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
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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.
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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
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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.
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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
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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
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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
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