The lack of supportive policies for families in the United States, such as paid parental leave, has serious implications for health equity, as it affects families’ overall health and financial stability, says a new report from the National Academies of Sciences, Engineering, and Medicine. Implementing paid family leave at the federal, state, or local levels could improve workforce participation, sustain household income, and in turn, promote children’s health and well-being, says the report. It also recommends improving financial stability, food security, and housing quality and safety to help families meet basic needs during the prenatal through early childhood periods.
Health equity is the notion that all people have the potential to live their healthiest life, regardless of race and ethnicity, zip code, or socio-economic status. People are exposed to different experiences and factors – which are often beyond their control – that shape their health throughout the life course. Those factors include the extent of family and social supports, economic and food security, access to highquality early care and education, stable and safe housing, and access to quality, affordable health care. However, the odds of good health or poor health are not set for life, and early intervention can help mitigate the effects of early life adversity, says Vibrant and Healthy Kids: Aligning Science, Practice, and Policy to Advance Health Equity.
When a parent or primary caregiver faces major life stressors – for example, homelessness or intimate partner violence – they are likely to experience severe psychological distress that interferes with successful parenting. Moving children in at-risk circumstances toward positive health trajectories requires a life-course, multigenerational approach, because the well-being of a child depends on the well-being of parents and caregivers, says the report.
“To achieve health equity – and reinforce it in our policies and practices – it is crucial to consider the connection between adverse childhood experiences, health, and resilience,” said Jennifer DeVoe, professor and chair of the family medicine department at Oregon Health & Science University, and chair of the study committee that wrote the report. “Investing in early childhood pays off later. It represents our best chance of breaking vicious generational cycles of inequities, and helping children become healthier adults.”
To advance health equity, the report provides a roadmap containing several recommendations, some of which can be implemented immediately. Others, however, will require a sustained, long-term commitment to dismantling systemic racism and discrimination in employment, education, health care, and other systems.
Intervene early. Chronic diseases are a large driver of U.S. health care expenditures, but only a small fraction of spending goes to prevention. The greater a child’s exposure to adversity (prenatally and in early childhood), the greater the risk of heart disease, mental illness, obesity, and other chronic conditions later in life. In most cases, early intervention is easier, less costly, and more effective, the report says. Furthermore, tailored, culturally sensitive interventions are needed for subgroups of children known to be vulnerable – such as children who are living in chronic poverty, children in foster care, children from immigrant backgrounds, and children with incarcerated parents.
Support the well-being of parents and primary caregivers. The single most important factor influencing a child’s healthy development is having safe, stable, and nurturing relationships with his or her parent or primary caregiver – typically, the child’s mother, the report says. Therefore, ensuring mothers have ongoing supports for maintaining good mental health and psychological well-being is critical. Health providers should routinely assess mothers’ depressive symptoms, stress, feelings of rejection toward the child, and the degree to which they have familial and social support. There are also many instances when fathers are the primary caregiver, and their unique needs require attention. To successfully advance health equity, fatherhood initiatives need to actively address institutionalized racism in employment, education, housing, health care, criminal justice, and other systems that keep many low-income fathers and men of color from achieving their potential.
Strengthen and expand evidence-based home-visiting programs. Evidence suggests that home visits by a nurse, a social worker, or an early educator during pregnancy and in the first years of a child’s life have several benefits. Home-visiting programs help promote maternal and child health, prevent child abuse and neglect, and foster positive parenting, child development, and school readiness. In 2017, 300,000 families received home-visiting services, although the National Home Visiting Research Center estimates that about 18 million additional families could qualify. The report recommends the expansion of effective home-visiting programs to reach more populations.
Ensure access to stable, affordable, and safe housing. Housing affordability and quality are acute problems that disproportionately affect communities of color. Over 50 percent of black and Hispanic renters live in unaffordable housing, and health issues related to poor-quality housing, such as elevated blood lead levels and asthma, are more prevalent among these renters. The secretary of the U.S. Department of Health and Human Services, in collaboration with the Department of Housing and Urban Development and other relevant agencies, should create a comprehensive plan to ensure access to stable, affordable, and safe housing in the prenatal through early childhood period, the report says.
Reduce barriers to food assistance and other economic benefits to meet families’ basic needs. When parents do not have to worry about their family’s next meal, their housing security, or whether they can afford household necessities, they can foster a less stressful home environment. The report identifies a number of resources that have the most evidence of advancing health equity through family supports, including increased SNAP benefits, increased housing assistance, and a basic income allowance for young children. Receipt of SNAP benefits should not be tied to parent employment for families with young children or for pregnant women, as such requirements could unintentionally exclude or reduce participation.
Maximize the impact of early care and education to promote health equity. Early care and education (ECE) programs, which serve children both formally and informally before kindergarten, can be a platform for advancing health equity. However, access to ECE programs remains low. The report calls for:
- allocating adequate resources to support ECE programs and educators;
- training the ECE workforce on recognizing and responding to the impact of trauma (trauma-informed care) and adversity;
- incorporating cultural sensitivity practices in ECE;
- improving the quality of ECE programs by adopting health-promoting standards and expanding access to comprehensive high-quality and affordable programs; and
- developing a comprehensive approach to school readiness that explicitly incorporates health outcomes and leverages ECE systems and programs, including home visiting.
Reform health care system services to promote healthy development. Advancing health equity will require ensuring ongoing access to care, improving the quality of care, improving the organization and financing of care, transforming the content of health care services, and holding providers accountable for addressing disparities. The health system should prioritize:
- transforming preconception, prenatal, postpartum, and pediatric care to focus on identifying and addressing adverse social determinants of health;
- integrating the delivery of physical, mental, and behavioral health services;
- promoting culturally and linguistically tailored outreach and services; and
- developing and implementing national measures to assess disparities in care and best practices to eliminate disparities.
Promote cross-sector collaboration. Policymakers and leaders in the health care, public health, social service, criminal justice, early care and education, and other sectors should align strategies and combine their expertise to advance health equity, the report says. In particular, these sectors should enhance detection of early-life adversity and trauma and improve response systems. The report also recommends these sectors align strategies to improve data sharing and integration.
The study — undertaken by the Committee on Applying Neurobiological and Socio-Behavioral Sciences from Prenatal through Early Childhood Development: A Health Equity Approach — was sponsored by the Robert Wood Johnson Foundation. The National Academies are private, nonprofit institutions that provide independent, objective analysis and advice to the nation to solve complex problems and inform public policy decisions related to science, technology, and medicine. They operate under an 1863 congressional charter to the National Academy of Sciences, signed by President Lincoln. For more information, visit nationalacademies.org.