Exploring Traumatic Influences
farm1980
TheImpactofHealth-PromotingBehaviorsonLow-IncomeChildrensHealth-ARiskandResiliencePerspective.pdf
The Impact of Health-Promoting Behaviors on Low-Income Children's Health:
A Risk and Resilience Perspective Joan Yoo, Kristen S. Slack, and fane L. Holl
This study's objective was to examine whether five child health-promoting behaviors by caregivers would be associated with caregivers' assessments of their children's health as "excellent," controlling for an array of risk factors for adverse health outcomes.The study used the third and fourth waves of the Illinois Families Study-Child Well-being Supplement—a four-year panel study examining the impact of welfare reform on the well-being of the youngest children of current and former welfare recipients. Logistic regression techniques were used.The analytic results show that low-income children whose caregivers exercise child health-promoting behaviors (for example, mealtime routines, dental hygiene practices, safety practices), with the exception of having a regular bedtime, are more likely to be reported as having excellent health than their low-income counterparts. Moreover, a statistically significant cumulative effect above and beyond the individual effects of health-promoting behaviors was found.The findings suggest that child health-promoting behaviors by caregivers can make a difference in promoting better health for low-income children. Although large systemic changes (for example, changes in health care policy) are needed to reduce overall health disparities and to enhance health for all members of society, individual health-promoting behaviors may lead to incremental improvements in low-income children's health.
KEY W O R D S : caregivers; child health-promoting behaviors; low-income children; physical health; risk and resilience framework
I t has been well established that there are socio- economic disparities in children's physical health outcomes (Case, Lubotsky, & Paxson, 2002;
Chen, Matthews, & Boyce, 2002). Children who live below the federal poverty line have higher mortality and morbidity rates than children in higher income fan-lilies (Case et ah, 2002; Starfield, Robertson, & Riley, 2002). However, less is known about within- group variation in physical health outcomes among low-income children. Using the risk and resilience framework, the aim of this study was to examine how, controlling for the presence of multiple risk factors, child health-promoting behaviors initiated by caregivers would explain within-group variation in caregiver-reported health among children from low-income families.
CONCEPTUAL FRAMEWORK: RISK AND RESILIENCE MODEL Although the medical model has been the pre- dominant framework for examining determinants of health, health researchers have emphasized the need to apply alternative models, such as the risk and
resilience framework, that provide a more holistic perspective on health with greater focuses on posi- tive health and well-being (R. G. Evans & Stoddart, 1990;Vinson, 2002).
Resilience has generally been defmed by research- ers in developmental psychopathology as a process wherein a person exhibits better-than-expected outcomes in the face of adversity (Garmezy, 1993; Vinson, 2002). Three major components of this framework—experience of adversity, adaptive out- comes, and protective or promotive factors—are discussed here.
First, for resilience to occur, there must be an experience of adversity—that is, a single risk or mul- tiple risks that may have significant negative effects on an individual's outcomes. Resilience researchers have further emphasized the importance of under- standing risk experiences at a more proximal than distal level (Luthar, Cicchetti, & Becker, 2000; Mas- ten, 2001; Rutter, 1990)—that is, risks that directly affect children's lives more imminently, as opposed to distal risks (for example, low socioeconomic status) that affect children through a chain of mediating
CCC Code: 0360-7283/10 $3.00 ©2010 National Association of Social Workers 133
A health-promoting behavior is considered
to be a promotive factor if it only has a
significant main effect on children's health.
variables. For example, material hardships, which reflect families' living conditions and experiences of meeting their basic physical needs (Ouellette, Burstein, Long, & Beecroft, 2004), are considered better approximations of the direct effects of low income on children (Beverly, 2000). On the basis of this rationale, we focused on three domains of proximal risks—material hardship,caregivers health, and children's access to health care—found to be associated with children's physical health.
To date, most studies examining the impact of material hardship on children's physical health have focused on the individual dimensions of hardship, such as food hardship or housing conditions (for example, Ashiabi & O'Neal,2007;Cook et al.,2006; Kim, Sataley Curtis, & Buchanan, 2002; Weinreb, Goldberg, Bassuk, & Perloff, 1998). These studies have shown that children who experience food hards hip, generally defined as unstable or insufficient levels of food intake or insufficient variety of food consumption due to financial constraints (Ashiabi & O'Neal, 2007; Cook et al, 2006;Weinreb et. al., 2002), and who experience housing insecurity and poor-quality housing (Kim et al., 2002; Mueller & Tighe, 2007; Weinreb et al., 1998) are more likely to have health problems than children who do not experience these hardships. In addition, there is some evidence that cumulative experiences of ma- terial hardship may also negatively affect children's health (Yoo, Slack, & Holl, 2009). Also, caregivers' poor physical health and poor mental health have been found to be negatively associated not only with their children's health, but also with their preventive practices (Kahn, Zuckerman, Bauchner, Homer, & Wise, 2002; McLennen & Kotelchuck, 2000; Minkovitz,0'Canipo, Chen, &Grason, 2002; Scalzo, Williams, & Holmbeck, 2005). However, other studies have cautioned that caregivers'physical and mental health may also influence how caregivers report their children's health conditions (Waters et al., 2000). Finally, previous research has shown that children who do not have adequate access to health care services are more hkely to have unmet health care needs, which may have detrimental effects on
their health, than are children who do have such access (Holl et al.,2000;Newacheck,Hughes,Hung, Wong, &Stoddard, 2000).
When examining multiple risk factors, some re- searchers use an additive model that tests the unique relationships between individual risk variables and outcomes (Ackerman, Izard, Schoff, Youngstroni, & Kogos, 1999). Others use a cumulative approach, in which risk experiences are summed into a single score to account for the accumulation of co- occurring risks (Appleyard, Egeland, van Dulmen, & Sroufe, 2005). Acknowledging the strengths and weaknesses of each approach, the present study included three risk domains that capture the cumula- tive effect of individual risks within each domain.
The second component of the risk and resilience framework is the achievement of adaptive outcomes despite adversities (Luthar et al.,2000;Rutter, 1990). The emphasis is on the presence of positive outcomes (for example, positive health and well-being) rather than the mere absence of negative outcomes (for example, illnesses and diseases [Masten, 2001; Ryff & Singer, 1998]).This emphasis is one of the major contributions offered by the risk and resilience framework to health research.
The last component of the risk and resilience framework consists of individual, familial, and en- vironmental factors that promote positive outcomes and reduce negative outcomes in response to risks and adversities (Masten & Garmezy, 1985). In the present study, we focused on famiHal factors that are characterized by child health-promoting behaviors by caregivers of young children, including family routines, dental hygiene practices, and home safety practices.
To better understand the nature of the relation- ship between child health-promoting behaviors and children's overall health as assessed by their caregivers, we examined both the main and inter- action effects of the health-promoting behaviors. A health-promoting behavior is considered to be a promotive factor if it only has a significant main effect on children's health (Sameroff, 2000). How- ever, if there is a significant interaction effect, the health behavior is considered be a protective factor (Rutter, 1990).
Family routines are generally defined as patterned interactions that are repeated on a regular basis over time (Wolin & Bennett, 1984). Most studies that have investigated the impact of family routines on child outcomes examined its positive association
134 Health & SocialWork VOLUME 35, NUMBER Z MAY ZOIO
with psychological well-being (see Fiese et al, 2002, for review). However, a few studies have shown that regular family routines, such as regular mealtime and bedtime routines, have positive effects on children's physical health (Boyce et al, 1977; Case & Paxson, 2002). Although few studies have examined the link between dental hygiene practices and low- income children's physical health, regular dental hygiene practices are directly related to children's oral health (Tiberia et al, 2007). Moreover, dental hygiene practices in early childhood are found to be predictive of oral health during adolescence (Alm,Wendt, Koch, & Birkhed, 2008). In addition, dental hygiene practices are commonly consid- ered as indicators for health-promoting behaviors (Lawton, Conner, oí McEachan, 2009). Most studies that have examined the association between safety precautions (for example, proper seat belt and car seat use, childproofmg the home) and children's health focused on understanding the impact on child injuries. Numerous studies have reported that proper seat belt and car seat use is associated with reductions in severe childhood injuries (see Howard, 2002, for review). However, the association between childproofmg the home and childhood injuries is less clear (S.A. Evans & Kohil, 1997; Jordan, Dug- gan, & Hardy, 1993). Although understanding the association between unintentional injuries and safety precautions was beyond the scope of this study, home childproofmg steps and seat belt and car seat use are used as proxy measures for caregivers' behavior as it relates to children's safety.
This study focused on explaining health variation among low-income children, who are, as a group, at greater risk for poor health than are higher income children.Three research questions were examined: (1) Do child health-promoting behaviors exercised by caregivers have a promotive effect on low-income children's physical health, controlling for an array of health risk factors? (2) Do child health-promoting behaviors moderate associations between risk factors and low-income caregivers' assessments of children's physical health? (3) Do child health- promoting behaviors have a cumulative effect on low-income caregivers' assessments of children's physical health?
METHOD
Study Design and Sample The analyses reported in this article were conducted using a subset of respondents from the Illinois Fami-
lies Study (IFS).The IFS was a five-year panel study examining the well-being of welfare recipients and their families during and following the implemen- tation of Temporary Assistance to Needy Families (TANF) in Illinois. A stratified sample of 1,899 families residing in Illinois and receiving welfare cash benefits in September 1998 were randomly selected from the 1998 TANF enrollment files of nine counties in Illinois, which together represented 75 percent of the Illinois TANF caseload (Lewis et al, 2000).
During the initial wave of the IFS, all respon- dents who had at least one child under the age of three (n = 582) were asked to participate in a supplemental study called the Illinois Families Study-Child WeU-being Supplement (IFS-CWB). The IFS-CWB, a four-year panel study, was aimed at understanding the links between welfare reform, child maltreatment, and health and well-being of the youngest child in the family. Annual surveys were administered from 2001 to 2004 to collect more in-depth information about focal children's health and well-being, access to health care services, home environment conditions, and experiences of economic hardship and respondents' parenting practices and health.
After an initial response rate of 72 percent (N = 1,363) for wave 1 of the IFS, the response rate for the first wave of IFS-CWB (administered in 2001) was 95 percent {N = 553).The retention rates for the second, third, and fourth waves of IFS-CWB were 88 percent (« = 484),92 percent (« = 445),and 91 percent [n = 405), respectively. Statistical weights were applied to all analyses to adjust for the over- representation of sample members from the smaller counties and for nonresponse and attrition.
Although child health status measures and sev- eral independent variables were measured in every IFS-CWB survey wave, some of the variables on health-promoting behaviors were measured only during the third wave. In the interest of being con- sistent lAiith timing of measurement, we obtained the information for all key independent variables from wave 3 IFS-CWB data rather than from earlier waves. This reliance on the third IFS-CWB wave for key independent variables also necessitated the use of wave 4 IFS-CWB for information on the dependent variable (that is, children's posi- tive health) to ensure the correct time order of independent and dependent variables. As a result, sample members who participated in both wave
Yoo, SLACK, AND H O L L / The Impact of Health-Promoting Behaviors on Low-Income Children's Health 135
3 and wave 4 of IFS-CWB were included in this study (« = 405)
Measures Dependent Variable. Child health was assessed with one of the most commonly used items in national health surveys (for example, the National Health Interview Survey). Respondents were asked to rate the focal child's general health status as "excellent," "very good,""good,""fair," or"poor."The validity of this measure has been tested in other studies and has been found to be associated with objec- tive measures of child health, including childhood mortality, morbidity, child functioning, and other objective latent health measures (Case et al., 2002; Slack et al., 2007). The objective of the study was to examine factors that distinguish children who were reported to be in excellent physical health from those reported to be in less than excellent health (that is, very good, good, fair, or poor health). Children who were reported to be in "excellent" health were coded 1 on this dichotomous outcome; all others were coded 0.
Multiple Risks. Information for all independent variables, including risk and health-promoting be- havior variables, ŵ as obtained from IFS-CWB wave 3 data. Three domains of risk—material hardship, caregivers physical and mental health, and child's access to health services—were included in the analyses.
A cumulative material hardship index was created using a commonly applied procedure (Appleyard et al., 2005) in which each type of material hardship is dichotomized so that 1 = high risk and 0 - low risk. On the basis of recommendations from previous studies (Danziger et al, 1999; Ouellette et al.,2004), children were considered to be at high risk if each of these six material hardship conditions were met: (1) The caregiver answered "yes" to any of five housing insecurity items, assessed as occurring within the past year (for example, living in a car or other vehicle, living in an abandoned building); (2) the caregiver responded "yes" to two or more housing problems items (for example, leaky roof, ceiling, or walls; broken windows); (3) the caregiver reported that the child was living in a crowded household (that is, more than two people per bedroom); (4) the care- giver answered "often" to any of four child-specific food insecurity items derived from the USDA Core Food Security Module (Price, Hamilton, & Cook, 1997); (5) the caregiver reported that any utilities
(for example, gas, electricity, oil, telephone) had been turned off since the last interview due to lack of payments; and (6) the caregiver reported that he or she did not have a driver's license or regular access to a car and reported problematic public transportation in the neighborhood. Then the six dichotomized variables were summed to construct a cumulative material hardship score. A cumulative variable capturing caregiver's poor physical and mental health was also created for the analyses. First, two dichotomous variables for caregiver's physical health and mental health were created to indicate high risk. Caregivers were considered to be in poor physical health if they answered "fair" or "poor" to this question: "Overall would you say your health is excellent, very good, good, fair, or poor?" Caregivers were considered to be in poor mental health if their scores were 16 or above on the 20-item Center for Epidemiological Studies Depression Scale (Radloff, 1977). The summary score ofthese two variables was used as an indicator for caregiver's poor physical and mental health.
Although the scales used to create the cumulative variables were first dichotomized and then summed, the statistical properties of the original scales (for example, housing problems, food hardship, physical functioning) were evaluated.With the exception of the four-item housing instability scale, which yielded an alpha of .69, the coefficient alphas for all other scales ranged from .77 to .92.
Two measures were used to assess whether a child had poor access to health care services. Due to low variation in these measures, we created a dichoto- mous variable, with 1 assigned to children whose caregivers indicated that their child did not have a usual place of care, that they used the emergency room for regular medical care, or that their child had not been able to receive necessary medical services since the last interview because they were unable to afford it and 0 assigned to children whose caregivers indicated that their child had a usual place of care.
Child Health—Promoting Behaviors. Five care- giver behaviors hypothesized to promote children's health were included in the analyses. Similar to those for the risk variables, the scales in this analysis were dichotomized. However, when the statistical properties of the original scales for regular meal- time and bedtime routines (four-item scale) and childproofing the home were evaluated, each scale yielded values of Cronbach's alpha greater than .70. Other health-promoting behaviors were derived
136 Health & Social Work VOLUME 35, NUMBER 2 MAY 2010
from single- or two-item measures that were not part of a larger scale.
Regtilar routines: Children's regular routines were assessed using a six-item scale that asked how often the family or the target child engaged in mealtime and bedtime routines Qensen, James, Boyce, & Hartnett, 1983). Responses ranged from "every day" to "never." Two dichotomous variables (regular mealtime routine and regular bedtime routine) were created, where 1 indicated that caregivers answered "every day" to all of the related items and 0 was assigned for all other responses.
Hygiene practices: Dental hygiene practices were assessed by asking respondents whether the target child brushed his or her teeth every day. A child was considered to be engaging in regular dental hygiene practices when he or she was reported to brush his or her teeth every day. In previous analyses, we also considered regular bathing as one of the indicators for hygiene practices. However, the variable was dropped due to lack of variability (approximately 75 percent of the respondents answered that their focal child bathed once a day or more).
Safety practices: Two dichotomous variables (car seat/seatbelt use and childproofmg the home) were created to characterize caregivers' behavior in rela- tion to their children's safety. A child was considered to be using car seats regtilarly when she or he was reported to be riding in a car at least once a month and sitting in a car seat or wearing a seat belt "all or most of the time." A seven-item questionnaire that asked whether respondents ever engaged in activities to childproof their home (for example, put up gates or barriers, installed locks or safety latches, kept syrup of pecac) was used to assess whether respondents childproofed their homes. A child was considered to be living in a childproofed home if his or her caregiver answered "yes" to six items or more.
Cumulative health-promoting behaviors: A cumula- tive health-promoting behavior index was created by summing up all five dichotomous health-pro- moting behavior variables (range = 0 to 5). This cumulative index was used to examine whether child health-promoting behaviors by caregivers yielded a cumulative effect above and beyond the individual effects.
Finally, basic demographic variables—such as the child's age, gender, and race and ethnicity (non- Hispanic white and other ethnicities, Hispanic, and African American)—were included as controls, in addition to caregiver's age, marital status, cohabita-
tion with a significant other, and region of residence (Cook County versus downstate Illinois) at the wave ] IFS interview.
Data Analysis Logistic regression techniques were applied to ex- amine the association between health-promoting behaviors and children's physical health, controlling for basic demographic variables and risk factors. Then, we examined the interaction effects of risk factors and health-promoting behaviors by adding the products of each risk and health-promoting behavior variable. Also, the cumulative effect of the health-promoting behaviors was examined,To test the robustness of our findings, we conducted sen- sitivity tests with a restricted sample that excluded children with chronic conditions (for example, developmental disabilities, physical illnesses) that were expected to last 12 months or more.
Sample Characteristics Descriptive statistics for key variables are presented in Table 1. The descriptive statistics indicate that the sample children experienced, on average, one type of material hardship, and approximately 51 percent of the children lived in households with at least one type of material hardship. However, the mean of the cumulative variable capturing caregiver's poor health was 0.32 {SD = 0.60),and approximately 25 percent of the children lived with a caregiver who was re- ported to be in poor physical or mental health.
RESULTS
Results from the logistic regression analyses are presented in Table 2. The associations between caregiver's ratings of children's health as excellent and risk and demographic variables were examined in model 1. Caregiver's poor physical and mental health was the only risk domain significantly asso- ciated with ratings of children's health as excellent health (odds ratio [OR] = 0.542,p < .01 ).Children's age and being Hispanic, in comparison with being African American, were negatively associated with children's excellent health ratings.These results were consistent in subsequent models.
When health-promoting behaviors were included in the analytic model, the variables, in general, had a positive main effect (that is, promotive efFect) on children's health being rated excellent (see model 2). The odds of being in excellent health were ap- proximately three times greater for children who had
Y o o , S L A C K , A N D H O L L / The Impact of Health-Promoting Behaviors on Low-Income Children's Health 137
Table 1: Descriptive Characteristics of Illinois Families Study-Child Well-being Supplement Wave 4 Children (n = 405)
Child Gender (male)
Age (range = 1—7 years)
Race/ethnicity
African American (reference)
Hispanic
White and other ethnicities
Caregiver
Age of primary caregiver (range = 21-55 years)
Marital status
Currently married
Cohabiting with significant other
Not married and not cohabiting (reference)
Residing in Cook County (Chicago area)
Risk factors
Cumulative material hardships (range = 0-5)
Caregiver in poor mental or physical health (range = 0-2)
Poor access to health care services
Health-promoting behaviors
Family and child have regular mealtime every day
Child has regular bedtime and bedtime routines every day
Child brushes teeth every day
Car seat used all or most of time child rides in car
Home childproofed across six or more items
Dependent variable
Child in excellent health
56.90
80.88
8.47
10.65
12.11
12.08
75.74
91.29
3.80
32.19
43.77
89.59
76.02
31.97
47.29
3.91
31.33
0.73
0.32
1.40
6.58
0.87
0.60
regular mealtime routines or daily dental hygiene practices than for those who did not regularly en- gage in these behaviors. Children's regular car seat use increased their odds of heing in excellent health by 80 percent, and living in a childproofed home increased their odds of being in excellent health by 130 percent. However, an unexpected negative effect was found for regular bedtime routines. Analytic results indicate that children who had a regular bedtime routine every day were less likely to be in excellent health than were those who did not have a regular routine.
A sensitivity test was used to examine whether the effects of risk and promotive factors changed for a subsample of children who did not have any chronic conditions (n = 306).The results are pre- sented in Table 3. Among the four variables that had a positive effect on children's health in model 2 (see Table 2), regular meals, brushing teeth every
day, and childproofmg the home maintained positive effects. Regular car seat use, which had a significant positive effect in the earlier model, was reduced to marginal statistical significance in Table 3. The negative effect of regular bedtime also maintained its significance.
We examined the protective effects of caregiver's health-promoting behaviors by including interaction terms for each risk factor and health-promoting behavior individually and simultaneously in model 2. No statistically significant interaction effects emerged.
Finally, ŵ e examined whether health-promoting behaviors had a cumulative effect above and beyond the individual effects. The results are presented in Table 2 (model 3). Due to concerns of multicol- linearity, dichotomous variables for regular meals and regular bedtime were replaced with original summary scores.The summary score for cunTulative
Health & Social Work VOLUME 35, NUMBER 2 MAY 2010138
Table 2: Logistic Regression Analyses for Children in Excellent Health (n = 405)
Child gender
I Child age
African American (reference)
, Hispanic
White and other ethnicities
Caregiver's age
I Caregiver not married and not cohabiting (reference)
, Caregiver married
Caregiver cohabiting
Residing in Cook County
Cumulative material hardship
Caregiver's poor health
Inadequate access to health care
Regular meals'
Regular bedtime'
Brushes teeth every day
Car seat use
Childproofed home
Cumulative health-promoting behaviors
Constant
0.355
0.166*
1.298**
0.324
0.010
0.223
0.081
0.406
0.407
0.017
1.426
0.847
0.273
0.723
1.010
0.631*
-0.202*
-1.626**
-0.789
0.017
0.248
0.089
0.440
0.443
0.018
1.879
0.817
0.197
0.454
1.017
0.444
-0.203*
-1.690**
-0.490
0.021
0.245
0.089
0.445
0.443
0.019
1.560
0.816
0.185
0.612
1.021
0.658 0.351
-0.556 0.370
0.559 0.399
0.034 0.136
-0.613** 0.206
-1.045 0.736
1.930
0.573
1.749
1.035
0.542
0.352
0.626
-0.590
0.632
0.131
-0.552*
-1.001
1.056**
-0.843**
1.024*
0.603*
0.852**
0.376
0.386
0.423
0.152
0.221
0.772
0.299
0.270
0.445
0.291
0.261
1.871
0.554
1.882
1.140
0.576
0.368
2.873
0.431
2.785
1.828
2.344
0.568
-0.538
0.597
0.019
-0.544*
-0.880
0.726*
-1.109**
0.555
0.137
0.300
0.498*
0.375
0.392
0.427
0.156
0.230
0.793
0.252
0.235
0.514
0.364
0.369
0.234
1.765
0.584
1.817
1.020
0.581
0.415
2.066
0.330
1.742
1.146
1.350
1.646
-0.169 0.666 0.844 -2.117** 0.868 0.120 -1.700 1.023 0.183 Notes: Model 1 shows associations between caregiver's ratings of children's health as excellent and risk and demographic variabies: in addition to those variables, model 2 shows associations between caregiver's ratings of children's heaith as excellent and chiid health-promoting behaviors; buiiding on model 2, mode! 3 shows the association between caregiver's ratings of children's health as excellent and cumulative health-promoting behaviors. Coeff. = coefficient; OR = odds ratio, 'The dichotomous variable used in modeis 1 and 2 was replaced with the original summary score in model 3 due to issues of muiticoilinearity. • p < .05. **p < .01.
health-promoting behavior had a mean of 3.48 and standard deviation of 1.26. The correlations between cumulative health-promoting behaviors and the dichotomized regular bedtime and meal routine variables were greater than .60, whereas the correlation between cumulative health-promoting behaviors and the original summary score for the two variables was around .50. The cumulative health-promoting behavior variable was signifi- cantly associated with children's excellent health. This fmding suggests that engaging in additional health-promoting behavior increases the odds of being reported by a caregiver as being in excellent health (OR = 1.646,p < .05). Similar results (not shown) were found for the subsaniple of children without any chronic conditions.
DISCUSSION Using a risk and resilience framework, we exam- ined the association between several risk factors for children's adverse health outcomes, child health-
promoting behaviors exercised by caregivers, and caregivers' positive assessments of children's health. The results provide some evidence that health- promoting behaviors have a positive association with caregiver ratings of children's physical health. Specifically, children whose caregivers followed regular family mealtime routines, engaged their children in everyday dental hygiene practices, and childproof their homes were more likely to be assessed by their caregivers as being in excellent health, regardless of the presence or absence of chronic conditions, controlling for other health risk factors.These fmdings support those from previous studies examining the association between a single type of health behavior and child outcomes (Case & Paxson, 2002; Larson, Branscomb, & Wiley, 2006; Peres et al., 2005).
A major fmding of this study is that health-pro- moting behaviors have a cumulative effect above and beyond the individual effect of each health behavior. This study suggests that there may be additional
Yoo, SLACK, AND HOLL / The Impact of Health-Promoting Behaviors on Low-Income Children's Health 139
Table 3: Logistic Regression Analyses for Children Without Any Chronic
Physical Conditions (n = 306)
Child gender
Child age
African American (reference)
Hispanic
White and other ethnicities
Caregiver's age
Caregiver not married and not cohabiting (reference)
Caregiver married
Caregiver cohabiting
Residing in Cook County
Cumulative material hardship
Caregivers poor health
Inadequate access to health care
Regular meals
Regular bedtime
Brushes teeth every day
Car seat use
Childproofed home
Constant Note: OR = odds ratio. *p < .10. *p < .05. **p < .01.
0.473
-0.250*
-1.709**
-0.115
-0.004
0.812'
0.066
0.978*
0.043
-0.439
-0.937
1.026**
-0.902**
1.607**
0.602'
0.829**
-2.782*
0.288
0.107
0.525
0.524
0.022
0.456
0.452
0.492
0.190
0.293
0.822
0.283
0.232
0.529
0.360
0.299
1.072
1.605
0.779
0.181
0.891
0.996
2.253
1.068
2.659
1.044
0.645
0.392
2.791
0.406
4.987
1.825
2.291
0.062
benefits to regularly engaging in multiple health- promoting behaviors with low-income children.The benefits may be derived from the actual cumulative health effects of these behaviors or from the positive effects of regularity and stability provided by these behaviors in children's daily lives. Although future studies need to test these hypotheses, existing re- search has demonstrated that regularity and stability are critical for healthy child development, especially for those children who are more hkely to live in chaotic environments (Brody & Flor, 1997; G.W. Evans, GonneUa, Marcynyszyn, Gentile, & Salpekar, 2005).Thus, this study supports the concept that a more structured home environment with regular routines may provide some incremental benefits for physical health among children in poverty
No significant interaction effects between risk variables and health-promoting behaviors were found in the analyses.Therefore, results suggest that the particular set of health behaviors examined have promotive rather than protective effects on children's health. However, because the sample children were
mostly from low-income families with already heightened levels of risk, variation in risk may be liinited. Future studies are needed to examine whether greater variation in risk exposure leads to significant interaction effects in a more representative sample of the general child population.
The negative association between regular bedtime routines and children's health was an unexpected finding. This association persisted even when other child and caregiver characteristics (for example, children's behavior problems, children's health at wave 3, parenting stress, caregiver's self-efficacy) were controlled for. We examined whether social desirabihty bias may have influenced this finding by analyzing the association between interviewer assessments of respondents' level of truthfulness in answering survey questions at wave 1 IFS and the key variables. (Interviewers were asked to rate a respondent's level of truthfulness during the wave 1 IFS survey interview Thus, this rating does not directly reflect respondents' level of truthfulness for the survey waves used in this study. However, the variable was deemed a reasonable proxy to examine the possibility of social desirability bias.) We found that respondents' truthfulness was mildly associated with regular bedtime routines and cumulative mate- rial hardship (r= - . 1 1 , r = —.12, respectively; both ps < .05) but not with other variables. It may be that respondents'biases in reporting regular bedtime routines influenced this association. However, fur- ther investigation using more objective measures is needed to determine whether social desirability bias has actually occurred in reporting regular bedtime routines. Moreover, future studies that examine a wider range of family routines and the mechanisms that may explain the associations with children's health outcomes are necessary to elucidate the implications of this unexpected finding.
Among the three risk domains, caregiver's poor health was the only one significantly associated with children's excellent health ratings. However, this finding was not preserved when the sample was restricted to children without chronic conditions, suggesting that the negative association between caregiver's poor health and children's excellent health may be influenced by children's chronic conditions. However, the exact manner in which the chronic conditions affect the association between caregivers' poor health and caregivers' assessments of children's excellent health could not be discerned in this study.
140 Health & Social Work VOLUME 35, NUMBER 2 MAY 2010
This study is among the first to examine the effect of health-promoting behaviors on children's physical health using a risk and resilience framework. Few studies have applied the risk and resilience framework to children's physical health (Gordon Rouse, IngersoU, & Orr, 1998;Vinson, 2002), and even fewer studies have tried to operationalize and include positive physical health as the main outcome of interest. The present study attempted to address this gap in knowledge by using the risk and resil- ience framework to understand children's positive physical health outcomes. An additional strength of this study is its focus on understanding the within- group variation in health among children -from low-income families. Although numerous studies have demonstrated socioeconomic disparities in children's physical health, few have shed light on why variations in health exist among children of similar socioeconomic status. This study suggests that health-promoting behaviors can provide some explanation for the within-group variation in low- income children's physical health.
Several limitations of the present study need to be addressed. First, most of the information regard- ing the key independent and dependent variables was gathered from a single informant—the primary caregiver. It is possible that the associations between the independent and dependent variables were overestimated due to this mode of data collection. Second, we recognize that our measures of health- promoting behaviors did not fuUy capture the behav- iors' multidimensional nature.This is attributable to the relative paucity of validated measures currently available to assess these behaviors (Committee on Evaluation of Children's Health, 2004), suggesting that future work is needed to develop such multidi- mensional measures.Third, the correlational design of the present study is a limitation for understanding the complex relationships among risk factors, health behaviors, and children's health. Although lagged predictors were used to partially address this issue, longitudinal studies that can test complex associa- tions between key variables are needed.
IMPLICATIONS The fmdings from this study support the growing body of literature on the importance of regular health-promoting behaviors (for example, regular family meals, safety practices) of the family for children's health outcomes. Moreover, the significant cumulative effect of health-promoting behaviors on
Although structural changes need to be made to effectively reduce disparities
in child health, collaborative efforts in promoting healthy behaviors may contribute
to a reduction in the damaging effects of childhood poverty on health.
low-income children's health suggests that there may be additional benefits for caregivers and their children in engaging in multiple types of health- promoting behaviors. Although it cannot be deter- mined from this study whether health intervention and prevention programs that encourage families to regularly engage in a wide array of health-promoting behaviors can influence health disparities among low-income children, the present findings suggests that ongoing study to specifically address this ques- tion is warranted.
Collaborative efforts between various agencies— including health services, social services, educational, and community-based agencies—to promote and reinforce relevant health-promoting behaviors at each developmental stage may contribute to a cumulative effect of such behaviors on children's health. For example, anticipatory guidance and health education programs in health care settings can provide health information relevant to a child's health needs (for example, hygiene practices, safety practices, healthy eating). Home-based services, such as home visiting programs, can be effective in increasing home safety and reducing child injury (Sweet & Appelbauni, 2004). Moreover, effective school-based or child care programs that involve parents and communities may improve hygiene practices, eating habits, and physical activities (Peters, Kok, Ten Dam, Buijs, & Paulussen, 2009; Sandora et al., 2005).
Low-income children are disproportionately at a disadvantage for poor health outcomes during child- hood as well as adulthood (Power & Kuh, 2006). Although structural changes need to be made to effectively reduce disparities in child health, collab- orative efforts in promoting healthy behaviors may contribute to a reduction in the damaging effects of childhood poverty on health. liH'l'i
REFERENCES Ackerman, B. P., Izard, C. E., SchofF, K.,Youngstrom,
E. A., & Kogos,J. (1999). Contextual risk, caregiver
Y o o , S L A C K , A N D H O L L / The Impact of Health-Promoting Behaviors on Low-Income Children's Health 141
emotionality, and the problem behaviors of six- and seven-year-old children from economically disadvan- taged families. Child Development, 70, 1415-1427.
Aim,A.,Wendt, L. K., Koch, G., & Birkhed, D. (2008). Oral hygiene and parent-related factors during early child- hood in relation to approximal caries at 15 years of age. Caries Research, 42, 28—36.
Appleyard, K.,Egeland, B., van Dulmen, M.H.M., & Sroufe, L. A. (2005).When more is not better:The role of cumulative risk in child behavior outcomes. fournal of Child Psychology and Psychiatry, 46, 235—245.
Ashiabi, G. S., & O'Neal, K. K. (2007). Food insecurity and adjustment problems in a national sample of adoles- cents. Jowma/of C/iiWreM and Poî erty, 13, 111—132.
Beverly, S. G. (2000). Using measures of material hardship to assess well-being. Focus, 23(2), 65—69.
Boyce,W.T.,Jensen, E.W., Cassel,J. C , Collier,A. M., Smith, A. H., & Ramey, C.T. (1977). Influence of life events and family routines on childhood respiratory illnesses. Pediatrics, 60, 609-615.
Brody, G. H., & Flor, D. L. (1997). Maternal psychological functioning, family processes, and child adjustment in rural, single parent, African American families. Developmental Psychology, 33, 1000-1009.
Gase, A., Lubotsky, D., & Paxson, G. (2002). Economic status and health in childhood; The origins of the gradient. American Economic Review, 92, 1308—1334.
Gase, A., & Paxson, G. (2002). Parental behavior and child heúú\. Health Affairs, 21, 164-178.
Ghen, E., Matthews, K. A., & Boyce,W.T (2002). Socio- economic differences in children's health: Hovy and why do these relationships change with age? Psycho- logical Bulletin, 128, 295-329.
Gommittee on Evaluation of Children's Health. (2004). Children's health, the nation's wealth:Assessing and improving child /¡ra/í/í. Washington, DGr National Academies Press.
Gook, J . T , Frank, D. A., Levenson, S. M., Neault, N. B., Heeren,T G., Black, M. M., et al. (2006). Ghild food insecurity increases risks posed by household food insecurity to young children's health. Jowma/ of Nutrition, 136, 1073-1076.
Danziger, S., Gorcoran, M., Danziger, S., Helfm, G., Kalil, A., Levine, J., et al. (1999). Barriers to work among welfare recipients. Focus, 20(2), 31—35.
Evans, G.W., Gonnella, G., Marcynyszyn, L.A., Gentile, L., & Salpekar, N. (2005). The role of chaos in poverty and children's socioemotional adjustment. Psychological Science, 16, 560—565.
Evans, R . G., & Stoddart, G. L. (1990). Producing health, consuming health care. In R. G. Evans, M. L. Barer, & T. R. Marmor (Eds.), Why are some people healthy and others not? (pp. 27-64). NewYork: Aldine de Gruyter.
Evans, S.A., & Kohil, H. S. (1997). Socioeconomic status and the prevention of childhood injuries: A survey of par- ents of preschool children. Injury Prevention, 3, 29—34.
Fiese, B. H.,Tomcho,T. J., Douglas, M., Josephs, K., Poltrock, S., & Baker,T. (2002). A review of 50 years of research on naturally occurring family routines and rituals: Gause for celebration? JoMma/ of Family Psychology, í í , 381-390.
Garmezy, N. (1993). Ghildren in poverty: Resilience de- spite risk. Psychiatry, 56, 127—136.
Gordon Rouse, K. A., IngersoU, G. M., & Orr, D. P (1998). Longitudinal health endangering behavior risk among resilient and nonresilient early adolescents. fournal of Adolescent Health, 23, 297-302.
Holl,J. L., Szilagyi, P G., Rodewald, L. E., Shone, L. P, Zwanziger, J., Mukamel, D. B., et al. (2000). Evaluation of NewYork State's Ghild Health Plus: Access, utilization, quality of care, and health status. Pediatrics, 105, 711-718.
Howard,A.W. (2002).Automobile restraints for children: A review for clinicians. Canadian Medical Association fournal, 167, 769-773.
Jensen, E.W.,James, S.A., Boyce,T, & Hartnett, S.A. (1983).The family routines inventory: Development and validation. Social Science and Medicine, 17, 201-211.
Jordan, E.A., Duggan, A. K., & Hardy,J. B. (1993). Injuries in children of adolescent mothers: Home safety edu- cation associated with decreased injury risk. Pediatrics, 91, 481-487.
Kahn, R. S., Zuckerman, B., Bauchner, H., Homer, G. J., & Wise, P H. (2002).Women's health after pregnancy and child outcomes at age 3 years: A prospective cohort study. American fournal of Public Health, 92, 1312-1318.
Kim, D.Y., Sataley, E, Gurtis, G., & Buchanan, S. (2002). Relation between housing age, housing value, and childhood blood lead levels in children in Jefferson Gounty, Ky. American fournal of Public Health, 92, 769-770.
Larson, R.W.,Branscomb, K. R., & Wiley, A. R. (2006). Forms and functions of family mealtimes: Multidis- ciplinary perspectives. New Directions for Child and Adolescent Development, 111, 1-15.
Lawton, R., Gönner, M., & McEachan, R. (2009). Desire or reason: Predicting health behaviors from affective and cognitive attitudes. Health Psychology, 28, 56—65.
Lewis, D. A., Shook, K. L., Stevens,A. B., Kleppner, P., Lewis, J., & Riger, S. (2000). Work, welfare, and well-being: An independent look at welfare reform in Illinois: Project description and first-year report. Evanston, IL: Institute for Policy Research, Northwestern University.
Luthar, S. S., Gicchetti, D., & Becker, B. (2000).The construct of resilience: A critical evaluation and guidelines for future work. Child Development, 71, 543-562.
Masten, A. S. (2001). Ordinary magic: Resilience processes in development. ^HieriMH Psychologist, 56, 227—238.
Masten, A. S., & Garmezy, N. (1985). Risk, vulnerability and protective factors in developmental psycho- pathology. In B. B. Lahey & A. E. Kazdin (Eds.), Advances in clinical child psychology (Vol. 8, pp. 1—52). NewYork: Plenum Press.
McLennen,J. D , & Kotelchuck, M. (2000). Parental pre- vention practices for young children in the context of maternal depression. Pediatrics, 105, 1090-1095.
Minkovitz, G., O'Gampo, P J., Ghen,Y.-H., & Grason, H.A. (2002).Association between maternal and child health status and patterns of medical care use. Ambulatory Pediatrics, 2, 85-92.
Mueller, E.J., &Tighe,J. R. (2007). Making the case for affordable housing: Gonnecting housing with health and education outcomes. Jouma/ of Planning Literature, 21, 371-385.
Newacheck, P, Hughes, D. G., Hung,Y.-Y.,Wong, S., & Stoddard,J.J. (2000).The unmet health needs of America's children. Pediatrics, 105, 989-997.
Ouellette,T., Burstein, N., Long, D , & Beecroft, E. (2004). Measures of material hardship: Final report. Washington, DG: U.S. Department of Health and Human Services.
Peres, M. A., Latorre, M.R.D.O., Aubrey, S., Peres, K. G., Barros, F. G., Hernandez, P G., et al. (2005). Social and biological early life influences on severity of dental caries in children aged 6 years. Community Dentistry and Oral Epidemiology, 33, 53—63.
Peters, L.WH., Kok, G.,Ten Dam, G.T.M., Buijs, G. J., & Paulussen,T.G.W.M. (2009). Effective elements of school health promotion across behavioral domains: A systematic review of reviews. BMC Public Health, 9, 182-196.
142 Health & Social Work VOLUME 35, NUMBER 2 MAY 2010
Power, C , & Kuh, D. (2006). Life course development of unequal health. InJ. Siegrist & M. Marmot (Eds.), Social inequalities in health (pp. 27-54). New York: Oxford University Press.
Price, C , Hamilton.W., & Cook,J. C. (1997). Cuide to im- plementing the Core Food Security Morfu/e. Washington, DC: U.S. Department of Agriculture.
Radloff, L. S. (1977).The CES-D Scale: A self-report de- pression scale for research in the general population. Applied Psychological Measurement y Í, 385—401.
Rutter, M. (1990). Psychosocial resilience and protective mechanisms. InJ. Rolf,A. S. Masten, D. Cicchetti, K. H. Nuechterlein, & S. Weintrauh (Eds.), Risk and protective factors in the development of psychopathology (pp. 181—214). New York: Cambridge University Press.
Ryff, C. D., & Singer, B. (1998). The contours of positive human health. Psychological Inquiry, 9, 1—28.
Sameroff,A.J. (2000). Ecological perspectives on develop- mental risk. InJ. D. Osofsky & H. E. Fitzgerald (Eds.), WAIMH handbook of infant mental health (pp. 4—33). New York: John Wiley & Sons.
Sandora,T.J.,Taverras,E. M., Shih, M.-C.,Resnick, E.A., Lee, G. M., Ross-Degnan, D., & Goldmann, D. A. (2005). A randomized, controlled trial of a multifac- eted intervention including alcohol-hased hand sani- tizer and hand-hygiene education to reduce illness transmission in the home. Pediatrics, 1Í6, 587-594.
Scalzo, CWiUiams, P. G., & Holmbeck, G. H. (2005). Maternal self-assessed health and emotionality predict maternal response to child illness. Children's Health Care, 34, 61-79.
Slack, K. S., H o l l J . L.,Yoo,J. P., Amsden, L. B., Collins, E., & Bolger, K. (2007).Welfare, work, and health care access predictors of low-income children's physical health outcomes. Children andYouth Services Review, 29, 782-801.
Starfield, B., Robertson,J., & Riley,A.W. (2002). Social class gradients and health in childhood. Ambulatory Pediatrics, 2, 238-246.
Sweet, M.A., & Appelbaum, M. I. (2004). Is home visiting an effective strategy? A meta-analytic review of home visiting programs for families with young children. Child Development, 75, 1435-1456.
Tiberia, M. J., Milnes, A. R., Feigal, R. J., Morley, K. R., Richardson, D. S., Croft,W. G., & Cheung,W. S. (2007). Risk factors for early childhood caries in Canadian preschool children seeking care. Pédiatrie Dentistry, 29, 201-208.
Vinson,J. A. (2002). Children with asthma: Initial develop- ment ofthe child resilience model. Pédiatrie Nursing, 28, 149-158.
Waters, E., Doyle,J.,Wolfe, R.,Wright, M.,Wake, M., & Salmon, L. (2000). Influence of parental gender and self-reported health and illness on parent-reported child health. Pediatrics, 106, 1422-1428.
Weinreb, L., Goldberg, R., Bassuk, E., & Perloff, J. (1998). Determinants of health and service use patterns in homeless and low-income housed children. Pediatrics, 102, 554-562.
Weinreb, L.,Wehler, C , Perloff,J., Scott, R., Hosmer, D., Sagor, L., et al. (2002). Hunger: Its inipact on chil- dren's health and mental health. Pediatrics, 110, e41.
Wolin, S.J., & Bennett, L. A. (1984). Family rituals. Family Process, 23, 401-420.
Yoo,J. P., Slack, K. S., & HoU,J. L. (2009). Material hard- ship and the physical health of school-aged children in low-income households. American Journal of Public Health, 99, 829-836.
Joan Yoo, PhD, MSSH^ is assistant professor. Department of Social Welfare, College of Social Sciences, Seoul National
University, 599 Gwanak-ro, Gwanak-gu, Seoul, 151-746,
Korea; e-mail: [email protected]. Kristen S. Slaek, PhD,
MSHÇis associate professor. School of SocialWork, University of
Wisconsin—Madison.Jane L. Holl, MD, MPH, is associate professor. Department of Pediatrics and Institute for Healthcare
Studies, Feinberg School of Medicine, Northwestern Univer-
sity, Chicago. Tins research was supported by the John D. and
Catherine T. MacArthur Foundation, the Joyce Foundation, the
Woods Fund of Chicago, the National Institute of Child Health
and Human Development (Grants ROÍ HD39148 and K01
HD4Í703), the Administration for Children and Families
(Grant 90PA0005), and the Area Poverty Research Center of
the Institute for Research on Poverty, University of Wisconsin.
Survey data were collected by the Metro Chicago Information
Center.The authors thank Stephanie A. Robert,ArthurJ. Reyn-
olds, Dan Bolt, Mia Ihm, and the reviewers for their insightful
and helpful comments on the manuscript of this article.
Original manuscript received November 6, 2007 Final revision received November 6, 2009 Accepted December 7, 2009
READERS: WRITE TO US!
Submit your reactions to and commentsabout an article published in Health & Social Work or a contemporary issue in the field. Send your letter (three double-spaced pages or fewer) to Letters, Health & Social Work, NASW Press, 750 First Street, NE, Suite 700, Washington, DC 20002-4241.
Yoo, SLACK, AND HOLL / The Impact of Health-Promoting Behaviors on Low-Income Children's Health 143
Copyright of Health & Social Work is the property of National Association of Social Workers and its content
may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express
written permission. However, users may print, download, or email articles for individual use.
