The health of women in transition from welfare to employment

Maternal health, well-being, and employment transitions: A longitudinal comparison of partnered and single mothers in Germany

Balancing parenthood and employment can be challenging and distressing, particularly for single mothers. At the same time, transitioning to employment can improve the financial situations of single mothers and provide them with access to social networks, which can have beneficial effects on their health and well-being. Currently, however, it is not well understood whether the overall impact of employment on single mothers is positive or negative, and to what extent it differs from the impact of employment on partnered mothers. Building on the literature on work-family conflict, we investigate the differential effects of employment transitions on the health and well-being of single mothers and partnered mothers. Using longitudinal data from the German Socio-Economic Panel (1992-2016), we apply panel regression techniques that address the potential endogeneity of maternal employment, as well as the dynamic nature of the relationship between employment transitions and maternal health and well-being. We find that employment has a positive impact on single mothers, and that single mothers benefit from employment significantly more than partnered mothers. Surprisingly, income does not appear to be an important driver of these results. Overall, our findings suggest that employment plays a key role in the well-being of single mothers.

Economic solvency in the context of violence against women: a concept analysis

The aim of this concept analysis is to define economic solvency in the context of violence against women. Poverty, or lack of resources, is often discussed as a risk factor for intimate partner violence. The concept of economic solvency, which may be a protective factor for women, is less often discussed and not well defined. Databases searched for the analysis included EBSCOhost, CINAHL, PubMed and Gender Watch. The Rodgers evolutionary method was used to perform the concept analysis. A total of 134 articles were retrieved, using the specified search terms 'economic solvency and women', 'economic self-reliance and women' and 'economic self-sufficiency and women'. Articles were included if they were peer reviewed, contained the keywords with sufficient context to determine the author's intended meaning, and focused on women only or contrasted men to women. Thirty-five articles were used in the concept analysis. The definition of economic solvency drawn from the concept analysis is: a long-term state that occurs when there is societal structure that supports gender equity and external resources are available and can be used by a woman who has necessary human capital, sustainable employment and independence. Just as poverty and violence are cyclical, so are economic solvency and empowerment of women. To decrease women's risk of intimate partner violence around the world and further improve the status of women, we recommend continued research on economic solvency, including the individual, family, community and societal resources required to obtain economic solvency and the human capital characteristics needed for sustainability.

In-work tax credits for families and their impact on health status in adults

BACKGROUND

By improving two social determinants of health (poverty and unemployment) in low- and middle-income families on or at risk of welfare, in-work tax credit for families (IWTC) interventions could impact health status and outcomes in adults.

OBJECTIVES

To assess the effects of IWTCs on health outcomes in working-age adults (18 to 64 years).

SEARCH METHODS

We searched 16 electronic academic databases, including the Cochrane Public Health Group Specialised Register, Cochrane Database of Systematic Reviews (The Cochrane Library 2012, Issue 7), MEDLINE and EMBASE, as well as six grey literature databases between July and September 2012 for records published between January 1980 and July 2012. We also searched key organisational websites, handsearched reference lists of included records and relevant journals, and contacted academic experts.

SELECTION CRITERIA

We included randomised and quasi-randomised controlled trials and cohort, controlled before-and-after (CBA) and interrupted time series (ITS) studies of IWTCs in working-age adults. Included primary outcomes were: self rated general health; mental health/psychological distress; mental illness; overweight/obesity; alcohol use and tobacco use.

DATA COLLECTION AND ANALYSIS

Two review authors independently extracted data and assessed the risk of bias in included studies. We contacted study authors to obtain missing information.

MAIN RESULTS

Five studies (one CBA and four ITS) comprising a total of 5,677,383 participants (all women) fulfilled the inclusion criteria and were synthesised narratively. The in-work tax credit intervention assessed in all included studies is the permanent Earned Income Tax Credit in the United States, established in 1975. This intervention distributed nearly USD 62 billion to over 27 million individuals in 2011, and its administration costs were less than one per cent of its total costs. All included studies carried a high risk of bias (especially from confounding and insufficient control for underlying time trends). Due to the small number of (observational) studies and their high risk of bias, we judged this body of evidence to have very low overall quality.One study found that IWTC had no detectable effect on self rated general health and mental health/psychological distress five years after its implementation (i.e. a considerable change in the generosity of the permanent IWTC) and on overweight/obesity eight years after implementation. One study found no effect of IWTC on tobacco use five years after implementation, one a moderate reduction in tobacco use one year after implementation (odds ratio 0.95, 95% confidence interval (CI) 0.94 to 0.96), and one differential effects, with no effect in African-Americans and a large reduction in European-Americans two years after implementation (risk difference -11.1%, 95% CI -20.9% to -1.3%). No evidence was available for the effect of IWTC on mental illness and alcohol use. No adverse effects of IWTC were identified.One study also found no detectable effect of IWTC on the number of bad physical health days and of risky biomarkers for inflammation, cardiovascular disease and metabolic conditions eight years after implementation. One study found that IWTC had a large, positive effect on income from wages or salaries one year after implementation. Two studies found no effect on employment two and five years after implementation, whereas two found a moderate increase five and eight years after implementation and one a large increase in employment due to IWTC one year after implementation.No differences in outcomes between groups with different educational status were found for self rated health and mental health/psychological distress. In one study European-American women with lower levels of education were more likely to reduce tobacco use, while tobacco use did not change among African-American women with lower levels of education. However, no differences in tobacco use by educational status were observed in a second study. Two studies found that the intervention may have reduced inequity with respect to employment, where women with less education were more likely to move into employment (although one did not establish whether this difference was statistically significant), while two studies found no such difference and no studies found differences by ethnic group on employment rates.

AUTHORS' CONCLUSIONS

In summary, the small and methodologically limited existing body of evidence with a high risk of bias provides no evidence for an effect of in-work tax credit for families interventions on health status (except for mixed evidence for tobacco smoking) in adults.

Ghana's National Health Insurance Scheme in the context of the health MDGs: an empirical evaluation using propensity score matching

In 2003 the Government of Ghana established a National Health Insurance Scheme (NHIS) to improve health-care access for Ghanaians and eventually replace the cash-and-carry system. This study evaluates an important aspect of its promise in the context of the Millennium Development Goals #4 and #5 which deal with the health of women and children. We use Propensity Score Matching techniques to balance the relevant background characteristics in our survey data and compare health indicators of recent mothers who are enrolled in the NHIS with those who are not. Our findings suggest that NHIS women are more likely to receive prenatal care, deliver at a hospital, have their deliveries attended by trained health professionals, and experience less birth complications. We conclude that NHIS is an effective tool for improving health outcomes among those who are covered, which should encourage the Ghanaian government to promote further enrollment, in particular among the poor.

Impoverished women with children and no welfare benefits: the urgency of researching failures of the Temporary Assistance for Needy Families program

In the United States, the numbers of impoverished women with children and no cash safety net are increasing and constitute an emerging population. Many have exhausted cash benefits from Temporary Assistance for Needy Families, the work-based welfare program that replaced Aid to Families With Dependent Children in 1996. We examine empirical evidence about poverty and use of welfare programs in the United States, jobs for women on welfare, the consequences of leaving welfare, health disparities disproportionate to those of the general population, and outcomes for children of needy families. It is important that public health researchers investigate the experiences of the families for whom Temporary Assistance for Needy Families has failed.

Developing a health screening questionnaire for women in welfare transition programs in the United States

Women in United States Welfare Transition Programs (WTPs) have high rates of chronic health problems that might present significant barriers to obtaining and/or maintaining employment. Inadequate, standardized health screening in WTPs across the United States contributes to the problem of achieving self-sufficiency for disadvantaged women. Using community-based participatory research as a framework, the study's purpose was to develop a culturally relevant and sensitive health screening questionnaire that would be acceptable for use with women enrolled in WTPs. Three rounds of focus groups (n = 10) were conducted with a total of 61 women. Analysis of focus group interviews revealed not only content areas identified as important to health, but critical process issues involved in administering the tool. The distinction between process and content was a critical finding because it stressed the importance of not only what women were asked, but how, when, and by whom they were asked.

Health Risk Characteristics of Black Female Informal Caregivers on Welfare

This exploratory study examines differences in health risk characteristics and perceived health by caregiver status in two groups of Black women, 37 informal caregivers and 20 noncaregivers, transitioning from welfare to work. Health risk characteristics were assessed with the Center for Epidemiologic Studies Depression Scale and Healthier People Network Health Risk Appraisal—Version 6. Body mass index (BMI) calculations were based on the standard Centers for Disease Control formula. Perceived health status was assessed using a single-item Cantril ladder. Results show no statistically significant between-group differences in perceived health status, depressive symptoms, frequency of lifestyle behaviors, or BMI. Clinically significant proportions of participants in both groups rated their health as poor or fair; reported mild to severe depressive symptoms; smoked cigarettes; did not perform monthly self-breast exams; were physically inactive, overweight, or obese; and consumed high-fat diets. Black women receiving welfare show increased risk for premature chronic health problems, which warrants development of effective community-based risk-reduction programs.

Psychosocial and physiological stress among women leaving welfare

Women receiving Temporary Assistance for Needy Families (TANF) report more stress and have poorer health than women in the general population. Studies suggest chronic stress may contribute to poor health via physiological mechanisms, yet little is known about these mechanisms in this population. This study examined psychosocial stress, salivary cortisol, 24-hr ambulatory blood pressure and heart rate, and health among 40 single mothers before and after exiting TANF. As a group, perceived stress decreased after leaving TANF (p = .02), with other measures of psychosocial and physiological stress remaining unchanged. Within participants, changes in psychosocial stress predicted depression and general health over time (adjusted R(2) = .30 and .22; p = .006 and .004, respectively). These findings indicate psychosocial stress is positively associated with depression and negatively associated with general health as women exit welfare. Psychosocial stress was not associated with changes in physiologic indicators of stress.

Women who did not succeed in the work-based welfare program

Welfare reform, enacted more than 5 years ago, created dramatic changes in the lives of single mothers living in poverty. The purpose of this study was to describe the lives of women who were unable to sustain involvement with work-based welfare. A multimethodological design and snowball sampling were used to gather qualitative and quantitative data from 31 urban women. Instruments were a demographic form, an interview guide, and the General Well-Being Schedule from the U.S. Health and Nutrition Examination Survey. Interviews were taped, transcribed, and entered into software to facilitate analysis. Thematic coding and narrative analysis were done. The study population had higher levels of severe and moderate distress than the reference standards for the general population. Barriers within the Temporary Assistance for Needy Families (TANF) system and personal barriers were identified by the women. Policy changes that address these obstacles would serve as blueprints for achieving the Healthy People 2010 goals for the nation.

Intimate partner violence, welfare receipt, and health status of low-income african american women: a lifecourse analysis

Although the association among intimate partner violence (IPV), welfare receipt, and health status has been well-established, little is known about the temporal sequencing of these events. In a random sample of low-income African American women in an urban Midwestern county, lifecourse data about IPV and welfare receipt were obtained using the Life History Calendar method (D. Freedman, A. Thornton, D. Camburn, D. Alwin, & L. Young-DeMarco, 1988), along with data about mental and physical health status. Controlling for relevant factors, longitudinal analyses found that previous experience of IPV increased women's odds of receiving welfare benefits in a given year, but previous welfare receipt did not. Cumulative IPV, but not cumulative welfare receipt, was associated with current and past-year health problems. These findings are consistent with the hypothesis that IPV leads women to turn to welfare assistance, and that compromised physical and mental health due to past cumulative IPV interferes with women's gainful employment.

Problems with parsimony in research on socioeconomic determinants of health

Despite growing evidence that social and economic factors are important determinants of health disparities, there is a lack of understanding of how these factors operate in relation to health. This article explores 3 conceptual and methodological issues impeding nursing research in this area: (1) ambiguity surrounding socioeconomic status (SES), both conceptually and as a scientific indicator; (2) the narrow focus on biological and behavioral risks for chronic disease development; and (3) the persistent centrality of individual behavior in studies examining SES-health contextual relationships. A brief overview of emerging approaches for enhancing nursing science in the area of SES and health disparities is presented.

Handling missing data in nursing research with multiple imputation

BACKGROUND

In the data analysis phase of research, missing values present a challenge to nurse investigators. Common approaches for addressing missing data generally include complete-case analysis, available-case analysis, and single-value imputation methods. These methods have been the subject of increasing criticism with respect to their tendency to underestimate standard errors, overstate statistical significance, and introduce bias.

OBJECTIVES

This article reviews the limitations of standard approaches for handling missing data, and suggests multiple imputation is a useful method for nursing research.

METHOD

Secondary analysis was conducted to examine the effect of a public policy on the health of women using a data set that had a large degree and complex patterns of missing data.

DISCUSSION

In the example, accommodation of the incomplete data was critical to making valid inferences; however, complete-case, available-case, or single imputation could not be defended as an adequate method for dealing with the missing data patterns. Alternative methods for dealing with incomplete data were sought, and a multiple imputation approach was selected given the missing data pattern. Nurse researchers confronting similar complex patterns of missing data may find multiple imputation a useful procedure for conducting data analysis and avoiding the bias associated with other methods of handling missing data.