State Contexts and Stigma-Related Disparities in Health Among Mothers Receiving Public Assistance Benefits

Background & Purpose: The stigmatizing nature of the US welfare system is of particular importance not only because it has shown to deter eligible applicants from participating in public assistance programs despite facing economic hardship (Moffit, 1987), but also because stigma is an important fundamental cause of health inequities (Hatzenbuehler, Phelan & Link, 2013). In fact, studies show welfare stigma is linked to several adverse mental health outcomes (e.g, Bassuk et al., 1997; Crocker, Major, & Steele, 1998). Although scholars agree stigma is shaped by individual and contextual dimensions (Link & Phelan, 1995), the role of context is often overlooked. Given the heterogeneous nature of US state welfare environments, it may be critical to consider the ways in which state policy, social and economic contexts condition the relationship between welfare stigma and health. Using a multilevel lens, this study examines (1) the impact of experienced and perceived welfare stigma on self-reported health among female public assistance recipients with children, (2) the moderating effect of uneven state-level TANF policies, income inequality and public welfare attitudes, and (3) whether any disparities in the relationship between stigma and health exist for groups who historically have been stigmatized for engaging with the U.S. welfare system.

Methods: Using public and restricted data from the Fragile Families and Child Wellbeing Study merged with state-level economic and social measures, we employ a series of multilevel logit models with random effects to (1) estimate the association between experiences and perceptions of welfare stigma and health, (2) test whether state contexts moderate these associations, and (3) examine whether associations vary by education and race/ethnicity.

Results: Findings show experiences and perceptions of welfare stigma are significantly linked to poor health regardless of state contexts, and outcomes vary markedly by race, ethnicity and education. When considering the moderating effects of state contexts, we find states with strong anti-welfare attitudes amplified the relationship between experienced welfare stigma and poor health for Black and Hispanic mothers, and state economic contexts modified the relationship between experienced welfare stigma and poor health for mothers with less than a high school education. In contrast, TANF generosity had no moderating effect on health suggesting state policy environments have limited ability to protect welfare recipients against the stigmatizing effects of the US welfare system.

Implications: Results from this study underscore that ongoing gendered and racialized welfare discourse perpetually reinforces a social climate that is less supportive of welfare policies which imparts exacerbated health consequences for groups historically subjected to welfare related stigma. Moreover, this study makes clear that structural-level and individual-level factors have synergistic effects on the health of individuals engaged with the U.S. welfare system. Findings have critical implications for explaining stigma related disparities in health within the context of U.S. welfare environments and understanding the intersection of social welfare use, race and socioeconomic factors for social justice. Policymakers should consider individual and structural strategies to reduce negative perceptions associated with participation in public assistance programs and eradicate their stigmatizing effects.