It has been well established that there are socioeconomic disparities in children's physical health outcomes (Case, Lubotsky, & Paxson, 2002; Chen, Matthews, & Boyce, 2002). Children who live below the federal poverty line have higher mortality and morbidity rates than children in higher income families (Case et al., 2002; Starfield, Robertson, & Riley, 2002). However, less is known about within-group variation in physical health outcomes among low-income children. Using the risk and resilience framework, the aim of this study was to examine how, controlling for the presence of multiple risk factors, child health--promoting behaviors initiated by caregivers would explain within-group variation in caregiver-reported health among children from low-income families.
CONCEPTUAL FRAMEWORK: RISK AND RESILIENCE MODEL
Although the medical model has been the predominant framework for examining determinants of health, health researchers have emphasized the need to apply alternative models, such as the risk and resilience framework, that provide a more holistic perspective on health with greater focuses on positive health and well-being (R. G. Evans & Stoddart, 1990; Vinson, 2002).
Resilience has generally been defined by researchers in developmental psychopathology as a process wherein a person exhibits better-than-expected outcomes in the face of adversity (Garmezy, 1993; Vinson, 2002). Three major components of this framework--experience of adversity, adaptive outcomes, and protective or promotive factors--are discussed here.
First, for resilience to occur, there must be an experience of adversity--that is, a single risk or multiple risks that may have significant negative effects on an individual's outcomes. Resilience researchers have further emphasized the importance of understanding risk experiences at a more proximal than distal level (Luthar, Cicchetti, & Becker, 2000; Masten, 2001; Rutter, 1990)--that is, risks that directly affect children's lives more imminently, as opposed to distal risks (for example, low socioeconomic status) that affect children through a chain of mediating variables. For example, material hardships, which reflect families' living conditions and experiences of meeting their basic physical needs (Ouellette, Burstein, Long, & Beecroft, 2004), are considered better approximations of the direct effects of low income on children (Beverly, 2000). On the basis of this rationale, we focused on three domains of proximal risks--material hardship, caregiver's health, and children's access to health care--found to be associated with children's physical health.
To date, most studies examining the impact of material hardship on children's physical health have focused on the individual dimensions of hardship, such as food hardship or housing conditions (for example, Ashiabi & O'Neal, 2007; Cook et al., 2006; Kim, Sataley, Curtis, & Buchanan, 2002; Weinreb, Goldberg, Bassuk, & Perloff, 1998). These studies have shown that children who experience food hardship, generally defined as unstable or insufficient levels of food intake or insufficient variety of food consumption due to financial constraints (Ashiabi & O'Neal, 2007; Cook et al., 2006; Weinreb et. al., 2002), and who experience housing insecurity and poor-quality housing (Kim et al., 2002; Mueller & Tighe, 2007; Weinreb et al., 1998) are more likely to have health problems than children who do not experience these hardships. In addition, there is some evidence that cumulative experiences of material hardship may also negatively affect children's health (Yoo, Slack, & Holl, 2009). Also, caregivers' poor physical health and poor mental health have been found to be negatively associated not only with their children's health, but also with their preventive practices (Kahn, Zuckerman, Bauchner, Homer, & Wise, 2002; McLennen & Kotelchuck, 2000; Minkovitz, O'Campo, Chen, & Grason, 2002; Scalzo, Williams, & Holmbeck, 2005). …