Vibrant and Healthy Kids Aligning Science, Practice, and Policy to Advance Health Equity (2019) / Chapter Skim
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6 Creating Healthy Living Conditions for Early Development
6 Creating Healthy Living Conditions for Early Development
Pages 389-472
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From page 389... ...
Healthy communities continuously create and improve physical and social environments and expand community resources that enable people to mutually support each other in daily life and in developing 1 This quote is from a public meeting of the committee, held on October 1, 2018. The meeting webcast is available at www.nationalacademies.org/earlydevelopment (accessed July 29, 2019)
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From page 390... ...
. Healthy living conditions are made up of the SDOH, or
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From page 391... ...
Chapter recommendations in brief: •• Implement paid parental leave. •• educe barriers to participation to Special Supplemental Nutrition Program R for Women, Infants, and Children and Supplemental Nutrition Assistance Program (SNAP)
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From page 392... ...
The chapter includes discussions of the existing evidence and committee recommendations for solutions to address economic stability and security, food security and nutrition, housing, neighborhood conditions, and environmental exposures and exposure to toxicants. ECONOMIC STABILITY AND SECURITY Children's well-being and future health outcomes are strongly related to family income, and as the review in Chapter 3 shows, poverty is associated with significant detrimental effects on children's health, development, and well-being.
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From page 393... ...
safety net programs that are intended to increase financial resources of families with children through cash transfers or tax credits. In the following paragraphs, the committee assesses programs that provide targeted benefits to address food or housing shortfalls and programs to address neighborhood conditions.
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, and then on tax credits, focusing on the Earned Income Tax Credit (EITC) and the Child Tax Credits (CTCs)
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The best package it could design combines ex pansions of the EITC, the Child and Dependent Care Tax Credit, a minimum wage increase, and a promising career development program. Although this package is estimated to add more than a million workers to the labor force, generate $18 billion in additional earnings, and cost the government only $8.6–$9.3 billion annually, its estimated reductions in child poverty are less than half of what is needed to meet the goal.
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From page 396... ...
. TANF has been a shrinking component of the nation's social safety net for children since the passage in 1996 of the Personal Responsibility and Work Opportunity Reconciliation Act, when Aid to Families with Dependent Children (AFDC)
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NOTE: AFDC = Aid to Families with Dependent Children; CTC = Child Tax Credit; EITC = Earned Income Tax Credit; SNAP = Supplemental Nutrition ssistance A Program; SSI = Supplemental Security Income; TANF = Temporary Assistance for Needy Families. a AFDC became TANF after the 1996 welfare reform.
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From page 398... ...
While this section's focus is the federal level, many states offer similar tax credits to working families. In theory, working family tax credits avoid the potential work disincentives of cash transfer programs, and research has demonstrated large increases in labor force participation, particularly for single mothers with children, as a result of the EITC (Nichols and Rothstein, 2016)
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From page 399... ...
Given the similar structure of the CTC and EITC, many of the effects are expected to be the same, with the important exception that the CTC is available to most moderate-income families, unlike the EITC, which is targeted at families with low incomes. As noted above, the EITC and the CTC together are effective in reducing child poverty: nearly 5 million children lived in families whose incomes were brought above the poverty level after including working family tax credits, and more than 7 million additional children experienced less severe poverty (CBPP, 2018c)
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. Unlike the working family tax credits, minimum-wage policies are not targeted specifically at low-income families with children.
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From page 401... ...
Second, the lowest-income families often cannot take full advantage of tax credits and exemptions if their income is so low that they do not owe income tax. A child allowance paid to families on a monthly basis and not tied to earnings or employment would provide support for many of the lowest-income children in the United States whose parents do not work or have unstable and insufficient earnings.
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From page 402... ...
Alternatively, the child allowance could be phased out at 300 percent of the federal poverty level. Replacement of the current child tax credits with a monthly child allowance could provide families with a more regular source of cash income to support their children's needs (NASEM, 2019)
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estimated that the Family and Medical Leave Act (FMLA) , which allows for 12 weeks of unpaid maternity leave, resulted in lower infant mortality and slightly higher birth weight outcomes for college-educated women.
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The authors found that the program doubled the use of maternity leave in California, with notable increases among non-college-educated mothers with infants (from 2.4 to 7.7 percent) , unmarried mothers (from 1.9 to 9.3 percent)
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From page 405... ...
The AEI-Brookings Working Group on Paid Family Leave published two reports in 2017 and 2018 that focused on paid parental leave and paid family care and medical leave, respectively. Based on the extant literature on paid parental leave and its impact on family outcomes, the 2017 report puts forth a federal paid parental leave proposal.
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From page 406... ...
Given the high rate of child poverty in this country compared to other wealthy nations, as well as large disparities across racial and ethnic groups in poverty rates, reducing childhood poverty is a critical, foundational step in reducing health disparities in early childhood. Conclusion 6-1: Increasing the economic resources families have avail able to meet basic needs when children are young (including prenatally)
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From page 407... ...
Universal 1. Work- universal supports supports oriented support and work and work package package package package Expand EITC X X X X Work-oriented programs and Expand Child X X X X Care Tax Credit policy Increase the X X minimum wage Roll out X WorkAdvance Expand housing X voucher program Income support-oriented programs and policies Expand SNAP X benefits Begin a child X X allowance Begin child X support assurance Eliminate 1996 X immigration eligibility restrictions Percent reduction −18.8% −35.6% −50.7% −52.3% in the number of poor children Percent reduction −19.3% −41.3% −51.7% −55.1% in the number of children in deep poverty Change in +1,003,000 +568,000 +404,000 +611,000 number of low income workers Annual cost, in $8.7 $44.5 $90.7 $108.8 billions SOURCE: NASEM, 2019.
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From page 408... ...
Recommendation 6-1: Federal, state, local, tribal, and territorial policy makers should implement paid parental leave. In part nership with researchers, policy makers should model vari ations in the level of benefits, length of leave, and funding mechanisms to determine alternatives that will have the largest impacts on improving child health outcomes and reducing health disparities.
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From page 409... ...
The National Academies report A Roadmap to Reducing Child Poverty details a number of additional strategies to reduce child poverty through, for example, increases in the minimum wage, job training programs, child care subsidies, and child support assurance, in addition to the policies discussed in this section. There is limited evidence of the impacts of these on child health, with the exception of the minimum wage (discussed earlier)
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From page 410... ...
Current Programs and Policies Two major federal programs in the United States target the adequacy of food and nutrition for children living in households with limited resources: the Supplemental Nutrition Assistance Program (SNAP) , formerly known as the Food Stamp Program, and the Special Supplemental Nutrition Program for Women, Infants, and Children (WIC)
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From page 411... ...
. While SNAP benefits can be spent only on eligible food items, these benefits add to the total resources the family has to spend on all necessities.
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A review of studies prior to 2003 concluded that SNAP participation increased household food expenditures (USDA, 2004) , which suggests that SNAP would reduce food insecurity among recipient households.
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The study findings also showed a small reduction in infant mortality for white babies in Los Angeles County. There is more recent evidence of a positive connection between receiving SNAP benefits (or food stamps)
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In addition to reducing hunger and food insecurity, a second key objective of the nation's food assistance programs is to improve the healthfulness of American food consumption and provide nutrition education. Studies have examined the effect of SNAP on the quality or healthfulness of a family's food consumption as a possible mechanism through which SNAP might affect obesity (and other health)
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. The report cites evidence that increasing SNAP benefits would substantially reduce child poverty and that current benefit levels do not account for food preparation time or geographic variation in food costs (Ziliak, 2016)
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. Numerous studies using varied methods have found evidence of improved birth outcomes for women participating in the WIC program (see, for example, Figlio et al., 2009; Fingar et al., 2017; Foster et al., 2010; Hoynes et al., 2011)
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WIC may also reduce food insecurity. One study found that WIC participation reduced the number of children experiencing food
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Box 6-4 describes Healthy Mothers on the Move as an example of a promising model to improve nutrition and healthy lifestyles. Summary Both the SNAP and WIC programs have been studied extensively, and a large body of literature points to strong associations between program participation and positive outcomes, including less food insecurity, 10 See https://www.fns.usda.gov/wic/wic-eligibility-and-coverage-rates (accessed July 14, 2019)
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. These examples all apply developmental science and aim to advance health equity during the preconception through early childhood periods.
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, providing resources to ensure families have access to sufficient and healthy foods can improve birth outcomes and child health outcomes. Because safety net programs, such as WIC and SNAP, have been shown to improve birth outcomes and to reduce food insecurity for young children, the committee recommends: Recommendation 6-2: Federal, state, local, territorial, and tribal agencies should reduce barriers to participation in the Special Supplemental Nutrition Program for Women, Infants, and Chil dren (WIC)
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From page 421... ...
For more information on the evidence supporting the role of affordable housing in promoting positive outcomes for child health and development, see Chapter 3. Improving Housing Affordability and Quality Federal housing assistance is provided through a number of programs, including the Housing Choice Voucher Program, public housing, and the Low Income Housing Tax Credit.
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. HUD housing assistance can help families obtain improved housing quality and residential stability (social factors that are associated with child development and disparities)
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. A Roadmap to Reducing Child Poverty modeled "expansions of voucher availability rather than other modifications, such as an increase in the level of housing subsidies, primarily because most experts agree that limited availability is currently the primary barrier preventing subsidized housing programs from having a larger impact on poverty reduction" (NASEM, 2019, p.
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From page 424... ...
Several states, including Maryland and New York, have undertaken state- and municipality-level lead prevention and mitigation efforts that have led to significant decreases in childhood lead exposure and poisoning. In New York, the City of Rochester implemented a Lead-Based Paint Poisoning Prevention Ordinance in 2006, which requires inspections for lead paint as part of existing inspections of most rental properties built before 1978.
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Many high-quality reviews of lead poisoning prevention have been completed and contain important recommendations for remediation and prevention. For example, a report by the Health Impact Project (2017)
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From page 426... ...
Physicians at Cincinnati Children's primary care clinics and social workers screen patient families for issues that may be affect ing their children's health, such as food insecurity, inadequate housing, adverse childhood experiences, and poor-quality education. Physicians receive training to better identify legal and social issues, which has been shown to successfully increase their comfort level with and knowledge of the social determinants of health (SDOH)
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From page 427... ...
. Families have received assistance in obtaining Supplemental Nutrition Assistance Program and Special Supplemental Nutrition Program for Women, Infants, and Children benefits, health insurance coverage, transportation to jobs, day care for young children, enrollment in school and special education services, and adequate housing to prevent homelessness.
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From page 428... ...
Conclusion 6-6: Healthy early development cannot occur without safe and stable housing. Lack of affordable housing and environmen tal hazards in housing disrupt healthy childhood development and 14 The National Healthy Housing Standard is available at https://nchh.org/resource/ national-healthy-housing-standard-full-document (accessed March 21, 2019)
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From page 429... ...
Rental Assistance Demonstration (RAD) is a federal program that "converts public housing subsidies into a form that can be used as the basis for securing private financing and can be combined more easily with other subsidies" (Allbee et al., 2015, p.
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Conclusion 6-7: Housing affordability and quality is an acute problem that disproportionately impacts people of color and contributes to health disparities among children. Over half of black and Hispanic renters live in unaffordable housing, and health issues related to poor-quality hous ing, such as elevated blood lead levels and asthma, are more prevalent among these renters.
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From page 431... ...
Founded in the review of the evidence of health impacts and the committee's expertise, the recommendation is based on increased resources for access to food and stable housing and income support in the form of a child allowance: Recommendation 6-6: Federal, state, tribal, and territorial pol icy makers should address the critical gaps between family resources and family needs through a combination of benefits that have the best evidence of advancing health equity, such as increased Supplemental Nutrition Assistance Program benefits, increased housing assistance, and a basic income allowance for young children. The costs of providing more resources to families with young children by increasing SNAP benefits, housing assistance, or a child allowance depend on many parameters, including the size of the benefit per family 16 The collaborators in this council are the Corporation for National and Community Ser vice, General Services Administration, HHS, HUD, Office of Management and Budget, SSA, U.S.
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The key advantage of a child allowance (over, for example, tax credits) is that funds are available to 17 It is important to note that these estimates are net costs to the government, and they are not suitable for comparison to other cost estimates cited in this chapter.
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Increased SNAP benefits and housing allowances would address current inadequacies in both of these programs and provide targeted support for the critical food and housing needs of young children. Paid parental leave would also recognize and support the special needs of the earliest years, in which parental time and attention are critically important for children's health and development.
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. This section addresses neighborhood conditions broadly; other sections in this chapter discuss the evidence related to specific neighborhood-level factors, such as housing, environmental exposures, food security, and economic security.
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Improving neighborhood conditions to diminish exposure to crime and violence plays an important role in reducing children's biological stress and improving their health outcomes. For more on exposure to violence as an adverse childhood experience, see Chapter 3.
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436 VIBRANT AND HEALTHY KIDS health and well-being outcomes (see Figure 6-3)
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MTO established that places matter for health but not what it is about them that matters most: it was not designed to tease apart which aspects of places drove those health improvements, nor did it specifically address prenatal or birth outcomes. Other studies have attempted to further illuminate which aspects of a neighborhood -- for example, better economic environments, built environment features that promote healthy lifestyles, or improved social cohesion -- might represent the most important levers for improving health and birth outcomes.
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From page 438... ...
For an example of a promising initiative that aims to support and strengthen families by providing community-based supportive services, see Box 6-6. ENVIRONMENTAL EXPOSURES AND EXPOSURE TO TOXICANTS Each year, Americans are exposed to chemicals in the environment at increasingly greater levels.
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In its review of the literature, the committee found that children (from fetal development through early childhood) are at greater risk than adults from adverse health effects of environmental exposures due to their smaller size and proportionally large intake of food, air, and water to body weight and are subject to rapid developmental processes that may be influenced and disrupted by chemicals and toxicants.
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From page 440... ...
The following section provides a review of the limited research currently available that specifically examines policies and practices to reduce the risk of environmental exposures among preconception, prenatal, and postnatal populations. Reducing the Risk of Environmental Exposures in the Home and in Child Care Settings The Center for Medicaid and CHIP Services (CMCS)
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From page 441... ...
Moreover, licensing guidelines vary, with limited requirements addressing child care provider training on mitigation of early childhood exposures. Reviewing existing state policies on the regulation of environmental exposures in child care facilities offers policy makers an opportunity to compare policy approaches and consider nonregulatory approaches to effect change (Environmental Law Institute, 2015)
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From page 442... ...
Reducing the Risk of Environmental Exposures in the Community In a 2018 study, researchers linked 2011 National Emissions Inventory data with block groups from the 2009–2013 American Community Survey data (Mikati et al., 2018)
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. In another example, the Community Action to Fight Asthma Initiative in California used an environmental justice approach to reduce risk factors for asthma in school-aged children.
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This was acknowledged as a community-driven solution to promote health equity in the 2017 National Academies report Communities in Action: Pathways to Health Equity. The report asserts that "civil rights, health, and environmental justice laws and policies provide a framework to promote equal access to publicly funded resources and prohibit discrimination based on race, color, national origin, income, gender, disability, and other factors" (NASEM, 2017, p.
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From page 445... ...
. In 1994, an executive order was issued on Federal Actions to Address Environmental Justice in Minority Populations and Low-Income Populations.21 Civil rights laws and their enforcement not only aim to protect populations in at-risk contexts -- thereby reducing disparities -- but also allow for a crosscutting approach that can apply to many of the determinants of health and development discussed in this report (e.g., housing, environmental exposures, education)
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From page 446... ...
The Communities in Action: Pathways to Health Equity report (NASEM, 2017) also outlines some guidance for civil rights attorneys, public health professionals, community groups, public agencies, recipients of public funding, foundations, and other stakeholders to advance equity using civil rights tools (see Box 6-7 for a listing of these guiding strategies)
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From page 447... ...
. The alignment between this report and Communities in Action with respect to health equity and the applicability of civil rights strategies for addressing environmental exposures in communities warrants serious consideration of these findings and the abovementioned recommendation for promoting healthy and equitable early development.
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From page 448... ...
. However, despite broad consensus on the importance of addressing exposure to environmental toxicants, studies show that many obstetricians and gynecologists do not screen their patients for harmful environmental exposures (Grindler et al., 2018; Stotland et al., 2014)
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From page 449... ...
A work group of faculty members and residents23 formed at a meeting convened by the Mid-Atlantic Center for Children's Health and the Environment and The George Washington University's Department of Obstetrics and Gynecology identified several approaches to better incorporate environmental health into medical education, including 1. Integrating environmental health into basic science courses and the organ systems approach (Gehle et al., 2011)
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From page 450... ...
Located across the United States and Canada, Pediatric Environmental Health Specialty Units are a national network of experts in reproductive and children's environmental health who are located at academic medical centers and provide medical information and advice and respond to requests for information on the prevention, diagnosis, management, and treatment of the effects of environmental exposures on children and adults of child-bearing age (PEHSU, n.d.)
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From page 451... ...
Revising existing conceptual models aims to improve evaluation and assessment of environmental exposures to improve accuracy, enhance the overall fit of statistical modeling, and ensure improved predictive power in research studies examining environmental exposures and effects on early childhood development. In another approach, a conceptual framework relying on a holistic approach to maternal and child health research includes both psychosocial stressors and environmental hazards to better explain factors that influence poor health outcomes for populations that experience higher risks of environmental exposure.
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From page 452... ...
. In addition to federal regulations, state environmental and public health agencies engage in efforts to prevent environmental exposures and to translate existing data and research findings into actionable policies and practices.
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statements of principles, general policy, and targeted annual pri orities to guide the federal approach to achieving the goals of this order; b. coordinated research agenda for the federal government, includ a ing steps to implement the review of research databases described in Section 4 of the executive order; 29 For more information, see https://ptfceh.niehs.nih.gov (accessed April 8, 2019)
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reducing the burden of environment-related illnesses by addressing the environmental origins of diseases to promote health and reduce health disparities (PTFCEH, 2016b)
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Program, a group of more than 70 cohort studies aimed at understanding the relationship between environmental exposures and five main domains: upper and lower airways; obesity; pre-, peri-, and postnatal outcomes; neurodevelopment; and positive health outcomes (ECHO, 2019a,b)
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From page 456... ...
Conclusions and Recommendations to Reduce Exposure to Environmental Toxins Given the importance of safe early learning environments, as discussed above, the committee recommends: Recommendation 6-7: The Administration for Children and Families, Maternal and Child Health Bureau, and federal and state regulators should strengthen environmental protection in early care and education settings through expanded workforce training, program monitoring, and regulations. Training professionals who regularly interact with children and their families on how to prevent and mitigate exposure to environmental toxicants during early development is an important opportunity to advance health equity; therefore, the committee recommends: Recommendation 6-8: Professional societies, training programs, and accrediting bodies should support expanded or innovative models for training of prenatal and childhood health care pro viders on screening, counseling, and interventions to prevent or mitigate toxic environmental exposures.
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CONCLUSION Creating healthy living conditions to promote optimal development requires a multipronged approach to support caregivers and families so that they may meet the fundamental needs of their children. This chapter
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From page 458... ...
Furthermore, the recommendations highlight the many roles of government at all levels in shaping healthy early living conditions (e.g., removing barriers to accessing public nutrition programs, creating a comprehensive plan for healthy housing, passing legislation to authorize and fund paid parental leave, strengthening environmental protections in ECE settings)
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From page 459... ...
2016. State earned income tax credits and the production of child health: Insurance coverage, utilization, and health status.
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2018c. Policy basics: The Earned Income Tax Credit.
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2012. The impact of family income on child achievement: Evidence from the Earned Income Tax Credit.
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2015. Reducing environmental exposures in child care facilities: A review of state policy.
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From page 463... ...
2016. The Supplemental Nutrition Assistance Program and food insecurity.
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2016. Poverty and child development: A longitudinal study of the impact of the Earned Income Tax Credit.
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2015. Paid maternity leave and breastfeeding practice before and after California's implementation of the nation's first paid family leave program.
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2019. Effects of state level earned income tax credit laws on birth outcomes by race and ethnicity.
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From page 467... ...
2018. Cash-on-hand and college enrollment: Evidence from popu lation tax data and the Earned Income Tax Credit.
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2016. The Earned Income Tax Credit.
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2016. Research review: Environmental exposures, neuro development, and child mental health -- new paradigms for the study of brain and behavioral effects.
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2012. Environmental exposures: How to counsel preconception and prenatal patients in the clinical setting.
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2010. Effects of prenatal poverty on infant health: State earned income tax credits and birth weight.
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2012. Supplemental Nutrition Assistance Program partici pation and health; evidence from low-income individuals in Tennessee.
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