Advertisement

Associations Between Housing Instability and Food Insecurity With Health Care Access in Low-Income Children

  • Christine T. Ma
    Affiliations
    From the Department of Pediatrics (Dr Ma), Division of General Internal Medicine (Ms Gee and Dr Kushel), University of California, San Francisco, San Francisco General Hospital, San Francisco, Calif
    Search for articles by this author
  • Lauren Gee
    Affiliations
    From the Department of Pediatrics (Dr Ma), Division of General Internal Medicine (Ms Gee and Dr Kushel), University of California, San Francisco, San Francisco General Hospital, San Francisco, Calif
    Search for articles by this author
  • Margot B. Kushel
    Correspondence
    Address correspondence to Margot Kushel, MD, University of California, San Francisco, Box 1364, San Francisco, California 94143-1364.
    Affiliations
    From the Department of Pediatrics (Dr Ma), Division of General Internal Medicine (Ms Gee and Dr Kushel), University of California, San Francisco, San Francisco General Hospital, San Francisco, Calif
    Search for articles by this author

      Objective

      Homelessness and hunger are associated with poor health care access among children. Housing instability and food insecurity represent milder and more prevalent forms of homelessness and hunger. The aim of this study was to determine the association between housing instability and food insecurity with children's health care access and acute health care utilization.

      Methods

      We conducted a cross-sectional analysis of 12 746 children from low-income households included in the 2002 National Survey of America's Families (NSAF). In multivariate models controlling for important covariates, we measured the association between housing instability and food insecurity with 3 health care access measures: 1) no usual source of care, 2) postponed medical care, and 3) postponed medications. We also measured 3 health care utilization measures: 1) not receiving the recommended number of well-child care visits, 2) increased emergency department visits, and 3) hospitalizations.

      Results

      Our analysis showed that 29.5% of low-income children lived in households with housing instability and 39.0% with food insecurity. In multivariate logistic regression models, housing instability was independently associated with postponed medical care, postponed medications, and increased emergency department visits. Food insecurity was independently associated with no usual source of care, postponed medical care, postponed medications, and not receiving the recommended well-child care visits.

      Conclusion

      Families that experience housing instability and food insecurity, without necessarily experiencing homelessness or hunger, have compromised ability to receive adequate health care for their children. Policy makers should consider improving programs that decrease housing instability and food insecurity, and clinicians should consider screening for housing instability and food insecurity so as to provide comprehensive care.

      Key Words

      To read this article in full you will need to make a payment

      Purchase one-time access:

      Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online access
      One-time access price info
      • For academic or personal research use, select 'Academic and Personal'
      • For corporate R&D use, select 'Corporate R&D Professionals'

      Subscribe:

      Subscribe to Academic Pediatrics
      Already a print subscriber? Claim online access
      Already an online subscriber? Sign in
      Institutional Access: Sign in to ScienceDirect

      References

      1. The Urban Institute. A New Look at Homelessness in America. Urban Institute. Available at: http://www.urban.org/url.cfm?ID=900302. Accessed February 7, 2007.

        • Burt M.
        • Aran L.
        • Douglas T.
        • Valente J.
        • Lee E.
        • Iwen B.
        Homelessness: Programs and the People they Serve: Findings from the National Survey of Homeless Assistance Providers and Clients, Technical Report.
        The Urban Institute, Washington, DC1999
        • Miller D.S.
        • Lin E.H.
        Children in sheltered homeless families: reported health status and use of health services.
        Pediatrics. May 1988; 81: 668-673
        • Roth L.
        • Fox E.R.
        Children of homeless families: health status and access to health care.
        J Community Health. 1990; 15: 275-284
        • Wood D.
        • Valdez R.B.
        Barriers to medical care for homeless families compared with housed poor families.
        Am J Dis Child. 1991; 145: 1109-1115
        • Orenstein J.B.
        • Boenning D.A.
        • Engh E.P.
        • Zimmerman S.J.
        Emergency care of children in shelters.
        Pediatr Emerg Care. 1992; 8: 313-317
        • Weinreb L.
        • Goldberg R.
        • Bassuk E.
        • Perloff J.
        Determinants of health and service use patterns in homeless and low-income housed children.
        Pediatrics. 1998; 102: 554-562
        • Alperstein G.
        • Rappaport C.
        • Flanigan J.M.
        Health problems of homeless children in New York City.
        Am J Public Health. 1988; 78: 1232-1233
        • Nord M.
        • Andrews M.
        • Carlson S.
        Household Food Security in the United States, 2005.
        United States Department of Agriculture: Economic Research Service, Washington, DC2006 (Report number 29)
        • McIntyre L.
        • Connor S.K.
        • Warren J.
        Child hunger in Canada: results of the 1994 National Longitudinal Survey of Children and Youth.
        CMAJ. 2000; 163: 961-965
        • Alaimo K.
        • Olson C.M.
        • Frongillo Jr., E.A.
        • Briefel R.R.
        Food insufficiency, family income, and health in US preschool and school-aged children.
        Am J Public Health. 2001; 91: 781-786
        • Weinreb L.
        • Wehler C.
        • Perloff J.
        • et al.
        Hunger: its impact on children's health and mental health.
        Pediatrics. 2002; 110: e41
        • Gilman S.E.
        • Kawachi I.
        • Fitzmaurice G.M.
        • Buka L.
        Socio-economic status, family disruption and residential stability in childhood: relation to onset, recurrence and remission of major depression.
        Psychol Med. 2003; 33: 1341-1355
        • Kushel M.B.
        • Gupta R.
        • Gee L.
        • Haas J.S.
        Housing instability and food insecurity as barriers to health care among low-income Americans.
        J Gen Intern Med. 2006; 21: 71-77
      2. U.S. Department of Urban Housing and Development. Affordable Housing Needs: A Report to Congress on the Significant Need for Housing.
        U.S. Department of Urban Housing and Development, Washington, DC2003
        • Phinney R.
        • Danziger S.
        • Pollack H.A.
        • Seefeldt K.
        Housing instability among current and former welfare recipients.
        Am J Public Health. 2007; 97: 832-837
        • Anderson S.A.
        Core indicators of nutritional state for difficult-to-sample populations.
        J Nutr. 1990; 120: 1559-1600
        • Cook J.T.
        • Frank D.A.
        • Levenson S.M.
        • et al.
        Child food insecurity increases risks posed by household food insecurity to young children's health.
        J Nutr. 2006; 136: 1073-1076
        • Siefert K.
        • Heflin C.M.
        • Corcoran M.E.
        • Williams D.R.
        Food insufficiency and physical and mental health in a longitudinal survey of welfare recipients.
        J Health Soc Behav. 2004; 45: 171-186
        • Vozoris N.T.
        • Tarasuk V.S.
        Household food insufficiency is associated with poorer health.
        J Nutr. 2003; 133: 120-126
      3. National Survey of America's Families. Public Use Datasets: Family Respondent, Round 3 2002. Available at: http://anfdata.urban.org/nsaf/cpuf/accessdata.cfm. Accessed July 31, 2006.

        • Brick J.M.
        • Ferraro D.
        • Strickler T.
        • Liu B.
        National Survey of America's Families: 2002 Sample Design. Methodology Report No. 2.
        The Urban Institute, Washington, DC2003
        • Brick J.
        • Ferraro D.
        • Strickler T.
        • et al.
        National Survey of America's Families: 2002 Weighting Procedures. Methodology Report No. 3.
        The Urban Institute, Washington, DC2004
        • Recommendations for preventive pediatric health care
        American Academy of Pediatrics Committee on Practice and Ambulatory Medicine.
        Pediatrics. 2000; 105: 645-646
      4. National Association for the Education of Homeless Children and Youth, National Health Care for the Homeless Council, National Policy and Advocacy Council on Homelessness, Volunteers of America. Questions and Answers About Expanding HUD's Definition of Homelessness. Available at: http://www.npach.org/deffaqFINAL.pdf. Accessed May 17, 2007.

        • Gelberg L.
        • Andersen R.M.
        • Leake B.D.
        The Behavioral Model for Vulnerable Populations: application to medical care use and outcomes for homeless people.
        Health Serv Res. 2000; 34: 1273-1302
        • Selden T.M.
        • Hudson J.L.
        Access to care and utilization among children: estimating the effects of public and private coverage.
        Med Care. 2006; 44: I19-I26
        • Stevens G.D.
        • Seid M.
        • Mistry R.
        • Halfon N.
        Disparities in primary care for vulnerable children: the influence of multiple risk factors.
        Health Serv Res. 2006; 41: 507-531
        • Cunningham W.E.
        • Andersen R.M.
        • Katz M.H.
        • et al.
        The impact of competing subsistence needs and barriers on access to medical care for persons with human immunodeficiency virus receiving care in the United States.
        Med Care. 1999; 37: 1270-1281
        • Gelberg L.
        • Gallagher T.C.
        • Andersen R.M.
        • Koegel P.
        Competing priorities as a barrier to medical care among homeless adults in Los Angeles.
        Am J Public Health. 1997; 87: 217-220
        • Riportella-Muller R.
        • Selby-Harrington M.L.
        • Richardson L.A.
        • Donat P.L.
        • Luchok K.J.
        • Quade D.
        Barriers to the use of preventive health care services for children.
        Public Health Rep. 1996; 111: 71-77
        • Whitaker R.C.
        • Phillips S.M.
        • Orzol S.M.
        Food insecurity and the risks of depression and anxiety in mothers and behavior problems in their preschool-aged children.
        Pediatrics. 2006; 118: e859-e868
        • Casey P.
        • Goolsby S.
        • Berkowitz C.
        • et al.
        Maternal depression, changing public assistance, food security, and child health status.
        Pediatrics. 2004; 113: 298-304
        • Shinn M.
        • Weitzman B.C.
        • Stojanovic D.
        • et al.
        Predictors of homelessness among families in New York City: from shelter request to housing stability.
        Am J Public Health. 1998; 88: 1651-1657
        • Himmelgreen D.A.
        • Perez-Escamilla R.
        • Segura-Millan S.
        • et al.
        A comparison of the nutritional status and food security of drug-using and non-drug-using Hispanic women in Hartford, Connecticut.
        Am J Phys Anthropol. 1998; 107: 351-361
        • Bassuk E.L.
        • Buckner J.C.
        • Weinreb L.F.
        • et al.
        Homelessness in female-headed families: childhood and adult risk and protective factors.
        Am J Public Health. 1997; 87: 241-248
        • Skalicky A.
        • Meyers A.F.
        • Adams W.G.
        • et al.
        Child food insecurity and iron deficiency anemia in low-income infants and toddlers in the United States.
        Matern Child Health J. 2006; 10: 177-185
        • Rauh V.A.
        • Chew G.R.
        • Garfinkel R.S.
        Deteriorated housing contributes to high cockroach allergen levels in inner-city households.
        Environ Health Perspect. 2002; 110: 323-327
        • Seifert R.W.
        • Rukavina M.
        Bankruptcy is the tip of a medical-debt iceberg.
        Health Aff (Millwood). 2006; 25: w89-w92
        • Xu K.
        • Evans D.B.
        • Kawabata K.
        • et al.
        Household catastrophic health expenditure: a multicountry analysis.
        Lancet. 2003; 362: 111-117
        • Keenan D.P.
        • Olson C.
        • Hersey J.C.
        • Parmer S.M.
        Measures of food insecurity/security.
        J Nutr Educ. 2001; 33: S49-S58
        • Nord M.
        • Andrews M.
        • Carlson S.
        Household Food Security in the United States, 2002.
        United States Department of Agriculture: Economic Research Service, Washington, DC2003 (Report number 35)
        • Carlson S.J.
        • Andrews M.S.
        • Bickel G.W.
        Measuring food insecurity and hunger in the United States: development of a national benchmark measure and prevalence estimates.
        J Nutr. 1999; 129: 510S-516S
        • Nelson K.
        • Brown M.E.
        • Lurie N.
        Hunger in an adult patient population.
        JAMA. 1998; 279: 1211-1214