Profiles of Risk: Maternal Health and Well-being

January/FebruaryFebruary 2012 2012 Research Brief No. 6

This ICPH research brief is the sixth in a series that highlights the characteristics of families with young children who become homeless in the urban United States. The series explores in the context of housing status and puts a spotlight on the characteristics that make families who experience different from otherwise similar poor families who consistently maintain stable housing. The current brief builds on the fifth in this series, “Profiles of Risk: Sources of Income,” and examines maternal health and well-being.

Physical and Mental Health of mothers who were ever at risk of homelessness reported Disparities in health are important due to the direct associa- good health (28%). Ever-homeless and ever-at-risk mothers tion between health, personal welfare, and financial stability. also experienced depression at significantly higher rates (28% This brief uses data from the Fragile Families and Child Well- and 27%, respectively) than stably housed mothers (9%). being Study (FFCWS), a national survey that followed nearly 5,000 families for five years after the birth of a focal child (see While stably housed mothers who were single at the base- description on back). Figure 1 presents poor mothers’ average line experienced worse health compared to all stably housed self-reported physical and mental health by housing status— mothers, remaining single (e.g. not marrying or cohabiting) ever homeless or doubled up, ever at risk of homelessness, or is associated with better outcomes for mothers at risk of always stably housed—over the five-year period between the homelessness; at-risk women who were single at the baseline focal child’s first to fifth birthdays. reported higher rates of good physical health (36% vs. 28%) and lower rates of depression (23% vs. 27%) than those who Among all poor women, those who were stably housed re- were married or cohabiting. Physical and mental health did ported better physical and mental health than ever-homeless not vary significantly by relationship status for mothers who or ever-at-risk women.1 Mothers who ever experienced home- were ever homeless; such women experienced poor physical lessness reported having good physical health at half the rate health and high rates of depression regardless of their rela- of stably housed women (20% vs. 41%); less than one-third tionships. Disadvantaged women experience physical and

Figure 1 SELF-REPORTED HEALTH AND DEPRESSION YEARS 1–5 (by housing status years 1–5 and relationship status at baseline)

All poor mothers Poor mothers single at baseline

Good Physical Health Depressed

Ever homeless or doubled up 20% 28% (n = 716; n = 425) 20% 28%

Ever at risk of homelessness 28% 27% (n = 795; n = 409) 36% 23%

Always stably housed 41% 9% (n = 325; n = 142) 23% 10%

Source: ICPH analysis of Fragile Families and Child Wellbeing data. n = 1,836. Excluded are mothers who did not participate in the year-five survey, do not live with the focal child at least half of the time at year five, do not have valid sample weights, or report an average (baseline to year five) income-to-poverty ratio greater than 1.25. Differences in self-reported physical health are statistically significant at 10% for always stably housed vs. ever-homeless or ever-at-risk women. Differences in rates of depression are statistically significant at 10% for all groups. page 2

mental health challenges at greater rates than their non-poor reported illegal drug use at nearly three times the rate of stably counterparts. Such limitations contribute to employment insta- housed mothers (8% vs. 3%). Rates of drug use did not differ bility and financial insecurity (see “In Context: Poverty, Health, significantly by relationship status for stably housed or ever-home- and Employment,” below). less women. However, as with physical and mental health, mothers at risk of homelessness who remained single reported Drug Use higher rates of well-being than those who married or cohabited. There are also clear differences in rates of illegal drug use be- tween poor women who maintain housing stability and those The association between illegal drug use and housing instabil- who experience unstable housing.2 Figure 2 shows that moth- ity is well established; drug use both perpetuates homelessness ers who experienced homelessness between years one and five by depleting economic and social resources and results from the reported using illegal drugs during that period at almost four stress and strain associated with housing instability.3 Chronic times the rate of poor women who maintained stable housing drug users work and earn less than those who do not use drugs.4 (11% vs. 3%); women who were ever at risk of homelessness Additionally, mental health problems and experiences with domes- tic violence have been found to co-occur with substance abuse, suggesting that drug use is one of many interconnected barriers Figure 2 faced by homeless and at-risk poor mothers.5 ILLEGAL DRUG USE YEARS 1–5 (by housing status years 1–5 and relationship status at baseline)

All poor mothers Poor mothers single at baseline

11% 11%

8% Source: ICPH analysis of Fragile 6% Families and Child Wellbeing data. n = 1,836. Excluded are mothers who did not participate in the year- 4% five survey, do not live with the 3% focal child at least half of the time at year five, do not have valid sample weights, or report an average (baseline to year five) income-to- poverty ratio greater than 1.25. Differences in rates of drug use are Ever homeless or doubled up Ever at risk of homelessness Always stably housed statistically significant at 10% for (n = 716; n = 425) (n = 795; n = 409) (n = 325; n = 142) all groups.

In Poverty, Health, and Employment Context The connection between health and poverty is well documented; poor women and their children experience physical health limitations and mental health disorders at higher rates than their non-poor peers.6 Poor women often lack access to health care and are more likely to engage in risky health behaviors than those who are not poor.7 Women and children living in poverty are also exposed to physical and social environments, such as unsafe neighbor- hoods, toxins, and , which in addition to stress from the experience of poverty itself can be damaging to health. Residential crowding and poor housing quality have also been linked to adverse health outcomes.8 The ability of poor women to maintain consistent employment and achieve economic stability is hindered by health challenges. Poor women who report health barriers, such as physical disability, depression, or Post-traumatic Stress Disorder, work less frequently and consistently than those who do not.9 Health problems can also lead to job loss; studies show that approximately 10% of job losses by welfare recipients are attributed to poor health.10 Finally, caring for sick children limits the employment of impoverished women; such women are both more likely to have a child with special health needs and less likely to have access to paid sick leave and flexible child care than non-poor women.11

Profiles of Risk: Maternal Health and Well-being page 3

Domestic Violence Figure 3 Figure 3 shows that exposure to is another DOMESTIC VIOLENCE YEARS 1–5 factor that distinguishes poor women who are stably housed (by housing status years 1–5 and relationship status at baseline) from those who are not.12 Of all poor women in the FFCWS sample, stably housed mothers experienced the least domestic All poor mothers Poor mothers single at baseline violence between years one and five, reporting less than half 28% the rate of ever-homeless mothers (10% vs. 22%). Notably, poor 22% mothers at risk of homelessness experienced the most violence 20% (28%). Regardless of housing stability, mothers who remained 16% single at the baseline experienced lower rates of domestic 10% violence. Domestic violence has long been linked to housing 4% instability through numerous mechanisms (see “In Context: Domestic Violence and Housing Instability,” below). Ever homeless Ever at risk of Always stably or doubled up homelessness housed (n = 716; n = 425) (n = 795; n = 409) (n = 325; n = 142) Health and Well-being: A Differentiating Factor Health and well-being is a clear differentiating factor between Source: ICPH analysis of Fragile Families and Child Wellbeing data. n = 1,836. Excluded are mothers who did not participate in the year-five survey, do not live with the focal child at least poor mothers who experience homelessness and those who half of the time at year five, do not have valid sample weights, or report an average (baseline to year five) income-to-poverty ratio greater than 1.25. Differences in rates of domestic vio- maintain stable housing. Unstably housed women report worse lence are statistically significant at 10% for all groups. physical health, higher rates of depression, more drug use, and higher rates of domestic violence than their stably housed counterparts. Housing and welfare policies that aim to reduce uncertainty.13 Contrary to what has been found for single women child and family homelessness should incorporate comprehen- in general, women at risk of homelessness who remain single are sive mental and physical health services and support pathways to in better health, report less drug use, and experience less domes- overcome drug use and escape domestic violence. Poor women tic violence than those who marry or cohabit.14 It is vital that with such limitations are unlikely to maintain sufficient employ- work- and marriage-centered welfare policies addressing the dual ment critical to exiting poverty. problems of poverty and homelessness do not inadvertently jeop- ardize the health, safety, and employability of vulnerable women. The high rates of domestic violence reported among women at risk of homelessness are noteworthy. As reported in “Profiles of The snapshot of poor families presented in this brief reveals Risk: Family Structure,” poor women at risk of homelessness distinct differences in health and well-being by housing status. cohabit at high rates, an arrangement that is characterized by Upcoming briefs in this series will examine the interactions

In Domestic Violence and Housing Instability Context Domestic violence leads to increased risk of homelessness through multiple pathways.15 Women who separate from abusive partners often face housing instability as a consequence, particularly if they are dependent on their partners for economic support. Violent partners often obstruct employment and education opportunities in an effort to restrict victims’ economic resources and limit self-sufficiency.16 Research has found that abused women work fewer months and hours per year and have more trouble maintaining employment than those who do not experience domestic violence. The negative impacts of domestic violence on mental and physical health are also well documented; domestic violence has been linked to chronic physical health problems and psychological distress as well as increased drug and alcohol abuse, barriers that have been shown to limit employment.17 Additionally, exposure to domestic violence has negative consequences for child well-being. Relative to children who live in nonviolent families, those who witness abuse experience difficulties in social, emotional, behavioral, and cognitive function and development.18

ICPH page 4

between individual components of family poverty and explore Endnotes the well-being of children in homeless families. 1 Mothers are classified as being in “good physical health” if they reported an average of “very good” or “excellent” health between years one and five. Depression is measured using the Composite International Diagnostic Interview— Short Form (CIDI— SF), a standardized instrument for assessment of mental disorders. 2 Mothers are classified as drug users if they reported using illegal drugs in the past 12 months at years three and five or using illegal drugs in the past month at year one. Mothers who Homelessness in Fragile Families indicated that drug use interfered with personal relationships or daily functioning at year one are also classified as drug users. The Fragile Families and Child Wellbeing Survey is a nation- 3 Timothy Johnson, Sally Freels, Jennifer Parsons, and Jonathan Vangeest, “Substance Abuse and Homelessness: Social Selection or Social Adaption?” Addiction 92, no. 4 (1997): 437– 45. ally representative study of nearly 5,000 mostly poor urban 4 Michael French, Christopher Roebuck, and Pierre Alexandre, “Illicit Drug Use, Employment, and Labor Force Participation,” Southern Economic Journal 68, no. 2 (2001): 349 – 68. American families with young children born between 1998 5 Maria Testa, Jennifer Livingston, and Kenneth Leonard, “Women’s Substance Use and Experiences of Intimate Partner Violence: A Longitudinal Investigation Among a Community and 2000. The survey follows mothers from the birth of a focal Sample,” Addictive Behaviors 28 (2003): 1649 – 64. 6 Centers for Disease Control and Prevention, U.S. Department of Health and Human Services, “CDC Health Disparities and Inequalities Report—United States, 2011,” Morbidity and child through the child’s first, third, and fifth birthdays. When Mortality Weekly Report 60, Supplement (January 14, 2011): 1–113. 7 Nancy Adler and Katherine Newman, “Socioeconomic Disparities in Health: Pathways and weighted, Fragile Families is representative of births in 20 U.S. Policies,” Health Affairs 21, no. 2 (2002): 60 –76; Nancy Adler and David Rehkopf, “U.S. Disparities in Health: Descriptions, Causes, and Mechanisms,” Annual Review of Public Health cities with populations greater than 200,000. 29 (2008): 235 –52. 8 Gary Evans and Lyscha Marcynyszyn, “Environmental Justice, Cumulative Environmental Risk, and Health Among Low- and Middle-Income Children in Upstate New York,” American Using Fragile Families data, ICPH has classified families into Journal of Public Health 94, no. 11 (2004): 1941– 44. 9 Krista Olson and LaDonna Pavetti, Personal and Family Challenges to the Successful Transition three distinct housing categories based on their most severe from Welfare to Work, The Urban Institute, 1996; Mary Corcoran, Sandra Danziger, and Rich- ard Tolman, “Long Term Employment of African-American and White Welfare Recipients living arrangement in years one, three, and five: homeless or and the Role of Persistent Health and Mental Health Problems,” Women and Health 39, no. 4 (2004): 21– 40; Sandra Danziger, Ariel Kalil, and Nathaniel Anderson, “Human Capital, doubled up, at risk of homelessness, or stably housed. “Home- Health and Mental Health of Welfare Recipients: Co-occurence and Correlates,” Journal of Social Issues 56, no. 4 (2000): 635–54. less” families are those who have lived in a shelter or place 10 Alan Hershey and LaDonna Pavetti, “Turning Job Finders into Job Keepers,” The Future of Children 7, no. 1 (1997): 74 – 86. not intended for housing as well as those who have doubled 11 Jody Heymann and Alison Earle, “The Impact of Welfare Reform on Parents’ Ability to Care for Their Children’s Health,” American Journal of Public Health 89, no. 4 (1999): 502–5; Jodie up with friends or family. Families who are “at risk” were not Levin-Epstein, Welfare, Women and Health: The Role of Temporary Assistance for Needy Families, Henry J. Kaiser Family Foundation, 2003. homeless or doubled up but have had trouble paying essential 12 Mothers are classified as victims of domestic violence if they ever experienced financial abuse, sexual abuse, or physical abuse in years one, three, or five. bills, move frequently, or have been evicted. “Stably housed” 13 Please visit www.ICPHusa.org to access “Profiles of Risk: Family Structure.” 14 In general, research has established that married adults are in better health and engage in families faced none of these housing challenges. fewer risky health behaviors than their single peers. For a summary of recent research, please see Robert Wood, Brian Goesling, and Sarah Avellar, The Effects of Marriage on Health: A Synthesis of Recent Research Evidence, Mathematica Policy Research, 2007. A total of 1,836 families are included in the final analysis, which 15 Joanne Pavao, Jennifer Alvarez, Nikki Baumrind, and Marta Induni, “Intimate Partner Vio- lence and Housing Instability,” American Journal of Preventive Medicine 32, no. 3 (2007): 143 – 6. employs the year-five sample. Families with an income greater 16 Stephanie Riger, Susan Staggs, and Paul Schewe, “Intimate Partner Violence as an Obstacle to Employment Among Mothers Affected by Welfare Reform,” Journal of Social Issues 60, no. than 125% of the federal poverty line are excluded from the 4 (2004): 801–18; Richard Tolman and Hui-Chen Wang, “Domestic Violence and Women’s Employment: Fixed Effects Models of Three Waves of Women’s Employment Study Data,” analysis to ensure that comparisons between groups reflect American Journal of Community Psychology 36, nos. 1/2 (2005): 147–58; Thomas Moore and Vicky Selkowe, Domestic Violence Victims in Transition from Welfare to Work: Barriers to Self- differences in housing status rather than poverty. Please see Sufficiency and the W-2 Response, Institute for Wisconsin’s Future, 1999. 17 Ann Coker, Keith Davis, Ileana Arias, Sujata Desai, Maureen Sanderson, Heather Brandt, and the first brief in this series, “Profiles of Risk: Characterizing Paige Smith, “Physical and Mental Health Effects of Intimate Partner Violence for Men and Women,” American Journal of Preventive Medicine 23, no. 4 (2002): 260 – 8. Housing Instability,” for additional details on the sample used 18 David Wolfe, Claire Crooks, Vivien Lee, Alexandra McIntyre-Smith, and Peter Jaffe, “The Effects of Children’s Exposure to Domestic Violence: A Meta-Analysis and Critique,” Clinical in this series. Child and Family Psychology Review 6, no. 3 (2003): 171– 87.

Ralph da Costa Nunez, PhD President, Institute for Children, Poverty, and Homelessness

Felicia Yang DeLeone, PhD Principal Policy Researcher

Leighann Starkey Research Assistant

The Institute for Children, Poverty, and Homelessness (ICPH) is an indepen- dent nonprofit research organization based in New York City. ICPH studies the impact of poverty on family and child well-being and generates research that will enhance public policies and programs affecting poor or homeless children and their families. Specifically, ICPH examines the condition of ex- treme poverty in the United States and its effect on educational attainment, housing, employment, child welfare, domestic violence, and family wellness. Please visit our Web site for more information: www.ICPHusa.org.