Child poverty and environmental justice

Child poverty and environmental justice

ARTICLE IN PRESS Int. J. Hyg. Environ. Health 210 (2007) 571–580 www.elsevier.de/ijheh Child poverty and environmental justice Claudia Hornberg, An...

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ARTICLE IN PRESS

Int. J. Hyg. Environ. Health 210 (2007) 571–580 www.elsevier.de/ijheh

Child poverty and environmental justice Claudia Hornberg, Andrea Pauli Department of Environment and Health, School of Public Health, Bielefeld University, P.O. Box 100131, 33501 Bielefeld, Germany

Abstract Background: Child poverty and social inequality in Western countries are growing both in scope and in complexity. The clustering of income poverty in urban settings reflects the complex process of residential segregation. Living in segregated neighbourhoods with much poverty and predominantly substandard housing is usually associated with poor physical, chemical and social environmental living conditions at the individual and community level which influence and shape children’s health both directly and indirectly. Objective: This paper shows research data on the link between child poverty and income-related health inequalities according to the unequal exposure to environmental hazards as well as the unequal distribution of environmental resources in the domestic environment and within the local context as an increasing public health issue in Germany. The links between these factors are drawn from the conceptual framework of environmental justice. Examples are shown of integrated approaches to alleviate social and environmental disparities at the community level. Conclusion: The implications of environmental justice for public health include the need to uncover the link between socioeconomic factors and environmental health disparities related to the man-made environment. Developing relevant indicators for environmental inequalities in the context of housing and health is an important task for public health research. More emphasis should be placed on a comprehensive holistic approach to understand the mechanisms by which socioeconomic factors modify children’s susceptibility and exposure to environmental hazards, particularly in low-income areas. r 2007 Elsevier GmbH. All rights reserved. Keywords: Child poverty; Health disparities; Environmental exposure; Environmental justice

Background of child poverty Globalisation together with the environmental degradation and the worsening of socioeconomic disparities between nations and within them represents a major challenge not only for the developing countries, but also for the highly developed ones (United Nations Environment Programme (UNEP), 2002). While poverty appeared to have been eradicated in the industrialised Corresponding author. Tel.: +49 521 106 4365; fax: +49 521 106 6492. E-mail address: [email protected] (C. Hornberg).

1438-4639/$ - see front matter r 2007 Elsevier GmbH. All rights reserved. doi:10.1016/j.ijheh.2007.07.006

countries during the 1960s and 1970s, growing child poverty in Europe during the 1990s was entirely ignored by policy makers and considered to be a marginal phenomenon hardly worth any attention. Since the mid1990s, however, poverty in Germany has steadily been growing and could no longer be misconceived as marginal and to be only affecting a small group within the society (Hauser and Becker, 2003). At present, much attention from the media and policy makers (Federal Ministry of Health/Federal Ministry of Labour and Social Affairs, 2005) is given to the increasing poverty amongst children. They are addressed as a particularly vulnerable subgroup of the population in

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the context of social reports specifically about children (German Welfare Society (Deutscher Parita¨tischer Wohlfahrtsverband), 2005; UNICEF, 2005). These reports fill the gap of insufficient empirical research and offer a comprehensive portrait of child poverty in Germany. Rising poverty rates coupled with spatial patterns of social segregation are closely associated with the reforms of the German welfare system and the overall demographic and economic transformations (Schluter, 2001). Furthermore, the unemployment benefits II package (Hartz IV) introduced in 2005 has increased the economic pressure on low-income families and led to growing numbers of people depending on welfare Preschool and grade school children in households headed by foreign citizens, households with unemployed or underemployed parents (the ‘‘working poor’’), households headed by women and households with more than three children are at the highest risk of poverty in Germany (Corak et al., 2005; UNICEF, 2005).

How to measure child poverty Despite increasing attention on child poverty and its underlying socioeconomic factors, which has become a major and pressing social and health policy challenge in Germany (Butterwegge et al., 2003), there is no consensus on how poverty should be measured and operationalised (Piachaud, 1992; Zimmermann, 2000). Empirical analyses and official data are often based on different operationalisations of poverty, and also yield different poverty statistics, which are hardly comparable. While the poverty rate for 2004 of 1.7 million children and adolescents reported by the German Welfare Society (Deutscher Parita¨tischer Wohlfahrtsverband) (2005) uses the ratio of welfare recipients under the age of 15, a comparative UNICEF study ‘‘Child poverty in rich countries’’ includes children and adolescents under 18 and cites a child poverty rate of 1.5 million for Germany (UNICEF, 2005). This UNICEF study also was based on a median equivalent income of 50%. The threshold value on which data from the European Union is based is 60% of the average net income. Since poverty in Germany rarely corresponds to a situation where absolute physical existence is not guaranteed, poverty research in Germany uses the concept of relative poverty, i.e., a poverty threshold of 50% or 60% of the mean weighted net income of a household. According to this definition, poverty in Germany would mean earning less than half of the average income and being unable to partake of a lifestyle corresponding to the national standard (Toppe and Dallmann, 2000).

Child poverty and social inequality Child poverty is not defined only by the basic economic buying power. Further operationalisations of child poverty use a multidimensional concept (e.g., in the German National Children’s and Adolescents’ Health Survey (KIGGS)) (Lampert et al., 2002) as found in the ‘‘living circumstances concept’’ (in German: ‘‘Lebenslagenkonzept’’). When applying the living circumstances concept to the special situation of children, not only the material aspect is considered, but also the resources and care regarding aspects which are central to children’s lives (e.g., health, nutrition, peer relations as well as social capital, social networks, housing and neighbourhood conditions) (Zimmermann, 2000). It also gives the option of expanding objective analysis to include the subjective perspective of selfassessment (Chasse´ et al., 2003). The living circumstances concept also makes clear that child poverty is intimately associated with social inequality, i.e., an unequal distribution of opportunities (education, health, etc.) and access to resources, goods and services. Vertical social stratification like education, occupation and/or parents’ income continue to play an important role (Sperlich and Mielck, 2003), as social class gradients in the health status of children shows. They are closely associated with horizontal demographic characteristics like gender, age, type of household, place of residence, ethnicity, etc. (Mielck, 2005). In order to gain a better insight into the complex relations between child poverty, social and health-related inequalities, it is necessary to consider the vertical and horizontal social differences of inequality simultaneously as well as their mutual interdependence. This also appears to be beneficial for a better understanding of the role of environmental conditions in income-related health disparities.

The impact of poverty on children’s health and development Children experience poverty (depending on spatial and temporal factors) not only as a lack of access to a variety of material and non-material resources, but also as environment-related and psychosocial deprivation at the cultural, social and health levels (Bradley and Corwyn, 2002; Chasse´ et al., 2003; Richter, 2005). As in other industrialised countries, in Germany poverty correlates with a considerably higher risk of poor physical and mental health (Mielck, 2005). Poverty and deprivation in early childhood influence both health and development in various dimensions and can have serious negative health consequences for their entire life (Ellsa¨sser et al., 2002; Reißlandt and Nollmann, 2006).

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Even though more empirical research is needed on health disparities with a focus on children, a low socioeconomic status (SES) was found to be associated with a low birth weight, increased neonatal mortality and injury rates, motor and speech development disorders, physical neglect, a higher risk for disabilities, chronic diseases (e.g., diabetes) and lower developmental scores (Bradley and Corwyn, 2002; Kamensky et al., 2000; Richter, 2005). Psychosocial risk factors like parenting quality, domestic violence, lack of social networks, etc. are likely to co-vary with poverty. They may also be preexisting conditions (Evans et al., 2004), which influence and modify a child’s susceptibility to adverse health outcomes from exposure within in the home and outside in the immediate social and physical environment (Blair et al., 2003). Besides these adverse health outcomes, it is important to notice that poverty does not inevitably go together with health problems. Research on resilience has shown that children’s capacity to cope with adverse socioeconomic circumstances depends on the availability of health resources (Reißlandt and Nollmann, 2006) which can promote health, attenuate the effects of poverty (Merten, 2003) and protect against harmful exposure in the social and physical environment (Chasse´ et al., 2003; Merten, 2003).

The social and physical environmental context of child poverty The health effects of child poverty are depending on a wide range of individual factors and environmental conditions in the immediate and extended living space. Seen in this context, environment needs a holistic definition, which goes beyond the one-sided biomedical focus on pathogenesis and the usual narrow scientific– technical view. The holistic definition would include the natural, physical, chemical and socio-cultural environment, with the central dimensions of living conditions in the various areas of life where children spend most of their time (e.g., housing, home environment) (SchmitdtDenter, 2002). There is a major impact on children’s physical and mental development not only by the direct effects of low income (e.g., access to health care), but also indirect effects from a deficient social environment (e.g., social isolation, lack of social support, crime) and the physical environment (e.g., low air quality, lack of safe playgrounds) (Blair et al., 2003). Given that the social structure in a residential area usually reflects the local living conditions, environmental stressors and resources, it is an important indicator of the health of children and adolescents living there. Finally, the socio-economic health gradient in children is the result of a complex interaction of mechanisms (Mielck, 2005). These are primarily influenced by

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factors located in the man-made environment, including housing and the immediate living space, which in turn are affected by poverty and a low socio-economic status (Blair et al., 2003). Living in poverty usually means living in socio-structurally weak neighbourhoods. These often receive emissions from surrounding industrial plants and transportation thoroughfares, show substandard housing and mounting neglect as well as a greater population density and simultaneously lower access to environmental commodities (e.g., public green and recreational areas) and infrastructure (e.g., health care, groceries, leisure facilities) (Northridge et al., 2003; Frumkin, 2005). These combinations of environmental and social discrimination (Maschewsky, 2001) lead to environmental injustice in the everyday living spaces of children of a lower socioeconomic status.

Social differences in the distribution of environmental resources and hazards The conceptual basics of environmental justice The public discussion about environmental justice started in the USA, where it is an important concept, and extensive field research has been done there in the last three decades. The concept of environmental justice refers to the uneven distribution of environmental quality between different social groups and relates decreasing socioeconomic status to an increasing burden of exposure to environmental hazards. The issue of environmental discrimination becomes readily apparent when one considers the fact that polluting industrial plants, contaminated and abandoned sites and waste facilities and roads with heavy traffic are often located near primarily low-income households or minority neighbourhoods in economically – and hence socially and politically – weak communities. Compared to residents in affluent areas, these social groups are likelier to be exposed to health-threatening environmental conditions and tend to be more susceptible to adverse health effects from environmental exposures – all this in addition to the already heavy burden of social inequality (Mohai and Bryant, 1992; Stephens and Bullock, 2002). Environmental justice aims at preventing new environmental hazards via participation and equal access to health for all, reducing existing environmental hazards and striving for a socially fair distribution of inevitable environmental risks (Maschewsky, 2001; Bolte, 2006). It was to fight these ‘‘geographies of exposure and susceptibility’’ (Jerrett and Finkelstein, 2005) that the environmental justice movement was launched in the 1980s, when a mainly African-American community in Warren County (NC, USA) protested against the

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location of a polychlorinated biphenyl (PCB) landfill. The environmental justice movement as a form of political resistance has substantially contributed to raising public awareness of the increased environmental exposure amongst lower-income groups. Based on the principle that all people have the right to live in a healthy environment and to be involved in environmental health decisions regardless of race, colour or income, environmental justice concerns have become a core topic, especially in US policy and law. Since the 1990s, much research in environmental justice has been done in the USA, and although it was often criticised for weak methodology (Bowen, 2002; Maschewsky, 2001), it has generally shown that environmental risks are distributed unequally across different social groups and ethnicities (Evans and Kantrowitz, 2002; Brulle and Pellow, 2006). Stimulated by the international discussion on the nature of social health disparities, awareness of the relationship between environmental and social issues has increased throughout the USA (Stephens and Bullock, 2002). On the global scale, the link between children’s health, poverty and environmental degradation (with particular focus on developing countries) was established at several global conferences and international agreements over the past decade (e.g., the World Summit on Sustainable Development in 2002).

Environmental justice in Europe In Europe, there is great interest in matters of social and spatial inequality of environmental exposure where disadvantaged ethnic groups are concerned, although it usually takes the form of empirical studies and theoretical debate while little is done regarding prevention and compensation. Great discrepancy is also evident in Europe between perception of and commitment to environmental justice (Maschewsky, 2004); e.g., environmental justice has been on the political agenda in Scotland since 2002 (Poustie, 2005). In the Netherlands, the National Institute of Public Health and the Environment (RIVM; Rijksinstituut voor Volksgezondheid en Milieu) has started a research project on differences in local environmental quality between socioeconomic groups and the effects of environmental policy on distribution (Kruize et al., 2004). Most environmental justice studies in Europe were done on adults. As part of the Policy Interpretation Network on Children’s Health and Environment (PINCHE), a survey of EU-funded projects on children’s environmental health showed that effect modification on the vulnerability towards environmental hazards by socioeconomic factors is not considered sufficiently in assessments, thus disregarding a possible influence which social status might have on children’s environmental health (Bolte and Kohlhuber, 2005). However,

current efforts to improve the significance and explanatory power of analysis by integrating social and environmental factors into epidemiological studies reflect a growing interest in uncovering social stratification in environmental exposure and environmental health in children in Europe (Bolte and Kohlhuber, 2005; Bolte et al., 2005; Bolte, 2006).

Environmental justice in Germany Contrary to the USA, the issue of environmental justice is not well known by the German public and media. While social disparities in health are an established field of scholarly research in Germany (Mielck, 2005); far less research is done on environmental inequality (Bolte and Mielck, 2004; Maschewsky, 2001). As early as 1975, Jarre was able to show that working-class neighbourhoods in parts of the northern Ruhr area had a considerably higher dust burden than neighbourhoods inhabited mainly by white-collar employees and self-employed individuals (Jarre, 1975). It was not only 23 years later that the Office of Technology Assessment at the German Parliament (TAB) commissioned a study on the current state of knowledge on the relationships between indicators of social class and environmental hazards (Heinrich et al., 1998, 2000). In Germany, Maschewsky (2001, 2004) greatly contributed to starting discussion on environmental justice while Bolte and Mielck (2004) gave a comprehensive overview on empirical environmental justice data in Germany. Until now, awareness of social and spatial differences in environmental exposure, environmental health and vulnerability has been growing only at the expert level in various fields of research (e.g., public health, social science, geography) and in environmental health politics. The fact that the topic of environmental justice is now on the agenda of the Environment and Health Programme in North Rhine-Westphalia (APUG NRW, Action Programme Environment and Health for North Rhine-Westphalia) is an indication of the increased political awareness of social and spatial differences in environmental quality and exposure.

Child poverty and environmental inequality in the man-made environment: important features of environmental justice The discussion about mitigating health hazards in the man-made environment shows obvious parallels to the fundamental questions of social medicine and the urban sanitary reform movement targeting the control of infectious diseases by improving housing conditions in the 19th century (Krieger and Higgins, 2002). Today,

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the increasing polarisation of living conditions with social, ethnic and demographic segregation have created new public health problems in the built environment which must be solved (Jackson, 2003). The concentration of low-income households at the community level (Mielck, 2002) in substandard rental stocks (often highrise housing) in areas with poor environmental conditions and infrastructure can be traced back to a mechanism of residential segregation, with its major impact on social and environmental inequality (Brulle and Pellow, 2006; Lo´pez and Hynes, 2006). Segregation is usually linked to a decreasing population, wage earners and families with children moving to more attractive locations, economic decline and social erosion. Low-income families who cannot afford to spend much money on housing are left behind, living in public housing and social flats located in cheaper areas with lower environmental quality (Maschewsky, 2001). In Germany, this is seen mainly in impoverished, sociostructurally weak and environmentally disadvantaged urban districts (e.g., old industrial regions like the Ruhr area) where the neighbourhoods themselves become stigmatised, bringing about social decline and the added disadvantage of social exclusion, the so-called lift effect (Ha¨ußermann, 2000). In turn, the social context of a community is inversely linked to the quantity and quality of environmental resources and risks in its immediate environment.

Social differences in exposure to environmental hazards in the man-made environment Young children spend most of their time at home, indoors and in their immediate environment. Sources of exposure in these living spaces are particularly important for children as a more vulnerable group compared to adults. The developmental immaturity of children, their constitution and specific behaviours – e.g., (ingestion, or ‘‘mouthing’’, of soil and dust) – raise the likelihood to receive higher doses of harmful substances both indoors and outdoors which can be taken up through various routes, including the gut, the airways and the skin (Heinemeyer and Gundert-Remy, 2002; United Nations Environment Programme (UNEP) et al., 2002). Some of the sources of outdoors pollutants reported most often by European and German studies which correlate with a socially unequal distribution include noise, pollution from traffic (Hoffmann et al., 2003), air pollution (e.g., carbon monoxide, ozone, particulate matters (PM10, PM2.5)) (Heinrich et al., 2005), soil pollution, high-frequency radiation, traffic, as well as the quality and number of open space and green areas (Evans, 2003; Evans and Kantrowitz, 2002; Lo´pez and Hynes, 2006).

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Heinrich et al. (2000) concluded that low-income households face the highest burden of exposure levels to harmful substances both in the ambient air as well as indoors. Possible indoor air pollutant concentrations – which usually are higher than those outdoors – related to substandard housing conditions and a low socioeconomic status (Evans and Kantrowitz, 2002) can come from a number of sources. Thus, indoor air quality can be affected by chemicals such as gases (Cyrys et al., 2000); heavy metals such as lead from heating and cooking systems, plumbing, building materials, etc.; biological factors (e.g., microbial contamination of food, indoors contamination by bacteria and mould) (Hood, 2005); as well as physical factors (e.g., noise) (Elvers et al., 2004; Seidel, 1998). Furthermore, indoor behaviour can influence the level of exposure, as to tobacco smoke (Becker et al., 2002) and household chemicals (Chaudhuri, 2004). The cumulative risk of exposure (Evans et al., 2004) due to substandard housing and insufficient physical structure and infrastructure of the immediate environment can contribute both directly and indirectly to a variety of adverse health outcomes, depending on intensity, degree and duration of the exposure. Finally, children who live in these areas face a double threat: they are not only burdened with social health disparities, but are also likelier to be exposed to adverse environmental conditions in their everyday environment (Hood, 2005). This might influence their vulnerability to environmental hazards and, the often higher, incidence of acute and a higher prevalence of chronic diseases and disorders (e.g., respiratory diseases, infectious diseases, etc.) (Evans and Kantrowitz, 2002; Krieger and Higgins, 2002). In 2005, the APUG examined data from an environmental health study on 968 children starting school who suffered from particularly heavy environmental exposure to assess correlations between social status and environment-related exposure factors as well as between social status and health endpoints. Indicators of social status were education, professional training, occupation and the parents’ nationalities. The results clearly showed that children from low-income families lived in areas with an environmental burden significantly more often than did children from financially stronger families. There were significant correlations between social status indicators and external factors of environmental exposure as well as health outcomes (e.g., allergies, infections). As earlier studies also showed (Mielck, 2005; Heinrich et al., 2000), socially better-off groups showed a higher prevalence of infections and allergies whereas children from low-income families were exposed considerably more to suspended particles, passive smoking and unhealthy living conditions at home (Ministry of the Environment and Conservation, Agriculture and Consumer Protection of the state of North Rhine-Westphalia, MUNLV, 2006).

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The results of this analysis underscore the complexity of the social inequality of environmental health burdens. They also show that preventive action at the communal level is possible only if the local environment-related health risks and their socio-spatial distribution are known.

Social differences in availability and access to environmental resources The main thrust in public health research on the social distribution of exposure in the man-made environment has centred on environmental risks and adverse health outcomes (Frumkin, 2005). Other than this perception of risk, there is no similar research agenda for the sociospatial distribution of environmental resources and the physical and mental health benefits of nature (Evans, 2003). A social gradient in the availability and quality of urban nature (e.g., trees, water, plants, and public gardens) as well as access to green spaces, parks, etc. open to pedestrians was confirmed by several studies. They show that a high percentage of low-income households in a community is both a significant predictor of higher levels of exposure to environmental pollutants (Evans and Kantrowitz, 2002; Brulle and Pellow, 2006) and of fewer environmental amenities like streets lined by trees, green spaces in the community, safe playgrounds in the neighbourhood, etc. (Lo´pez and Hynes, 2006; Maas et al., 2006). Thus, the absence of green spaces, degraded parks (e.g., littering, disrepair), environmental vandalism and less access to nature are some of the main problems in socially disadvantaged urban areas, where the burden of psychosocial stressors is much higher. Contact with nature is described as an important opportunity to regenerate and recover from stress. Nature and a balanced vegetation around the home (acting as a buffer against stress) can also enhance coping and is inversely linked with children’s perceived health and self-esteem (Flade, 2006; Maas et al., 2006). Urban nature and green elements also seem to be a critical part of neighbourhood quality and a strong predictor of well-being and satisfaction (Frumkin, 2001; Krieger and Higgins, 2002; Lo´pez and Hynes, 2006). Regarding social and environmentally segregated areas, the availability of nearby green spaces and recreational sites can mitigate the adverse effects of urbanisation, reduce the degree of exposure to noise, air and soil pollution, make cities more attractive, and reduce the need for transport (Evans and Kantrowitz, 2002; Flade, 2006). Designing green elements into the living space is likely to promote healthier behaviour, such as physical activity, which in turn indirectly affects health (Maller et al., 2005). Important questions would include which types of contact with nature can promote physical

and/or mental health and healthy behaviour (Frumkin, 2001).

How to address environmental inequality regarding children: perspectives for public health research and action Needs and challenges in public health research The increasing global environmental burden of disease in children associated with social stratification in exposure and a wide range of environment-related health problems (Valent et al., 2004) requires a new focus in public health research to close the ‘‘environmental health gap’’ (Brulle and Pellow, 2006, p. 3.15) regarding social differences in children’s exposure to pollution and its effects on health. For a better insight into the relationship between environmental inequality, health disparities and the underlying mechanism, it is imperative that a comprehensive conceptual and analytical framework considering cumulative socioeconomic and environmental risks in the environment is developed. Most of the evidence gained over the past few decades is characterised by descriptions of single exposure–health associations without considering socioeconomic factors (Bolte and Kohlhuber, 2005) and the importance of interacting factors in the man-made environment which may influence human health (Hood, 2005). Conditions like quality of housing and related indicators like dampness, mould, central heating, crowding, proximity to busy roads, etc. as well as neighbourhood quality should be regarded as important indicators of socioeconomic status (Ansari et al., 2003). Analyses are needed on how the social health gradient could be partially attributed both to social differences in environmental exposure and to susceptibility characteristics (Bolte et al., 2005; Bolte, 2006; Kohlhuber et al., 2006a, b) (Fig. 1). These analyses are prerequisites and form the empirical basis for target group-specific, social space oriented prevention and health promotion to counteract

Fig. 1. Conceptual model of mechanisms how socio-economic factors may have an impact on children’s health and environment (Bolte and Kohlhuber, 2005).

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health problems at the local level, due to a povertyassociated lack of care and environmental factors. A hitherto little-used possibility of linking objective indicators of children’s health status with subjective indicators of home and living space quality (e.g., annoyance by traffic noise, satisfaction with green spaces) and placing these in context with data on the environment in social areas would be expanding the continuously ongoing start-of-school statistics and specific analysis of social status indicators (e.g., living conditions, health behaviour) and data assessment by social area.

Public health action: collaboration and integrated community-based programmes Seen from the public health perspective, environmental justice can make an important contribution in uncovering and addressing health inequalities related to environmental hazards in the home environment, with integrative strategies ranging from communitybased research to urban planning, neighbourhood management, etc. What is needed are differentiated, mutually complementing services and networks at the level of the community (macro), the living environment (middle level) as well as at the individual households and families (micro) which take into account the living space and the environment with all their resources and limitations. Integrated programmes which have become established both at the national and the international level over the last few years form the basis of an integrated cooperation of health, urban development and the environment. The most important programmes in Germany are the Action Programme Environment and Health, the Local Agenda 21, the Healthy Cities Network, and the programme Socially Integrative City. The distinguishing feature of integrated programmes is their focus on man-made places and interdisciplinary cooperation between different technical fields to shape living conditions in socio-structurally weak areas where socio-epidemiological and environment-related health risks are particularly high. Despite the different frameworks in integrated programs, there are comparable synergisms such as multiissue approaches, bottom-up strategies, participation of the social groups in question, resource pooling, etc. (Reißlandt and Nollmann, 2006). A growing number of projects and measures at the community level, particularly at low-income social hot spots, are directed at the man-made environment and improving housing and its environment (Bo¨hme et al., 2005). Although they are not explicitly focused on health, they can indirectly significantly influence children’s health and environmental health benefits, as by upgrading housing conditions in the context of its location (Chaudhuri, 2004), by improving social infrastructure and public spaces, and

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by empowering residents (Krieger and Higgins, 2002; Philippsen et al., 2003). Health promotion in integrated programmes means a combination of environmental and behavioural orientation following a resourceoriented approach at the community level in particular settings which social and environmentally disadvantaged children and their parents are familiar with (e.g., child care centres, schools, social institutions) and where they develop lifestyles and healthy behaviour. Regarding the major impact of housing-related physical and mental health effects on the quality of life and its significant economic aspects (e.g., the burden of disease caused by environmental pollution from road traffic), public health should direct more attention to children living in severely inadequate housing with suboptimal conditions in their immediate environment. This means looking beyond the individual risk factors and health behaviours to artificial and socio-structural factors in the environment where children live and grow up. The case of nutrition and physical activity shows that primary preventive measures to promote a healthier lifestyle through more exercise and improved nutrition are by no means isolated from infrastructural factors like safe and well-built biking and pedestrian lanes or their connection with the short-distance public transport. Heavy traffic in residential areas and living in segregated marginalised neighbourhoods (e.g., adjacent to a highway) is associated not only with higher noise levels, a greater exposure to air-borne hazards, but also to an increased risk of traffic accidents. These factors also shorten the radius within which children can be active and reduce the activities in their living space. Likewise, first results of the German National Health Survey of Children and Adolescents (KIGGS Study) also show a clearly higher risk here for children from socially disadvantaged classes and children of immigrants (Robert Koch-Institut, 2006). Worse yet, resources like parks, green areas and free playing areas which encourage physical activity and so indirectly influence health behaviour and status are rare in sociostructurally disadvantaged residential areas, and when available, quality is usually low (Flade, 2006). Under such conditions, lasting, long-term success cannot be achieved either with isolated infrastructural or building initiatives or with preventive measures aimed mainly at disease prevention, such as campaigns for physical activity and improved nutrition. Seen from a public health perspective, it is clear that these problems can only be changed through small-scale, organised, genderoriented and culture-specific concepts. Despite different perspectives and strategies, prevention and health promotion can complement each other (Altgeld and Kolip, 2004), and behaviour prevention could include resource-promoting, situation-oriented settings approaches which are rooted in the immediate living space and so based on the everyday. Environmental justice can

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therefore also help fight the tendency to overvalue individual health behaviour (and its influence) and put greater emphasis on the living conditions as a factor influencing behaviour (Franzkowiak, 2006).

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