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Profiles of Risk No. 9: Child Health

Figure 2
Source: ICPH analysis of Fragile Families and Child Wellbeing data, n = 1,836. Excluded are mothers who did not participate in the year-five survey, do not live with the focal child at least half of the time at year five, do not have valid sample weights, or report an average (baseline to year five) income-to-poverty ratio greater than 1.25. Differences in asthma prevalence are statistically significant at 10% for always stably housed vs. ever-homeless or ever-at-risk women.

Asthma

Asthma is one of the leading chronic childhood diseases.[vi] The symptoms of asthma include shortness of breath, coughing, wheezing, chest pains, and lack of sleep, all of which negatively influence children’s quality of life and limit their activities.[vii]

While asthma is a controllable disease, poorly managed asthma can result in emergency-room visits, school absence for children, missed work for parents, and high health care costs. Figure 2 shows that, in addition to low birth weight, children who were ever homeless between ages one and five were more likely to have asthma at age five than at-risk or stably housed children. Approximately 17% of stably housed and at-risk children had asthma, while 23% of ever-homeless children suffered from the condition. Although the exact cause of asthma is unknown, research has linked the disease to environmental and behavioral factors related to housing instability (see “In Context: Poverty and Health”).

Health Care Utilization

Lacking a regular source of health care is detrimental to child health and often results in unnecessary expenditures. Children who have regular doctors and dentists are less likely to experience serious illness and to use hospital emergency rooms for health care than those who do not (see “In Context: Poverty and Health Care Utilization,” page 3). Housing instability threatens routine and preventive care; as Figure 3 shows, ever-homeless mothers reported almost double the rate of hospital emergency-room visits of their stably housed counterparts during the focal children’s first year (1.6 vs. 0.9 visits).

Figure 4 reveals that children who ever experienced homelessness received dental care less often than stably housed children. While 86% of stably housed children and 82% of children at risk of homelessness had seen dentists in the past year at age five, only 76% of ever-homeless children had received oral care. Tooth decay is the most common chronic disease among children, and oral health care ranks as the greatest unmet child health need.[ix]

Lack of appropriate dental care can lead to pain, infections, sleep deprivation, dysfunctional speech, and compromised learning and growth and result in missed school for children, absence of work for parents, and costly emergency room visits.[x]

Figure 3 Figure 4
Source: ICPH analysis of Fragile Families and Child Wellbeing data. For ER visits: n = 1,701. Excluded are mothers who did not participate in the year-five or year-one surveys, do not live with the focal child at least half of the time at year five, do not have valid sample weights, or report an average (baseline to year five) income-to-poverty ratio grater than 1.25. Differences in ER visits are statistically significant at 10% for ever-homeless vs. at-risk or always stably housed women.
Source: ICPH analysis of Fragile Families and Child Wellbeing data. For dental visits: n = 1,390. Excluded are children whose mothers did not participate in the year-five or year-five in-home surveys, do not have valid sample weights, did not live with their mothers at least half of the time at year five, or lived in families with an average (baseline to year five) income-to-poverty ratio greater than 1.25. Differences in dental visits are statistically significant at 10% for ever-homeless vs. ever-at-risk or always stably housed women.

Conclusion

There are clear differences in health status between children who experience housing instability and those who maintain stable housing. Children of unstably housed mothers have low birth weight more often than their stably housed peers. Children who ever experienced homelessness are more likely to have asthma and to visit emergency rooms than those who are stably housed. Ever-homeless children also visit dentists less frequently than those who are stably housed. These results suggest that the health of children who experience housing instability is compromised from an early stage.

Differences in maternal health and behaviors contribute to this child health disparity. Health policy targeting poor and residentially unstable populations should include education and outreach campaigns that focus on primary and preventive care as well as disease management. The needs of this group should be made part of the existing national discussion over expanding insurance coverage and improving access to high-quality pediatric and dental care.

The snapshot of poor families presented in this brief reveals distinct differences in health outcomes and health care utilization by housing status. Future topics explored in this series will include differences in maternal and child characteristics by race and nativity.

In Context
Poverty and Health Care Utilization

Inadequate and inconsistent health care is harmful to child health and expensive for families and society. Children who have continuous primary care or a fixed source of medical attention are more likely to receive preventive care and adhere to prescribed medication and less likely to visit emergency rooms or be hospitalized.[xi] Primary pediatric care, including routine and preventive attention, is the most cost-efficient and effective option for improving health outcomes. Up to half of all emergency-room visits, which contribute greatly to public health care costs, are avoidable with improved access to primary care.[xii] Poor child health also strains family resources and has the potential to precipitate housing instability by pushing poor families deeper into poverty.[xiii]

Health insurance is not the primary differentiating factor in health care utilization: most poor and homeless children are publicly insured through Medicaid.[xiv] While provision of health insurance is necessary, it is not sufficient to maintain good health and does not guarantee appropriate care. Unavailability of providers, inability to make copayments, transportation costs, and foregone earnings may lead to lower utilization among children in lower-income families.

Poor parents may lack knowledge about the importance of child health conditions, especially oral health and dental services.[xv] Further, Medicaid-participation rates, specifically among dentists, are low nationwide. Dental providers may be discouraged from treating Medicaid patients due to low reimbursement rates and administrative requirements.


[vii] Asthma is a chronic respiratory disorder characterized by attacks of impaired breathing. A child was categorized as having asthma at age five if his/her mother reported one or more of the following: that a medical professional had diagnosed the child with asthma, that the child had an asthma attack in the past 12 months, or if the child had required emergency/urgent care for asthma in the past 12 months. For more information please see: Lara Akinbami, “Advance Data from Vital and Health Statistics: The State of Childhood Asthma, United States, 1980–2005,” National Center for Health Statistics, no. 381 (2006).

[viii] Lara Akinbami, Jeanne Moorman, and Xiang Liu, “National Health Statistics Reports: Asthma Prevalence, Health Care Use, and Mortality: United States: 2005–2009,” National Center for Health Statistics, no. 32 (2011): 115; Robert Lemanske and William Busse, “Asthma,” Journal of the American Medical Association 278, no. (1997): 1855–73.

[ix] Paul Newacheck, et al., “The Unmet Health Needs of America’s Children,” Pediatrics 105, no. 4 (2000): 989–97; U.S. Department of Health and Human Services, Oral Health in America: A Report of the Surgeon General (Rockville, MD: U.S. Department of Health and Human Services, National Institute of Dental and Craniofacial Research, National Institutes of Health, 2000).

[x] Helen Gift, Susan Reisine, Dina, Larach, “The Social Impact of Dental Problems and Visits,” American Journal of Public Health 82, no. 12 (1992): 1663–8; U.S. Department of Health and Human Services, Oral Health in America: A Report of the Surgeon General (Rockville, MD: U.S. Department of Health and Human Services, National Institute of Dental and Craniofacial Research, National Institutes of Health), 2000; Clemencia Vargas and Cynthia Ronzio, “Disparities in Early Childhood Caries,” BMC Oral Health 6, no. S3 (2006): 1–5.

[xi] D. Christakis, et al., “Association of Lower Continuity of Care with Greater Risk of Emergency Department Use and Hospitalization in Children,” Pediatrics 107, no. 3 (2001): 524–29; B. Starfield and L. Shi, “The Medical Home, Access to Care, and Insurance: a Review of Evidence,” Pediatrics 113, no. 5 supplement (2004): 1493–98; Barbara Starfield, Primary Care: Concept, Evaluation, and Policy (New York: Oxford University Press, 1992).

[xii] Eric Nawar, Richard Niska, and Jainmin Xu, Advance Data from Vital and Health Statistics, Number 386: National Hospital Ambulatory Medical Care Survey: 2004 Emergency Department Summary, National Center for Health Statistics, 2007; Derek DeLia, “Potentially Avoidable Use of Hospital Emergency Departments in New Jersey,” Rutgers Center for State Health Policy, 2006; Excellus Blue Cross Blue Shield, “The Facts About Potentially Avoidable Emergency Room Visits in Upstate New York,” 2011.

[xiii] Anne Case, Darren Lubotsky, and Christine Paxson, “Economic Status and Health in Childhood: The Origins of the Gradient,” American Economic Review 92, no. 5 (2002): 1308–34; Hope Corman, Kelly Noonan, and Nancy Reichman, “Mothers’ Labor Supply in Fragile Families: The Role of Child Health,” Eastern Economic Journal 31, no. 4 (2005): 601–16; Marah Curtis, et al., “Life Shocks and Homelessness” (working paper, National Institute of Child health and Human Development, 2012).

[xiv] Xuemei Luo, et al., “Children’s Health Insurance Status and Emergency Department Utilization in the US,” Pediatrics 112 (2003): 314–9; Colin Sox, et al., “Insurance or Regular Physician: Which Is the Most Powerful Predictor of Health Care?” American Journal of Public Health 88, no. 3 (1998): 364–70. ICPH analyses of children’s health insurance status (insured, not insured) and type (Medicaid, private) by housing status revealed no consistent patterns. Most children were insured by Medicaid at any given point in time, and over half of all groups were stably insured over all five years.

[xv] U.S. Government Accountability Office, Oral Health: Factors Contributing to Low Use of Dental series by Low-Income Populations (Washington, DC: U.S. Government Accountability Office, 2000).


A Hand Still Raised: How New York City's Homeless Students Fit into Charter Schools
2/2013

One Degree of Separation: Education, Sex, and Family Planning among New York City's Homeless Mothers
10/2012

Profiles of Risk No. 10: Father Involvement
8/2012


Low-weight Births and Maternal Prenatal Behaviors
(by housing status years 1–5)


Asthma at Age 5
(by housing status years 1–5)


Emergency Room Visits at Age 1
(by housing status years 1–5)


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