How Understanding Poverty Can Improve Health Outcomes Karen Kelley, MSN, RN Assistant Professor of Nursing Harding University Carr College of Nursing Sigma Theta Tau Research Day March 28, 2019

Learning outcomes: At the end of this session the learner will be able to: 1. Know a holistic definition of poverty and defining characteristics of poverty. 2. Know the complex causes of poverty at the individual, community, and systems levels. 3. Know the effects of poverty on health status of individuals and communities. 4. Know ways that nurses can improve the health outcomes of people experiencing poverty.

Important points… We will discuss patterns and there are always exceptions to these patterns This is a brief overview. Poverty is complex and there are no simple solutions. We will cover only a few examples very briefly.

Defining Poverty What would you say poverty is? How would you define it?

Defining Poverty What is poverty? Payne (2013) – the extent to which an individual does without resources (financial, emotional, mental/ cognitive, spiritual, physical, support systems, relationships/ role models, knowledge of hidden rules, and language/ formal register)

Resources (Payne) Financial – having the money to purchase goods and services. Emotional – being able to choose and control emotional responses, particularly to negative situations, without engaging in self- destructive behavior. This is an internal resource and shows itself through stamina, perseverance, and choices.

Resources (cont.) Mental – having the mental abilities and acquired skills (reading, writing, computing) to deal with daily life. Spiritual – believing in divine purpose and guidance. Physical – having physical health and mobility. (and poverty is strongly related to poor health outcomes) Support systems – having friends, family, and backup resources available to access in times of need. These are external resources.

Resources (cont.) Relationships/ role models – having frequent access to adult(s) who are appropriate, who are nurturing to the child, and who do not engage in self-destructive behavior. Knowledge of hidden rules – knowing the unspoken cues and habits of a group. Language/ formal register – being able to competently, use the vocabulary and sentence structure of work and school.

Defining Poverty Myers (2011) Poverty as Deficit – not having enough food, clean water, place to sleep, land, education and skills, markets, health care systems, etc. (p.113) Poverty as Entanglement – “a cluster of disadvantage” or the “poverty trap” “may lack hope and be unable to believe that change is possible (p. 115) Poverty as lack of access to social power (p. 118) Poverty as diminished personal and relational well-being – marred identity – “marred by disrespect, exclusion, humiliation, and erasure of identity” (p. 120 -122) Poverty as a disempowering system – captive to the “god-complexes” of the non-poor – decisions made at a distance (p.123 – 124) Poverty as a lack of freedom to grow (p.131)

Myer’s summary (p.132) Poverty is a complicated social issue involving all areas of life – physical, psychological, social, cultural and spiritual. The way we describe or see poverty depends on our worldview, training & education. It occurs in all races & countries Essentially poverty is about relationships but it continues to defy simplistic descriptions, definitions and easy solutions.

A Holistic understanding of Poverty Poverty is the result of relationships that don’t work. Relationships that are fragmented, dysfunctional or oppressive At it’s core, poverty is relational.

US Census Bureau Poverty rate in the US in 2017 was 12.3% of the population – or 39.7 million people Non-Hispanic whites – 10.3% Blacks – 25.2% Hispanics – 22.2% Asians – 11.9% Children – 20.3% https://www.census.gov/library/publications/2018/demo/p 60-263.html https://factfinder.census.gov/faces/tableservices/jsf/pages/ productview.xhtml?src=CF

USDHHS Poverty Guidelines https://aspe.hhs.gov/poverty-guidelines

In the World Who is Poor? Globally – World Bank says that in 2015 , 10% of the world’s population live at or below the extreme poverty measure of $1.90 per day. Nearly 1.1 billion fewer people are living in extreme poverty than in 1990. In 2015, 736 million people lived on less than $1.90 a day, down from 1.85 billion in 1990. (World Bank, http://www.worldbank.org/en/topic/poverty/overview 3.4 billion people (nearly half the global population – 46%) still lives on less than $5.50 per day - the global poverty line for upper-middle income countries 1.9 billion people or 26.2% or the global population lives on less than $3.20 per day – the poverty line for lower-middle income countries http://www.worldbank.org/en/news/press-release/2018/10/17/nearly-half-the- world-lives-on-less-than-550-a-day

World Bank definition What is poverty? Poverty is hunger. Poverty is lack of shelter. Poverty is being sick and not being able to see a doctor. Poverty is not having access to school and not knowing how to read. Poverty is not having a job, is fear of the future, living one day at a time. Poverty is losing a child to illness brought about by unclean water. Poverty is powerlessness, lack of representation and freedom.

Voices of the Poor Robert Chambers working with the World Bank sent a team of researchers to listen to over 60,000 of the world’s poorest people. Overall they wanted modest material goods – many expressed desires were relational – take care of family, harmony within family and community, having friends and helping others. They also expressed the need for psychological well-being – to feel better about oneself, a sense of dignity and respect, peace of mind, lack of anxiety, being God-fearing, and happy or satisfied with life. – Myers,p. 32 “Researchers reported that the poor spoke of psychological dimensions of poverty such as personal ‘powerlessness, voicelessness, shame and humiliation as well as their manifestations in alcoholism, domestic violence and depression. ‘ “ (Sloan, 2003) (Myers, p. 121)

Voices of the Poor http://web.worldbank.org/WBSITE/EXTERNAL/TOPICS/EXTPOVERTY/0 ,,contentMDK:20622514~menuPK:336998~pagePK:148956~piPK:216 618~theSitePK:336992,00.html

Causes of Poverty What do you think causes poverty? Is it a failure of personal responsibility? Is it a failure of the systems, community?

Causes of Poverty Generational patterns Prevailing attitude – society “owes me a living” (Payne, p. 61) Hidden Rules: Money is to be used and spent – money used for security is a part of middle class and wealth p. 54 Present time orientation – decisions based on survival or feelings Education – hoped for but not seen as a reality Destiny - can’t do much to change fate Language – casual register – may not be able to access formal register Family structure – matriarchal World view – local Driving forces – survival, relationships, and entertainment (Payne, p. 54)

Causes of Poverty “The generationally poor are usually as confined by their poverty as if they lived in a maximum security prison.” Allison Boisvert (Payne, p.62) The reality of generational poverty… housing instability violence food insecurity unstable employment addiction unmet health needs homelessness predators crowded housing incarceration lack of education time spent getting assistance death limit knowledge bases (Payne, p. 62)

Causes of Poverty What does the Adverse Childhood Events Study (ACES) tell use about poverty? “What happened to you?” In 1998 researchers mailed questionnaires to 13,494 adults who were part of an HMO. 9,508 (70.5%) responded. 7 categories of adverse childhood experiences were were included: psychological, physical or sexual abuse, violence against the mother, substance abuse in the home, or mental illness or suicidal, or incarcerated. Compared to measures of adult risk behavior, health status, and disease to determine the association between the cumulative number of childhood adverse experiences (0-7) and risk factors for the leading causes of death in adult life. (Felitti, 1998)

Causes of Poverty ACES (cont.) Results: (excerpts “We found a graded relationship between the number of categories of childhood exposure and each of the adult health risk behaviors and the diseases that were studied. “ “Persons who had experienced four or more categories of childhood exposure compared to those who had experienced none, had 4-12 fold increased health risk for alcoholism, drug abuse, depression, and suicide attempt; a 2- to 4-fold increase in smoking, poor self-rated health, _> 50 sexual intercourse partners, and sexually transmitted disease; and a 1.4 to 1.6-fold increase in physical inactivity and severe obesity.” (Felitti, 1998)

Causes of Poverty ACES Conclusion: “We found a strong graded relationship between the breadth of exposure to abuse or household dysfunction during childhood and multiple risk factors for several of the leading causes of death in adults.” (Felitti, 1998)

About the CDC-Kaiser ACE Study The ACE Pyramid

Causes of Poverty County Health Rankings,2019) What is the relationship of poverty and violence? County Health Rankings,2019) Data from 2012-14 Number of violent crime offenses per 100,000 population “Although exposure to violence affects all socioeconomic status groups, youth from lower SES backgrounds tend to have increased exposure and likelihood of suffering from detrimental future outcomes”. (APA, 2019)

The Impact of Poverty on Health What is the relationship of health to socioeconomic status? Census Bureau, 2017) https://www.census.gov/data- tools/demo/saipe/saipe.html?s_a ppName=saipe&map_yearSelecto r=2017&map_geoSelector=aa_c&s _state=05

The Impact of Poverty on Health The Social Determinants of Health Largely responsible for the disparities in health status Health is more than healthcare – jobs, income, schools, and neighborhoods are as important as our genes, behaviors, and medical care. (UnNatural Causes, 2008) In the US income is a strong predictor of health and the chronic stress of poverty is toxic to health (UnNatural Causes, 2008) http://www.unnaturalcauses.org/about_the_series.php

The Impact of Poverty on Health Barriers tied to SES? access – financial, lack of insurance, lack of understanding how to access care transportation attitudes of healthcare workers Others??

The Impact of Poverty on Health Life expectancy County Health Rankings (2019)

The Impact of Poverty on Health

Ideas: addressing issues related to poverty to improve health Health literacy – teaching may need to be adjusted. Goals need to be written, education through, return demonstration – remember they may have a hard time planning, live in chaos, not see everything on a page, etc. Foods they can afford; dental issues – what foods are they unable to eat? Coordination and follow-up Need detailed and specific follow-up, walk with them through the health care system Assess for neglected physical and mental health issues – won’t necessarily seek care if not assisted.

Ideas

Ideas From the Camden Coalition of Healthcare Providers, Healthcare Hotspotting Care Interventions 101 Care is grounded in acceptance – “meet patients where they are, without judgement or preconceptions, and understanding and respecting who they are, we enable genuine healing relationships that can lead to meaningful change.” Four key principles of care: - motivational interviewing - trauma-informed care - accompaniment - harm reduction

Ideas

References California Newsreel, (2008). UnNatural Causes…is inequality making us sick?. Retrieved from http://www.unnaturalcauses.org/assets/uploads/file/primers.pdf Centers for Disease Control and Prevention. (2016, June 14). About the CDC-Kaiser ACE Study. Retrieved from https://www.cdc.gov/violenceprevention/childabuseandneglect/acestudy/about.html County Health Rankings. (2018). Health factors: Violent Crime. Retrieved from http://www.countyhealthrankings.org/app/arkansas/2018/measure/factors/43/data County Health Rankings. (2018). Health factors: Premature Death. Retrieved from http://www.countyhealthrankings.org/app/arkansas/2019/measure/outcomes/1/map Felitti, V.J., Anda, R.F., Nordenberg, D., Williamson, D.F., Spitz, A.M., Edwards, V., Koss, M.P., & Marks, J.S. (1998). Relationship of Childhood Abuse and Household Dysfunction to Many of the Leading Causes of Death in Adults. American Journal of Preventative Medicine. 14(4), 245-258. (Prevention, 2016) Myers, B. (2011). (revised and expanded edition). Walking with the poor: Principles and practices of transformational development. Maryknoll, New York: Orbis Books. Payne, Ruby K. (2013). A framework for understanding poverty. Highlands, TX: Aha! Process, Inc.