access to healthcare or quality of work, has also been established.2 3 In turn, this has lead to increasing pressure in research, practice and policy-making environments to tackle these wider social determinants of health, through the implementation of appropriate interventions, and thereby reducing the gradient and health inequalities.2e4 However, there are two concurrent problems. First, the social determinants evidence base is dominated by descriptive, epidemiological studies that, by highlighting associations, are only implicitly able to suggest possible interventions. For example, studies consistently show associations between higher job control and better mental health; by implication, therefore, interventions that increase job control should result in health improvements.5 What is lacking though is further evidence about what sort of interventions might be required or whether they will actually be effective in improving health or reducing the social gradient. Second, where interventions aimed at reducing health inequalities have been developed and evaluated, they tend to focus on modifying lifestyle factors such as smoking. This may reflect the fact that lifestyle issues are often easier to identify and treat, or it may be indicative of differences in the respective evidence bases; with evidence on tackling the wider social determinants being less apparent and less accessible to policy makers and practitioners. Therefore, what is needed is evidence about what can actually be done to tackle the social determinants of health and health inequalitiesdspecifically which interventions are effective and for whom.6 This requires evaluative studies of interventions that address the social determinants of health.3 7 The WHO Measurement and Evidence Knowledge Networkdfor example, noted that it is vital to continue to develop evidence bases about tackling the social determinants of health and health inequalities.8 However, turning this need for better evidence about interventions around the social determinants of health into action requires the identification of what we already know in terms of the effects of interventions and also identifying areas where new studies are needed. This information could then be used to identify priorities for new research. It was in this context that the English Department of Health, Policy Research Programme, via the Public Health Research Consortium, commissioned this umbrella review. Umbrella reviews are an increasingly common way of identifying, appraising and synthesising systematic review evidence.9e12 In addition, umbrella reviews are able to present the overarching findings of such systematic reviews.13 This article therefore synthesises recent systematic reviews on the effects on health and health inequalities of interventions aimed at influencing the social determinants of health. METHODS Systematic review methodology was used to locate and evaluate published and unpublished systematic reviews of interventions around the wider social determinants of health (“umbrella” review). Search strategy Initially, the Centre for Reviews and Dissemination Wider Public Health database (a web-based database of systematic reviews of public health and related interventions) was manually searched. This consists of evidence from systematic reviews relevant to public health policy and practice and covers the period from 2000 to 2002. To supplement this, the Cochrane Database of Systematic Reviews and J Epidemiol Community Health 2010;64:284e291. doi:10.1136/jech.2008.082743 J Epidemiol Community Health: first published as 10.1136/jech.2008.082743 on 19 August 2009. Downloaded from http://jech.bmj.com/ on 23 May 2018 by guest. Protected by copyright. Review the Database of Abstracts of Reviews of Effects (both administrative and public databases) were searched electronically, whereas the Campbell Collaboration Database and the EPPI Centre database of health promotion and public health studies were manually searched from January 2002 to April 2007. Electronic searches of the Criminal Justice Abstracts database (2000e2007) were also undertaken (as it is not covered by any of these databases of systematic reviews). Bibliographies, reference lists and relevant websites were also searched. Experts were contacted and we hand searched four leading journals (American Journal of Public Health, American Journal of Preventive Medicine, Journal of Epidemiology and Community Health, Social Science and Medicine) from January 2002 to April 2007. Full search strategy is in web appendix 1. Inclusion and exclusion criteria We used the widely cited Dahlgren and Whitehead rainbow model of the main determinants of health (figure 1) as a framework to help to identify the range of social determinants upon which interventions could be based.14 We concentrated on the outer two layers, which included macroeconomic, cultural and environmental conditions in the outermost layer; and living and working conditions and access to essential goods and services in the next layer, specifically water and sanitation, agriculture and food, access to health (and social care) services, unemployment (and welfare), work conditions, housing (and living environment), education and transport. We therefore excluded reviews that only examined interventions based on the inner most layers of the rainbow: individual lifestyle factors and social and community networks. Only studies of adult participants (16+) or the general population in developed countries (North America, Europe, Australasia, Japan) were eligible for inclusion. We limited our study to adults because an Institute of Education team was conducting a concurrent umbrella review of child health outcomes.15 In terms of outcomes, we were particularly interested in the impacts on inequalities in health or well-being (by socioeconomic status), although we also looked at the overall health effect. We also considered as outcomes the non-health effects (such as employment or income) on people from a disadvantaged group with a pre-existing health condition. Systematic reviews had to meet the two mandatory criteria of Database of Abstracts of Reviews of Effects: (1) that there is a defined review question (with definition of at least two of, the interventions, participants, outcomes or study designs) and (2) that the search strategy included at last one named database, in conjunction with either reference checking, hand-searching, citation searching or contact with authors in the field. Data extraction Two reviewers (CB/MG) independently screened all titles and abstracts identified from the literature search for relevance (n¼1694). Full paper manuscripts of any titles/abstracts that were considered relevant by either reviewer were obtained (n¼84) and independently assessed for inclusion. Any discrepancies were resolved by consensus and, if necessary, a third reviewer (MP) was consulted. Only studies meeting all the inclusion criteria were data extracted (n¼30). RESULTS Thirty systematic reviews of interventions were identified. These are synthesised by domain type in tables 1e4 and in the text below. Housing and living environment There is a “housing evidence base” that goes back many decades, including early evaluation studies from the 1930s and a number of controlled trials, and more recently several randomised controlled trials.16 Given this historical focus on the relationship between housing and health, it is probably not surprising that the systematic review housing evidence base is better developed than for other domains. We identified nine systematic reviews focussing on housing and health (table 1)17e24 two were of “social” changes (rental assistance programmes),17 18 five were of “environmental” changes to housing (eg, changes in lighting, or physical infrastructure, to reduce risk of falls, or injury)19e23 and two were of wider area-based initiatives.24 25 Figure 1 Dahlgren and Whitehead’s model of the social determinants of health. J Epidemiol Community Health 2010;64:284e291. doi:10.1136/jech.2008.082743 285 J Epidemiol Community Health: first published as 10.1136/jech.2008.082743 on 19 August 2009. Downloaded from http://jech.bmj.com/ on 23 May 2018 by guest. Protected by copyright. Review Table 1 Summary details of housing and community reviews Citation Anderson et al 17 Intervention(s) Summary of results “Social” changes (rent assistance so that low-income families can choose where to live, eg, public/private) Improvements in self-reported health status such as a decrease in depression; improvements in social outcomes including neighbourhood safety and social disorder. Improvements reported in terms of overall health, distress and anxiety, depression, problem drinking, substance abuse and exposure to violence. NS reduction in “at least one fall” (adjusted risk ratio of 0.90 0.77 to 1.05). NS reduction in monthly rate of falling (adjusted incidence rate ratio 0.85 0.65 to 1.11). Significant decreases in some types of fall-related injuries (relative reduction in fall related injuries ranging from 6% to 33%). Two studies reported decreases in certain injuries but most of the studies found no decline in rates of any kind of injury. Mixed effects on self-reported mental and/or physical health with some studies reporting small improvements and others small negative effects. Improvements found in social outcomes such as perceptions of crime. 49/72 studies reported a significant improvement in health. Impact of interventions was highly variable with some studies reporting improvements (in mortality), whereas others found deteriorations (in self-reported health). Findings were inconsistent with some studies reporting reductions in homicides and suicides, whereas others reported increases. Acevedo-Garcia et al 200418 “Social” changes (rent assistance so that low income families can choose where to live, eg, public/private) Chang et al19 “Environmental” changes (changes in the housing infrastructure to reduce risk of falls) McClure et al20 Thomson et al22 “Environmental” changes (changes in the housing infrastructure to reduce risk of falls) “Environmental” changes (changes in the housing infrastructure to reduce injuries) “Environmental” changes (rehousing, renovation, updating) Saegert et al23 Thomson et al25 “Environmental” changes (rehousing, renovation, updating) Area-based urban regeneration Hahn et al24 Area-based firearms restrictions Nilsen21 NS, non-significant. Reviews of rental assistance (eg, use of rent subsidies to create mixed-income or desegregated housing in poorer US neighbourhoods) suggested that interventions to promote mixed housing may result in increases in perceived neighbourhood safety, perhaps because exposure to crimes against person and property is reduced, along with neighbourhood social disorder. There is tentative systematic review evidence that such housing mobility policies (at least in the USA) do improve health and health behaviours, but the effects are small. Research on the mechanisms is lacking and therefore required. General housing improvement is also associated with positive change in social outcomes, including reductions in fear of crime and improvements in social participation. These interventions ranged from home visits, risk assessments and removal of hazards to reduce the risk of injury, to physical changes to housing structure such as insulation, furniture and more general housing policies. Table 2 Although two reviews considered the effects on inequalities,22 25 none of the primary studies differentiated their results by socioeconomic status. Work environment There has been a recent shift in focus, from work as a source of occupational diseases to the wider impacts of work on health and well-being.5 This is reflected in the seven systematic reviews we located.26e32 They focussed on four types of intervention (table 2): increased employee control (via participatory “health circle” staff meetings to discuss ways to improve the work environment, more generic staff participation at work or task restructuring),26e28 changing the organisation of shift work (less nights, shorter shift lengths, etc, or the compressed working week),29 30 privatisation31 and the health and safety regulations.32 Summary details of work environment reviews Citation Aust and Ducki 26 Intervention(s) Summary of results Dusseldorf health circlesdstaff discussion groups on improving working conditions Mixed results: sickness absence increased in the controlled study, whereas it decreased in the four uncontrolled studies. One study reported improvements in some psychosocial outcomes such as relationships with colleagues. Participatory committee interventions that increased employee control had a consistent and positive impact on self-reported health. Task structure interventions did not generally alter levels of employee control. However, where job control decreased (and psychosocial demands increased), self-reported mental (and sometimes physical) health appeared to get worse. Health effects were inconclusive, although there was seldom a detrimental effect. Work-life balance was often improved. Switching from slow to fast shift rotation; changing from backward to forward shift rotation; and the self-scheduling of shifts were found to benefit health and workelife balance. Higher-quality studies suggested that job insecurity and unemployment resulting from privatisation impacted adversely on mental health and on some physical health outcomes. Increased regulation, when enforced with inspections, might be associated with a decrease in fall injury rates. Egan et al27 Organisational-level work reorganisation: participatory committees, control over hours of work Bambra et al28 Task structure work reorganisation: task variety, team working, autonomous groups Bambra et al29 Bambra et al30 Changing from an 8-h, 5-day week to a compressed working week of a 12 h/10 h, 4-day week. Changes to the organization of shift work schedules Egan et al31 Privatisation of public utilities and industries Rivara and Thompson32 Legal regulations (increased safety regulations) to prevent falls from height in construction industry 286 J Epidemiol Community Health 2010;64:284e291. doi:10.1136/jech.2008.082743 J Epidemiol Community Health: first published as 10.1136/jech.2008.082743 on 19 August 2009. Downloaded from http://jech.bmj.com/ on 23 May 2018 by guest. Protected by copyright. Review Table 3 Summary details of transport and access to health and social care services reviews Citation Transport Bunn et al35 Intervention(s) Summary of results Area-wide traffic calming schemes (creation of one ways, speed humps, etc) Intervention has potential to reduce traffic injuries and deaths: road user deaths (pooled RR 0.63, 0.14 to 2.59) and injuries (pooled RR 0.89, 0.8 to 1.00) decreased. Little evidence that major new urban roads reduce injury incidence. Bypasses do appear to reduce injury accidents on main routes, but this may be achieved at the cost of displacing accidents to secondary routes. Mixed evidence of effects of engineering interventions but financial incentives and providing alternative services had some success in changing journey type. Absence of evidence rather than evidence of no effect. Decreasing the MLDA increased road injuries (effect range 2% to 38%), whereas increasing the MLDA decreased road injuries (effect range 33% to 6%). Decreased BAC led to decreases in vehicle crashes. All studies reported a reduction in road traffic collisions and casualties, with the reduction in the vicinity of the camera ranging from 5% to 69% for collisions, 12 to 65% for injuries and 17% to 71% for deaths. Egan et al36 New road building (major urban roads, bypasses, major connecting roads) Ogilvie et al34 Population-level interventions to promote shift from using cars to walking and cycling (engineering measures; financial incentives; providing alternative services) Shults et al33 MLDA laws and BAC laws Pilkington and Kinra37 Fixed or mobile speed cameras Access to health and social care services Anderson et al38 Cultural accessd“culturally competent healthcare” (language and culture training for health professionals, use of interpreters, etc) Lewin et al39 Cultural accessdlay health worker interventions (intended to promote health, manage illness or support people) delivered in primary and community healthcare settings Pignone et al40 Gruen et al41 Cultural accessdhealth education materials for patients with low literacy Improving geographic accessdspecialist outreach clinics in primary care or rural hospital settings No evidence on health outcomes found, however, healthcare use and access increased. In comparison with usual care, promising benefits were shown for promoting the uptake of immunisation in both children and adults (pooled estimate RR 1.30, 1.14:1.48). May also be effective in promoting the uptake of breastfeeding (pooled estimate RR¼1.05, CI 0.99 to 1.12). Mixed effects on health, difficult to draw conclusions due to diversity of outcomes, interventions and quality of studies. Specialist outreach appears to improve access to primary care and self-reported health (eg, a decrease in disease symptoms in the intervention group (pooled RR 0.63, CI 0.52 to 0.77)). BAC, blood alcohol concentration; MLDA, minimum legal drinking age. Overall, interventions to improve employee control (three reviews)26e28 found consistently positive health effects when job control was actually increased27 (and negative effects when job control decreased).28 The two reviews of changes to shift work29 30 identified some interventions (such as increased control over shift times) that had positive impacts on selfreported (particularly mental) health.30 Conversely, the privatisation review suggested that job insecurity and unemployment resulting from privatisation impacted adversely on mental Table 4 health.31 The single review of increased health and safety legislation in the construction industry found a decrease in fallrelated injuries after the intervention.32 Five of the reviews explicitly looked for evidence of effects on health inequalities and three included studies that reported differences by socioeconomic status (occupation).27 28 31 In one review of participatory interventions,27 one uncontrolled study found improvements in terms of mental health outcomes among manual workers but not managers or clerical employees. In Summary details of unemployment and welfare, agriculture and food, and water and sanitation reviews Citation Unemployment and welfare Adams et al45 Intervention(s) Summary of results Professional welfare rights advice in healthcare settings (welfare benefit maximisation) Little evidence that the advice leads to measurable health and social benefits, although some studies reported improvements in self-reported mental health. Absence of evidence rather than evidence of no effect. No significant impact on employment outcomes in comparison to standard care. Some evidence that supported employment more effective than prevocational training. Evidence of positive employment outcomes was not compelling because, although positive outcomes ranged from 11% to 50%, controls were rarely used, so there is possible confounding effect by relatively buoyant labour market. Crowther et al43 Supported employment or prevocational training to help people with severe mental illness get into employment Bambra et al44 Welfare to work interventions aimed at people out of work due to a health condition or disability Agriculture and food Wall47 Water and sanitation Demos et al48 Monetary incentives, including price decreases on low-fat snacks in vending machines, farmers’ market coupons for fruit and vegetables, free food provision. Positive effect s were found on weight loss, consumption of fruit and vegetables, redemption of coupons and attitudes towards fruit and vegetable consumption. Changes in water fluoridation levels (typical levels were 0.05 to 1.5 ppm) Fluoridation at levels up to 1 ppm has no adverse effects on bone fracture incidence, bone mineral density or bone strength. J Epidemiol Community Health 2010;64:284e291. doi:10.1136/jech.2008.082743 287 J Epidemiol Community Health: first published as 10.1136/jech.2008.082743 on 19 August 2009. Downloaded from http://jech.bmj.com/ on 23 May 2018 by guest. Protected by copyright. Review another review of task restructuring,28 an uncontrolled study found that the adverse health effects of a team working intervention were only experienced by the lowest grade of employees. The review of privatisation also identified one study that found that 8 months after privatisation, occupational stress increased only among clerical and administrative staff, and not among manual workers or managers.31 Transport Transport policies are often cited as a major influence on health and health inequalities, although it is a field where relatively few evaluative studies and reviews have been carried out (at least, ones measuring health outcomes). We located five reviews addressing transport issues (table 3).33e37 Each dealt with a different type of intervention: promoting modal shift from driving to walking and cycling; impacts of new roads; reductions in permissible alcohol when driving, area-wide traffic calming and speed cameras. Despite the differences in intervention type, four of the five reviews included outcomes related to road injuries.33 35e37 In relation to road injury outcomes, the review of legislative interventions to curb alcohol-impaired driving33 found strong evidence to support the reduction of fatal and non-fatal crashes, as did the reviews of traffic calming interventions35 and speed cameras.37 Evidence for the impact of new of road building on injuries36 was less conclusive because whereas out-of-town bypasses delivered reductions in injuries, major new roads did not. There was very limited evidence available on the health effects of interventions aiming to encourage modal transport shift from driving to walking and cycling.34 None of the reviews presented any information relating to impacts on health inequalities. Health and social care services (the latter being the so-called direct health selection hypothesis).42 Two of the three reviews we located in this domain were of interventions that aimed to assist those who were prevented from entering the labour market by ill healthdfor example, through supported employment, providing skills and training, and other mechanisms.43 44 The other review evaluated interventions to increase the uptake of welfare entitlements.45 Details of the reviews are presented in table 4. One review found that although supported employment delivered more positive employment outcomes than prevocational training, there was no significant improvement in comparison with standard care.43 Furthermore, there was little evidence of any impact on health. Similarly, the review44 of welfare to work found some evidence of positive employment effects, although it was not clear to what extent this was due to the influence of contextual confounding factors. This review contained no information on health outcomes. The review of welfare rights interventions45 indicated that there were clear financial effects with a mean gain in income of £1026 per client in the year after the intervention (2004). However, the effects on health outcomes were limited to short-term improvements in mental health. None of the reviews specifically examined differential impacts across socioeconomic groups, although importantly all interventions were targeted at disadvantaged groups. Agriculture and food Agricultural policies affect the quality, quantity, price and availability of food, all of which are important for public health.46 Whereas overall increases in life expectancy may be partly attributed to better nutrition, increases in the prevalence of obesity in many countries point to the contribution food policies also make to overnutrition. Agriculture and food policies and interventions may therefore provide some of the mechanisms for addressing diet-related health inequalities. However, only one review was identified (table 4).47 This focussed on monetary incentives (including price decreases) on low-fat snacks, coupons for farmers’ markets, financial rewards and free food provision. All four RCTs included in the review found a positive effect of incentives on the outcomes measured: weight loss, consumption of fruit and vegetables, redemption of coupons and attitudes towards fruit and vegetable consumption. None of the studies differentiated their results by socioeconomic position and none of the reviews focussed on disadvantaged groups. Access to effective healthcare is another determinant of population health. Several different types of access are relevant to the wider social determinants of health, particularly geographic, economic and cultural access. We identified four reviews in the Organisation for Economic Co-operation and Development (OECD) countries (table 3), three of which focused on interventions to improve cultural access (acceptability and appropriateness of services)38e40 and one41 on improving geographic access (location and physical availability of health services) in rural areas. No reviews of economic access (affordability of services) were identified relating to high-income countries. Overall, the evidence evaluating interventions to promote culturally relevant healthcare was generally inconclusive. For example, although positive effects were found for lay health workers in promoting immunisation uptake, there was insufficient evidence to support the use of lay health workers in other contexts.39 Rural outreach interventions improved geographic access to care and self-reported health.41 The reviews all focused on interventions intended to improve access for disadvantaged groups (low-income and minority populations) and there was some evidence that the interventions were effectivedfor example, ethnic minority patient satisfaction with healthcare services increased after the cultural training intervention.38 However, none of the reviews reported whether impacts of interventions differed for different groups in the population studied. There are many aspects of water and sanitation likely to impact on population health. Aside from the direct effects of pollution and contamination, other aspects of water management, including abstraction, water metering and the provision of flood defences, may all have potential public health implications. However, there are few available systematic reviews reporting health outcomes and only one that met our inclusion criteria (table 4).48 It focussed on changes in levels of water fluoridation and did not report on the effects on health inequalities. The authors concluded that fluoridation at levels up to 1 ppm had no adverse effects on bone fracture incidence, bone mineral density or bone strength in developed countries. Unemployment and welfare Education There is considerable observational evidence on the linkages between unemployment and health, which suggests that ill health can be both a cause and a consequence of unemployment There is undoubtedly a strong case for highlighting education as a major determinant of health and health inequalitiesdnot least though its interaction with other determinants. For example, 288 Water and sanitation J Epidemiol Community Health 2010;64:284e291. doi:10.1136/jech.2008.082743 J Epidemiol Community Health: first published as 10.1136/jech.2008.082743 on 19 August 2009. Downloaded from http://jech.bmj.com/ on 23 May 2018 by guest. Protected by copyright. Review “Education has traditionally been an important route out of poverty for disadvantaged groups in many countries. Generally, qualifications improve people’s chances of getting a job and of having better pay prospects and the resulting increase in standard of living. This in turn improves opportunities to obtain the prerequisites for healthdnutritious food, safe housing, a good working environment and social participation.”14 However, perhaps surprisingly, we found no systematic reviews of the health effects of adult education interventions in OECD countries published in the current decade. It should be noted that person-based health education interventions aimed at social determinants in the two inner most layers of the “rainbow” were excluded from this review. DISCUSSION This project aimed to identify the “state of the systematic review evidence base” in the current decade in developed countries, addressing the effects on health and health inequalities of interventions targeting the social determinants of health, as well as identifying fruitful areas for future research. The study therefore does what it aims to do, but this is of necessity a very limited answer to the problem of what works in terms of tackling health inequalities as, disappointingly, very few relevant reviews have been conducted. It has already been demonstrated elsewhere that the public health evidence base is sparsely populated,49 and this is particularly true in terms of evaluations of interventions addressing the social determinants of health, especially in relation to health inequalities. Evidence on the differential impacts of interventions by socioeconomic position is largely absent (only 3 of 30 reviews presented results for specified population subgroups), although this is likely to reflect the state of the primary study evidence base rather than that of the systematic reviews.22 25 29 30 34 What we do have however is suggestive evidence that certain categories of intervention may impact positively on inequalities or on the health of specific disadvantaged groups, particularly interventions in the fields of housing and the work environment. In the reviews of work environment interventionsdfor example (such as changes to the organisation of work and privatisation), there is evidence that the effects of change are experienced differently by different levels of employee and that health outcomes differed accordingly. This suggestsdas noted by Marmot and others50dthat the workplace may indeed be an important setting in which inequalities may be addressed. Similarly, there is suggestive evidence that housing change may positively affect physical and mental health, but the actual effects may be small. In the case of transport, the strongest evidence derives from studies of injury prevention, but the wider health impacts of transport policies on inequalities remain to be elucidated further. Given the importance of access to healthcare in potentially helping to reduce health inequalities, it was notable that there is still only limited evidence of effects on health and no direct evidence of impacts on inequalities in health. Similarly, the systematic review evidence base in regards to the other social determinant domains is very limited particularly in terms of the effects of interventions on health inequalities, and in the case of the unemployment and welfare domain on general health, too. We found no reviews on interventions relating to macroeconomic, cultural and environmental conditions (the outermost layer of the rainbowdfigure 1). These conditions influence the standard of living achieved by different sections of the population, the prevailing level of income inequality, unemployment, J Epidemiol Community Health 2010;64:284e291. doi:10.1136/jech.2008.082743 job security and so on. Interventions within this category would therefore be aimed at altering the macroeconomic or cultural environment to reduce poverty and the wider adverse effects of inequality on society, including measures to ensure legal and human rights, “healthier” macroeconomic and labour market policies, the encouragement of cultural values promoting equal opportunities and environmental hazard control (including upholding international obligations and treaties in this field).51 This gap may be as a result of our focus on intervention studies and it may well be that the evidence base therefore needs to be widened to include reviews of comparative (non-intervention) studies such as those conducted within social epidemiology (such as that by Lynch et al52 on the association between income inequality and population health). Clearly, education is the starkest example of an area in which there can be further development. The reviews that do exist either date from pre-2000 or relate to developing countries. We located no reviews relating to education and adult health outcomes published in this current decade concerning the situation in the high-income countries of the OECD. There are therefore unanswered questions, ripe for review, concerning the relationships between levels of education in a society and/or the nature of educational systems and health outcomes, and how these health outcomes differ by socioeconomic position. Similarly, it was particularly difficult to identify appropriate reviews in the domain of “access to health and social care” as a social determinant of health. Despite extensive and rigorous searching, we only identified four systematic reviews that met our inclusion criteria. Moreover, the studies in the reviews do not represent the full range or intensity of potential intervention types in this domain. There isdfor example, a clear need for reviews of the effects of nationwide changes in health systems to improve geographic, economic or cultural access for the population as a whole and for groups in greater need in particular. In terms of the unemployment and welfare domain, there are still areas in need of further research, particularly in terms of the effects on health of welfare to work policies (eg, for lone parents, for the long-term unemployed, for young people), as well as the effects of interventions designed to prevent ill health among people out of work. Similarly, in the transport domain, the effects of policies to promote healthy transport (such as policies to promote walking) require further research.53 More studies are needed in terms of food policies (eg, the effects of the EU Common Agricultural Policy on food pricing and consumption); and in relation to water and sanitation interventions, the effects of water metering, which has been suggested may to lead to poorer families economising on water to the detriment of child health, is an important gap in the systematic review evidence. Limitations The main challenge was simply that there were too few systematic reviews conducted. It was also a challenge to locate the relevant systematic reviews that had been conducted. Searching for studies on the social determinants of health and/or health inequalities is difficult and time-consuming, and the searches can often suffer from a lack of sensitivity and a lack of specificity.54 55 However, to ensure the searches were as extensive as possible, our search strategies were piloted and revised. Furthermore, the searches were conducted by experienced specialist staff at the York Centre for Reviews and Dissemination. In addition, leading public health journals were hand searched and review authors were contacted. Despite this, as for any review of complex and difficult-to-define social 289 J Epidemiol Community Health: first published as 10.1136/jech.2008.082743 on 19 August 2009. Downloaded from http://jech.bmj.com/ on 23 May 2018 by guest. Protected by copyright. Review interventions, it is not possible to be sure that all reviews have been located.55 However, there is confidence that the gaps identified, although perhaps surprising, are real. Another important issue to consider with umbrella reviews is the risk of study overlap between the included systematic reviews. However, in keeping with previous public health policy umbrella reviews,9 we found very little overlapdfor example, in the work environment domain, there were no common studies. A more general limitation of public policy research is also relevant as a lot of the studies included in this umbrella review are from the USA, and there is evidence that the contextual determinants of health act differently in the USA than in Europe due in part to the different welfare systems in place.56 The findings of the USA studies may not therefore be easily transferrable to the European policy context. CONCLUSION It appears, then, that not only is the public health systematic review evidence base weak in terms of how to tackle the social determinants, but that there are specific areas that appear especially sparsely populated. These are sector-wide policies in education, the health system, food and agriculture, and more generally on the influence of macro-level policies on health inequalities. Although it is now a given that the effects of any interventions on inequalities should be assessed, the systematic review evidence base does not yet allow us to say with any confidence what the effects of interventions on reducing health inequalities are because differential impacts by socioeconomic position are rarely assessed. Nonetheless, one of the positive messages from this umbrella review is that there is a growing systematic review evidence base around housing and regeneration and a significant evidence base on the work environment suggesting that this is indeed a sector with significant responsibility for improving health and reducing inequalities. Given the few intervention studies that address inequalities, it is particularly important to assemble evidence on the mechanisms by which policies may affect health; this will help identify points at which to intervene and will provide a framework for the development of new research.51 For example, the results of systematic reviews that have evaluated the effects of interventions on the determinants of health (but which do not have health as an outcome) could also be examined and their findings extrapolated to tackling health inequalities. This is consistent with the WHO Commission on Social Determinants and the Measurement and Evidence Knowledge Network advice that as evidence comes in many shapes and forms, there is a need to get smarter about synthesising and appraising that evidence.8 Funding The work was supported by the Public Health Research Consortium. The Public Health Research Consortium is funded by the English Department of Health Policy Research Programme. The views expressed in the publication are those of the authors and not necessarily those of the DH. Information about the wider programme of the PHRC is available from www.york.ac.uk/phrc. The funders had no involvement in the study design, execution or write-up. Other funders: Department of Health. Competing interests None. Contributors CB participated in the design of the study, collected, analysed and synthesised the data; led the writing of the article; and is a guarantor. MG assisted with data collection, analysis and synthesis and contributed to the writing of the article. AS participated in the design of the study, assisted in analysis and synthesis and contributed to the writing of the article. KW participated in data collection and contributed to the writing of the article. MW assisted in analysis and synthesis and contributed to the writing of the article. MP participated in the design of the study, assisted in analysis and synthesis and contributed to the writing of the article. All the named authors approved the final version. Provenance and peer review Not commissioned; externally peer reviewed. What is already known on this topic REFERENCES < The importance of the social determinants of health inequalities is well established. < Therefore, there is increasing pressure to tackle these wider social determinants of health, through the implementation of appropriate interventions. < However, there is a lack of evidence about what can actually be done to tackle the social determinants of health and health inequalities. 1. 2. 3. 4. 5. 6. 7. What this study adds 8. < This study synthesises recent systematic reviews on the 9. effects on health and health inequalities of interventions aimed at influencing the social determinants of health. < It thereby identifies what we already know in terms of the effects of interventions on health and health inequalities, and also where further work needs to be done. < Evidence on the differential impacts of interventions by socioeconomic position is largely absent in the systematic review evidence base, although there is suggestive evidence that certain categories of intervention may impact positively on inequalities or on the health of specific disadvantaged groups, in particular, interventions in the fields of housing and the work environment. 290 10. 11. 12. 13. 14. 15. Graham H. Unequal lives: health and socioeconomic inequalities. Maidenhead: Open University Press, 2007. Acheson D. Independent inquiry into inequalities in health (the Acheson Report). London: HMSO, 1998. 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Review Food Security, Poverty, and Human Development in the United States JOHN T. COOK AND DEBORAH A. FRANK Department of Pediatrics, Boston University School of Medicine, at Boston University Medical Center, Boston, Massachusetts 02118 Access to food is essential to optimal development and function in children and adults. Food security, food insecurity, and hunger have been defined and a U.S. Food Security Scale was developed and is administered annually by the Census Bureau in its Current Population Survey. The eight child-referenced items now make up a Children’s Food Security Scale. This review summarizes the data on household and children’s food insecurity and its relationship with children’s health and development and with mothers’ depressive symptoms. It is demonstrable that food insecurity is a prevalent risk to the growth, health, cognitive, and behavioral potential of America’s poor and near-poor children. Infants and toddlers in particular are at risk from food insecurity even at the lowest levels of severity, and the data indicate an “invisible epidemic” of a serious condition. Food insecurity is readily measured and rapidly remediable through policy changes, which a country like the United States, unlike many others, is fully capable of implementing. The food and distribution resources exist; the only constraint is political will. Key words: children’s health; human development; hunger; poverty Introduction Optimal physiological, cognitive, and emotional development and function in children and adults requires access to food of adequate quantity and quality at all stages of the lifespan. Efficient epidemiological measurement of access to food by U.S. populations has challenged researchers since the 1980s. Lack of access to adequate food by U.S. households because of constrained household financial resources has been measured by questions assessing “hunger,” “risk of hunger,” “food insufficiency,” and most recently “food insecurity.”1–5 In 1990 an expert working group of the American Institute of Nutrition developed the following conceptual definitions of food security, food insecurity, and hunger, which were published by the Life Sciences Research Office of the Federation of American Societies for Experimental Biology.2 • Food security. “Access by all people at all times to enough food for an active, healthy life. Food security includes at a minimum: (1) the ready availability of nutritionally adequate and safe foods, Address for correspondence: John T. Cook, Ph.D., Department of Pediatrics, Boston Medical Center, Maternity Bldg., Rm. 4208, 91 E. Concord St., Boston, MA 02118-2393. Voice: 617-414-5129; fax: 617-414-3679. john.cook@bmc.org Neither author has anything to disclose regarding potential or actual conflicts of interest. • • and (2) an assured ability to acquire acceptable foods in socially acceptable ways (e.g., without resorting to emergency food supplies, scavenging, stealing, or other coping strategies).” Food insecurity. “Limited or uncertain availability of nutritionally adequate and safe foods or limited or uncertain ability to acquire acceptable foods in socially acceptable ways.” Hunger. “The uneasy or painful sensation caused by a lack of food. The recurrent and involuntary lack of access to food. Hunger may produce malnutrition over time. . .. Hunger . . . is a potential, although not necessary, consequence of food insecurity.” These conceptual definitions were made operational, and a scale was developed to measure the operational conditions at the household level in the U.S. population under the guidance and sponsorship of the National Center for Health Statistics and the U.S. Department of Agriculture in 1995–1997.3–5 Consisting of 18 questions, the U.S. Food Security Scale (FSS) is administered annually by the Census Bureau in its Current Population Survey, with results reported by the U.S. Department of Agriculture’s (USDA) Economic Research Service (ERS). These repeated cycles of the FSS now provide a 10-year time series of data on food security, food insecurity, and hunger in the U.S. population for 1995–2005.6 C 2008 New York Academy of Sciences. Ann. N.Y. Acad. Sci. 1136: 193–209 (2008).  doi: 10.1196/annals.1425.001 193 194 Annals of the New York Academy of Sciences TABLE 1. Questions in the U.S. Food Security Scale, with Child Food Security Scale questions in the lower section 1. “We worried whether our food would run out before we got money to buy more.” Was that often, sometimes, or never true for you in the last 12 months? 2. “The food that we bought just didn’t last and we didn’t have money to get more.” Was that often, sometimes, or never true for you in the last 12 months? Household Food Secure 3. “We couldn’t afford to eat balanced meals.” Was that often, sometimes, or never true for you in the last 12 months? 4. In the last 12 months, did you or other adults in the household ever cut the size of your meals or skip meals because there wasn’t enough money for food? (Yes/No) 5. (If yes to Question 4) How often did this happen—almost every month, some months but not every month, or in only 1 or 2 months? 6. In the last 12 months, did you ever eat less than you felt you should because there wasn’t enough money for food? (Yes/No) 7. In the last 12 months, were you ever hungry, but didn’t eat, because you couldn’t afford enough food? (Yes/No) Household Food Insecure Without Hunger 8. In the last 12 months, did you lose weight because you didn’t have enough money for food? (Yes/No) 9. In the last 12 months, did you or other adults in your household ever not eat for a whole day because there wasn’t enough money for food? (Yes/No) 10. (If yes to Question 9) How often did this happen—almost every month, some months but not every month, or in only 1 or 2 months? Household Food Insecure With Hunger (Questions 11–18 are asked only if the household included children aged 0–18 years) 11. “We relied on only a few kinds of low-cost food to feed our children because we were running out of money to buy food.” Was that often, sometimes, or never true for you in the last 12 months? Child Marginally Food Secure 12. “We couldn’t feed our children a balanced meal, because we couldn’t afford that.” Was that often, sometimes, or never true for you in the last 12 months? 13. “The children were not eating enough because we just couldn’t afford enough food.” Was that often, sometimes, or never true for you in the last 12 months? 14. In the last 12 months, did you ever cut the size of any of the children’s meals because there wasn’t enough money for food? (Yes/No) Child Food Insecure Without Hunger 15. In the last 12 months, were the children ever hungry but you just couldn’t afford more food? (Yes/No) 16. In the last 12 months, did any of the children ever skip a meal because there wasn’t enough money for food? (Yes/No) 17. (If yes to Question 16) How often did this happen—almost every month, some months but not every month, or in only 1 or 2 months? 18. In the last 12 months, did any of the children ever not eat for a whole day because there wasn’t enough money for food? (Yes/No) Relatively recently, a Children’s Food Security Scale (CFSS) consisting only of the eight child-referenced items in the larger 18-item FSS has been validated by USDA/ERS. The CFSS can be scored and scaled to more directly depict the food security status of children in a household. This child-referenced scale has also been shown to yield higher prevalence of child hunger when administered separately than that obtained from the FSS.7 The 18 questions making up the FSS are shown in TABLE 1, with the eight items that make up the CFFS in the lower section. Thresholds for the various household and child food security categories are also indicated. Child Food Insecure With Hunger USDA/ERS recently implemented more changes in how results from the Census Bureau’s annual administration of the FSS are reported.8 These changes affect terminology used to label the most severe level of deprivation measured by both the household and children’s scales by replacing the term “hunger” with the blander term “very low food security.”6 Because this change is relatively recent, and not uniformly accepted by either scientists or advocates, we have elected to use the original term “hunger” in this review where appropriate. In this chapter, we summarize available research on the direct associations of household and children’s food Cook & Frank: Food Security, Poverty, and Human Development insecurity with children’s health and development and with mothers’ depressive symptoms by using a developmental framework extending from the prenatal period to adolescence. Within selected developmental stages, we briefly review the effect of the Food Stamp Program (FSP) and the Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) on outcomes influenced by food insecurity. We also delineate emerging information about food insecurity’s complex roles as an outcome, mediator, and moderator of effects of multiple risks, as well as its associations with policies such as income maintenance (“welfare”), housing assistance, and home energy assistance—factors not historically considered nutritional issues. Relationship of Food Insecurity to Poverty Food insecurity and hunger, as measured by the FSS, are specifically related to limited household resources.3,5 Thus, by definition they are referred to as “resource-constrained” or “poverty-related” conditions. Financial resources available to households can include income earned by household members and additional resources derived from cash and in-kind assistance provided by public and private safety-net programs, including public and private food assistance programs, housing subsidies, and energy assistance.9–12 The Department of Health and Human Services manages most federal sources of cash assistance available to families and children. You can find descriptions of these financial assistance programs at http://www.dhhs. gov/children/#income (last accessed June 25, 2007). The official definition of poverty for the U.S. population uses income before taxes and does not include capital gains or noncash benefits (such as public housing, Medicaid, and food stamps). The definition is based roughly on historical estimates of the portion of an average household’s income required to purchase a “minimally nutritious diet” (about 30% in the early 1960s). Poverty thresholds, set at three times the amount necessary to buy such a diet, are amounts that the federal government estimates to approximate levels of necessity for families of different size and composition (i.e., number of people in the household and number of children or elderly). Although the cost of living varies widely from state to state and region to region, poverty thresholds do not vary geographically. They are, however, updated annually for inflation by using the Consumer Price Index, a broad national index of overall increases in aggregate consumer prices. 195 Moreover, though an average U.S. family currently spends only about 12% of its total annual expenditures on food, implying a poverty threshold closer to eight (100%/12%) times the cost of a minimally nutritious diet instead of three times this “multiplier” has not been updated since its conception in the early 1960s. See “The Development of the Orshansky Thresholds and Their Subsequent History as the Official U.S. Poverty Measure,” by Gordon M. Fisher (1992), at http://www.census.gov/hhes/www/povmeas/papers/ orshansky.html (last accessed July 13, 2007). The official poverty threshold for families of four people—two adults and two children—was $20,444 in 2006.13 All members of a household with income below this level will be categorized as being in poverty. Both the definition of poverty and the poverty thresholds have been criticized on the grounds that they do not accurately reflect families’ true financial resources or the amount of money that families actually need to be economically self-sufficient.14 Estimates of minimum income levels required for families to achieve basic economic self-sufficiency range around twice the federal poverty thresholds.15 On the basis of the official poverty definitions, in 2005 (the latest year for which data are available) 37 million people (12.6%) lived in households with incomes below the poverty thresholds in the United States. Of these, 13 million were children younger than 18 years, and 5 million were children younger than 6 years. Subpopulations with highest prevalence of poverty are people in female-headed households with no spouse present (28.6%), blacks (24.9%), Latinos (21.8%), and children younger than 6 years (20.0%).16 From 2000 to 2004, the poverty rates for all major ethnic groups increased steadily, though they declined in 2005 (FIG. 1). Though the populations affected by poverty and food insecurity overlap, they are not identical. Not all poor people are food insecure, and the risk of food insecurity extends to people living above the federal poverty level.3,6 In 2005, 35 million people (12.1%) lived in food-insecure households, 24.3 million in households without hunger, and 10.8 million with hunger. Of the 35 million food-insecure people in the United States in 2005, 12.4 million were children younger than 18 years. As with poverty, subpopulations with the highest prevalence of household food insecurity are blacks (22.4% of households), Latinos (17.9% of households), households with children younger than 6 years (16.7%), and single-mother households (30.8%).6 In 2005, 38.5% of all people in the United States with incomes below the poverty thresholds were food 196 Annals of the New York Academy of Sciences FIGURE 1. Proportion of U.S. Families with Incomes Below Poverty by Race/Ethnicity, 1999–2005∗ ∗ Includes households with and without children. Source: U.S. Census Bureau, Current Population Survey, various years. FIGURE 2. Proportion of U.S. Households that are Food Insecure by Race/Ethnicity: 1999–2005∗ ∗ Includes households with and without children. Source: USDA/ERS Food Security in the United States, various years. insecure. Of all people with incomes equal to or above the poverty threshold but below 130% of poverty (gross income cutoff for the FSP), 28.7% were food insecure, whereas 20.8% of all people with incomes equal to or above 130% but below 185% of poverty (gross income cutoff for WIC) were food insecure. Only 5.4% of all people with incomes at or above 185% of poverty were food insecure. These prevalence estimates indicate that for some families “safety net” programs—such as the national food assistance programs; housing and energy subsidies; and in-kind contributions not included in the federal poverty calculations, like those from relatives, friends, food pantries, or other charitable organizations, not included in the federal poverty calculations— may partly decrease the risk of food insecurity. Families who do not receive public benefits for which they are income eligible (either because of bureaucratic barriers or because the programs are not entitlements and are insufficiently funded to reach all who are eligible) may be more likely to be food insecure. Moreover, many families whose incomes exceed the eligibility cutoff for these programs may still be unable to avoid food insecurity without assistance if the costs of competing needs such as energy or housing are overwhelming. We will present empirical data below to support these contentions. From 1999 to 2004, the prevalence of food insecurity increased steadily for all major race/ethnic groups but declined in 2005 (FIG. 2). Food Insecurity, Child Health, and Development Food insecurity influences health and development through its effects on nutrition and as a component of overall family stress. The condition of food insecurity includes both inadequate quantities and inadequate quality of nutrients available. At less severe levels of food insecurity, household food managers (usually mothers) trade off food quality for quantity to prevent household members, especially children, from feeling persistently hungry.3,5 Conceptually, social safety-net programs can influence the relationships between food insecurity and child health, growth, and development by helping to prevent food insecurity or by moderating its effects once it does occur. Overall, less expensive filling foods are more energy dense and nutrient sparse, whereas nutrient-dense, Cook & Frank: Food Security, Poverty, and Human Development energy-sparse foods are more expensive.17 This inverse relationship between food prices and food quality has implications for micronutrient deficiencies at all ages and has recently been suggested as a potential factor in the widespread emergence of overweight in adults and possibly in older children.17–21 Inexpensive energy-dense foods can be cost-effective for lowincome and food-insecure families, especially those whose members can ward off the feeling of hunger only by consuming cheap foods, which often contain large amounts of starches, sugar, salt, and fats. In contrast, for infants and younger children with smaller stomach capacity, satiety is rapidly reached with nutrientpoor, cheap foods, such as sweetened liquids and french fries. Although a young child subsisting on cheap “junk food” may not cry from hunger, total intake of both macronutrients (calories and protein) and micronutrients may be insufficient for normal growth, leading to stunted growth (nutritional short stature) and underweight for age or height.22 Moreover, poor nutrition, and by extension food insecurity, influences health and well-being throughout the life cycle, from the prenatal period on into elder years.22–28 Also, effects of food insecurity on adults in households with children can adversely affect those children in a variety of ways, including diminution of parents’ energy for providing care and developmental stimulation. Parental (especially maternal) depression has been associated with food insecurity,29 and in many contexts, not limited to those involving food insecurity, such depression has been linked with adverse effects on parenting, parent–child interaction and attachment, child growth, development, health, and well-being.30–33 Prenatal and Neonatal Periods Adequate prenatal nutrition is critical for normal development of the fetal body and brain. Although much research has confirmed the importance of nutrition during the prenatal and neonatal periods,22–25,34–36 far fewer studies have specifically addressed the role of food security per se for this part of the life cycle. Food insecurity has been associated with low-birthweight deliveries37 and with a variety of psychosocial risk factors in moderate-risk to high-risk pregnancies with observable dose–response relationships (increasingly higher psychosocial risks with increasing severity of food insecurity).38 However, evidence on the influence of food insecurity on prenatal development remains mostly indirect, deriving from the large body of evidence for the critical role of healthful nutrition during this period. Many recent studies have examined prenatal nutrition and care within a broader scope that includes birth 197 spacing and nutrition and care between births.39–44 Motivated in part by persistently high rates of low birthweight and preterm births in some U.S. subpopulations, a growing recognition of the limits of prenatal care alone in reducing these problems has emerged, with increasing attention being paid to preconception and internatal care.39–43 Amid this emerging view of maternal health are expressions of concern about the effects of food insecurity on nutrition and health during the internatal period.39,43,44 Of particular concern is the risk of food-insecure mothers entering pregnancy with insufficient iron stores and with low-folate diets. Poor iron and folic acid status are linked to preterm births and fetal growth retardation, respectively.36,39 Prematurity and intrauterine growth retardation are critical indicators of medical and developmental risks that affect not only children’s short-term well-being but also extend into adulthood, where these problems have been linked recently to obesity, adult-onset diabetes, and risk of cardiac disease.35,43,44 A woman’s folate-poor diet in the periconceptual period has also been clearly associated with neural tube defects and possibly other birth defects.36 For low-income mothers, especially black, Latina, and single mothers, food insecurity is a prevalent risk factor generally, including during internatal periods.6,16,19,44 Breastfeeding and the Neonatal Period Breastfeeding is the best possible choice for neonatal nutrition under a wide range of circumstances.45 Although relatively few studies have directly examined associations between breastfeeding behavior and food insecurity, there is some evidence that mothers in food-insecure households have lower rates of initiating breastfeeding at all and that they initiate and continue breastfeeding for shorter periods on average than do mothers in food-secure households.46 However, relationships between food insecurity and breastfeeding are poorly studied and appear to vary with mother’s ethnicity, immigration status, and other factors. Latina mothers have higher breastfeeding initiation rates than those of black or white mothers and are more likely to follow American Academy of Pediatrics infant feeding recommendations.47 Also, U.S. citizen infants born to Latina immigrant mothers have higher initiation rates than those of similar infants born to black or white immigrant mothers.48 Although the families of breastfed infants of immigrant mothers generally had greater odds of being food insecure in this latter study than those of nonbreastfed infants of immigrant mothers, the breastfed infants had lower odds of having their health status reported as fair/poor (versus excellent/good), lower odds of having a chronic health 198 Annals of the New York Academy of Sciences condition, and lower odds of having previously been hospitalized than those of nonbreastfed infants of immigrant mothers,48 indicating that breastfeeding in the early months of life may buffer young infants from the adverse health effects of household food insecurity. Early Childhood: Ages 0–3 Years A relatively large number of studies have examined associations between food insecurity and child health and development in this age group, many conducted by the Children’s Sentinel Nutrition Assessment Program (C-SNAP). (We [Cook and Frank] are among the principal investigators in the C-SNAP study group.) An ongoing multisite pediatric clinical research program, C-SNAP has conducted household-level surveys and medical record audits at seven central-city medical centers, including acute care and primary care clinics (Baltimore, MD; Minneapolis, MN; Philadelphia, PA; and Washington, DC) and hospital emergency departments (Boston, MA; Little Rock, AR; and Los Angeles, CA) since 1998 (sites in Los Angeles, CA, and Washington, DC are currently inactive). Primary adult caregivers accompanying children aged 0–36 months seeking care are interviewed by trained interviewers in private settings during waiting periods. We chose this age group for sampling because its special vulnerability makes it a sentinel population for adverse health outcomes in pediatric populations related to constrained household resources and changes in social policies and economic conditions. Because of their locations in inner cities, the C-SNAP sites serve populations with high prevalence of low-income families, those most affected by social policy changes. Children’s weight and, if possible, length are recorded at the interview. The C-SNAP survey instrument consists of questions on household characteristics, children’s health and hospitalization history, maternal health, maternal depressive symptoms, participation in federal assistance programs, energy insecurity, and changes in benefit levels. The C-SNAP interview also includes the U.S. Food Security Scale,3,4,48,49 and recent cycles of data collection since July 2004 have added the PEDS (Parents’ Evaluation of Developmental Status, a well-validated and reliable standardized instrument that meets the American Academy of Pediatrics standards for developmental screening).50 These studies suggest complex relationships between food insecurity and participation of families with young children in public income maintenance and nutrition programs. They also indicate similarly complex relationships between participating in these programs and food insecurity, health, growth, and development of young children. Welfare Reform and the Health of Young Children Welfare reform legislation passed in 1996 (the Personal Responsibility and Work Opportunity Reconciliation Act) made sweeping changes to the main cash assistance program in the United States (Temporary Assistance to Needy Families [TANF], previously known as Aid to Families with Dependent Children). These changes included several previously nonexistent requirements enforced by a range of punitive sanctions, which often led to partial or total termination of a family’s TANF benefits. C-SNAP found that families with children younger than 3 years whose welfare benefits had been reduced or terminated by sanctions had 50% greater odds of being food insecure than those with stable benefits. Children in families that suffered welfare sanctions also had 30% greater odds of having been hospitalized since birth, and 90% greater odds of being admitted from an emergency department (ED) visit (only for children whose caregivers were interviewed in one of the three ED sites), than those of similar children in families whose benefits had not decreased, after adjusting for relevant confounding factors.51 Unexpectedly, we also found that infants and toddlers in families whose TANF benefits had been reduced administratively because of changes in income or expenses also had 50% greater odds of being food insecure, and 182% greater odds of being admitted the day of an ED visit, than those of children in families whose benefits had not been reduced. We also found that receiving food stamps did not mitigate the associations of losing TANF benefits with these health outcomes. Food Insecurity and Adverse Health Outcomes in Young Children By 2003, much research literature had confirmed a range of adverse health and development outcomes associated with malnutrition in young children, and a few had found food insufficiency (a precursor construct to the food security measures), hunger, and risk of hunger related to poor health in children (aged 10 µg/dL). In logistic regressions adjusted for a range of possible confounders, food-insecure children had adjusted 140% greater odds of having IDA than those of food-secure children. This study examined only CFI not HFI.64 Food Insecurity, Maternal Depression, and Child Health Maternal depression is strongly related to child development in a variety of ways, including reduced ability to provide needed care, impaired mother–child interaction and attachment, and child neglect and abuse.30–33,65–69 Several recent studies have found associations between food insecurity and maternal depression.23,29,38,65–70 A recent C-SNAP study examined associations among mothers’ positive depressive symptoms (PDS), food insecurity, and changes in benefits from federal assistance programs.29 Using a subsample of 5,306 mother–child dyads seen at three C-SNAP sites, we found that mothers with PDS had 169% greater odds of reporting household food insecurity, 58% greater odds of fair/poor child health, and 20% greater odds of child hospitalizations than those of mothers without PDS, after adjusting for possible confounders. Also, controlling for the same covariates, mothers with PDS had 52% greater odds of reporting decreased welfare support and 56% greater odds of reporting loss of FSP benefits than those of mothers without PDS.29 200 These results indicate that maternal depression may be an indirect pathway by which HFI negatively influences child health and development. Determining the direction of causality from these results or ruling out the possibility of some amount of dual causality is not possible. We need more research to determine whether and under what circumstances maternal depression temporally precedes food insecurity or vice versa. Effects of Program Participation on Food Insecurity In a C-SNAP study examining associations between participation in the WIC program and indicators of underweight, overweight, length, child’s health status, and food security in children aged 12 months or less, infants that did not receive WIC benefits because of access problems were more likely to be underweight, be short, and perceived as having fair/poor health than were WIC recipients, after adjusting for possible confounders.71 Although these two groups did not differ statistically significantly on food security status after adjustment for covariates, children in both groups were more likely to be food insecure than children whose caregivers did not perceive a need for WIC. These results supported findings from other research indicating that low-income infants aged 12 months or less benefit from participation in the WIC program.59,72,73 Another C-SNAP study examining the relationships between receiving housing subsidies and nutritional and health status among low-income, food-insecure children younger than 3 years living in rented housing found that children in food-insecure renting families not receiving housing subsidies had statistically significantly lower weight for age than those in families receiving subsidies. Also, compared with food-insecure children in subsidized housing, those in nonsubsidized housing had 111% greater odds of having weight-forage z-scores that were more than 2 standard deviation units below the mean.74 These findings help inform another dimension in the understanding of how household food security interacts with other survival needs to influence children’s health, in concert with recent studies showing strong associations between housing conditions and health among low-income children.75–77 Similar findings have emerged in evaluating the association between a family’s participation in the Low-Income Home Energy Assistance Program (LIHEAP) and the anthropometric status and health of their young children. LIHEAP is the nation’s primary assistance program for helping low-income families having difficulties affording energy payments. Using Annals of the New York Academy of Sciences a sample of 7,074 caregiver–child dyads in households eligible to receive LIHEAP, this study, after controlling for identified confounders, found that children in nonrecipient households had greater adjusted odds of being at aggregate nutritional risk for growth problems (defined as weight for age below the 5th percentile or weight for height below the 10th percentile) and had statistically significantly lower age-gender– specific weight-for-age z-scores than those of similar children in recipient households. Also, for the 4,445 of 7,074 children evaluated at ED sites, those from eligible households not receiving LIHEAP had greater adjusted odds of acute hospital admission on the day of the interview.78 These findings highlight the difficult tradeoffs that low-income parents must make during times of extreme temperature variations.79,80 Recent trends in energy and food price increases indicate that this “heat or eat” threat to child health, growth, and development is likely to increase in the future. Association between Food Insecurity and Early Childhood Developmental Risk A recent C-SNAP study evaluated the relationship between household food security status and developmental risk among 2,010 children aged 4–36 months on the basis of responses to the PEDS.81 After controlling for established correlates of child development, including mothers’ depressive symptoms and education, the study found that food-insecure children in this age group were statistically significantly more likely to be identified by their caretakers as being at developmental risk than were similar children in food-secure households.81 School Age and Adolescence Over the past decade, a modest but steadily accumulating body of research has examined the influence of food insecurity on physical and mental health and academic, behavioral, and psychosocial functioning of preschool-aged and school-aged children. These studies have used several different measures of food insecurity, including one screening question developed by the USDA and referred to as “the USDA food sufficiency question,” a scale developed by the Community Childhood Hunger Identification Project prior to release of the U.S. FSS, and the FSS itself. These measures differ in the questions they include, in the wording of some questions, and in psychometric properties.3,5 Although each research report addresses a somewhat different set of correlates of food insecurity and related constructs, there is consistency in the basic findings that emerge from applications of these measures regarding adverse Cook & Frank: Food Security, Poverty, and Human Development effects on physical and mental health, academic performance, and behavioral and psychosocial problems in preschool-aged and school-aged children. Several studies using data on responses to the USDA food sufficiency question in the Third National Health and Nutrition Examination Survey (NHANES III) examined associations between household food sufficiency and children’s health, school performance, and psychosocial functioning. One study, consistent with the C-SNAP food insecurity work summarized above, found food insufficiency associated with higher prevalence of fair/poor health, and iron deficiency, and with greater likelihood of experiencing stomachaches, headaches, and colds in children aged 1–5 years.53 Another found that children aged 6–11 years in foodinsufficient families had lower arithmetic scores, and were more likely to have repeated a grade, to have seen a psychologist, and to have had more difficulty getting along with other children, than similar children whose families were food sufficient. This study also found teenagers from food-insufficient families more likely than food-sufficient peers to have seen a psychologist, to have been suspended from school, and to have had difficulty getting along with other children.82 A third study showed children aged 15–16 years from foodinsufficient households statistically significantly more likely to have had dysthymia, to have had thoughts of death, to have had a desire to die, and to have attempted suicide.83 Another set of studies used a food security measurement tool developed by the Community Childhood Hunger Identification Project (CCHIP1 ; a validated scale to assess hunger in children developed prior to, and partly incorporated into, the FSS) to examine associations between hunger and physical and mental health in school-aged children. One of these studies, using data from implementation of the CCHIP scale in nine states, found that children younger than 12 years categorized as hungry or at risk of hunger were twice as likely as nonhungry children to be reported as having impaired functioning by either a parent or the child her/himself. Teachers reported statistically significantly higher levels of hyperactivity, absenteeism, and tardiness among hungry/at-risk children.54 A second CCHIP study used a sample of 328 parents and children from families with at least one child younger than 12 years. Parents with a child aged between 6 and 12 years completed a Pediatric Symptom Checklist (PSC). This study found that children categorized as hungry by the CCHIP scale were more likely to have clinical levels of psychosocial dysfunction on the PSC than either at-risk or nonhungry children. Analy- 201 sis of individual items from the PSC found that most all behavioral, emotional, and academic problems were more prevalent in hungry children, but aggression and anxiety had the strongest degree of association with hunger.55 A third CCHIP study used data on externalizing and internalizing behaviors and anxiety/depression from the Child Behavior Checklist, along with chronic health indicators adapted from the National Health Interview Survey, Child Health Supplement, in a sample of 180 preschool-aged and 228 school-aged children in Worcester, Massachusetts. This research found that, after adjustment for confounders, severe hunger was a statistically significant predictor of chronic illness among both preschool-aged and school-aged children and was statistically significantly associated with internalizing behavior problems, whereas moderate hunger was a statistically significant predictor of health conditions in preschool-aged children. Severe hunger was also associated with higher reported anxiety/depression among school-aged children, after adjusting for confounders.84 Finally, a small set of fairly recent studies used data from administration of the FSS in national and local surveys to examine associations of food insecurity with health, growth, and development after the first 3 years of life. A recent study used data from the new Early Childhood Longitudinal Survey Kindergarten cohort (ECLS-K) to test the hypothesis that food insecurity is associated with overweight among kindergarten-aged children. The authors found no statistically significant association of food insecurity with overweight in this cross-sectional study, in any of several configurations of regression models. The authors conclude that though there are many sound reasons to be concerned about food insecurity in kindergarten-aged children, the results indicate that concern about overweight should not be one.85 A second study from the ECLS-K included data from the kindergarten and third grade administrations in a longitudinal assessment of how food insecurity over time is related to changes in reading and mathematics test performance, weight and body mass index (BMI; kilograms per square meter of body surface area), and social skills in children.86 This much more elaborate and extensive longitudinal study found food insecurity in kindergarten associated with lower mathematics scores, increased BMI and weight gain, and lower social skills in girls at third grade, but not in boys, after controlling for time-varying and timeinvariant covariates in a lagged model. Using difference score and dynamic models based on changes in predictors and outcomes from kindergarten to third 202 grade, the authors found that children from persistently food-insecure households (food insecure at both kindergarten and third grade years) had greater gains in BMI and weight than those of children in persistently food-secure households, after controlling for covariates, though these effects were statistically significant only for girls in stratified analysis. Also among girls, but not boys, persistent food insecurity was associated with smaller increases in reading scores over the period than for persistently food-secure girls. In dynamic models, for households that transitioned from food security to food insecurity over kindergarten to third grade (i.e., became food insecure), the transition was associated with statistically significantly smaller increases in reading scores for both boys and girls than those for children from households remaining food secure. For children transitioning from food insecurity to food security (i.e., becoming food secure) the transition was associated with larger increases in social skills scores for girls but not for boys. Similarly, in difference models when children from households that became food insecure were compared with children who became food secure, food insecurity was associated with smaller increases in reading scores for both boys and girls, though differences were statistically significant only for girls. In gender-stratified difference models examining BMI, weight, and social skills, becoming food insecure was associated with statistically significantly greater weight and BMI gains for boys but not for girls. Becoming food insecure was associated with greater declines in social skills scores for girls but not boys. The authors of this rather complicated study conclude that it provides the strongest empirical evidence to date that food insecurity is linked to developmental consequences for girls and boys, though these consequences are not identical across gender. Particularly strong associations are found between food insecurity and impaired social skill development, reading performance, and increased BMI and weight gain for girls, though the effects on BMI and weight gain appear to differ depending on whether the girls are persistently food insecure or their status changes over time. The longitudinal and dynamic nature of the models used and the extensive controls for confounders at the household and individual levels lead the authors to conclude that the most plausible interpretation of their findings is that food insecurity in the early elementary years has both nutritional and nonnutritional developmental consequences.86 A third study used data from a cross-sectional telephone survey of households including 399 children Annals of the New York Academy of Sciences aged 3–17 years from 36 counties of the delta region of Arkansas, Louisiana, and Mississippi to examine associations between household food insecurity and proxyreported or self-reported child health–related quality of life...
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Health and social care services access is one of the key inequality issues addressed in
the readings. Cultural, social, and geographical factors influence this access, and therefore
health government agencies and NGOs are encouraged to intervene and ensure that cultural
acceptability and appropriateness of these services is available in rural areas and in areas
which are economically disadvantaged. Rural outreach interventions should be introduced to
ensure access of these services to all, by targeting ethnic minorities, various demographics,
and ensuring culture training of involved professionals.
Unemployment and welfare is also a significant inequality issue ...


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