Welfare-to-work interventions and their effects on the mental and physical health of lone parents and their children

Cross-national variation in the association between family structure and overweight and obesity: Findings from the Health Behaviour in School-aged children (HBSC) study

Background

Trends of increased complexity in family structure have developed alongside increasing prevalence of overweight and obesity. This study examines cross-national variations in the likelihood of living with overweight and obesity among adolescents living with one parent versus two parents, as well as the influence of living with stepparents, grandparents and siblings. Furthermore, the study explores how these associations relate to age, gender and individual-level socioeconomic status (SES) and country-level SES. We hypothesised that adolescents living in one-parent versus two-parents families, were more likely to live with overweight and obesity.

Methods

The study is based on nationally representative data from 41 countries participating in the 2013/14 Health Behaviors in School-Aged Children study (n = 211.798). Multilevel logistic regression analysis was used to examine the associations between family structure and overweight and obesity by age, gender, SES, and geographic region, among adolescents aged 11, 13 and 15 years.

Results

Living with one versus two parent(s) was associated with a higher likelihood of overweight and obesity (ORadj.1.13, 95%CI 1.08,1.17). Age, gender, individual-level SES, and living with grandparents were also associated with a higher likelihood of overweight and obesity, whereas living with siblings was associated with a lower likelihood of overweight and obesity. The effect of family structure varied also by age and gender with no significant associations found between living with one parent and overweight and obesity in the 15-year-old age group. Some cross-national variation was observed, and this was partly explained by country-level SES. The effect of family structure increased by a factor 1.08 per one-unit change in country-level SES (OR 1.08, 95%CI1.03, 1.12).

Conclusion

The study indicates that living in a one-parent family, as well as living together with grandparents, are associated with overweight and obesity among adolescents, particularly in the Nordic European region. Existing welfare policies may be insufficient to eliminate inequalities related to family structure differences.

Unconditional cash transfers for reducing poverty and vulnerabilities: effect on use of health services and health outcomes in low- and middle-income countries

BACKGROUND

Unconditional cash transfers (UCTs; provided without obligation) for reducing poverty and vulnerabilities (e.g. orphanhood, old age, or HIV infection) are a social protection intervention addressing a key social determinant of health (income) in low- and middle-income countries (LMICs). The relative effectiveness of UCTs compared with conditional cash transfers (CCTs; provided only if recipients follow prescribed behaviours, e.g. use a health service or attend school) is unknown.

OBJECTIVES

To assess the effects of UCTs on health services use and health outcomes in children and adults in LMICs. Secondary objectives are to assess the effects of UCTs on social determinants of health and healthcare expenditure, and to compare the effects of UCTs versus CCTs.

SEARCH METHODS

For this update, we searched 15 electronic academic databases, including CENTRAL, MEDLINE and EconLit, in September 2021. We also searched four electronic grey literature databases, websites of key organisations and reference lists of previous systematic reviews, key journals and included study records.

SELECTION CRITERIA

We included both parallel-group and cluster-randomised controlled trials (C-RCTs), quasi-RCTs, cohort studies, controlled before-and-after studies (CBAs), and interrupted time series studies of UCT interventions in children (0 to 17 years) and adults (≥ 18 years) in LMICs. Comparison groups received either no UCT, a smaller UCT or a CCT. Our primary outcomes were any health services use or health outcome.

DATA COLLECTION AND ANALYSIS

Two review authors independently screened potentially relevant records for inclusion, extracted data and assessed the risk of bias. We obtained missing data from study authors if feasible. For C-RCTs, we generally calculated risk ratios for dichotomous outcomes from crude frequency measures in approximately correct analyses. Meta-analyses applied the inverse variance or Mantel-Haenszel method using a random-effects model. Where meta-analysis was impossible, we synthesised results using vote counting based on effect direction. We assessed the certainty of the evidence using GRADE.

MAIN RESULTS

We included 34 studies (25 studies of 20 C-RCTs, six CBAs, and three cohort studies) involving 1,140,385 participants (45,538 children, 1,094,847 adults) and 50,095 households in Africa, the Americas and South-East Asia in our meta-analyses and narrative syntheses. These analysed 29 independent data sets. The 24 UCTs identified, including one basic universal income intervention, were pilot or established government programmes or research experiments. The cash value was equivalent to 1.3% to 81.9% of the annualised gross domestic product per capita. All studies compared a UCT with no UCT; three studies also compared a UCT with a CCT. Most studies carried an overall high risk of bias (i.e. often selection or performance bias, or both). Most studies were funded by national governments or international organisations, or both. Throughout the review, we use the words 'probably' to indicate moderate-certainty evidence, 'may/maybe' for low-certainty evidence, and 'uncertain' for very low-certainty evidence. Health services use We assumed greater use of any health services to be beneficial. UCTs may not have impacted the likelihood of having used any health service in the previous 1 to 12 months, when participants were followed up between 12 and 24 months into the intervention (risk ratio (RR) 1.04, 95% confidence interval (CI) 1.00 to 1.09; I² = 2%; 5 C-RCTs, 4972 participants; low-certainty evidence). Health outcomes At one to two years, UCTs probably led to a clinically meaningful, very large reduction in the likelihood of having had any illness in the previous two weeks to three months (RR 0.79, 95% CI 0.67 to 0.92; I² = 53%; 6 C-RCTs, 9367 participants; moderate-certainty evidence). UCTs may have increased the likelihood of having been food secure over the previous month, at 13 to 36 months into the intervention (RR 1.25, 95% CI 1.09 to 1.45; I² = 85%; 5 C-RCTs, 2687 participants; low-certainty evidence). UCTs may have increased participants' level of dietary diversity over the previous week, when assessed with the Household Dietary Diversity Score and followed up 24 months into the intervention (mean difference (MD) 0.59 food categories, 95% CI 0.18 to 1.01; I² = 79%; 4 C-RCTs, 9347 participants; low-certainty evidence). Despite several studies providing relevant evidence, the effects of UCTs on the likelihood of being moderately stunted and on the level of depression remain uncertain. We found no study on the effect of UCTs on mortality risk. Social determinants of health UCTs probably led to a clinically meaningful, moderate increase in the likelihood of currently attending school, when assessed at 12 to 24 months into the intervention (RR 1.06, 95% CI 1.04 to 1.09; I² = 0%; 8 C-RCTs, 7136 participants; moderate-certainty evidence). UCTs may have reduced the likelihood of households being extremely poor, at 12 to 36 months into the intervention (RR 0.92, 95% CI 0.87 to 0.97; I² = 63%; 6 C-RCTs, 3805 participants; low-certainty evidence). The evidence was uncertain for whether UCTs impacted livestock ownership, participation in labour, and parenting quality. Healthcare expenditure Evidence from eight cluster-RCTs on healthcare expenditure was too inconsistent to be combined in a meta-analysis, but it suggested that UCTs may have increased the amount of money spent on health care at 7 to 36 months into the intervention (low-certainty evidence). Equity, harms and comparison with CCTs The effects of UCTs on health equity (or unfair and remedial health inequalities) were very uncertain. We did not identify any harms from UCTs. Three cluster-RCTs compared UCTs versus CCTs with regard to the likelihood of having used any health services or had any illness, or the level of dietary diversity, but evidence was limited to one study per outcome and was very uncertain for all three.

AUTHORS' CONCLUSIONS

This body of evidence suggests that unconditional cash transfers (UCTs) may not impact a summary measure of health service use in children and adults in LMICs. However, UCTs probably or may improve some health outcomes (i.e. the likelihood of having had any illness, the likelihood of having been food secure, and the level of dietary diversity), two social determinants of health (i.e. the likelihoods of attending school and being extremely poor), and healthcare expenditure. The evidence on the relative effectiveness of UCTs and CCTs remains very uncertain.

Association between a single mother family and childhood undervaccination, and mediating effect of household income: a nationwide, prospective birth cohort from the Japan Environment and Children's Study (JECS)

Background

Although childhood undervaccination among single mother families is a concern for child healthcare, their association is still under debate. This study aimed to investigate the association between maternal marital status and the risk of childhood undervaccination and determine the mediating effect of household income.

Methods

We utilised prospective birth cohort from the Japan Environment and Children’s Study (JECS). Of 104,062 foetal records (children) from 97,413 mothers, 82,462 that included mothers recruited between 2011 and 2014, were analysed. Childhood undervaccination was defined as not having been vaccinated with at least one routine vaccine. A log-binomial regression analysis was used to estimate the risk ratio (RR) for the association between maternal marital status and the risk of childhood undervaccination. A causal mediation analysis was further performed to investigate the proportion of the association mediated by household income.

Results

Among 82,462 children, 3188 and 79,274 had unmarried and married mothers, respectively. Childhood undervaccination was observed in 1053 (33.0%) and 16,901 (21.3%) children of unmarried and married mothers, respectively. Maternal marital status was associated with a higher risk of childhood undervaccination (adjusted risk ratio [aRR], 1.34; 95% confidence interval [CI], 1.27 to 1.41). Compared with married and older mothers, both unmarried and older (aRR, 1.54; 95% CI, 1.35 to 1.77) and unmarried and younger (aRR, 1.66; 95% CI, 1.54 to 1.79) mothers were associated with a higher risk of childhood undervaccination. The causal mediation analysis showed that the proportion mediated by household income was 10.5% (95% CI, 9.9 to 11.0%).

Conclusions

This nationwide, prospective, large-scale birth cohort study found that a household with a single mother was associated with an increased risk of childhood undervaccination, and 10% of this association was explained by household income. These findings underscore the importance of improving the social environment among single mother families, including not only poverty but also working conditions.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12889-022-12511-7.

Mental Health and Wealth: Depression, Gender, Poverty, and Parenting

Depression is a common and debilitating condition that adversely affects functioning and the capacity to work and establish economic stability. Women are disproportionately burdened by depression, and low-income pregnant and parenting women have particularly high rates of depression and often lack access to treatment. As depression can be treated, it is a modifiable risk factor for poor economic outcomes for women, and thus for children and families. Recent national and state health care policy changes offer the opportunity for community-based psychological and economic interventions that can reduce the number of pregnant and parenting women with clinically significant depressive symptoms. Moreover, there is strong evidence that in addition to benefiting women's well-being, such reforms bolster children's emotional and social development and learning and help families rise out of poverty. This review summarizes the mental health and economic literature regarding how maternal depression perpetuates intergenerational poverty and discusses recommendations regarding policies to treat maternal depression in large-scale social services systems.

Socioeconomic inequalities and adverse pregnancy outcomes in the UK and Republic of Ireland: a systematic review and meta-analysis

OBJECTIVE

There has been an unprecedented rise in infant mortality associated with deprivation in recent years in the United Kingdom (UK) and Republic of Ireland. A healthy pregnancy can have significant impacts on the life chances of children. The objective of this review was to understand the association between individual-level and household-level measures of socioeconomic status and adverse pregnancy outcomes.

DESIGN

Systematic review and meta-analysis.

DATA SOURCES

Nine databases were searched (Medline, Embase, Scopus, ASSIA, CINAHL, PsycINFO, BNI, MIDRIS and Google Scholar) for articles published between 1999 and August 2019. Grey literature searches were also assessed.

STUDY SELECTION CRITERIA

Studies reporting associations between individual-level or household socioeconomic factors on pregnancy outcomes in the UK or Ireland.

RESULTS

Among the 82 353 search results, 53 821 titles were identified and 35 unique studies met the eligibility criteria. Outcomes reported were neonatal, perinatal and maternal mortality, preterm birth, birth weight and mode of delivery. Pooled effect sizes were calculated using random-effects meta-analysis. There were significantly increased odds of women from lower levels of occupation/social classes compared with the highest level having stillbirth (OR 1.40, 95% CI 1.23 to 1.59, I²98.62%), neonatal mortality (OR 1.39, 95% CI 1.22 to 1.57, I²97.09%), perinatal mortality (OR 1.39, 95% CI 1.23 to 1.57, I²98.69%), preterm birth (OR 1.41, 95% CI 1.33 to 1.50, I²70.97%) and low birth weight (OR 1.40, 95% CI 1.19 to 1.61, I²99.85%). Limitations relate to available data, unmeasured confounders and the small number of studies for some outcomes.

CONCLUSIONS

This review identified consistent evidence that lower occupational status, especially manual occupations and unemployment, were significantly associated with increased risk of multiple adverse pregnancy outcomes. Strategies to improve pregnancy outcomes should incorporate approaches that address wider determinants of health to provide women and families with the best chances of having a healthy pregnancy and baby and to decrease pregnancy-related health inequalities in the general population.

PROSPERO REGISTRATION NUMBER

PROSPERO CRD42019140893.

Association of Work Requirements With Supplemental Nutrition Assistance Program Participation by Race/Ethnicity and Disability Status, 2013-2017

IMPORTANCE

Increased work requirements have been proposed throughout federal safety net programs, including the Supplemental Nutrition Assistance Program (SNAP). Participation in SNAP is associated with reduced food insecurity and improved health.

OBJECTIVES

To determine whether SNAP work requirements are associated with lower rates of program participation and to examine whether there are racial/ethnic disparities or spillover effects for people with disabilities, who are not intended to be affected by work requirements.

DESIGN, SETTING, AND PARTICIPANTS

This nationally representative, pooled cross-sectional study examined how changes in SNAP work requirements at state and local levels in the US are associated with changes in food voucher program participation. The study combined information on state and local SNAP work requirements with repeated cross-sections from the 2012 through 2017 American Community Survey (with outcomes covering 2013 to 2017). The analytical approaches were based on difference-in-difference and triple-difference methods, after controlling for other economic and social factors. The sample included low-income adults without dependents, stratified by racial/ethnic group and disability status. The study also included parents who would otherwise meet work requirement criteria as a comparison group to estimate triple-difference models. This accounted for otherwise unobserved factors affecting trends in SNAP participation within local areas. Data were analyzed from January 2019 through March 2020.

EXPOSURE

Residence in areas where SNAP work requirements apply.

MAIN OUTCOMES AND MEASURES

The primary outcome is SNAP participation measured by whether anyone in the household received food vouchers at any point over the prior 12 months.

RESULTS

The final analytical sample included 866 000 low-income adults (weighted mean [SE] age, 33.6 [0.01] years; 42.5% [SE, 0.07%] men). The racial/ethnic breakdown was 56.5% (SE, 0.07%) non-Hispanic white respondents, 19.4% (SE, 0.06%) non-Hispanic black respondents, 17.7% (SE, 0.06%) Hispanic respondents, 2.5% (SE, 0.02%) Asian respondents, and 3.9% (SE, 0.03%) respondents of other or multiple races. In final triple-difference models, work requirements were associated with a 4.0 percentage point decrease in participation (95% CI, -0.048 to -0.032; P < .001) for childless adults without disability, equivalent to a 21.2% reduction in SNAP participation (95% CI, -25.5% to -17.0%). For childless adults with disability, work requirements were associated with a 4.0 percentage point reduction (95% CI, -0.058 to -0.023; P < .001), equivalent to 7.8% fewer SNAP participants with disability (95% CI, -11.2% to -4.4%). When the final models were stratified by race/ethnicity, benefit reductions were larger for non-Hispanic black adults (7.2 percentage points; 95% CI, -0.092 to -0.051; P < .001) and Hispanic adults (5.5 percentage points; 95% CI, -0.072 to -0.038; P < .001) than for non-Hispanic white adults (2.6 percentage points; 95% CI, -0.035 to -0.016; P < .001).

CONCLUSIONS AND RELEVANCE

Because of the association of SNAP with food security and health, work requirements that lead to benefit loss may create nutritional and health harm for low-income Americans. These findings suggest that there may be racially disparate consequences and unintended harm for those with disability.

The Effects of SNAP Work Requirements in Reducing Participation and Benefits From 2013 to 2017

Objectives. To assess the effects of work requirements for able-bodied adults without dependents in the Supplemental Nutrition Assistance Program (SNAP).Methods. We used changes in waivers of work requirements to assess the impact of requiring work on the number of SNAP participants and benefit levels in 2410 US counties from 2013 to 2017 using 2-way fixed effects models.Results. Adoption of work requirements was followed by reductions of 3.0% in total SNAP participation, 4.5% in SNAP households, and 3.8% in SNAP benefit dollars, after controlling for the unemployment, poverty, and Medicaid expansions. Because able-bodied adults without dependents comprise 8% to 9% of all SNAP participants, our findings indicate that work requirements caused more than one third of able-bodied adults without dependents to lose benefits.Conclusions. Expansions of work requirements caused about 600 000 participants to lose SNAP benefits from 2013 to 2017 and caused a reduction of about $2.5 billion in federal SNAP benefits in 2017. The losses occurred rapidly, beginning a few months after work requirements were imposed.Public Health Implications. SNAP work requirements rapidly reduce caseloads and benefits, reducing food and health access. Effects on participation could be similar for work requirements in Medicaid or other programs.