Social Work

Parks, Jessica

2018 Social Work

doi: 10.1093/sw/swy017

How the Other Half Banks, by Mehrsa Baradaran, has timely implications for the social work field. It can serve as a primer for social workers to learn more about credit and banking in low- and middle-income families. This book centers on how unbanked populations (that is, those who do not frequently use a traditional bank) manage in a cash economy and includes a discussion about a reinstated postal banking system that was used in the late 1800s as self-sustaining, federally funded, bank branches that relied on the already established infrastructure of the U.S. Postal System. Each of the eight chapters can be read independently or in sequential order. This book is well supported by hundreds of appropriate references. Despite Baradaran’s attempts to provide definitions and relatable examples, this topic can be inherently overwhelming for lay readers. Collectively, the eight chapters provide an overview of the U.S. banking system, paint a picture of credit for the unbanked population, and demonstrate the need for a postal banking system. Overview of Banks The introduction begins with the stories of Tanya, Thelma, and Steve, who interestingly symbolize how credit differs between financial institutions and consumers during the Great Recession. Chapters 1 through 3 provide a basic overview of banking and can usefully supplement public policy and administration content. Chapter 1 shows why and how banks have developed over time. Appropriately here, Baradaran defines conventional economics terms to then give an overview of how banks operate. For instance, discount rate, federal funds rate, and quantitative easing are distinguished. Chapter 2 delves into the social contract between the federal government and banks. It traces the purpose and significance of banking institutions throughout history, from the days of our founding fathers to the Obama administration. It also highlights significant policies that changed banking operations (for example, the Troubled Asset Relief Program, the Federal Reserve Act, the New Deal, and so on). This chapter sets up how some institutions have changed from their original intent of serving the poor and farmers during the 1700s to their current portfolio of middle- and high-income clients. “Banks with Souls” (chapter 3) discusses how credit unions, Freeman Banks, and savings and loans institutions have developed over time as a response and alternative to these changed institutions. Who Is Unbanked? Professionals who have unbanked clients will benefit from chapters 4 and 5. Chapter 4 outlines various religious viewpoints of borrowing and lending. Alternative financial services (AFS) and fringe lenders (also known as fringe bank products) are explored in depth. A fringe lender is a nonbank credit entity that offers AFS (for example, check cashing, cash advancing). This chapter debunks the stereotypes of typical AFS users as frivolous, excessive spenders purchasing for personal luxury. Rather, data showed that AFS are used for necessities and emergencies. In many cases, such borrowers have steady jobs and bank accounts. Often, some of these borrowers are divorced or separated white women between the ages of 25 and 45. Minority races and single parents are also more likely to use AFS. This chapter provides a glimpse into the life of an unbanked individual or underbanked family. Having this insight might assist social workers who work closely with unbanked or underbanked clients who may not meet the current policy definition of poverty. Chapter 5, “Unbanked and Unwanted,” explains how those who are unbanked struggle to survive in a cash economy. Approximately 70 million Americans do not have access to traditional banking services. This chapter outlines the process that an unbanked individual endures in trying to pay bills and living expenses. A quotation from David states that “the fees he pays for cashing checks, paying bills and wiring money cannibalize the paycheck that he gets from part-time construction work” (p. 143). This example illustrates how overdraft protection, bank fees, minimum balance requirements, and ChexSystem might derail families maintaining traditional financial services. This chapter is helpful for practitioners looking to understand better the day-to-day financial challenges that their unbanked clients might encounter. Possible Solutions Chapter 6 provides a basic overview of nontraditional financial institutions worldwide. Instead of overregulating AFS or changing U.S. banks, Baradaran suggests adopting other efficient models from other nations. Some include Kenyan mobile banking, informal lending circles, and peer-to-peer lending initiatives. This chapter outlines some common, nontraditional financial products and services (for example, prepaid cards, Walmart’s money services, and so on). In addition, it will contribute to one’s understanding of the financial services and products outside of the United States, possibly benefiting practitioners in serving the immigrant and international population. Chapter 7 explores the need for and history of a U.S. postal banking system. Baradaran delves into the history and structure of the former postal system model and its role in “leveling the information playing field by disseminating information” (p. 183). However, can the current post office system handle the challenges of becoming a bank? The last chapter examines the pros and cons of reinstating a postal banking system. Some of the benefits include the already established infrastructure and the public trust of the postal service. Some drawbacks, as mentioned by Baradaran, include training postal workers, underwriting loans, collecting payments, and pricing the services. This chapter is useful to create discussion about whether reinstating a previously used system might address some of our financial issues. Implications for Social Work This book, especially chapters 4 and 5, can assist readers in better understanding how various financial products affect social work clients. Some immediate implications include how fringe banking products affect clients of social work professionals. For example, one might consider how to guide recipients of Temporary Assistance for Needy Families or Supplemental Nutrition Assistance Program benefits who also use AFS. A public health professional might benefit from understanding the toll that being unbanked takes on one’s physical and mental health. Members of the clergy might be interested in chapter 4's treatment of AFS as forms of usury as it relates to religion. Having some basic knowledge of the economic system (that is, how banks work) will aid in understanding the book’s material. © 2018 National Association of Social Workers This article is published and distributed under the terms of the Oxford University Press, Standard Journals Publication Model (https://academic.oup.com/journals/pages/about_us/legal/notices)

Radcliff, Elizabeth;Gustafson, Erin;Crouch, Elizabeth;Bennett, Kevin J

2018 Social Work

doi: 10.1093/sw/swy022pmid: 29722863

Abstract In 2015, over 15 percent of U.S. households with children were food insecure at some point during the year. The largest program created to address food insecurity in the United States is the Supplemental Nutritional Assistance Program (SNAP). However, research has suggested that safety net programs such as SNAP may be underutilized by eligible families. This secondary data analysis examined receipt of SNAP benefits among 2,249 SNAP-eligible participants in a South Carolina home visiting program. Benefit status was obtained at program enrollment and six months post-enrollment. Results showed that 15.6 percent of home visiting program participants without SNAP benefits at program enrollment were receiving benefits by six months post-enrollment. Unmarried caregivers were least likely to obtain SNAP benefits. Programs such as home visiting can be important to ensuring that eligible families receive federal assistance promoting food security, and targeted efforts to overcome barriers to SNAP enrollment continue to be important. The majority of U.S. households with children under age 18 years were food secure in 2015, meaning that members of the household had access to enough food to sustain an active and healthy life (Anderson, 1990; Coleman-Jensen, Rabbitt, Gregory, & Singh, 2016). Conceptually, food-secure families have “secure access to enough food at all time” (Maxwell & Smith, 1992, p. 15). However, 16.6 percent of U.S. households with children were food insecure at some point during the year, with 5 percent of these households having very low food security (Coleman-Jensen et al., 2016). Households that are food insecure are more likely to have children with poorer general health, more social and emotional disorders, a lower likelihood of completing high school, and an increased likelihood of hospitalizations (Cook et al., 2008; Howard, 2011; McLaughlin et al., 2012). Food insecurity is thus a significant public health issue. The largest federal program created to address food insecurity in the United States is the Supplemental Nutritional Assistance Program (SNAP). SNAP is designed to improve food security by providing nutrition assistance to families with limited resources who live at or below 130 percent of the poverty level (Coleman-Jensen, Nord, Andrews, & Carlson, 2012). Uptake of SNAP benefits can be important for significantly reducing both the rate and the depth of poverty among America’s poorest families (Tiehen & Ver Ploeg, 2012). Research has suggested that safety net programs such as SNAP may be underutilized by eligible families (Meyers, Gornick, & Peck, 2001). In 2015, fewer than half (44.6 percent) of food-insecure households nationwide received SNAP assistance (Coleman-Jensen et al., 2016). A range of barriers may exist to the uptake of SNAP benefits among eligible individuals, including a lack of understanding about eligibility requirements, lack of time to apply among the working poor, or an application site inaccessible by public transportation (Kaye, Lee, & Chen, 2013; U.S. Department of Agriculture, Food and Nutrition Service [USDA, FNS], 2011a, 2011b). Linguistic barriers, cultural stigma, or a refusal to accept government services can also be barriers to SNAP uptake (USDA, FNS, 2011b). In addition, SNAP services may be used differentially across demographic characteristics. For example, black and Hispanic families are more likely than white families to receive SNAP benefits (Cheng & Tang, 2016; Grieger & Danziger, 2011; Kaiser, 2008; Purtell, Gershoff, & Aber, 2012); individuals without a high school diploma are more likely than those with a high school diploma to receive SNAP benefits (Algert, Reibel, & Renvall, 2006; Grieger & Danziger, 2011; Purtell et al., 2012); and unemployed individuals are more likely than employed individuals to receive SNAP benefits (Kaiser, 2008). Examination of rural–urban differences in SNAP utilization has shown mixed results. Although one study reported low levels of SNAP applications among rural food-insecure households (Zekeri, 2007), others have shown no association between geographic residence and SNAP utilization (Mills, Dorai-Raj, Peterson, & Alwang, 2001; Purtell et al., 2012). Food insecurity is a particularly important issue in South Carolina (SC), where 13.2 percent of the state’s almost 2 million households reported being food insecure between 2013 and 2015; 4.6 percent of SC households reported very low food security during this time period (Coleman-Jensen et al., 2016). Approximately 21 percent of all SNAP-eligible individuals in SC did not participate in the program, and 30 percent of SNAP-eligible individuals who are employed did not participate (Nchako & Cai, 2017). One program working to increase the use of SNAP benefits among eligible families is the SC Maternal, Infant, and Early Childhood Home Visiting (MIECHV) program. The nationwide MIECHV program, created by Congress in 2010 under the Patient Protection and Affordable Care Act, funds local evidence-based home visiting programs designed to improve child and family health and well-being. Funding for MIECHV programs is awarded in each of the 50 states, as well as to some U.S. territories and tribal entities (Health Resources and Services Administration [HRSA], Maternal and Child Health Bureau [MCHB], 2017). These home visiting programs may be delivered by social workers, nurses, or educators and target high-risk pregnant women and families with children up to entry in kindergarten (U.S. Congress, 2010). Aims of the MIECHV program include improving maternal and child health, improving child development and early learning, reducing child maltreatment, and increasing family self-sufficiency (HRSA, MCHB, 2017). One component of MIECHV focuses on increasing a family’s earned or benefit-related income by improving coordination and referrals to community resources (Sama-Miller et al., 2016; HRSA, Administration for Children and Families, 2016). The SC MIECHV program chose to operationalize this measure by promoting and measuring participants’ receipt of SNAP benefits. The SC MIECHV program supports five evidence-based home visiting models operating out of 16 sites across the state, such as hospital clinics, local physicians’ offices, early childhood development agencies, and federally qualified health centers. Using SC MIECHV data, this research examined changes in the receipt of SNAP benefits among SNAP-eligible individuals. We hypothesized that the proportion of MIECHV-enrolled families receiving SNAP benefits would increase following program enrollment although, based on previous research, we expected a differential uptake of those services by enrollees’ race, ethnicity, educational status, and age (Algert et al., 2006; Cheng & Tang, 2016; Grieger & Danziger, 2011; Kaiser, 2008; Purtell et al., 2012). Understanding the role of home visitors in facilitating SNAP uptake among its participants may suggest a valuable tool for targeting and improving food insecurity through the implementation of programs that improve the coordination of referrals to community resources and supports. Method This retrospective cohort study examined characteristics of caregivers who enrolled in the SC MIECHV program between October 1, 2010, and September 30, 2015, and who were eligible for SNAP (N = 2,249). Participants are eligible for SNAP if their household gross income is 130 percent of the poverty line or less (based on gross income and household size provided by the caregiver at time of enrollment). Data were obtained from the SC Rural Health Research Center, which, as the state evaluator for the SC MIECHV program, collects and manages all demographic and outcome data reported by local implementing agencies via a Web-based data collection system. The primary outcome of interest was receipt of SNAP services, measured at MIECHV program enrollment and six months post-enrollment. Receipt of SNAP services was defined as receiving services anytime within 12 months prior to MIECHV enrollment and receiving SNAP services at six months post-enrollment. Receipt of SNAP services was self-reported by the MIECHV client and measured as a dichotomous “yes or no” variable. Informed by Aday and Andersen’s behavioral model of health service use (Aday & Andersen, 1974; Andersen, 1995), which has previously been applied to the utilization of SNAP (Cheng & Tang, 2016; Fuller-Thomson & Redmond, 2008), the following covariates were examined as potential predisposing or enabling factors for uptake of SNAP benefits: age, race and ethnicity, marital status, education, and caregiver’s geographic residence at enrollment (rural or urban). Age was aggregated into four categories: younger than 18, 18 to 24, 25 to 35, and older than 35 years. Race and ethnicity was categorized as non-Hispanic white, non-Hispanic black, Hispanic, and other. Marital status was categorized as married, unmarried, and unknown. Rural or urban residence was identified by conducting a cross-walk of self-reported residential Zone Improvement Plan (referred to as ZIP) codes with county names and their corresponding urban influence codes (UICs). Based on previous research, UIC codes 1 and 2 were defined as urban residence, and UIC codes 3 through 12 were considered rural (Baer, Johnson-Webb, & Gesler, 1997). Caregivers with missing data for any of these variables were excluded from the study. Using standard descriptive statistics, we calculated counts and proportions for each demographic variable. Using bivariate analyses, we compared characteristics of all SNAP-eligible families by receipt of SNAP services at MIECHV program enrollment. Also using bivariate analyses, we examined characteristics of SNAP-eligible MIECHV enrollees who did not have SNAP benefits at MIECHV enrollment by receipt of services at six months post-enrollment. P values with an alpha value of less than .05 were considered statistically significant. Examining only those MIECHV participants who did not have SNAP benefits at home visiting program enrollment, we used logistic regression to observe for associations between selected demographic characteristics and receipt of SNAP services at six months, adjusting for age, race and ethnicity, education, marital status, and geographic residence. The institutional review board at the University of South Carolina approved this research. The data analysis for this article was generated using SAS (Version 9.4) (SAS Institute, 2002–2012) software. Results Our original sample size was 3,161. We excluded 215 participants (6.8 percent) because of missing data. We then limited our analyses to SNAP-eligible participants only, for a final analytic sample of 2,249. The majority of caregivers were between 18 and 35 years of age (80.1 percent) and had a high school education or less (62.6 percent); 49.8 percent were non-Hispanic black (see Table 1). Most caregivers were unmarried (75.7 percent) and resided in an urban location (69.2 percent). Table 1: Characteristics of SNAP-Eligible Caregivers Enrolled in a South Carolina Home Visiting Program, and by SNAP Status at the Time of Home Visiting Program Enrollment, 2010–2015 Characteristic All Caregivers at MIECHV Enrollment Receiving SNAP Benefits at MIECHV Enrollment p Valuea n (%) No Yes n (%) n (%) All caregivers 2,249 (100) 968 (43.0) 1,281 (57.0) Age (years)  Younger than 18 228 (10.1) 99 (43.4) 129 (56.6) .44  18 to 24 1,052 (46.8) 469 (44.6) 583 (55.4)  25 to 35 749 (33.3) 305 (40.7) 444 (59.3)  Older than 35 220 (9.8) 95 (43.2) 125 (56.8) Race and ethnicity  Hispanic 428 (19.0) 262 (61.2) 166 (38.8) <.0001  Non-Hispanic white 553 (24.6) 272 (49.2) 281 (50.8)  Non-Hispanic black 1,120 (49.8) 381 (34.0) 739 (66.0)  Otherb 148 (6.6) 53 (35.8) 95 (64.2) Marital status  Married 449 (20.0) 268 (59.7) 181 (40.3) <.0001  Unmarriedc 1,703 (75.7) 655 (38.5) 1,048 (61.5)  Unknown 97 (4.3) 45 (46.4) 52 (53.6) Education  High school or less 1,408 (62.6) 550 (39.1) 858 (60.9) <.0001  More than high school 741 (33.0) 370 (49.9) 371 (50.1)  Other/unknown 100 (4.4) 48 (48.0) 52 (52.0) Geographic residenced  Rural 692 (30.8) 264 (38.2) 428 (61.8) .002  Urban 1,557 (69.2) 704 (45.2) 853 (54.8) Characteristic All Caregivers at MIECHV Enrollment Receiving SNAP Benefits at MIECHV Enrollment p Valuea n (%) No Yes n (%) n (%) All caregivers 2,249 (100) 968 (43.0) 1,281 (57.0) Age (years)  Younger than 18 228 (10.1) 99 (43.4) 129 (56.6) .44  18 to 24 1,052 (46.8) 469 (44.6) 583 (55.4)  25 to 35 749 (33.3) 305 (40.7) 444 (59.3)  Older than 35 220 (9.8) 95 (43.2) 125 (56.8) Race and ethnicity  Hispanic 428 (19.0) 262 (61.2) 166 (38.8) <.0001  Non-Hispanic white 553 (24.6) 272 (49.2) 281 (50.8)  Non-Hispanic black 1,120 (49.8) 381 (34.0) 739 (66.0)  Otherb 148 (6.6) 53 (35.8) 95 (64.2) Marital status  Married 449 (20.0) 268 (59.7) 181 (40.3) <.0001  Unmarriedc 1,703 (75.7) 655 (38.5) 1,048 (61.5)  Unknown 97 (4.3) 45 (46.4) 52 (53.6) Education  High school or less 1,408 (62.6) 550 (39.1) 858 (60.9) <.0001  More than high school 741 (33.0) 370 (49.9) 371 (50.1)  Other/unknown 100 (4.4) 48 (48.0) 52 (52.0) Geographic residenced  Rural 692 (30.8) 264 (38.2) 428 (61.8) .002  Urban 1,557 (69.2) 704 (45.2) 853 (54.8) Notes: SNAP = Supplemental Nutrition Assistance Program; MIECHV = Maternal, Infant, and Early Childhood Home Visiting program. ap values compare uptake of SNAP benefits at six months and are considered significant at < .05; significant values are in boldface. bOther includes American Indian/Alaskan native, Asian, native Hawaiian/other Pacific Islander, or more than one category. cUnmarried includes single/never married, divorced, separated, and widowed. dRural or urban residence defined by urban influence codes. Table 1: Characteristics of SNAP-Eligible Caregivers Enrolled in a South Carolina Home Visiting Program, and by SNAP Status at the Time of Home Visiting Program Enrollment, 2010–2015 Characteristic All Caregivers at MIECHV Enrollment Receiving SNAP Benefits at MIECHV Enrollment p Valuea n (%) No Yes n (%) n (%) All caregivers 2,249 (100) 968 (43.0) 1,281 (57.0) Age (years)  Younger than 18 228 (10.1) 99 (43.4) 129 (56.6) .44  18 to 24 1,052 (46.8) 469 (44.6) 583 (55.4)  25 to 35 749 (33.3) 305 (40.7) 444 (59.3)  Older than 35 220 (9.8) 95 (43.2) 125 (56.8) Race and ethnicity  Hispanic 428 (19.0) 262 (61.2) 166 (38.8) <.0001  Non-Hispanic white 553 (24.6) 272 (49.2) 281 (50.8)  Non-Hispanic black 1,120 (49.8) 381 (34.0) 739 (66.0)  Otherb 148 (6.6) 53 (35.8) 95 (64.2) Marital status  Married 449 (20.0) 268 (59.7) 181 (40.3) <.0001  Unmarriedc 1,703 (75.7) 655 (38.5) 1,048 (61.5)  Unknown 97 (4.3) 45 (46.4) 52 (53.6) Education  High school or less 1,408 (62.6) 550 (39.1) 858 (60.9) <.0001  More than high school 741 (33.0) 370 (49.9) 371 (50.1)  Other/unknown 100 (4.4) 48 (48.0) 52 (52.0) Geographic residenced  Rural 692 (30.8) 264 (38.2) 428 (61.8) .002  Urban 1,557 (69.2) 704 (45.2) 853 (54.8) Characteristic All Caregivers at MIECHV Enrollment Receiving SNAP Benefits at MIECHV Enrollment p Valuea n (%) No Yes n (%) n (%) All caregivers 2,249 (100) 968 (43.0) 1,281 (57.0) Age (years)  Younger than 18 228 (10.1) 99 (43.4) 129 (56.6) .44  18 to 24 1,052 (46.8) 469 (44.6) 583 (55.4)  25 to 35 749 (33.3) 305 (40.7) 444 (59.3)  Older than 35 220 (9.8) 95 (43.2) 125 (56.8) Race and ethnicity  Hispanic 428 (19.0) 262 (61.2) 166 (38.8) <.0001  Non-Hispanic white 553 (24.6) 272 (49.2) 281 (50.8)  Non-Hispanic black 1,120 (49.8) 381 (34.0) 739 (66.0)  Otherb 148 (6.6) 53 (35.8) 95 (64.2) Marital status  Married 449 (20.0) 268 (59.7) 181 (40.3) <.0001  Unmarriedc 1,703 (75.7) 655 (38.5) 1,048 (61.5)  Unknown 97 (4.3) 45 (46.4) 52 (53.6) Education  High school or less 1,408 (62.6) 550 (39.1) 858 (60.9) <.0001  More than high school 741 (33.0) 370 (49.9) 371 (50.1)  Other/unknown 100 (4.4) 48 (48.0) 52 (52.0) Geographic residenced  Rural 692 (30.8) 264 (38.2) 428 (61.8) .002  Urban 1,557 (69.2) 704 (45.2) 853 (54.8) Notes: SNAP = Supplemental Nutrition Assistance Program; MIECHV = Maternal, Infant, and Early Childhood Home Visiting program. ap values compare uptake of SNAP benefits at six months and are considered significant at < .05; significant values are in boldface. bOther includes American Indian/Alaskan native, Asian, native Hawaiian/other Pacific Islander, or more than one category. cUnmarried includes single/never married, divorced, separated, and widowed. dRural or urban residence defined by urban influence codes. On average, over half (57.0 percent) of all caregivers reported currently or recently receiving SNAP benefits at the time of MIECHV enrollment; however, differences in SNAP uptake existed among demographic groups (see Table 1). Only 38.8 percent of SNAP-eligible Hispanic caregivers received SNAP at enrollment, compared with 50.8 percent of white caregivers and 66.0 percent of non-Hispanic black caregivers (p < .0001). Just over 50 percent of SNAP-eligible caregivers with more than a high school diploma received SNAP benefits at program enrollment, compared with 60.9 percent of caregivers with no more than a high school degree (p < .0001). More rural residents received SNAP benefits (61.8 percent) than urban residents (54.8 percent, p = .002). More unmarried caregivers (61.5 percent) received SNAP services at enrollment than those who were married (40.3 percent, p < .0001). Among SNAP-eligible MIECHV participants who were not receiving SNAP at enrollment, 15.6 percent had obtained SNAP benefits by six months post-enrollment (see Table 2). Table 2: Characteristics of SNAP-Eligible Caregivers Who Were Not Receiving SNAP Benefits at the Time of Enrollment in a South Carolina Home Visiting Program, and by SNAP Uptake at Six Months, 2010–2015 Characteristic All Caregivers without SNAP at MIECHV Enrollment Receiving SNAP Benefits Six Months after MIECHV Enrollment p Valuea n (%) No Yes n (%) n (%) All caregivers 968 (100) 817 (84.4) 151(15.6) Age in years  Younger than 18 99 (10.2) 82 (82.8) 17 (17.2) .003  18 to 24 469 (48.5) 377 (80.4) 92 (19.6)  25 to 35 305 (31.5) 273 (89.5) 32 (10.5)  Older than 35 95 (9.8) 85 (89.5) 10 (10.5) Race and ethnicity  Hispanic 262 (27.1) 229 (87.4) 33 (12.6) .03  Non-Hispanic white 272 (28.1) 237 (87.1) 35 (12.9)  Non-Hispanic black 381 (39.4) 305 (80.0) 76 (20.0)  Otherb 53 (5.5) 46 (86.8) 7 (13.2) Marital status  Married 268 (27.7) 244 (91.0) 24 (9.0) .0002  Unmarriedc 655 (67.7) 541 (82.6) 114 (17.4)  Unknown 45 (4.6) 32 (71.1) 13 (28.9) Education  High school or less 550 (56.8) 451(82.0) 99 (18.0) .02  More than high school 370 (38.2) 320 (86.5) 50 (13.5)  Other/unknown 48 (5.0) 46 (95.8) 2 (4.2) Geographic residenced  Rural 264 (27.3) 224 (84.8) 40 (15.2) .81  Urban 704 (72.7) 593 (84.2) 111 (15.8) Characteristic All Caregivers without SNAP at MIECHV Enrollment Receiving SNAP Benefits Six Months after MIECHV Enrollment p Valuea n (%) No Yes n (%) n (%) All caregivers 968 (100) 817 (84.4) 151(15.6) Age in years  Younger than 18 99 (10.2) 82 (82.8) 17 (17.2) .003  18 to 24 469 (48.5) 377 (80.4) 92 (19.6)  25 to 35 305 (31.5) 273 (89.5) 32 (10.5)  Older than 35 95 (9.8) 85 (89.5) 10 (10.5) Race and ethnicity  Hispanic 262 (27.1) 229 (87.4) 33 (12.6) .03  Non-Hispanic white 272 (28.1) 237 (87.1) 35 (12.9)  Non-Hispanic black 381 (39.4) 305 (80.0) 76 (20.0)  Otherb 53 (5.5) 46 (86.8) 7 (13.2) Marital status  Married 268 (27.7) 244 (91.0) 24 (9.0) .0002  Unmarriedc 655 (67.7) 541 (82.6) 114 (17.4)  Unknown 45 (4.6) 32 (71.1) 13 (28.9) Education  High school or less 550 (56.8) 451(82.0) 99 (18.0) .02  More than high school 370 (38.2) 320 (86.5) 50 (13.5)  Other/unknown 48 (5.0) 46 (95.8) 2 (4.2) Geographic residenced  Rural 264 (27.3) 224 (84.8) 40 (15.2) .81  Urban 704 (72.7) 593 (84.2) 111 (15.8) Notes: SNAP = Supplemental Nutrition Assistance Program; MIECHV = Maternal, Infant, and Early Childhood Visiting program. ap values compare uptake of SNAP benefits at six months and are considered significant at < .05; significant values are in boldface. bOther includes American Indian/Alaskan native, Asian, native Hawaiian/other Pacific Islander, or more than one category. cUnmarried includes single/never married, divorced, separated, and widowed. dRural and urban residence defined by urban influence codes. Table 2: Characteristics of SNAP-Eligible Caregivers Who Were Not Receiving SNAP Benefits at the Time of Enrollment in a South Carolina Home Visiting Program, and by SNAP Uptake at Six Months, 2010–2015 Characteristic All Caregivers without SNAP at MIECHV Enrollment Receiving SNAP Benefits Six Months after MIECHV Enrollment p Valuea n (%) No Yes n (%) n (%) All caregivers 968 (100) 817 (84.4) 151(15.6) Age in years  Younger than 18 99 (10.2) 82 (82.8) 17 (17.2) .003  18 to 24 469 (48.5) 377 (80.4) 92 (19.6)  25 to 35 305 (31.5) 273 (89.5) 32 (10.5)  Older than 35 95 (9.8) 85 (89.5) 10 (10.5) Race and ethnicity  Hispanic 262 (27.1) 229 (87.4) 33 (12.6) .03  Non-Hispanic white 272 (28.1) 237 (87.1) 35 (12.9)  Non-Hispanic black 381 (39.4) 305 (80.0) 76 (20.0)  Otherb 53 (5.5) 46 (86.8) 7 (13.2) Marital status  Married 268 (27.7) 244 (91.0) 24 (9.0) .0002  Unmarriedc 655 (67.7) 541 (82.6) 114 (17.4)  Unknown 45 (4.6) 32 (71.1) 13 (28.9) Education  High school or less 550 (56.8) 451(82.0) 99 (18.0) .02  More than high school 370 (38.2) 320 (86.5) 50 (13.5)  Other/unknown 48 (5.0) 46 (95.8) 2 (4.2) Geographic residenced  Rural 264 (27.3) 224 (84.8) 40 (15.2) .81  Urban 704 (72.7) 593 (84.2) 111 (15.8) Characteristic All Caregivers without SNAP at MIECHV Enrollment Receiving SNAP Benefits Six Months after MIECHV Enrollment p Valuea n (%) No Yes n (%) n (%) All caregivers 968 (100) 817 (84.4) 151(15.6) Age in years  Younger than 18 99 (10.2) 82 (82.8) 17 (17.2) .003  18 to 24 469 (48.5) 377 (80.4) 92 (19.6)  25 to 35 305 (31.5) 273 (89.5) 32 (10.5)  Older than 35 95 (9.8) 85 (89.5) 10 (10.5) Race and ethnicity  Hispanic 262 (27.1) 229 (87.4) 33 (12.6) .03  Non-Hispanic white 272 (28.1) 237 (87.1) 35 (12.9)  Non-Hispanic black 381 (39.4) 305 (80.0) 76 (20.0)  Otherb 53 (5.5) 46 (86.8) 7 (13.2) Marital status  Married 268 (27.7) 244 (91.0) 24 (9.0) .0002  Unmarriedc 655 (67.7) 541 (82.6) 114 (17.4)  Unknown 45 (4.6) 32 (71.1) 13 (28.9) Education  High school or less 550 (56.8) 451(82.0) 99 (18.0) .02  More than high school 370 (38.2) 320 (86.5) 50 (13.5)  Other/unknown 48 (5.0) 46 (95.8) 2 (4.2) Geographic residenced  Rural 264 (27.3) 224 (84.8) 40 (15.2) .81  Urban 704 (72.7) 593 (84.2) 111 (15.8) Notes: SNAP = Supplemental Nutrition Assistance Program; MIECHV = Maternal, Infant, and Early Childhood Visiting program. ap values compare uptake of SNAP benefits at six months and are considered significant at < .05; significant values are in boldface. bOther includes American Indian/Alaskan native, Asian, native Hawaiian/other Pacific Islander, or more than one category. cUnmarried includes single/never married, divorced, separated, and widowed. dRural and urban residence defined by urban influence codes. In bivariate analyses, limiting the study population to only those SNAP-eligible families with no SNAP services at enrollment in an SC home visiting program, we found differences in SNAP uptake by six months in categories of race and ethnicity, marital status, and educational attainment (see Table 2). Non-Hispanic black caregivers (20.0 percent) were more likely to have SNAP services by six months than Hispanic (12.6 percent) or white (12.9 percent) caregivers (p = .03). Caregivers 18 to 24 years (19.6 percent) and younger than 18 years old (17.2 percent) were more likely to receive SNAP services by six months than older participants (25–35 years, 10.5 percent; older than 35 years, 10.5 percent). Unmarried caregivers (17.4 percent) were more likely to have SNAP services at six months than married caregivers (9.0 percent, p = .0002). Caregivers with a high school diploma or less (18.0 percent) were more likely to have SNAP services by six months than caregivers with more than a high school diploma (13.5 percent, p = .02). In multivariable analysis predicting receipt of SNAP services at six months after MIECHV enrollment (see Table 3) among those families who did not have SNAP at enrollment, we found that none of the measured demographic characteristics was significantly related to SNAP uptake by six months post-enrollment. Table 3: Factors Associated with Receipt of SNAP Services at Six Months after Enrollment in a South Carolina Home Visiting Program Caregiver Characteristic Adjusted OR 95% Confidence Limits LL UL Age (years)  (Over 35)  25 to 35 0.78 0.36 1.70  18 to 24 1.31 0.62 2.76  Under 18 0.99 0.40 2.43 Race and ethnicity  (Non-Hispanic white)  Non-Hispanic black 1.50 0.95 2.37  Hispanic 0.94 0.55 1.61  Othera 1.12 0.46 2.72 Education  (More than high school)  High school or less 1.40 0.93 2.10  Other/unknown 0.25 0.06 1.08 Marital statusb  (Married)  Unmarriedc 1.58 0.94 2.65 Geographic residenced  (Urban)  Rural 0.76 0.50 1.17 Caregiver Characteristic Adjusted OR 95% Confidence Limits LL UL Age (years)  (Over 35)  25 to 35 0.78 0.36 1.70  18 to 24 1.31 0.62 2.76  Under 18 0.99 0.40 2.43 Race and ethnicity  (Non-Hispanic white)  Non-Hispanic black 1.50 0.95 2.37  Hispanic 0.94 0.55 1.61  Othera 1.12 0.46 2.72 Education  (More than high school)  High school or less 1.40 0.93 2.10  Other/unknown 0.25 0.06 1.08 Marital statusb  (Married)  Unmarriedc 1.58 0.94 2.65 Geographic residenced  (Urban)  Rural 0.76 0.50 1.17 Notes: SNAP = Supplemental Nutrition Assistance Program. Factors associated with receipt of services as reported by SNAP-eligible caregivers who were not receiving SNAP benefits at home visiting program enrollment, 2010–2015. OR = odds ratio; LL = lower limit; UL = upper limit. Referents are in parentheses. aOther includes American Indian/Alaskan native, Asian, native Hawaiian/other Pacific Islander, or more than one category. bData for unknown marital status presented here because interpretation is difficult due to small numbers: no SNAP at six months = 46 (95.8); SNAP at six months = 2 (4.2). cUnmarried includes single/never married, divorced, separated, and widowed. dRural and urban residence defined by urban influence codes. Table 3: Factors Associated with Receipt of SNAP Services at Six Months after Enrollment in a South Carolina Home Visiting Program Caregiver Characteristic Adjusted OR 95% Confidence Limits LL UL Age (years)  (Over 35)  25 to 35 0.78 0.36 1.70  18 to 24 1.31 0.62 2.76  Under 18 0.99 0.40 2.43 Race and ethnicity  (Non-Hispanic white)  Non-Hispanic black 1.50 0.95 2.37  Hispanic 0.94 0.55 1.61  Othera 1.12 0.46 2.72 Education  (More than high school)  High school or less 1.40 0.93 2.10  Other/unknown 0.25 0.06 1.08 Marital statusb  (Married)  Unmarriedc 1.58 0.94 2.65 Geographic residenced  (Urban)  Rural 0.76 0.50 1.17 Caregiver Characteristic Adjusted OR 95% Confidence Limits LL UL Age (years)  (Over 35)  25 to 35 0.78 0.36 1.70  18 to 24 1.31 0.62 2.76  Under 18 0.99 0.40 2.43 Race and ethnicity  (Non-Hispanic white)  Non-Hispanic black 1.50 0.95 2.37  Hispanic 0.94 0.55 1.61  Othera 1.12 0.46 2.72 Education  (More than high school)  High school or less 1.40 0.93 2.10  Other/unknown 0.25 0.06 1.08 Marital statusb  (Married)  Unmarriedc 1.58 0.94 2.65 Geographic residenced  (Urban)  Rural 0.76 0.50 1.17 Notes: SNAP = Supplemental Nutrition Assistance Program. Factors associated with receipt of services as reported by SNAP-eligible caregivers who were not receiving SNAP benefits at home visiting program enrollment, 2010–2015. OR = odds ratio; LL = lower limit; UL = upper limit. Referents are in parentheses. aOther includes American Indian/Alaskan native, Asian, native Hawaiian/other Pacific Islander, or more than one category. bData for unknown marital status presented here because interpretation is difficult due to small numbers: no SNAP at six months = 46 (95.8); SNAP at six months = 2 (4.2). cUnmarried includes single/never married, divorced, separated, and widowed. dRural and urban residence defined by urban influence codes. Discussion To our knowledge, this is the first study to examine differences in SNAP utilization among new MIECHV enrollees. With fewer than half of SNAP-eligible caregivers receiving SNAP benefits at enrollment in an SC home visiting program, this research confirmed that a high proportion of SNAP-eligible households among at-risk families in SC do not receive SNAP benefits (Coleman-Jensen et al., 2016; Nchako & Cai, 2017). This study also confirmed previous research identifying racial and ethnic differences in utilization of services, with non-Hispanic black caregivers being more likely than Hispanic and non-Hispanic white caregivers to receive services (Cheng & Tang, 2016; Grieger & Danziger, 2011; Kaiser, 2008; Purtell et al., 2012). The relationship between education and SNAP utilization was also confirmed, with individuals without a high school diploma being more likely than those with a high school diploma to receive SNAP benefits (Algert et al., 2006; Grieger & Danziger, 2011; Purtell et al., 2012). Following six months of enrollment in a home visiting program that promoted family well-being by linking eligible families to available community resources, we found that only 15.6 percent of eligible but previously unenrolled caregivers were newly enrolled in SNAP. Married caregivers (9.0 percent), caregivers 25 to 35 years of age (10.5 percent), and caregivers older than age 35 (10.5 percent) showed the lowest percentages of SNAP enrollment following six months in the MIECHV program. SNAP-eligible Hispanic caregivers showed the smallest increase in SNAP enrollment after six months in a home visiting program among the racial and ethnic categories (12.6 percent). Findings suggest that opportunities continue to exist to promote the uptake of SNAP benefits to unserved families. Although some eligible families may opt out of SNAP benefits because of personal preference, stigma, family challenges, or concerns about citizenship, others may face barriers in the application process, lack of accessibility to the application site, lack of awareness about remote applications, or inadequate availability of local retail locations that accept SNAP (Algert et al., 2006; Gundersen & Ziliak, 2014; Kaiser, 2008). Home visitors in programs like MIECHV are in an ideal position to facilitate the coordination of referrals to services such as SNAP, as they work to address the needs of eligible parents and children (AAP Council on Community Pediatrics, 2016). In addition to coordinating referrals, professionals such as those in the MIECHV program may also be able to address specific concerns of married and older caregivers during home visits by promoting education about federal assistance services and by providing trusted advice that addresses personal cultural norms or concerns about stigma related to accepting government help (Algert et al., 2006; Gundersen & Ziliak, 2014; Kaiser, 2008). A focused outreach by MIECHV home visitors or other community workers that addresses the perceived or actual barriers to SNAP enrollment among income-eligible Hispanic families will be important. Hispanic noncitizen immigrants may be eligible for SNAP but opt out of obtaining SNAP benefits because of perceptions that it may affect immigration status or their opportunity to become a U.S. citizen (USDA, FNS, 2011a). Language or literacy barriers may also present challenges for Hispanic caregivers during the application process (USDA, FNS, 2017). Home visitors, social workers, or other community care providers can be important communicators of current regulations regarding SNAP eligibility based on immigrant status among the Hispanic population and thus potentially increase the uptake of SNAP among eligible families. Policies that continue to protect essential benefits for vulnerable populations, including adequate nutrition, are important to maintaining and strengthening family health and stability. These policies may promote healthy families by providing culturally and linguistically appropriate services, providing education or raising awareness of available services, or streamlining enrollment procedures. Continued funding of programs such as SNAP, Temporary Assistance for Needy Families, and child health insurance coverage are important, as they provide crucial services to vulnerable families. Home visitors, social workers, and other community health workers can have an important role in the uptake of these services; thus, the continued funding of programs such as MIECHV and other home visiting or community outreach programs is important to ensure eligible families are linked to appropriate services. Strengths and Limitations One strength of this study was the use of a unique statewide, population-based data set, which provided a study sample of at-risk SC families with both SNAP uptake and income data. One limitation of this study was missing data. Although deletion of this missing data reduced the sample size and could potentially introduce bias if the data were not missing at random (Allison, 2001), the numbers missing and deleted were small and likely had no significant effect on the outcomes. A second limitation was that SNAP services were self-reported, which may have resulted in misclassification reports in either direction. Because of the nature of the data, we could not correct for any bias that may have been introduced because of self-reporting errors. Third, we did not have access to information on why eligible families opted in or out of obtaining SNAP benefits. Finally, the findings of this state-specific study are not generalizable to other regions; however, SC may be generally representative of a traditional southern state (U.S. Census Bureau, 2016). Future Research Qualitative studies that further examine why eligible families opt in or out of obtaining SNAP benefits could be useful for informing education and awareness campaigns. An examination of clients’ perceptions of the home visitor or social worker’s role in their decisions could also be important to informing effective personal counseling on the topic. 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Fenwick, Karissa

2018 Social Work

doi: 10.1093/sw/swy021pmid: 29718512

The United States is in the middle of a debate about how to address sexual misconduct on college and university campuses. On September 22, 2017, Education Secretary Betsy DeVos and the U.S. Department of Education’s [ED’s] Office for Civil Rights rolled back influential Obama-era guidance regulating school investigations of sexual misconduct (ED, 2017). These rollbacks responded to demands for greater due process for those accused of sexual misconduct, arguably at the cost of protecting victims (Know Your IX, 2017). Despite social work’s identity as a profession firmly rooted in social justice, gender equality, and advocacy, the social work voice has remained largely absent from the Title IX debate. A search in journals published by the National Association of Social Workers (NASW) revealed only one article related to Title IX in the past five years. Although NASW withheld support for DeVos’s confirmation in early 2017, it has yet to release a statement or put out a call to action regarding DeVos’s stance on Title IX. In this commentary, I briefly summarize Title IX as it relates to campus sexual misconduct, outline how DeVos’s new guidelines threaten to weaken the fight against campus sexual misconduct, and assert that social workers have a stake in the Title IX debate. What Is Title IX, and How Does It Apply to Sexual Misconduct? Title IX of the Civil Rights Act states that “no person in the United States shall, on the basis of sex, be excluded from participation in, be denied the benefits of, or be subjected to discrimination under any education program or activity receiving federal assistance” (Title IX, 1972, p. 1). Historically passed to mandate gender equality in college athletics, Title IX has more recently been applied to protecting students from sexual misconduct based on the argument that “sexual harassment of students, which includes acts of sexual violence, is a form of sex discrimination” that deprives victims of their fundamental right to education (ED, 2011, p. 1). Examples of sexual harassment in this context include “unwanted sexual advances, requests for sexual favors, and other verbal, nonverbal, or physical conduct of a sexual nature” (ED, 2011, p. 3). Sexual harassment may occur between individuals of any gender, gender identity, or sexual orientation, but victims are disproportionately women and individuals in the lesbian, gay, bisexual, transgender, and queer community (Cantor et al., 2015). Under Title IX, schools are required to take action against sex discrimination by investigating and enforcing consequences for sexual misconduct. School investigations are independent of any criminal investigation that may take place concurrently, and they do not determine guilt or innocence under the law. Instead, they enable schools to make evidence-based determinations about whether or not sexual misconduct occurred so that they can promptly eliminate further threats to the campus community and remediate harm to the victim (ED, 2014). Investigations typically involve fact finding, determining whether misconduct occurred based on a standard of evidence, administering sanctions, and implementing protections for victims (ED, 2014). Changes to Title IX under Trump The Obama administration took an unprecedented stance against campus sexual misconduct by imposing stringent new requirements for Title IX investigations, mandating rigorous enforcement, and linking compliance with federal funding (Brodsky, 2017; ED, 2011, 2014). Victims and their advocates praised these changes but pushed for further reform, pointing to the lengthy investigations, unsupportive administrations, confusing policies, and lack of transparency that still characterized Title IX investigations at many schools (see, for example, Know Your IX, 2017). Due-process advocates and men’s rights groups maintained that the Obama administration had gone too far, stating that respondents should be granted due process rights more closely akin to legal proceedings (see, for example, Foundation for Individual Rights in Education, 2017). The latest guidelines released by Trump and DeVos’s ED appear to be responding to this backlash, rolling back some of the Obama administration’s requirements at the risk of exposing victims to further harm. The specific changes outlined by the new guidelines are summarized in Table 1, presented side-by-side with the older Obama-era guidelines for comparison. Table 1: Old versus New Guidance for Title IX Sexual Misconduct Investigations Guideline Old Guidance New Guidance Argument for the Change Argument against the Change Informal resolution (for example, mediation) May not be used for complaints of sexual assault. May be used for any complaint. Avoids the time, energy, and emotional costs of formal investigations. Administrators may push mediation when it is not in victim’s best interest. Standard of proof Must use “preponderance of evidence” standard (50.1% likelihood misconduct occurred). May choose “clear and convincing” standard (75% likelihood misconduct occurred). Less risk of substantiating false accusations. More difficult to substantiate misconduct that did occur. Time frame for completing investigations 60 days suggested time frame. No fixed time frame. Less pressure to rush investigations, particularly in complex cases. Long investigations leave all parties “in limbo” and keep campus at risk. Appeal processes Offered to both complainant and respondent. May be offered only to the respondent. Avoids “double jeopardy”—accused will not be subjected to continued investigation once they are found not responsible. Allows schools to deny victims the right to appeal, providing more process to accused than victims. Direct cross-examination Strongly discouraged. Questions should be asked through an intermediary rather than directly. Permitted. Due process protections for accused. Direct questioning by their perpetrator exposes victims to secondary trauma. Guideline Old Guidance New Guidance Argument for the Change Argument against the Change Informal resolution (for example, mediation) May not be used for complaints of sexual assault. May be used for any complaint. Avoids the time, energy, and emotional costs of formal investigations. Administrators may push mediation when it is not in victim’s best interest. Standard of proof Must use “preponderance of evidence” standard (50.1% likelihood misconduct occurred). May choose “clear and convincing” standard (75% likelihood misconduct occurred). Less risk of substantiating false accusations. More difficult to substantiate misconduct that did occur. Time frame for completing investigations 60 days suggested time frame. No fixed time frame. Less pressure to rush investigations, particularly in complex cases. Long investigations leave all parties “in limbo” and keep campus at risk. Appeal processes Offered to both complainant and respondent. May be offered only to the respondent. Avoids “double jeopardy”—accused will not be subjected to continued investigation once they are found not responsible. Allows schools to deny victims the right to appeal, providing more process to accused than victims. Direct cross-examination Strongly discouraged. Questions should be asked through an intermediary rather than directly. Permitted. Due process protections for accused. Direct questioning by their perpetrator exposes victims to secondary trauma. Table 1: Old versus New Guidance for Title IX Sexual Misconduct Investigations Guideline Old Guidance New Guidance Argument for the Change Argument against the Change Informal resolution (for example, mediation) May not be used for complaints of sexual assault. May be used for any complaint. Avoids the time, energy, and emotional costs of formal investigations. Administrators may push mediation when it is not in victim’s best interest. Standard of proof Must use “preponderance of evidence” standard (50.1% likelihood misconduct occurred). May choose “clear and convincing” standard (75% likelihood misconduct occurred). Less risk of substantiating false accusations. More difficult to substantiate misconduct that did occur. Time frame for completing investigations 60 days suggested time frame. No fixed time frame. Less pressure to rush investigations, particularly in complex cases. Long investigations leave all parties “in limbo” and keep campus at risk. Appeal processes Offered to both complainant and respondent. May be offered only to the respondent. Avoids “double jeopardy”—accused will not be subjected to continued investigation once they are found not responsible. Allows schools to deny victims the right to appeal, providing more process to accused than victims. Direct cross-examination Strongly discouraged. Questions should be asked through an intermediary rather than directly. Permitted. Due process protections for accused. Direct questioning by their perpetrator exposes victims to secondary trauma. Guideline Old Guidance New Guidance Argument for the Change Argument against the Change Informal resolution (for example, mediation) May not be used for complaints of sexual assault. May be used for any complaint. Avoids the time, energy, and emotional costs of formal investigations. Administrators may push mediation when it is not in victim’s best interest. Standard of proof Must use “preponderance of evidence” standard (50.1% likelihood misconduct occurred). May choose “clear and convincing” standard (75% likelihood misconduct occurred). Less risk of substantiating false accusations. More difficult to substantiate misconduct that did occur. Time frame for completing investigations 60 days suggested time frame. No fixed time frame. Less pressure to rush investigations, particularly in complex cases. Long investigations leave all parties “in limbo” and keep campus at risk. Appeal processes Offered to both complainant and respondent. May be offered only to the respondent. Avoids “double jeopardy”—accused will not be subjected to continued investigation once they are found not responsible. Allows schools to deny victims the right to appeal, providing more process to accused than victims. Direct cross-examination Strongly discouraged. Questions should be asked through an intermediary rather than directly. Permitted. Due process protections for accused. Direct questioning by their perpetrator exposes victims to secondary trauma. The new guidelines are interim guidelines, intended to act as placeholders for evaluating school compliance with Title IX until promised permanent legislation is finalized. It is noteworthy that schools are not yet mandated to make any changes to their current procedures and instead have the option of adopting the new interim guidelines if they choose to. Some schools (for example, University of California, Washington University of St. Louis) have already issued statements expressing concern that the new guidelines undermine progress made in recent years and vowing their commitment to fighting sexual misconduct. However, the overarching message sent by the ED is clear: The Trump administration will not be following Obama’s lead when it comes to addressing campus sexual misconduct. A Call to Action for Social Work Title IX investigations do need reform, but adapting them to align more closely with the criminal justice system, as DeVos’s ED is doing, is not the answer. Schools must offer an alternate forum for adjudicating and addressing sexual misconduct that avoids some of the humiliation and frustration victims of sexual assault experience when they report to the criminal justice system. Otherwise, victims will be deterred from reporting, sexual misconduct will go unchecked, and schools will be unable to effectively protect their communities from risk (Brodsky, 2017). The ED has not set a time frame for issuing permanent Title IX guidelines and will meanwhile meet with stakeholders in a “notice and comment” process. This means that there is still time for action before permanent legislation is set. I argue that social workers should take a stance against DeVos and her attacks on Title IX for the following reasons. First, we have an ethical responsibility to speak out against gender discrimination that compromises access to education (NASW, 2017). Second, as members of a profession that advocates for those who have been marginalized, we should be leaders in advocating for victims of sexual misconduct. Finally, we must protect our social work student population, which is still predominantly female and, therefore, disproportionately more likely to experience sexual violence. The health of our profession, and of our society, depends on all students having equal access to educational opportunities, free from sexual harassment and assault. References Brodsky , A. ( 2017 ). A rising tide: Learning about fair disciplinary process from Title IX . Journal of Legal Education, 66 , 822 – 849 . Cantor , D. , Fisher , B. , Chibnall , S. H. , Townsend , R. , Lee , H. , Bruce , C. , & Thomas , G. ( 2015 ). Report on the AAU Campus Climate Survey on Sexual Assault and Sexual Misconduct . Washington, DC : Association of American Universities . Foundation for Individual Rights in Education. ( 2017 ). Spotlight on due process 2017: Executive summary. Retrieved from https://www.thefire.org/due-process-report-2017/ Know Your IX . ( 2017 ). New Title IX interim guidance betrays survivors of campus sexual assault. Retrieved from https://www.knowyourix.org/interim-guidance-statement/ National Association of Social Workers . ( 2017 ). Code of ethics of the National Association of Social Workers . Washington, DC : Author . PubMed PubMed Title IX ( 1972 ). 20 U.S.C. § 1681. U.S. Department of Education . ( 2011 ). Dear colleague letter. Retrieved from https://www2.ed.gov/print/about/offices/list/ocr/letters/colleague-201104.html U.S. Department of Education . ( 2014 ). Questions and answers on Title IX and sexual violence. Retrieved from https://www2.ed.gov/about/offices/list/ocr/docs/qa-201404-title-ix.pdf U.S. Department of Education . ( 2017 ). Q&A on campus sexual misconduct. Retrieved from https://www2.ed.gov/about/offices/list/ocr/docs/qa-title-ix-201709.pdf © 2018 National Association of Social Workers This article is published and distributed under the terms of the Oxford University Press, Standard Journals Publication Model (https://academic.oup.com/journals/pages/about_us/legal/notices)

Palley, Elizabeth

2018 Social Work

doi: 10.1093/sw/swy020pmid: 29701851

The profession of social work has a long commitment to social justice and defending vulnerable populations (National Association of Social Workers [NASW], 2017). Children are by their very nature a vulnerable population and need support to reach their potential. Social workers need to become more engaged in advocacy for the expansion and improvement of U.S. child care policy because of the importance of child care for families and the current state of U.S. child care policy. The need for more expansive child care and early education is a result of increased maternal labor force participation and the well-established research on the importance of early childhood development (Heckman & Masterov, 2007). Seventy percent of all U.S. mothers and 64.2 percent of those with children from birth to age five are in the paid labor force (Bureau of Labor Statistics, 2017). On average, children under five are in the care of someone other than their mother or father 36 hours a week. In other words, spending time in nonparental care is the norm for young children in the United States. Despite the clear need for care, there is no system to address the dearth of affordable care in most parts of the United States. Indeed, 65 percent of parents report that their work schedules are adversely affected by their child care needs (Child Care Aware of America, 2016). The Importance of Child Care There are many facets of child care and early education. Child care is a work support, particularly for women in the labor force. It can be used to support low-income women, to equalize educational opportunities for children, and to engage untrained women in the workforce as child care providers. It can also be seen as a broad-based universal social welfare support, as has been the case in much of Western Europe. Despite the many potential benefits of child care, in the United States there have been several obstacles to government engagement in the provision of child care and early education. Child care has traditionally been seen as solely the responsibility of individual families. Even as women have entered the workforce in great numbers, public support for early education and care has been largely limited to low-income families and more recently to locally based pre-K programs. Government involvement in child care has also been stymied by anti-government sentiments, fueled most recently by Tea Party conservatives. For many who do not oppose government involvement, there are tensions related to the balance of power between the federal, state, and local government over who should be primarily responsible for funding and regulating child care and early education policy (Palley & Shdaimah, 2014). However, few argue that the provision of child care and early education in the United States is optimal or even sufficient. Obstacles to U.S. Child Care Policy The United States struggles with three major problems in relation to child care: availability, quality, and cost. In a 2015 Pew survey, 62 percent of parents with children younger than six reported that it is either very or somewhat hard to find affordable quality child care (Pew Research Center, 2015). The Center for American Progress reported major problems with availability of access to child care (Malik & Hamm, 2016). They identified child care deserts as areas with 30 or more children and no child care center or three times the number of children under five as there were child care centers. They found that 55 percent of children in rural communities live in child care deserts and that in a sample of eight states—Colorado, Georgia, Illinois, Maryland, Minnesota, North Carolina, Ohio, and Virginia—48 percent of children lived in zip codes designated as child care deserts (Malik & Hamm, 2016). The State of U.S. Child Care Despite widespread knowledge that a child’s early learning environment is crucially important for his or her later cognitive skill development and emotional regulation abilities (National Scientific Council on the Developing Child, 2007), many children do not have access to high-quality care. Except for programs designed to help low-income families, and a brief period during World War II where the Lanham Act provided subsidized care to women to encourage them to work for the war effort while many U.S. men were fighting, child care has generally been paid for by individual families (Palley & Shdaimah, 2014). Private day cares help educate children from privileged families, and private options ranging from center-based and home-based care to in-home care by nannies or babysitters and extended family and friends have met U.S. child care needs. The quality of care largely varies with its cost. Much of the highest-quality care is expensive and therefore remains inaccessible to many. For example, the average cost of care in New York, one of the higher-cost states, ranges from $15,028 annually for center-based infant care to $10,972 annually for home-based care (Child Care Aware of America, 2017). Engagement in Child Care Policy Many national and local organizations advocate for the expansion of child care, quality improvement, and strategies to reduce the cost or supplement the cost of care. There seems to be a growing recognition that all these aspects of child care are connected, and advocates are exploring collaborative work, including collaborations between child care advocates and child care providers (Palley & Shdaimah, 2014). The field itself is now referred to as the field of child care and early education, with a recognition that quality care must involve developmentally appropriate educational programming in addition to basic safety. Conclusions: What Can Social Workers Do? There are at least three approaches that we, as social workers, need to consider to assist those people who are vulnerable or have been marginalized or oppressed (NASW, 2017). In the United States, the needs of children and families have long gone unrecognized and underserved. First, we need to familiarize ourselves with political candidates and vote for candidates who seem likely to support an agenda that includes more expansive child care. Second, we can and should understand proposed policy changes related to child care at both the state and the federal level. Policy changes may affect clients including local communities, child care providers, families receiving Temporary Assistance for Needy Families benefits, labor unions, or families whose children have special educational or developmental needs. The National Conference of State Legislatures [NCSL] provides links to early education and care legislation that was passed in 2016 and that which has been proposed in 2017 in all of the U.S. states and territories (NCSL, 2017). On a federal level, the Early Care and Education Consortium (2017) has a Web site that provides updates for all federal policies relating to child care and early education. Child Care Aware of America is another national organization with which we can become involved. These can be useful resources for those seeking to advocate on behalf of more expansive child care policies. Third, we are often in a position through agencies or in our role as lobbyists to help develop legislative proposals or advise legislators on the key considerations that need to be included in legislation (Weiss-Gal, 2013). As both agency representatives and citizens, we can attend public hearings to voice our concerns. This, of course, requires us to be connected to an advocacy community and to be aware when legislative proposals are being considered. In relation to child care, we have to speak to not only issues of cost, but also accessibility and affordability. We can also work to facilitate constituent participation in the legislative process through client outreach; troubleshooting logistical challenges for potential participants; knowing how citizens can participate in local, state, and federal policy making; and providing enough information to interested parties so that their participation can be meaningful. As much of the current advocacy around child care is happening at the state level, it is important for us to stay tuned to what is happening in each of our states. State-level policy making may also provide more opportunities for input because state legislators may be more accessible to citizens than the federal legislators. Finally, social workers can and should help to make a difference and be part of the conversation, if not leaders, in efforts to expand child care policy. Our professional experiences and skills make us uniquely situated to advocate on behalf of improving child care policy. It is time to get involved! References Bureau of Labor Statistics . ( 2017 ). Employment characteristics of families summary. Retrieved from https://www.bls.gov/news.release/famee.nr0.htm Child Care Aware of America . ( 2016 ). Parents and the high cost of child care: 2016 report. Retrieved from http://www.usa.childcareaware.org/advocacy-public-policy/resources/reports-and-research/costofcare/ Child Care Aware of America . ( 2017 ). Cost of child care. Retrieved from https://usa.childcareaware.org/advocacy-public-policy/resources/research/costofcare/ Early Care and Education Consortium . ( 2017 ). Federal legislative updates. Retrieved from http://www.ececonsortium.org/federal-action-center/federal-legislation/ Heckman , J. , & Masterov , D. ( 2007 ). The productivity argument for investing in young children . Review of Agricultural Economics, 29 , 446 – 493 . Google Scholar CrossRef Search ADS Malik , R. , & Hamm , K. ( 2016 ). Child care deserts. Retrieved from https://www.americanprogress.org/issues/early-childhood/reports/2016/10/27/225703/child-care-deserts/ National Association of Social Workers . ( 2017 ). Code of ethics of the National Association of Social Workers. Retrieved from https://socialworkers.org/pubs/code/code.asp National Conference of State Legislatures . ( 2017 ). Early Care and Education Bill Tracking database. Retrieved from http://www.ncsl.org/research/human-services/child-care-and-early-education-legislation-databas.aspx National Scientific Council on the Developing Child . ( 2007 ). The timing and quality of early experiences combine to shape brain architecture (Working Paper #5). Retrieved from https://developingchild.harvard.edu/resources/the-timing-and-quality-of-early-experiences-combine-to-shape-brain-architecture/ Palley , E. , & Shdaimah , C. ( 2014 ). In our hands: The struggle for US child care policy . New York : New York University Press . Pew Research Center . ( 2015 ). Parenting in America: 4. Child care and education: Quality, availability and parental involvement. Retrieved from http://www.pewsocialtrends.org/2015/12/17/4-child-care-and-education-quality-availability-and-parental-involvement/ Weiss-Gal , I. ( 2013 ). Policy practice in practice: The inputs of social workers in legislative committees . Social Work, 58 , 304 – 313 . Google Scholar CrossRef Search ADS © 2018 National Association of Social Workers This article is published and distributed under the terms of the Oxford University Press, Standard Journals Publication Model (https://academic.oup.com/journals/pages/about_us/legal/notices)

Fusaro, Vincent A

2018 Social Work

doi: 10.1093/sw/swy027

The social welfare system in the United States cannot be fully understood without also considering the tax system. Tax revenues fund redistributive programs and publicly supported social services. Who gets taxed, for what reasons, and at what rates shapes the distribution of economic resources. The tax system incorporates important cash transfer programs. With respect to those with low incomes, for example, the Earned Income Tax Credit (EITC) is now a far larger program, both by participation rates and federal expenditures, than Temporary Assistance for Needy Families (“welfare”). The tax system, then, deserves careful attention from social workers. Political scientist Vanessa Williamson’s Read My Lips: Why Americans Are Proud to Pay Taxes is an important addition to the literature on the politics of tax policy in the United States. It offers insights that social welfare professionals and researchers will find both pleasantly surprising and deeply troubling. Williamson’s central purpose is to understand Americans’ attitudes toward tax policy. The dominant narrative around taxation in the United States is one of hostility. It is widely assumed—and reinforced through media framing and political campaign rhetoric—that the typical person in the United States abhors taxes in all forms. These impressions are largely superficial, however, and Williamson uses qualitative data from in-depth interviews and open-ended survey questions, supplemented with quantitative opinion survey analysis, to better understand tax attitudes. Her central finding is that Americans, even those who lean to the political right, actually feel positively about paying taxes. They consider it a civic obligation, and contributing to the greater good is a source of pride. Further investigation, however, reveals severe limits to this sense of collective responsibility. Williamson uncovers a dramatic misperception in who pays taxes that stigmatizes the socially and economically marginalized. Almost all adults pay taxes of some form. Even those who don’t pay federal income tax, for example, might pay payroll taxes or state sales taxes. However, many Americans do not consider those with low incomes to be taxpayers, and Williamson finds that stereotypes about the undeserving poor emerge when discussing taxes. Williamson’s respondents take “taxpayer” to mean income tax payer and give centrality to the income tax as a conveyer of economic citizenship despite the burden of other taxes falling disproportionately on those with low or moderate incomes. Immigrants are also a target of ire, being perceived purely as beneficiaries of others’ tax contributions by some respondents. Williamson attributes the importance her respondents give to the income tax to the structure of the U.S. tax system. The income tax is highly visible and requires an investment of effort on the part of the individual taxpayer not found with other taxes. The payroll tax, for example, is seamlessly deducted from an employee’s paycheck; its value as given by the pay stub is also lower than the actual tax burden, as only the employee’s contribution is listed. State sales tax is simply tacked onto purchases, and, as Williamson’s own respondents note, its costs are often perceived only on very large purchases. In sharp contrast, properly filing the income tax requires action on the payer’s part that makes visible its actual costs. The centrality of the income tax has some surprising side effects. Respondents are often quite familiar with social welfare policies implemented through the income tax system, such as the EITC and the Child Tax Credit, and approve of these programs. Unsettlingly for those who assume policies such as the EITC sidestep traditional welfare politics, for some right-leaning respondents the rhetoric of deservingness often directed toward cash assistance recipients also applies to EITC beneficiaries. These few believe the EITC is excess reward for inadequate work, especially for those who receive a refund. Respondents generally favor a progressive tax code in which those who are wealthier pay a larger share in taxes, though with some caveats. Williamson finds, for instance, that her respondents are hesitant to punish hard work. Marginal tax rates, central to the United States’ progressive income tax system, are also misunderstood. Interviewees often mistake marginal rates for effective tax rates, with the assumption that an individual’s top rate applies to all income. The income tax filing process, which involves the taxpayer identifying the credits and other offsets for which he or she is eligible, also encourages individuals to think of taxes in terms of loopholes and tax breaks rather than in terms of tax rates. The focus on loopholes leads to a perception that the very wealthy are not contributing their fair share, but without reference to the sizable declines in marginal rates for very high earners in recent decades. Williamson uncovers two other important misperceptions with respect to progressivity. First, some individuals mistakenly view sales taxes as progressive, as someone who spends more also pays more tax. In reality, sales tax is quite regressive, disproportionately affecting low-income taxpayers. Second, because of the focus on tax breaks instead of tax rates, some respondents believe a flat income tax system would raise taxes on high earners when, again, it would negatively affect those with low incomes and likely reduce taxes for the very well off. Williamson’s work also reveals that, with respect to fiscal policy, the language used by policy researchers and other experts does not correspond to the way members of the general public use identical terms. “Government waste,” for example, may mean inefficiency to analysts of public policy, but to taxpayers waste is often merely a catchall term for disfavored programs and spending priorities. Similarly, respondents conflate foreign aid, a very small portion of the federal budget, with military support of foreign nations (military spending is otherwise quite positively perceived). It is therefore unsurprising that members of the general public give much larger estimates of the amount of waste in government spending and the proportion of the federal budget devoted to foreign aid than policy experts provide. Overall, Williamson concludes that the common belief about American tax attitudes—that the typical person is opposed to, or even angry about, taxation in any form—is incorrect. Members of the public feel positively about contributing to the common good, taking it as a marker of full participation in society. These feelings are warped, however, by misperceptions, misunderstandings, and biases against groups not perceived as adequate contributors. On the one hand, Williamson’s findings place members of the general public in a more positive light than other social science research on tax politics. Some previous studies of attitudes regarding taxation portray the typical American as woefully uninformed (Bartels, 2005). Williamson suggests that Americans are quite familiar with those taxes directly relevant to themselves and with some aspects of the tax system other researchers have assumed were outside the view of the general public. On the other hand, Williamson frequently encounters misinformation consistent with the more negative views expressed by other authors, but places the blame on the institutional structure of taxation rather than faulting individual taxpayers. She proposes that many of these problematic beliefs could be resolved through clear distribution of information, referencing experiments with social security statements that improved perceptions of the program. Although better information may address some problems, deeper societal change may be required to attenuate the biases expressed by some of Williamson’s respondents against those with low incomes, racial and ethnic minorities, and immigrants. I have two concerns with Williamson’s analysis. First, her entire claim that Americans are proud to pay taxes rests on the veracity of respondents’ self-reported attitudes. If the positive responses are merely an attempt by study participants to please the researcher, it undercuts the entire argument. Second, Williamson treats the information environment that produces many of the misunderstandings as value-neutral, treading lightly around the incentives of political and economic elites to sustain rather than correct misperceptions about tax policy. This approach is understandable; her purpose is to analyze Americans’ attitudes toward taxation, not to scrutinize American political economy writ large. The fiscal policy preferences of the very wealthy do not necessarily align with those of middle- and low-income Americans, however, and political scientists Jacob Hacker and Paul Pierson (2005) have argued that fiscal policy can be deliberately crafted to mislead the general public about the effects of tax changes. Williamson has identified blind spots in public knowledge and opinion that could be exploited for such purposes, and a greater discussion of whether and how such manipulation is happening would have been useful. Despite these limitations, the book makes substantial contributions to understanding taxation and tax politics in the United States. Its findings have a very clear relationship to the politics of the welfare state, especially with respect to economically and socially disadvantaged populations. These insights also inform contemporary debates over policy responses to extreme economic inequality, one of the central problems of the current era. Finally, Williamson’s analysis draws attention to the connection between economic stratification and perceptions about who is considered a full participant in society. The book is therefore a worthwhile read for social workers and others interested in U.S. social and economic policy specifically and the health of American democracy more broadly. References Bartels , L. M. ( 2005 ). Homer gets a tax cut: Inequality and public policy in the American mind . Perspectives on Politics, 3 ( 1 ), 15 – 31 . doi:10.1017/S1537592705050036 Google Scholar CrossRef Search ADS Hacker , J. S. , & Pierson , P. ( 2005 ). Abandoning the middle: The Bush tax cuts and the limits of democratic control . Perspectives on Politics, 3 ( 1 ), 33 – 53 . Google Scholar CrossRef Search ADS © 2018 National Association of Social Workers This article is published and distributed under the terms of the Oxford University Press, Standard Journals Publication Model (https://academic.oup.com/journals/pages/about_us/legal/notices)

Flores, Adriana

2018 Social Work

doi: 10.1093/sw/swy023pmid: 29722871

In the United States poverty is a barrier for individuals and families to access basic hygiene products. An individual who makes an income of less than $12,060 a year is considered below the poverty level (U.S. Department of Health and Human Services, 2017); this amount has to suffice for house or rent payments, car payments, trash, phone, water, electricity, food, buying warm clothing for the winter, and so on. Government assistance for food is available for those making less than the poverty line amount, but hygiene products are excluded from approved purchases. This lack of inclusion for basic hygiene products forces people to make a choice between the hygiene items and payments for living needs. In the United States, 14.4 percent of the population live below the poverty level (U.S. Census Bureau, 2011–2015a). The data are even more shocking within cities, as many demonstrate the disproportional income gap. For example, 40.3 percent of Detroit’s population have an income below the poverty line (U.S. Census Bureau, 2011–2015b). One source of assistance is the Supplemental Nutrition Assistance Program (SNAP). SNAP does not include the purchase of nonfood items including soaps, paper products, and household supplies (U.S. Department of Agriculture Food and Nutrition Service, 2016). Unfortunately, basic hygiene products, such as deodorant, tampons, toothpaste, toilet paper, and so on fall into the excluded categories. Therefore, those who qualify for governmental assistance cannot purchase these essential items with SNAP assistance. Basic hygiene items can quickly become costly. Beyond the essential hygiene products, women pay a higher price due to the necessary monthly cost of menstrual hygiene products. For example, when a woman is on her period, if she chooses to use tampons, she might need four tampons per day for approximately five days—a total of 20 tampons. One box contains 36 tampons and costs $7. Therefore, one woman will need to spend approximately $46 a year on tampons (Kane, 2015). These calculations do not include the taxes placed on these items or any other menstrual products that may be needed. Barriers and Implications for Not Having These Items During my interviews within an East Lansing community, members mentioned various difficulties to acquiring items. An elderly resident noted, “It is hard to get all the way to the bus stop, carry everything I buy from the store onto the bus, and get into my room with everything” (interview with residents of Edgewood Village Apartment complex, February 21, 2017). Others expressed that locations were difficult to access due to the distance and hours of operation: “There are some locations like the People’s Church that have free donated things, but finding time to get there by bus before they close is hard” (interview with residents of Edgewood Village Apartment complex, February 21, 2017). Hygiene products are a necessity, but for those who cannot afford them options are limited for purchase. These difficulties were echoed by Surratt, Kiley, Inciardi, and Kurtz (2005) regarding sex workers stating, “Even when a woman finds a service for which she qualifies and is able to get there during business hours, she is often the victim of stigma associated with her sex work, poor hygiene and appearance, and/or drug use” (p. 355). Currently, there is no research demonstrating the implications, including health consequences, of the lack of hygiene items aside from menstrual and oral hygiene products. There are stigmas and decreased sense of self-esteem when unclean. One can assume that this would affect job prospects and relationships. However, further research on the topic is crucial to obtain data. The lack of a basic need is one way, even in the United States, the cycle of poverty is perpetuated. Social Works Values This gap in service is unjust. The National Association of Social Workers (2017)Code of Ethics states, “Social workers’ social change efforts are focused primarily on issues of poverty, unemployment, discrimination, and other forms of social injustice” (p. 5). It is an injustice that low-income individuals in the United States cannot acquire basic hygiene items. Those who are afflicted by this gap in assistance include individuals, single parents, families, people with disabilities, the elderly, and children. Hygiene items are available, yet they are not accessible to those in need. This speaks to the value of the dignity and worth of individuals. Those who can obtain these items have a yearly income that allows for the purchase of these products while having enough money to pay for other living costs. Acquiring hygiene products should not be an option only for wealthier individuals. E2 |Empathy and Equity| Box Empathy and equity are well-known terms to any social work practitioner. An inaccessibility of basic needs products, due to poverty, demonstrates a gap in equity. Empathy is feeling with the individual who may feel isolated, dirty, or alone because the individual does not have the hygiene items needed. This is an issue requiring action. One project that can provide these basic products to individuals is the E2 |Empathy and Equity| Box. The E2 Box mirrors the concept of the Little Free Library. Rather than books, it is stocked with basic hygiene products including soap, shampoo, conditioner, tampons, pads, toilet paper, laundry detergent, deodorant, and so on. Similar to the Little Free Library, people can either take the products they need or leave products. The pilot E2 Box was launched August 2017 in a low-income apartment complex in East Lansing, Michigan. The project offers an anonymous space for people to acquire the items without judgment or a waiting period. Community engagement was essential to ensure that the E2 Box was a resource that community residents wanted. During community meetings in which challenges, barriers, and needs were discussed, residents were given the opportunity to express possible solutions. Different communities may express distinctive needs. For example, at the pilot location community members expressed need of toilet paper and laundry detergent. Another location may express need of menstrual hygiene products. Once the box was placed on site, creating sustainability was crucial. Partnerships offer strength to the social fabric among community residents of the apartment complex, outside community members, organizations, and institutions. Conclusion The accessibility of hygiene products to those living in poverty is a basic need that is not addressed. Social workers have the opportunity to create social change on the micro, mezzo, and macro levels. There must be policy change, research, and programs to offer people in need resources. The E2 Box is one method created to provide these items. Obtaining hygiene products, a basic need, should not be a barrier for anyone. References Kane , J. ( 2015 ). Here’s how much a woman’s period will cost her over a lifetime. Retrieved from http://www.huffingtonpost.com/2015/05/18/period-cost-lifetime_n_7258780.html National Association of Social Workers . ( 2017 ). Code of ethics of the National Association of Social Workers . Washington, DC : Author . PubMed PubMed Surratt , H. , Kiley , M. , Inciardi , J. , & Kurtz , S. ( 2005 ). Barriers to health and social services for street-based sex workers . Journal of Health Care for the Poor and Underserved, 16 , 345 – 361 . doi:10.1353/hpu.2005.0038 Google Scholar CrossRef Search ADS U.S. Census Bureau . ( 2011 –2015a). Food Stamps/Supplemental Nutrition Assistance Program (SNAP). Retrieved from https://factfinder.census.gov/faces/tableservices/jsf/pages/productview.xhtml?pid=ACS_15_5YR_S2201&prodType=table U.S. Census Bureau . ( 2011 –2015b). Selected economic characteristics. Retrieved from https://factfinder.census.gov/faces/tableservices/jsf/pages/productview.xhtml?src=bkmk U.S. Department of Agriculture Food and Nutrition Service . ( 2016 ). Supplemental Nutrition Assistance Program (SNAP). Retrieved from http://www.fns.usda.gov/snap/eligible-food-items U.S. Department of Health and Human Services . ( 2017 ). Poverty guidelines. Retrieved from https://aspe.hhs.gov/poverty-guidelines © 2018 National Association of Social Workers This article is published and distributed under the terms of the Oxford University Press, Standard Journals Publication Model (https://academic.oup.com/journals/pages/about_us/legal/notices)

Hurst, Carol Grace;Reno, Rebecca;Lefmann, Tess

2018 Social Work

doi: 10.1093/sw/swy028pmid: 29718477

Abstract This article addresses the importance of breastfeeding for the social work profession. Because breastfeeding is a critical component of maternal and child health, persistent racial and socioeconomic breastfeeding inequality is a social justice issue in need of social work commitment. Even while breastfeeding rates have been increasing in the United States there are some groups of mothers who initiate breastfeeding less frequently or have trouble with sustaining breastfeeding for recommended lengths. These mothers and their babies thus miss out on the ample benefits of this nurturing interaction. Using social work’s unique disciplinary perspective and commitment to social justice, the authors place essential understanding of breastfeeding health benefits within the core values of the National Association of Social Work ethical code. The practice context for early breastfeeding intervention with mothers and families is discussed with acknowledgment of the maternal–child health focus at the root of the profession. Recognition of the potential of contemporary social work to advance breastfeeding equity through practice, scholarship, and action positions breastfeeding support activities as integral to meeting the grand challenges of the social work profession. Breastfeeding, one of the first nurturing interactions between a mother and child, has long been recognized scientifically as the healthiest infant feeding method for the child (American Academy of Pediatrics [AAP], 2012; Victora et al., 2016) and more recently for the mother as well. Breastfeeding rates in the United States continue to increase, supported by public health promotion efforts and changing cultural understandings and acceptance for this embodied act of mothering. Even so, disparities remain; mothers who are poor, young, African American, or with less education are less likely to initiate and sustain breastfeeding (Allen et al., 2013). Expert recommendations for exclusive breastfeeding for the first six months of life, with continued breastfeeding to age one or two years and beyond (AAP, 2012; World Health Organization [WHO], 2017) present idealistic goals out of reach for many mothers for whom adequate community and policy supports are not in place. This challenge, coupled with the well-intentioned public health messaging strategy that “breast is best,” may inadvertently marginalize women who endorse the superiority of breast milk but are unable to provide it. A woman who wishes to breastfeed may face individual, cultural, and structural barriers, which are particularly pronounced for low-income women and women of color. Thus, breastfeeding represents a critical social justice issue warranting social work attention. Breastfeeding is a significant aspect of sexual and reproductive health for mothers (Alzate, 2009; Wright, Bird, & Frost, 2015). Breastfeeding research is typically conducted in disciplines such as nursing, public health, and medicine. Scholars and practitioners from these fields are not necessarily trained to recognize the environmental context within which women reside or to harness the strengths that marginalized populations draw on. This article addresses the importance of breastfeeding, grounding it within core social work values articulated by the National Association of Social Workers (NASW) and demonstrating how breastfeeding support aligns with the American Academy of Social Work and Social Welfare’s (AASWSW) Grand Challenges for Social Work. Health Benefits of Breastfeeding Breastmilk is a complete and perfect food including fatty acids, nutrients, and dynamic immunological components conferring scientifically well established, far-reaching effects on infant and child well-being (AAP, 2012; Victora et al., 2016). Breastfed infants have a strengthened immune system, even demonstrating a higher antibody response to vaccines (Silfverdal, Ekholm, & Bodin, 2007). They are less prone to respiratory infection, have a decreased probability of sudden infant death syndrome (AAP, 2012) and postneonatal mortality (Khan, Vesel, Bahl, & Martines, 2015), and are less susceptible to allergies and eczema (Moss & Yeaton, 2014). Diarrhea, the second leading cause of death in children under the age of five, is considerably less common among breastfed infants due to the high levels of lactose in breastmilk that supports growth of healthful bacteria in the gut (Andreas, Kampmann, & Le-Doare, 2015; Turin & Ochoa, 2014). Endorphins in breastmilk contribute to a higher pain tolerance, increasing an infant’s ability to combat the negative effects of stress and potential hardship (Harrison et al., 2014). Benefits of breastfeeding continue into childhood with breastfed children demonstrating lowered risks of acute leukemia (AAP, 2012); decreased likelihood of developing obesity or diabetes; and fewer psychological, behavioral, and learning problems (Binns, Lee, & Low, 2016). Many of these outcomes are a direct result of a decrease in the human stress hormone cortisol during critical periods of infancy related to attachment that stems from breastfeeding and direct skin-to-skin contact (Neelon, Stroo, Mayhew, Maselko, & Hoyo, 2015). Benefits of breastfeeding for the mother have also been established (AAP, 2012). After giving birth, oxytocin released during a newborn’s first latch initiates contractions that force the uterus back to its original size, leading to less blood loss after birth (Abedi, Jahanfar, Namvar, & Lee, 2016). Calcium is absorbed at a higher rate when a woman is lactating, contributing to stronger bones and a decreased propensity for osteoporosis. Women who have ever breastfed are also less likely to develop breast or uterine cancer (AAP, 2012). According to Mezzacappa (2004), breastfeeding is associated with an attenuated sympathetic cardiac nervous system response to stress, an increased parasympathetic nervous system modulation, decreased neuroendocrine response, and decreased negative mood. Breastfeeding mothers report feeling less life stress and depression and enhanced physical and mental health than nonbreastfeeding mothers (AAP, 2012). Furthermore, the release of oxytocin promotes warm maternal behavior and attachment to the infant, leading to positive parenting practices (Heinrichs, Neumann, & Ehlert, 2002). Breastfeeding and Policy Women do not breastfeed within an isolated context; rather, they live within larger social and structural contexts that affect their breastfeeding behavior. Although breastfeeding is often presented as natural and instinctual, many women struggle with establishing and maintaining a breastfeeding relationship with their infants. When problems arise, they need active support for breastfeeding (WHO, 2017). Such support is often provided by a lactation counselor, a physician, or a pediatrician (Amir, 2014). Thus, for many women, their breastfeeding relationship is mediated by their access to medical care, their trust in medical providers, and their care provider’s knowledge and attitudes about breastfeeding. If a care provider is ill informed or has a negative attitude about breastfeeding (Mass, 2015; Szucs, Miracle, & Rosenman, 2009), or if a mother has reason to mistrust health authorities, initiation and duration of breastfeeding may be affected. Although the excellent supplemental nutrition support program for pregnant mothers and young children, Women, Infants, and Children (WIC) effectively supports breastfeeding through information and food packages (Panzera et al., 2017), the program also provides free formula for the infants of many of the nation’s low-income families, which may undermine breastfeeding (Jensen & Labbok, 2011; WHO, 2017). Given the relatively inadequate family leave policies in the United States, many women, particularly low-income women, are returning to work before their milk supply is well established. Work concerns are associated with lower levels of breastfeeding initiation and shorter breastfeeding durations (Ogbuanu, Glover, Probst, Liu, & Hussey, 2011). For many women returning to low-wage jobs, taking breaks to express breastmilk may be stigmatized and discouraged, making breastfeeding difficult if not impossible (Rojjanasrirat & Sousa, 2010; WHO, 2017). Prioritization of protection for breastfeeding in our health policies is critical for protecting a woman’s right and ability to breastfeed (Bruk-Lee, Albert, & Stone, 2016). The Patient Protection and Affordable Care Act (ACA) has provisions in place to do just this, ensuring that women have access to breastfeeding support and breast pumps and working to legally protect a woman’s time and space to breastfeed in the workplace (Drago, Hayes, & Yi, 2011). The future of the ACA is uncertain, but social workers should continue to advocate for the protection of breastfeeding rights and ensure that low-income women have equitable access to benefiting from these breastfeeding policy provisions (Hawkins, Noble, & Baum, 2017). Social workers can empower women to be aware of their legal breastfeeding rights (Hurst, 2012), connect them with breastfeeding counselors, and help them secure access to a breast pump, as needed. This work is aligned with social work core values and was historically within the scope of social work practice in maternal and child health (Combs-Orme, 1988). Breastfeeding and the Core Values of Social Work Breastfeeding support fits within the profession’s primary mission to “enhance human well-being and help meet the basic human needs of all people, with particular attention to the needs and empowerment of people who are vulnerable, oppressed, and living in poverty” (National Association of Social Workers [NASW], 2017, para. 1). Ethical emphases of the social work profession are summarized in six core values that guide social work practice: service, social justice, importance of human relationships, dignity and worth of the person, integrity, and competence. Service Social workers seek to help people in need and address social problems (NASW, 2017). Given the benefits of breastfeeding, differential rates of breastfeeding based on race and socioeconomic status reveal pervasive injustice. Breastfeeding disparity is a social problem worthy of targeted attention. Social work researchers and practitioners are needed to uncover structural arrangements and other factors impeding disadvantaged women’s breastfeeding success and to assist them in initiating and sustaining breastfeeding, should they so choose. The imperative for social work to address this health inequity is not a new concern for our profession; maternal and child health was once a central priority for social work (Combs-Orme, 1990; Uehara et al., 2015). In fact, due in large part to the efforts of social workers beginning in the progressive era, the United States saw a significant, and lasting reduction in infant mortality rates (Combs-Orme, 1988). The social work promotion of breastfeeding was an integral part of these efforts. Settlement house social workers Julia Lathrop, Florence Kelley, and Grace Abbott forged a concern for maternal and child health improvement and launched the Children’s Bureau (Sorensen, 2008). Kelley’s policy expertise contributed to the passage of the Sheppard-Towner Maternity and Infancy Protection Act in 1921. Just as these pioneers once understood maternal and infant health to be a keystone of the health of our nation, present-day social workers can also engage breastfeeding as a health practice with a cascade of proven benefits. Social Justice Social workers pursue social change on behalf of vulnerable and oppressed groups of people, striving to ensure access to needed information, services, and resources to address injustice (NASW, 2017). Low-income women have lower rates of breastfeeding as do African American women. For African American women, this disparity persists across all socioeconomic levels (Allen et al., 2013; McDowell, Wang, & Kennedy-Stephenson, 2008). It would be easy to dismiss this as the result of personal preference, were it not for the contrast between breastfeeding intention rates during the prenatal period and breastfeeding initiation and continuation rates in the postpartum period. Lee et al. (2005) found that more low-income African American women intended to breastfeed in the prenatal period than their non-Hispanic, white counterparts, but Allen et al. (2013) reported that fewer African American women initiate breastfeeding in the hospital and have a lower average duration of breastfeeding. Personal, cultural, and structural breastfeeding barriers during pregnancy and the postpartum period affect breastfeeding among African American women (Reeves & Woods-Giscombe, 2015). These barriers are an outgrowth of the racialized history of the United States, especially the marginalization and oppression of African American women related to reproduction and maternal health (Roberts, 2016). African American women were used as wet nurses during slavery (Golden, 1996). Medical experimentation on black bodies without consent has multiple examples, from the Tuskegee syphilis study to the use of Henrietta Lacks’s genetic material (Skloot, 2011). More recently, while eugenics laws were in effect, numerous involuntary sterilizations were committed against African American women, continuing into the 1970s (Roberts, 2016). Furthermore, medical associations worked diligently to undermine and eradicate the practice of midwifery in African American communities (Goode & Katz Rothman, 2017). All of this reflects a deeply troubling history of suffering at the hands of the medical establishment, particularly related to reproduction, throughout American history (Russell, 2016). African Americans have reasons for a deep and enduring mistrust of the medical establishment, but this attitude negatively influences health-seeking behaviors and compliance with physician recommendations (Randall, 1995). Emerging epigenetic research suggests that both historical and present-day racial injustices affect human health. Geronimus, Hicken, Keene, and Bound (2006) demonstrated that coping with toxic stressors associated with race and racism can result in negative impacts on health, as measured by allostatic load. Allostatic loads are measures of cumulative wear and tear on body systems resulting from stress, and African American women have demonstrated the highest allostatic loads of all groups, including higher allostatic loads than African American men. Because black mothering matters, more research is needed to determine how allostatic load affects breastfeeding and whether breastfeeding can mitigate some of the cumulative negative impacts of toxic stress. Importance of Human Relationships A child is born with the instincts to connect to other humans. One of the earliest opportunities for connection happens within moments following birth, when the mother and child first see each other face-to-face. WHO (2017) endorses breastfeeding initiation within the first hour postbirth, which often happens without intervention as newborns are elegantly programmed to respond to the breast just minutes after birth. Without aid, the newborn can successfully find the breast and latch on, initiating a symbiotic relationship with long-lasting benefits (Klaus, 1998). With this, the act of breastfeeding often becomes a central part of establishing a nurturing relationship between mother and child. Breastfeeding over the early weeks can assist a mother in reading the unique signals of hunger or distress that her baby communicates. Breastfeeding empowers her to comfort and calm her baby. It is a method of infant care with profound biopsychosocial–spiritual synergies. As the mother suckles the infant and holds the child skin to skin, the baby is assisted with regulation of distress. The milk let-down reflex, prompted by the “love hormone” oxytocin in the mother’s body, helps her calm and relax as well (Heinrichs et al., 2002). A breastfeeding dyad that has established a successful breastfeeding rhythm move together as partners in this duet of attachment, grounding and soothing each other. A majority of mothers in studies exploring maternal breastfeeding attitudes perceive breastfeeding as a way to facilitate bonding (May et al., 2015; McCann, Baydar, & Williams, 2007), and breastfeeding is culturally associated with positive enactment of the mothering role. What happens when the ideal beginning does not happen? Breastfeeding is a natural part of the childbearing cycle, yet it is also a behavior that a mother needs to learn and persist in within the context of her other relationships (WHO, 2017). When breastfeeding goals are not met, a mother may be disappointed, even self-blaming, with her sense of efficacy as a mother affected. Thus, breastfeeding can facilitate human relationships, but when not adequately supported, it can also strain relationships or become a source of frustration and disappointment. Dignity and Worth of the Person Belief in the dignity and worth of each person in every complicated intimate family situation is needed to respect self-determination regarding breastfeeding. This core responsibility sensitizes the social worker to listen with compassion to clients as the experts on their own lived experiences. Emphasis on the importance of breastfeeding may raise concerns about excluding parents who do not want to breastfeed, cannot breastfeed, or wean early for any number of reasons. Breastfeeding is not an inclusive option for everyone; biologically, it is most available for the woman who gives birth to the child. Women’s experiences with lactation vary. For example, some women who have experienced sexual trauma may find breastfeeding uncomfortable (Núñez, 2016). Other women find the time-consuming nature and physical demands of breastfeeding overwhelming (Elfgen, Hagenbuch, Gorres, Block, & Leeners, 2017). From adoption and surrogacy scenarios to including fathers as primary caregivers, social workers can assist clients with informed choices regarding breastfeeding and the provision of human milk. People may individually ascribe meaning to their acts of breastfeeding that help them navigate the profound transitions required of them with a child’s entrance into the world. Birth mothers placing an infant for adoption may be comforted by breastfeeding for a brief time. Open adoptions may facilitate the sharing of pumped milk. Nonbiological mothers sometimes seek to stimulate the production of their own milk supply to assist with bonding with a child. This is physically possible and regularly achieved by adoptive mothers as well as mothers receiving a child from a surrogate birth arrangement (Newman & Goldfarb, 2015). Even fathers who parent without a birth mother may have an interest in banked breastmilk. Accurate knowledge of breastfeeding is relevant for practicing social workers in instances where breastfeeding may be contraindicated for medical reasons. Women who are undergoing cancer treatment, are taking certain psychotropic medications, are HIV-positive, or have other active infectious states may be medically advised against breastfeeding (AAP, 2012). In addition, for women using illegal drugs during or after pregnancy, breastfeeding may be inadvisable. Social workers must be mindful of such advice and assist the mother with information regarding expressing milk if the concern is short-term, so that return to breastfeeding could occur when medically safe to do so (AAP, 2012). It is the role of the social worker to respect the woman’s self-determination, listen to her preferences regarding her infant feeding method, and—if she is open to discussion—her rationale behind that decision. Breastfeeding is best for the infant, but it is not necessarily the best for every woman. By being open and nonjudgmental, a social worker can create the space to discuss a woman’s infant feeding choice and ensure that she understands the benefits of breastfeeding, helping to address any barriers to breastfeeding if the woman so wishes. Integrity Social workers must act honestly and in a trustworthy manner, upholding the values of the profession (NASW, 2017). Maintaining cultural competence and respect for diversity is an important ethical responsibility toward clients. Moral judgment regarding good mothering can easily be tied to breastfeeding. Mothers who do not breastfeed can still bond with their children and be good mothers. But whereas not all mothers should be expected to breastfeed, neither should any mother be assumed to be incapable or unworthy of breastfeeding and denied access to breastfeeding services because of such perception. Social workers practice each day with nonideal family situations, but breastfeeding may be helpful even in those situations. For example, if a mother who has struggled with addiction can stop using, breastfeeding may still be an option for her child. Infants born with neonatal abstinence syndrome are able to breastfeed, and the receipt of breastmilk results in a reduction of their withdrawal symptoms (Pritham, 2013). A mother’s breastfeeding may augment her own recovery, subvert the stigma of having exposed the baby to drug use, and help her bond with the baby (Mallory & Watson, 2016). Competence Social workers are expected to practice competently within their areas of expertise and to continue to develop and enhance their professional knowledge for effective practice (NASW, 2017). Generalist social work practice competence for breastfeeding includes knowing breastfeeding recommendations and common concerns of breastfeeding mothers, and a willingness to collaborate with lactation specialists and others to prioritize and preserve breastfeeding. Experts recommend exclusive breastfeeding for the first six months (AAP, 2012; WHO, 2017). The two most common problems experienced by novice breastfeeding mothers in the early weeks postpartum are nipple or breast pain and concern over a low milk supply (Amir, 2014). Report of these concerns from a mother means that she should be connected with a knowledgeable breastfeeding mother, lactation consultant, or breastfeeding support group as soon as possible to preserve breastfeeding. Breast pain indicates a poor latch, physical problems such as infant tongue-tie, or maternal breast infections. Many mothers doubt their milk supply when they cannot see the amount that the baby is getting; actual low milk supply can be reversed by allowing the infant to continue to suckle to stimulate the body to produce more milk. Grand Challenges Addressed by Breastfeeding AASWSW has identified 12 Grand Challenges for Social Work, aiming to focus social work intention and direct targeted efforts to address and remedy disparities and injustices (Uehara et al., 2013). The grand challenges provide a mechanism through which the field can organize, galvanize, and collectively advance the profession (Bent-Goodley, 2016). The grand challenges are categorized into three overarching areas: (1) the promotion of individual and family well-being, (2) strengthening of the social fabric, and (3) the creation of a just society. Investing in the pursuit of breastfeeding equity has the potential to both promote individual and family well-being and create a more just society. Within the 12 challenges, breastfeeding is directly related to the initiative to close the health gap and the achievement of equal opportunity and justice. Closing the Health Gap Breastfeeding is associated with a reduction of risk in many arenas that constitute the health gap between white people and people of color. It is associated with both short- and long-term psychological and physiological benefits for the mother–infant dyad and can serve as an upstream intervention, because the health benefits extend across both of their lifetimes. Although it alone cannot address the multiple social determinants of health that affect health inequity, breastfeeding may serve as a mediating factor, decreasing poor health outcomes that are pervasive in low-income communities of color. For example, in the immediate postpartum period, breastfeeding reduces an infant’s risk of dying in the first year of life (Khan et al., 2015). This is particularly noteworthy as the infant mortality rate for African Americans is more than twice the rate for white Americans (Kochanek, Murphy, Xu, & Tejada-Vera, 2016). In short, breastfeeding is a critical mechanism through which social work can pursue health equity for both infants and their mothers (White, 2014). Achieving Equal Opportunity and Justice Social work is a discipline that prioritizes the identification and remediation of social injustices, and breastfeeding is one component of maternal and child health inequity. Like other health disparities, breastfeeding is directly and indirectly affected by interpersonal and structural discrimination. For example, Gee, Zerbib, and Luckett (2012) found that African American women receive less in-hospital lactation support than their white counterparts following birth. The availability of community support at hospital discharge may differ by the mother’s race as well. Evans, Labbok, and Abrahams (2011) demonstrated that WIC clinics serving higher proportions of African American women had more limited and less intensive breastfeeding services than clinics predominantly serving white and Hispanic women. Even when services are available, they may not be culturally responsive, failing to recognize the unique barriers that women of color may face in breastfeeding (Reeves & Woods-Giscombe, 2015). Suppressed breastfeeding rates among African American women in particular are part of this nation’s historical and present-day legacy of racism, structural violence, and oppression (Freeman, 2015). As such, we have a moral and ethical obligation to acknowledge this history, uncover ways that injustice is still being perpetrated, and work systematically to dismantle our oppressive reproductive practices. Given the professional values of social work, and the unique, person-centered disciplinary lens, mobilizing and engaging social work professionals around the issue of breastfeeding could make great strides in achieving equal opportunity and justice. Role of Social Work in Research: Interdisciplinary Breastfeeding Collaborations The Grand Challenges for Social Work encourage innovative, collaborative work (Uehara et al., 2013). Breastfeeding represents an arena where social work must join forces with other disciplines. The unique perspective that social work brings to the interdisciplinary table, or our scholarly capital (Barth, Gilmore, Flynn, Fraser, & Brekke, 2014), includes the person-in-environment framework, the strengths-based lens, and ready recognition of multiple social–ecological factors. Using the strengths-based approach in breastfeeding scholarship can move beyond the identification of breastfeeding barriers toward understanding the factors that support resilience in achieving breastfeeding goals. Until the circumstances within which women are breastfeeding are considered, research and interventions will inherently be insufficient. Breastfeeding decision making is made within a woman’s social support network and work environment, while weighing child care availability and other contextual factors. This understanding of breastfeeding as a health behavior that is nested within varying social–ecological levels allows for a more comprehensive understanding of a mother’s breastfeeding support needs. Using a strengths-based lens is critical. Breastfeeding research has long been framed as trying to understand why deficient women make poor health choices in the face of all evidence to the contrary. A social work approach to breastfeeding is unique in that it explicitly calls for identifying sources of strength and recognizing resilience in breastfeeding women. Role of Social Work in Practice Hull House and Children’s Bureau practitioners pioneered the social work role in maternal and child health (Combs-Orme, 1990). Their policy, research, and practice efforts to address infant mortality contributed to a 92 percent reduction in infant deaths in the 20th century (Combs-Orme, 1988), representing a stunning accomplishment of the social work profession (Uehara et al. 2015). Given the 21st century’s research demonstrating the impact of social determinants of health on health outcomes, our discipline would be remiss in not preparing social work practitioners to reengage that maternal–child health work. Social work practitioners can support breastfeeding at a number of junctures. Social workers can advocate on behalf of breastfeeding women for more inclusive breastfeeding-friendly spaces and maternal leave policies that support women’s efforts to breastfeed in the critical postpartum period. Social workers can directly engage pregnant and parenting women throughout the perinatal period through programs such as WIC, early intervention home visiting programs, in hospitals, and in medical offices working as behavioral health specialists. During these interactions social workers can support breastfeeding mothers and work collaboratively within families to address barriers to breastfeeding. Understanding the context within which women are breastfeeding is critical to determine how best to provide support. This includes recognition of micro, mezzo, and macro factors affecting breastfeeding and intentional efforts to improve the chances that a mother can successfully maintain breastfeeding. It is easy to imagine that sustaining breastfeeding is difficult, if not impossible, when a young mother, with few family supports and little money, is sent home from hospital in a taxi alone with her newborn, to return to a precarious home base. Should breastfeeding problems arise, this mother may not have a support network knowledgeable of breastfeeding, and she may not have access to or be aware of professional breastfeeding resources. If she has not seen breastfeeding modeled in public, she may feel alone and uncertain about venturing out of the house, doubting that others welcome the sight of her breastfeeding. She may need to return to work earlier than her more affluent counterparts, without an efficient breast pump, which is necessary to maintain milk supply. Social workers can be part of the solution for such mothers. Support groups and early intervention community-centered programs counter isolation (Pérez-Escamilla, 2015). Peer counseling can provide mother-to-mother phone and home visit support. When programs are responsive to the conditions within which women live, and positive relationships and supportive networks are nurtured to celebrate motherhood and assist breastfeeding, breastfeeding itself can become part of reknitting the fabric of sisterhood, family, and community. Conclusion The Grand Challenges for Social Work compel us to tackle some of society’s toughest problems (Uehara et al., 2015); committing to breastfeeding will help affect entrenched health equity issues. Building on the core values of our discipline, social workers can empower women to achieve their breastfeeding goals, contribute to breastfeeding research, and help reduce health inequities across the life course for at-risk populations. If we do this, we will bring energy to achieving health equity and create a more inclusive and just society through attention to the health and well-being of mothers and children. References Abedi , P. , Jahanfar , S. , Namvar , F. , & Lee , J. ( 2016 ). 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Martinez, Linda Sprague;Thomas, Cathi A;Saint-Hilaire, Marie;McLaren, Jaye;Young, Jaime;Habermann, Barbara;Tickle-Degnen, Linda

2018 Social Work

doi: 10.1093/sw/swy026pmid: 29722873

Macro practice is intended to catalyze change in the systems that affect people’s lives, as such the focus is on the ecological context in which individuals and groups operate. Working from a place of empowerment and social justice, macro practitioners rely heavily on community partnerships and engagement and focus on community strengths and assets that can be leveraged to advance social justice. In an attempt to engage communities of color in Parkinson’s disease (PD) research, and to increase awareness of PD in communities of color, macro social work strategies were used by the emergence and evolution of Social Self-Management of Parkinson’s Disease (SocM-PD) research team. SocM-PD is a prospective cohort study examining the social self-management systems and trajectories of people living with PD (Tickle-Degnen et al., 2014). There are disparities in PD clinical trial participation; a systematic review revealed that African Americans in particular were poorly represented in PD clinical trials (Schneider et al., 2009). Among studies that reported enrolling people of color, African Americans represented just 1.7 percent of the study population (studies that targeted only people of color being excluded) (Schneider et al., 2009). Recruitment challenges, however, are not unique to PD researchers. People of color, particularly African Americans and Latinos, are underrepresented in clinical research and can be difficult to recruit (Hussain-Gambles, Atkin, & Leese, 2004; Mosenifar, 2007; Shavers-Hornaday, Lynch, Burmeister, & Torner, 1997). Schneider et al. (2009) described barriers to engaging people of color in PD research that include a lack of information about PD, fear, stigma, and not having a usual source of primary care. Added challenges to engaging people of color in PD research include historical and contextual factors. For example, systematic oppression has contributed to African American distrust and suspicion of the academic research enterprise (Alvarez, Vasquez, Mayorga, Feaster, & Mitrani, 2006; Sprague Martinez, Freeman, & Winkfield, 2017; Young, 2009). It is for this reason that studies seeking to work in collaboration with traditionally marginalized communities might consider drawing on macro practice strategies, such as community assessment and asset mapping. Asset mapping includes the identification and categorization of individual, organizational, and institutional assets. Assets are generally grouped in three categories based on control or ownership and place (Kretzmann & McKnight, 1993). Primary assets are located within and controlled by a given community, whereas secondary assets may be located within the community but controlled by outsiders (Kretzmann & McKnight, 1993). Finally, potential assets are those that are neither in nor controlled by a target community but may be leveraged by the community (Kretzmann & McKnight, 1993). This article adds to the literature, highlighting a need for community partnerships and campaigns designed to leverage existing community assets and engage diverse community stakeholders in the promotion of PD awareness. The macro social work–informed strategy used is described in detail, followed by a discussion of lessons learned. A Macro Social Work–Informed PD Outreach Strategy Primary and secondary assets in the PD community in and around Massachusetts—as well as assets in Boston neighborhoods with high concentrations of people of color not connected to the PD community—were mapped. Within the PD community support groups, programs and community events designed for individuals with PD and their caregivers were explored. In the broader community, the focus was on assets across multiple sectors of community life, such as religious, cultural, health, social services, elder-serving organizations, housing communities, media outlets, and community wellness events. Identified assets were categorized using a spreadsheet. Assets were grouped on the basis of the services and programming provided by the organization—for example, health care delivery organizations, housing supports, religious institutions, media outlets, and advocacy organizations. Spreadsheet data were imported to Google Earth to explore the geographic distribution of identified assets. In addition, based on Kretzmann and McKnight (1993), we determined the extent to which assets were locally controlled and operated, and the location of each asset. Primary and secondary assets were contacted by telephone and visited in person by members of the research team who shared general information about PD and information about the SocM-PD study. Sites were also invited to host educational sessions, which described PD symptoms and strategies for communicating with primary care providers about healthy aging. Sessions were available in English and Spanish. Outcomes Of the assets identified during our community outreach, primary assets included locally owned media outlets and PD support groups, as well as religious and cultural organizations. Secondary assets fell into the following categories: community health centers, hospitals, senior housing sites, community development corporations, social services organizations, and libraries. Potential assets identified included the following: elder services and local policymakers focused on elder issues. Insurers were also identified as potential assets, although we did not disseminate information to them. Figure 1 (based on Kretzmann & McKnight, 1993) provides an illustration of organizational assets identified in the community. Figure 1: View largeDownload slide Asset Map Figure 1: View largeDownload slide Asset Map In total, information about PD and the study was disseminated at 308 locations; 32 informational sessions about PD and healthy aging were held, and presentations about the study were made for 35 support groups. Figure 2 illustrates the geographic distribution of (a) PD-specific assets (support groups and programs) and (b) assets embedded in communities of color. Figure 2: View largeDownload slide Massachusetts Outreach Map and Boston Outreach Map Figure 2: View largeDownload slide Massachusetts Outreach Map and Boston Outreach Map The PD community demonstrated high awareness of PD, whereas among communities of color not connected to the PD community, knowledge of PD varied greatly. Within the PD community we found greater levels of interest in the SocM-PD study in cases where leaders shared positive personal experiences with research and were excited about research. When leaders were neutral, people were less likely to request further information. Educational sessions were well received by housing sites; however, resident awareness of PD was low. In-person outreach in communities of color was more effective than telephone and e-mail outreach. Lessons Learned Using the tools of macro practice social work aided in our ability to understand community systems and dynamics. Meanwhile, identifying and connecting with organizational leaders helped with the identification of individual assets and expanded our team’s reach. The more time we spent in the community, the more organizational contacts we received for sites interested in learning more about PD. Taking the time to provide resident forums and information sessions related to healthy aging and PD enhanced our relationships with housing and support organizations and increased community awareness. While spending time in the community, we learned about the extent to which health promotion programming designed for older adults of color in Boston is predominantly focused on chronic diseases such as diabetes, hypertension, cardiovascular disease, obesity, and cancer. During outreach and information sessions at community housing sites, we found few older adults of color with an awareness of chronic neurological conditions like Alzheimer’s and PD. Of note was the frequency with which older adults we spoke with saw these two very different conditions as being the same. Those who did report knowing about PD shared that they had a personal relationship with someone with a PD diagnosis. We found that there is great diversity with respect to the organization and structure of PD-specific groups. Among groups, some identified as traditional support groups, lending sympathetic ears to one another. Others were solely focused on the dissemination of community resources and symptom management. Nontraditional PD groups focused on healthy aging through active engagement in exercise. Group size varied dramatically, ranging from three to 27 attendees; group venues included churches, community centers, independent and dependent living accommodations, and fitness centers. We found few people of color participating in PD groups. Of note, the majority of PD support groups are in suburban communities; only one was identified in the city of Boston. Overall, community and organizational leaders were open to participating in educational, social, and research opportunities; this was true in both the PD community and the communities of color. The leaders of PD groups set the tone for their members. Many, for example, were adamant about getting their members involved in research as a way to give back to the PD community. They spoke about each and every person’s role in enhancing PD awareness and understanding, emphasizing a collective responsibility to increase quality of life for individuals living with PD, their families, and those who will be diagnosed in the future. A significant number of community leaders were skeptical of research. This hesitancy stemmed from unfamiliarity with research and previous negative experiences, including results not being reported back at the end of the study or feelings of being “over-tapped” by researchers to help with recruitment alone. However, even those not interested in the research were interested in the information about healthy aging and PD. Conclusion The barriers to engaging individuals with PD are complex; a lack of PD awareness and the absence of discourse related to healthy aging and PD in communities of color play a role. Although the prevalence of PD in communities of color is not clear, there are indicators that underdiagnosis persists (Branson & Saint-Hilaire, 2017). The more aware communities of color are of the signs and symptoms associated with PD, the more likely they will be diagnosed. Similarly, the more community providers are thinking about PD, the more likely they will be to discuss it. Community-driven campaigns and strategies conducted in partnership with community stakeholders may improve awareness. This might include campaigns designed in collaboration with religious and secular leaders as well as residents; older adult research advocacy training; hiring local community members who reflect the racial and ethnic makeup of the target population, to inform the development and implementation of research, as well as volunteer registries for neurodegenerative disorders; and engaging macro social workers as research team members and in the training of PD research teams in community partnership research. References Alvarez , R. A. , Vasquez , E. , Mayorga , C. C. , Feaster , D. J. , & Mitrani , V. B. ( 2006 ). Increasing minority research participation through community organization outreach . Western Journal of Nursing Research, 28 , 541 – 560 . Google Scholar CrossRef Search ADS Branson , C. , & Saint-Hilaire , M. ( 2017 ). A short commentary on the racial disparities in Parkinson’s disease . Journal of Neurological Disorders, 5 ( 338 ), 2 . doi:10.4172/2329-6895.1000338 Hussain-Gambles , M. , Atkin , K. , & Leese , B. ( 2004 ). Why ethnic minority groups are under-represented in clinical trials: A review of the literature . Health and Social Care in the Community, 12 , 382 – 388 . Google Scholar CrossRef Search ADS Kretzmann , J. P. , & McKnight , J. ( 1993 ). Building communities from the inside out: A path toward finding and mobilizing a community’s assets . Evanston, IL : Northwestern University, Center for Urban Affairs and Policy Research, Neighborhood Innovations Network . Mosenifar , Z. ( 2007 ). Population issues in clinical trials . Proceedings of the American Thoracic Society, 4 , 185 – 188 . Google Scholar CrossRef Search ADS Schneider , M. G. , Swearingen , C. J. , Shulman , L. M. , Ye , J. , Baumgarten , M. , & Tilley , B. C. ( 2009 ). Minority enrollment in Parkinson’s disease clinical trials . Parkinsonism & Related Disorders, 15 , 258 – 262 . doi:10.1016/j.parkreldis.2008.06.005 Google Scholar CrossRef Search ADS Shavers-Hornaday , V. L. , Lynch , C. F. , Burmeister , L. F. , & Torner , J. C. ( 1997 ). Why are African Americans under-represented in medical research studies? Impediments to participation . Ethnicity & Health, 2 , 31 – 45 . Google Scholar CrossRef Search ADS Sprague Martinez , L. , Freeman , E. R. , & Winkfield , K. M. ( 2017 ). Perceptions of cancer care and clinical trials in the black community: Implications for care coordination between oncology and primary care teams . Oncologist, 22 , 1094 – 1101 . Google Scholar CrossRef Search ADS Tickle-Degnen , L. , Saint-Hilaire , M. , Thomas , C. A. , Habermann , B. , Martinez , L. S. , Terrin , N. , et al. . ( 2014 ). Emergence and evolution of social self-management of Parkinson’s disease: Study protocol for a 3-year prospective cohort study . BMC Neurology, 14 , 95 . doi:10.1186/1471-2377-14-95 Google Scholar CrossRef Search ADS Young , I. M. ( 2009 ). Five faces of oppression. In G. Henderson & M. Waterstone (Eds.), Geographic thought: A praxis perspective (pp. 55 – 71 ). New York : Routledge . © 2018 National Association of Social Workers This article is published and distributed under the terms of the Oxford University Press, Standard Journals Publication Model (https://academic.oup.com/journals/pages/about_us/legal/notices)

Dodds, Robin L;Yarbrough, Dana V;Quick, Nubia

2018 Social Work

doi: 10.1093/sw/swy019pmid: 29701848

Effective peer support is important to the promotion of well-being in parents of children with disabilities or special health care needs, who may suffer from higher levels of stress due to increased caretaking burden and difficulty navigating systems of care (White & Hastings, 2004). Parents from culturally and linguistically diverse (CLD) communities may bear the effects of additional stressors, such as economic instability, language barriers, limited access to disability-related information, the aftereffects of trauma, and lack of social support (Khanlou, Haque, Sheehan, & Jones, 2015). Unfortunately, when CLD families of children with disabilities reach out, the support they receive may not be culturally sensitive or culturally appropriate (Fellin, Desmarais, & Lindsay, 2015). In this Practice Update we describe Parent to Parent (P2P), a peer support program for parents of children with disabilities, discuss barriers to serving families from diverse communities, and detail promising practices that have improved their ability to provide culturally agile support. P2P P2P is a peer support program that trains parents of children with disabilities to provide informational and emotional support to other parents who are seeking support through a one-to-one match. The volunteer parents who provide support receive extensive training in communication, systems navigation, and cultural competence. P2P matches are driven by the concerns, needs, and priorities of the help-seeking parent and may include assistance in navigating school, social services, and medical systems of care (Wood, 2016). Virginia’s P2P program provides one example of the challenges in identifying and supporting CLD families. Immigration to, and refuge in, the United States has increased the diversity of our communities. For example, in 1970, one in 100 Virginians were born in another country; by 2012, it was one in nine (Sen, 2014). In addition to this rise in the percentage of foreign-born people within the state, there has also been a large shift in the composition of the immigrant and refugee populations. These changes necessitate building diversity sensitivity and competence across Virginia P2P initiatives to provide supports and services that address the needs of children and families within the context of their respective cultures. Prior to 2009, the staff of the P2P program in Virginia all identified as white and 70 percent of the families they supported were white. With the addition of five CLD cultural brokers, Virginia’s P2P program staff now reports the racial and ethnic backgrounds of the over 2,800 families supported annually as 41 percent white, 20 percent African American, 12 percent Hispanic, 8 percent Asian, and 19 percent some other race or unknown. In the following sections we present barriers to engagement of CLD families in P2P, followed by promising practices for their inclusion culled from our experiences in P2P of Virginia. Barriers to Program Diversity Not Enough Diverse Trained Support Parents The first barrier to serving CLD parents in P2P is a dearth of volunteer supporting parents from diverse communities. If a parent from a community that is underrepresented in the pool of trained volunteer supporting parents calls in to P2P to request support, the coordinator cannot guarantee that the match will be close enough for the parents to bond over their shared experience. According to a mixed-methods evaluation of the P2P program, when parents were too different, the help-seeking parent did not benefit emotionally from the support relationship (Singer et al., 1999). Without suitable matches for parents seeking support it becomes imperative for a P2P organization to provide opportunities to identify and train more diverse parents. Conflicting Views and Beliefs The CLD recruitment deficit may be explained in part by a mismatch of views and beliefs around disability and support preferences between cultures. Parents who originate from a more collectivist culture may initially feel more comfortable in a group support setting because over time they may become “like family,” making the receipt of support and advice more acceptable and trustworthy (Mueller, Milian, & Lopez, 2009). Parents from cultures that place high value on the family as a unit may have different perspectives around topics such as independence and advocacy than those in the dominant culture (Fisher et al., 2014; Steidel & Contreras, 2003). These views and preferences may not align with those presented in a P2P training. Overworked Volunteers Help-seeking parents who are new to the country may also require more intense support around issues of acculturation, food and housing security, and systems navigation (Nicholas, Fleming-Carroll, Durrant, & Hellmann, 2017) in addition to the emotional support common to all P2P matches. This may put their supporting parents at increased risk for health consequences such as fatigue, decreased immune function, and depression associated with caregiver fatigue (Murphy, Christian, Caplin, & Young, 2007). Refugees and Undocumented Immigrant Wariness Refugees and undocumented immigrants are not reaching out to disability programs for support. Possible reasons for this include a lack of knowledge of services available, paucity of translated materials, and lower levels of acculturation. Refugee communities may also carry considerable distrust for health care professionals and disability organizations so that it may be difficult to gain their trust (Johnson, Ali, & Shipp, 2009). In addition, they may find the idea of being matched with someone from their home country threatening due to the issues they fled when they left their country of origin. Furthermore, families who are undocumented immigrants may not want to call attention to themselves for fear of judgment or the involvement of Immigration and Customs Enforcement. Promising Practices for Cultural Inclusivity There are a number of initial steps a P2P program can take toward serving the needs of CLD communities: conducting community mapping to identify prevalent CLD communities in their region or state, assessing whether their database of trained volunteers and help-seeking parent demographics matches with the mapping findings, writing a language access plan to align staffing and budget considerations to devote resources to CLD communities, and begin dialoguing with key leaders in CLD communities to build trust and support for the P2P program. If this is not practical, the P2P can identify at least one CLD group not currently served and begin to make plans to engage with members of that group. Go into the Community P2P programs have had success engaging underserved communities by volunteering for and creating coalitions with institutions that already serve that group, such as relief organizations and houses of worship (Dorsher, Kim, Krzyska, Perna, & Wolfish, 2014). This approach to engagement helps a P2P program assess unmet support needs and facilitates making connections with influential people within the community. This kind of networking has proved to be beneficial in reducing the stigma associated with disability in marginalized communities and increasing the capacity for disability advocacy (Miles, Fefoame, Mulligan, & Haque, 2012). Communicate Messages Effectively Scheduling “meet and greets,” where families from a cultural group are invited to have a meal and gather to introduce them to disability-related rights and services has also been successful for engaging CLD families in P2P. Having informational materials prepared in the native language of the group can improve communication and contribute to trust by showing a commitment to partnership. An evidence-informed practice the Virginia P2P program uses to produce materials and resources that meet the needs of CLD families is localization. Localization involves analyzing the semantics in a language to make sure that the right thing is said that the product works functionally and linguistically in the intended culture. Furthermore, localization takes into account the customs, traditions, and preferred formats of the group for which the information is intended (Sajan, 2017). Create Culture-Specific Groups Once a group of families has been introduced to the P2P organization, the program can begin to provide support by hosting a culturally specific support group in the primary language of the community. Parents of children with a disability or special health care need will then have the opportunity to share their experiences with other parents of their culture. This group model of social support can be beneficial to attendees who have not had the opportunity to talk to other parents with similar experiences. Support group members who successfully navigate health and education systems and exhibit good communication skills can later be recruited to be trained as support parents to improve the diversity of the program’s roster of volunteers available for matching. Employ Cultural Brokers P2P organizations that do not have the diversity in their program to adequately serve the community may also make use of paid cultural brokers. Cultural brokers are individuals who understand the values and beliefs of their culture toward health and education and also have had successful experiences with assimilation and navigation of health and education systems in the United States. Because they provide a more intensive level of support than a P2P volunteer and have a professional skill set not required of P2P support parents, they are hired as paid employees. Employing a cultural broker can reduce the amount of time P2P support parents spend providing instrumental support and allow them to give the kind of emotional support that only another parent can. Discussion and Recommendations The promising practices identified in this article have helped P2P of Virginia reach its goal of providing culturally agile peer support to parents of children with disabilities throughout the state; however, it is important to recognize that each program will have its own challenges. Regions will vary in their demographic makeup, resources, and organizational structure for systems of care and, as such, interventions to improve the cultural responsivity of a program will have to be approached in a way that is specific to the needs of the locale. Focus-group and survey research will need to be conducted with stakeholders, including parents, community members, P2P coordinators, social workers, and medical and school professionals to learn how to more effectively match the needs and preferences of families from different CLD communities with culturally informed evidence-based models of peer support. References Dorsher , P. , Kim , Y. , Krzyska , A. , Perna , A. , & Wolfish , J. ( 2014 , May 9). Identification and outreach to persons with disabilities: Memorandum to the Bureau of Population, Refugees, and Migration. Retrieved from http://conservancy.umn.edu/bitstream/handle/11299/163196/Dorsher_etal_Indentification_and_Outreach.pdf?sequence=1&isAllowed=y Fellin , M. , Desmarais , C. , & Lindsay , S. ( 2015 ). An examination of clinicians’ experiences of collaborative culturally competent service delivery to immigrant families raising a child with a physical disability . Disability and Rehabilitation, 37 , 1961 – 1969 . 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Child: Care, Health and Development, 33 , 180 – 187 . doi:10.1111/j.1365-2214.2006.00644.x Google Scholar CrossRef Search ADS Nicholas , D. , Fleming-Carroll , B. , Durrant , M. , & Hellmann , J. ( 2017 ). Examining pediatric care for newly immigrated families: Perspectives of health care providers . Social Work in Health Care, 56 , 335 – 351 . doi:10.1080/00981389.2017.1292985 Google Scholar CrossRef Search ADS Sajan . ( 2017 , January 12). The difference between translation and localization – industry lingo defined. Retrieved from https://www.sajan.com/difference-between-translation-and-localization/ Sen , S. ( 2014 , March). Immigrants in Virginia (Census Brief, Issue 3). Retrieved from https://demographics.coopercenter.org/sites/demographics/files/CensusBrief_Immigrants-in-Virginia_March2014_0.pdf Singer , G. H. , Marquis , J. , Powers , L. K. , Blanchard , L. , Divenere , N. , Santelli , B. , et al. . ( 1999 ). 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Parent-to-parent peer support for diverse low-income families of children with disabilities: A qualitative interview study of a self-help program as part of a medical home model (Doctoral dissertation, University of California). © 2018 National Association of Social Workers This article is published and distributed under the terms of the Oxford University Press, Standard Journals Publication Model (https://academic.oup.com/journals/pages/about_us/legal/notices)

Bent-Goodley, Tricia B

2018 Social Work

doi: 10.1093/sw/swy030pmid: 29800470

Since 2000, there has been an increase in mass shootings, most recently in schools (Donoghue & Raia-Hawrylak, 2016). Many of the challenges facing society are intricate and involve multiple issues. Social workers know that there are no simple solutions to complex challenges. The two primary recommendations to address school violence have been to advance gun control legislation and to put school safety officers in every school. The idea of gun control legislation is important and necessary. The National Association of Social Workers (NASW) has taken a firm position on this matter (Arp, Gonzales, Herstand, & Wilson, 2017). However, it is not enough. The recommendation to have more school safety officers is noble, and safety officers do many things (Saul, Williams, & Hartocollis, 2018). However, safety in schools should not be left to law enforcement. According to Sherman (2016), The perpetual lack of attention paid in schools to students’ psychological, social, and emotional well-being has led to increasing maladaptive behaviors in the classroom. These behavioral issues are often the demonstration of unacknowledged and untreated social, emotional, and familial stressors. (p. 150) Social workers have an important contribution to make in this area. NASW’s Children & Schools journal is completely devoted to children and schools. However, these issues are not only for social workers in school settings. It is imperative that social workers are engaged in assessing and providing leadership to tackle this troubling problem. It is important to understand the role of school social workers, how we can use the Adverse Childhood Experiences (ACE) Study in schools, the necessity of bullying and teenage dating violence (TDV) initiatives, threat assessment and social work, and the ways social workers can aid in parent and community engagement. Role of School Social Workers Putting more social workers in schools is important; however, emphasis is needed on the role and approaches that will be necessary to maximize the influence of these practitioners (Sherman, 2016). School social work is a specialty practice that requires training and education on purview and practices in the educational setting. The role of school social workers is inconsistent across states, jurisdictions, and even school systems (Sherman, 2016). In one school, a social worker could be charged to provide case management, whereas in another school the function may be to provide group counseling. Continuity in the role would greatly help to create a consistent presence that leverages the skill set of a professional social worker in the educational setting. It is also important to have an understanding of the staff-to-student ratio so that social workers are not overwhelmed with an unrealistic caseload. Finally, school social workers do not just help students; they also serve as a resource to families and school personnel. Their presence can be uniquely helpful in identifying issues and creating responses to them. School social workers, to date, have been an untapped resource in this effort (Sherman, 2016), and that must change. Importance of the ACE Study to Social Work Practice in Schools As we consider the role of the school social worker, it is also necessary to identify areas of focus that schools should consider. The ACE Study helps researchers to better understand student health and behavioral health needs. It is important for social workers to be familiar with the ACE Study. “The ACE Study has found that ‘adverse childhood experiences’ (ACEs) . . . are widespread, largely unrecognized, and play a decisive role in the overall health, well-being, and social function of the nation” (Larkin, Felitti, & Anda, 2014, pp. 1–2). In a study conducted by the Centers for Disease Control and Prevention and Kaiser Permanente between 1995 and 1997, 17,000 participants were surveyed to better understand how childhood experiences affect health, mental health, and social factors in adulthood. It was found that 40 percent of the respondents had two or more of these experiences and that there was a clear linkage between the experiences and negative social, health, and behavioral health outcomes throughout the person’s life span (Felitti et al., 1998). Being able to assess for adverse childhood events can be a powerful tool in creating innovative prevention intervention and developing new approaches to responding to these issues during a child’s life in school. Through anonymous testing, schools can gauge a sense of the needs within the school, provide targeted training, and develop practices responsive to the needs of the student population. The school system is a natural place to use the ACE Study to support proactive programming and ensure that schools are better equipped to meet the needs of students. Bullying Prevention and Intervention Bullying prevention and intervention strategies are key on all academic levels. As I talked with one young person about this, he told me,“Adults give you all the wrong advice about bullying. They tell you things to do that are not realistic or just don’t work. Telling the teacher does nothing. You can’t trust adults to help you. So you are basically left to figure it out by yourself.” Hearing this statement troubled me. Unfortunately, this sentiment is not his alone. Survivors of bullying often do not tell their parents or adults what is happening (Ramirez, 2013). The solution is not to cut adults out of the helping process, but to both better equip them to respond and empower children in this effort (Donoghue & Raia-Hawrylak, 2016; Williford, 2015). To do this, school systems must take bullying prevention seriously (Teasley & Nevarez, 2016). Displaying posters and having workshops are not enough. Training for all school personnel is important as a way to help prevent bullying and intervene when it occurs (Letendre, Ostrander, & Mickens, 2016; Williford, 2015). Parents must be taught signs to look for in their children who may be being bullied, and strategies are needed to respond to the bully. There are interventions in place to provide such guidance (U.S. Department of Health and Human Services, 2018). Policies are needed to address bullying and should include child- and teacher-friendly protocols to put into action. Children should be empowered to find confidential ways to report bullying, and the school climate should be a space where they are encouraged to do so (Letendre et al., 2016; Teasley & Nevarez, 2016). Interventions must include knowledge of the social media impact. Given that adults may struggle with managing social media, more is needed to educate parents about social media warning signs and how to better track and monitor what is being communicated. Understanding how cyberbullying affects children in different ways, from a developmental perspective, can help in developing interventions to address this serious issue (Beran, Mishna, McInroy, & Shariff, 2015). Having our children feel safe is not limited to the walls of a school building, but also in the cyberworld, which continues to be impactful after the school day ends. The result is that interventions must take place in a comprehensive fashion that tends to school climate, policy, and systems outside of the school (Donoghue & Raia-Hawrylak, 2016). Dating Violence: Importance of School Intervention Dating and domestic violence have been linked with some of the mass shootings we have seen in recent years (Leong, 2017). Stalking is an element of dating violence that warrants attention (Theriot, 2008). Many survivors of dating violence do not report what they are experiencing to the adults in their lives (Bent-Goodley, 2011; Hertzog, Harpel, & Rowley, 2016), resulting in possible risks for the child and others. The majority of school systems do not have policies on how to identify and respond to dating violence. In fact, only 20 states have TDV-related policies (Hertzog et al., 2016), and only 13 of those states require TDV education in schools (Black, Hawley, Hoefer, & Barnett, 2017). There is a limited understanding of how dating violence can link with threat assessment and other potential safety considerations. Dating violence and stalking can be important signals for school systems to identify early as a way of keeping children safe in school (Theriot, 2008). Thus, more training on red flags of dating violence is needed so that systems know when there is a heightened risk of serious injury or potential lethality. Lethality assessment has been done primarily in community settings; however, there is a need to include such assessment within schools as part of threat assessment and safety planning. School social workers may not be able to offer the direct level care for people affected by dating violence due to the purview of their role. However, social workers in the community can assist with dating violence and stalking education—providing safety planning and services to the survivor and family members—and help to coordinate needed services. Thus, working together social workers can be that much more effective in meeting the needs of this population (Black et al., 2017). Threat Assessment and Social Work Threat assessment is an important area for involvement of social workers. School social workers can be important members of threat assessment teams. Threat assessment teams are often charged with identifying and responding to potential threats, developing systemwide plans on how to respond, and offering interdisciplinary coordinated responses (Barton, 2008). Knowing how to work effectively on these teams is important. Social workers from within the community—youth programs and recreation centers—can be helpful by serving on threat assessment teams to increase the number of people with different types of information to help inform thinking and responses. They can help identify issues within the community that seep into the school and can also develop coordinated responses with school systems to assist. Thus, social workers bring an important element to threat assessment both within and outside of the school. Parent and Community Engagement Parent and community engagement are also useful elements to keeping schools safe (Progress, 2014). The solution is not simply in the children and the school. Schools exist as part of a larger community composed not only of individuals, but also of families who are often in need of help. Although school social workers may not have family and community engagement as part of their purview, there are often social workers working in those communities that have relationships in place. They can provide important linkages to the community and can work with families to provide necessary supports and care that are culturally responsive to ACE (Larkin et al., 2014). Having this broader trusted relationship in place when threats exist can provide an extra set of eyes to identify when a more coordinated and systemic intervention is needed (Theriot, 2008). This approach requires coordination and a collective effort, but social workers are well equipped to respond and are already in place in many communities. Conclusion It will take all of us to keep our children safe. All children have a right to learn in a safe environment. How we keep our schools safe can be strengthened when more social workers are at the table. Social workers bring a range of skills, and relationships with other community providers, to educational settings. Now, more than ever, schools would benefit from an increased social work presence. References Arp , J. , Gonzales , R. , Herstand , M. , & Wilson , M. ( 2017 ). Gun violence in the American culture [Social Justice Brief]. Washington, DC : National Association of Social Workers . Barton , R. ( 2008 ). Keeping schools safe through threat assessment . Education Digest, 74 ( 1 ), 20 – 25 . Bent-Goodley , T. B. ( 2011 ). The ultimate betrayal: A renewed look at intimate partner violence . Washington, DC : NASW Press . Beran , T. , Mishna , F. , McInroy , L. B. , & Shariff , S. ( 2015 ). Children’s experiences of cyberbullying: A Canadian national study . Children & Schools, 37 , 207 – 214 . Google Scholar CrossRef Search ADS Black , B. M. , Hawley , A. , Hoefer , R. , & Barnett , T. M. ( 2017 ). Factors related to teenage dating violence prevention programming in schools . Children & Schools, 39 , 99 – 107 . Google Scholar CrossRef Search ADS Donoghue , C. , & Raia-Hawrylak , A. ( 2016 ). Moving beyond the emphasis on bullying: A generalized approach to peer aggression in high school . Children & Schools, 38 , 30 – 39 . Google Scholar CrossRef Search ADS Felitti , V. J. , Anda , R. F. , Nordenberg , D. , Williamson , D. F. , Spitz , A. M. , Edwards , V. , et al. . ( 1998 ). Relationship of childhood abuse and household dysfunction to many of the leading causes of death in adults: The Adverse Childhood Experiences (ACE) Study . American Journal of Medicine, 14 , 245 – 258 . Hertzog , J. L. , Harpel , T. , & Rowley , R. ( 2016 ). Is it bullying, teen dating violence, or both? Student, school staff, and parent perceptions . Children & Schools, 38 , 21 – 29 . Google Scholar CrossRef Search ADS Larkin , H. , Felitti , V. J. , & Anda , R. F. ( 2014 ). Social work and adverse childhood experiences research: Implications for practice and health policy . Social Work in Public Health, 29 , 1 – 16 . Google Scholar CrossRef Search ADS Leong , N. ( 2017 , June 15). What do many mass shooters have in common? A history of domestic violence. Washington Post. Retrieved from https://www.washingtonpost.com/news/posteverything/wp/2017/06/15/what-do-many-mass-shooters-have-in-common-a-history-of-domestic-violence/?noredirect=on&utm_term=.448284e99f9f Letendre , J. , Ostrander , J. A. , & Mickens , A. ( 2016 ). Teacher and staff voices: Implementation of a positive behavior bullying prevention program in an urban school . Children & Schools, 38 , 237 – 245 . Google Scholar CrossRef Search ADS Progress . ( 2014 ). Parent and community engagement drive school transformation . Education Digest, 80 ( 2 ), 58 – 60 . Ramirez , O. ( 2013 ). Survivors of school bullying: A collective case study . Children & Schools, 35 , 93 – 99 . Google Scholar CrossRef Search ADS Saul , S. , Williams , T. , & Hartocollis , A. ( 2018 , March 4). School officer: A job with many roles and one big responsibility. New York Times. Retrieved from https://www.nytimes.com/2018/03/04/us/school-resource-officers-shooting.html Sherman , M. C. ( 2016 ). The school social worker: A marginalized commodity within the school ecosystem . Children & Schools, 38 , 147 – 151 . Google Scholar CrossRef Search ADS Teasley , M. L. , & Nevarez , L. ( 2016 ). Awareness, prevention, and intervention for elementary school bullying: The need for social responsibility [Editorial] . Children & Schools, 38 , 67 – 69 . Google Scholar CrossRef Search ADS Theriot , M. T. ( 2008 ). Conceptual and methodological considerations for assessment and prevention of adolescent dating violence and stalking at school . Children & Schools, 30 , 223 – 233 . 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