The POST Cover Story: Health Risks in Hiding
What if, somehow, you could see the number of calories a child burns as she runs from a slide to a swing in her local playground — or the number of calories she never consumed due to the new food policies in her school? What if you could see how the stress from her father’s mental illness is affecting her growing brain or how important her mother’s unemployment benefits were a year ago in ensuring she went to her last doctor’s visit?
Increasingly, scientists are engaged in research that examines the invisible connections between health and life as a whole, raising new questions about how lifestyle, environments and health intersect and alter one another. This growing field of inquiry, often referred to as the social determinants of health, examines how the broad social contexts in which people live impact their health and vice versa.
Specifically, scientists are examining how people operate within a web of factors that promote and impede health — directly and indirectly. For instance, paychecks, playgrounds and policies all play a role in crafting people’s lived experiences, affecting where they live, how many calories they burn, how fast they drive and how stressed they are. These factors impact their health, the health of their families and ultimately their communities’ health. The first key lies in knowing precisely how and why individual factors play the role they do. The next step is designing effective ways to address these factors through changes to people’s environments.
“This is a new and rapidly changing field, so in many ways we have more questions than answers right now, but that’s part of what makes it exciting,” says Betsy Shenkman, Ph.D., the chair of the department of health outcomes and policy and the director of the Institute for Child Health Policy. “We are moving beyond looking at health in isolation and are looking at health and well-being in its larger contexts, which demands innovative research methods that account for the multiple factors that impact people’s lives.”
Both the World Health Organization and Healthy People 2020, a document that sets a 10-year agenda for improving the health of Americans, have emphasized creating social and physical environments that promote good health as major objectives in recent years. This movement grows out of the fact that scientists have uncovered more connections between people’s environment — including their economic stability, their government’s policies, their education, their neighborhood and their social connections — and their health.
“It has also become increasingly clear that it is not enough to receive excellent health care,” says Shenkman, who conducts research that aims to improve the health of children and adults receiving Medicaid who have both physical and mental illness. “Instead, the field is recognizing that better health starts in families and communities — in people’s environments — and only by making progress on both fronts can we address health disparities across income and race.”
Faculty members in the Institute for Child Health Policy are tackling two research projects that aim to address both sides of that equation. One examines the effect of laws unrelated to health, such as minimum wage and unemployment benefits, on low-income families, and the other seeks to address periods of extreme stress in low-income pediatric patients to prevent their childhood trauma from affecting their mental and physical health into adulthood.
When many people think of what it means to be healthy, they often envision things like blood pressure cuffs, pedometers or calorie counters, not legislative bills or tax codes. However, policy experts at UF’s Institute for Child Health Policy and law scholars at Temple University are pioneering new methods to understand how economic policies — such as tax credits, minimum wage laws and unemployment compensation — affect the health and health behaviors of low-income families.
“Many of these policies directly affect children of families who are struggling financially,” says Kelli A. Komro, Ph.D., a professor in the College of Medicine and associate director of the Institute for Child Health Policy. “The importance of those early years for children’s long-term health into adulthood cannot be overstated, which underscores the importance of conducting rigorous analysis to see which social policies improve the health of families.”
In the United States, about 22 percent of children live below the federal poverty line and 45 percent come from low-income families, increasing their risk for many health problems. In 2012, the federal earned income tax credit lifted 6.5 million people, including 3.3 million children, above the poverty line. In broad brushstrokes, this change in economic status impacts the environment in which children grow up, potentially altering their exposure to health risks and increasing the likelihood of exposure to conditions that promote health, such as high-quality schools and healthy food.
In the past, researchers have attempted to determine the effect of these types of policies on health. In contrast, this team picks apart policies, painstakingly coding individual aspects of laws across all 50 states for the past 35 years. This process allows researchers to compare policies in different states and across time to see what measures are most effective in improving health. These data will be made available on LawAtlas.org as part of an effort to spur additional research by the Public Health Law Research Program, funded by the Robert Wood Johnson Foundation.
For example, the researchers are examining unemployment compensation laws by noting the maximum weekly benefit, how the benefit was calculated, the maximum benefit duration and the base period of eligibility. The team is currently analyzing the data to see which aspects of which laws impacted various health indicators.
In a recent article published in the journal Health Behavior and Policy Review, Komro and her co-authors called for the field to adopt a “bird-by-bird” approach to public health law research, not becoming overwhelmed by the tremendous amount of data but instead breaking down the complex web of factors that affect health and testing research questions.
“Working side by side with legal scholars, we are crafting new methods for identifying which policies work and which policies do not,” says Alexander Wagenaar, Ph.D., a professor of health outcomes and policy and a faculty member with the Institute for Child Health Policy. “Knowing what works, at a precise level, is the first step toward systematically putting into place policies that will challenge the status quo and engender lasting improvement in the culture of health in America.”
In addition to examining the impact of big-picture aspects of people’s lives, such as state policies and laws, faculty members at the Institute for Child Health Policy are finding out more about how life experiences — especially traumatic events — can affect children’s health into adulthood.
Melissa Bright, Ph.D., an Institute for Child Health Policy faculty member, and Lindsay Thompson, M.D., M.S., an associate professor of pediatrics, are leading an effort to discover how abuse, neglect and household dysfunction, such as domestic violence and parent mental illness, impact children’s health and what pediatricians can do about it.
Last year, Bright presented findings showing that children who experience three or more stressful events are six times more likely to suffer from a mental, physical or learning disorder than children who did not face these traumatic experiences. By linking data about one aspect of a person’s life with another aspect, the interdisciplinary team discovered novel insights into how children’s experiences connect with their health.
“The kids who have the highest number of adverse experiences have the highest likelihood of having multiple conditions,” says Bright, who believes the culprit could be toxic stress, a chronic state that can change children’s developing neurological and immune systems. “It is not one poor health outcome; it is a whole slew of poor outcomes across the board.”
Although the study showed that adverse experiences are linked to an increased risk for various health conditions, the researchers do not yet know if those experiences cause the conditions to occur, Bright said.
“It is also possible that having a child with multiple health conditions puts serious financial and emotional strains on families, making them more susceptible to adverse experiences such as caregiver mental illness and divorce,” she said.”
This line of inquiry acknowledges how health is interconnected with several facets of people’s lives, creating a web of causes and effects that are just beginning to be explored. However, the research team’s main focus is on implementing a way for pediatricians to collect information about adverse experiences that could affect children’s health in an effort to prevent long-term effects.
Three years ago, the American Academy of Pediatrics released a policy statement recommending that pediatricians screen for these types of adverse experiences. However, Bright has conducted research revealing that although doctors believe they should be asking caregivers and children about adverse events, many are not. Her team plans to design a project with funds from the Institute for Child Health Policy and the department of pediatrics that will explore the barriers that prevent and impede pediatricians from screening. For instance, pediatricians may be reluctant to discuss such sensitive issues with parents, especially if they feel it is outside their training or that they do not have the resources or ability to help.
“Several anecdotes from practicing clinicians indicate time is also a huge issue in asking these additional questions,” Bright says. “Preventing the most severe long-term effects of these adverse experiences cannot fall entirely to clinicians. We have to tackle this issue holistically, working with families, physicians, law enforcement, teachers and policymakers to discover the root causes and take steps to protect these children.”
While the workgroup is at the beginning stages of their efforts, their ultimate goal is to create a screening mechanism that would allow pediatricians to efficiently and effectively inquire about potential effects from trauma and difficult environments and take steps to address it before it affects children’s health in adulthood.
“This is a long-term but worthwhile process,” says Thompson, who also serves as the associate director of clinical research for the Institute for Child Health Policy. “Helping pediatricians find ways to detect trauma and prevent its effects is crucial for protecting vulnerable children and giving them the best possible start in life.”
For more on one of these projects, which examines the effects of alcohol taxes, view this story http://post.health.ufl.edu/2015/04/20/discovering-the-impact-of-alcohol-taxes/.