34.1 Social Planning and Policy Change

Cultural Influences on Health Policy Development

Health policymaking refers to the work of government bodies and other relevant organizations to formulate and establish policies and implementation methods to address any of the varied aspects of health care, which include public health and the health care system. It involves carefully thought-out decision-making processes to establish goals and priorities, fund the planned policy, and make plans for the policy’s eventual implementation (Smith, 2020).

Health policy developers need to be sensitive to differences between their own cultural backgrounds and those of the prospective populations the policies will impact. Culture, religion, and ethnicity may influence beliefs and values that people have about health and health care. It is important to consider these beliefs and values when attempting to create new policy, whether for a single hospital department or for the whole nation. Researching and understanding the customs and values of a group before drafting a policy is a good start. Working with leaders from within a cultural group to establish the concerns and needs of the group demonstrates support and respect. Each ethnic group brings its own perspectives and values to the health care system, and some of these beliefs and practices differ from those of the traditional American health care culture.

Poverty and Health Inequality

The federal government creates and sponsors many policies and programs intended to improve the health of the population of the United States as a whole. Past programs include those designed to find employment for individuals left destitute by the Great Depression, such as the Works Progress Administration (WPA) of the 1930s (Figure 34.2). While not designed to improve health status alone, the WPA program and many similar programs allowed individuals and families to afford shelter and food in a time of economic turmoil.

Figure 34.2 A worker employed by the Federal Works Progress Administration (WPA) that ran from 1935 to 1943 during Great Depression receives a paycheck. (credit: “Photograph of Works Progress Administration Worker Receiving Paycheck” by Federal Works Agency. Work Projects Administration. Division of Information. 7/1/1939-1943/National Archives Catalog, Public Domain)

In 2010, President Barack Obama signed the Patient Protection and Affordable Care Act (PPACA or ACA) into law. This was the government’s first major effort to improve access to health care since the introduction of Medicare and Medicaid in 1965. As a result of the ACA, by 2016, the number of uninsured U.S. citizens was cut nearly in half. Another beneficial, client-centered outcome of the ACA was a reduction in clients’ out-of-pocket costs due to preexisting conditions—health problems diagnosed before an insurance policy goes into effect. The ACA limited insurers’ ability to refuse to pay for treatments for preexisting conditions (Office of Disease Prevention and Health Promotion [ODPHP], 2020b). A major goal of the ACA was to improve the health of Americans who lived near or below the poverty line. Without health insurance, visiting a medical provider for preventative medicine was a luxury many could not afford. Often, the only place a low-income client could be treated for an illness or injury was the emergency department (ED). Although treatment in the ED requires no up-front payment, the relative cost of care in this medical setting generates large medical bills that uninsured clients may be unable to repay. This debt makes low-income families even more financially unstable as it lowers their credit scores and drives them toward medical bankruptcy. While this may sound like a problem that only affects individuals or families, this medical debt can be the entry into a multigenerational financial ruin.

The cycle of poverty, also known as the poverty trap, refers to a series of events that occur between generations. The main idea is that once a person or family becomes impoverished, it is almost impossible to change their economic status, and an external intervention is needed to break the cycle (Maryville University, 2022). As seen in Figure 34.3, many factors play a part in perpetuating this cycle.

Figure 34.3 The cycle of poverty most often begins when a low-income family has children but may also begin when students fail to graduate high school and have difficulty finding work that pays a living wage due to their limited education. (attribution: Copyright Rice University, OpenStax, under CC BY 4.0 license)

The cycle typically begins when a child is born into a poor family with few resources to create opportunities for healthy growth or advancement (Coughlin et. al, 2022). Children are often the family members who are affected the most by poverty, with one in seven children in the United States living in poverty (Children’s Defense Fund, 2023). Children depend on their families to meet all their needs, such as food, clothing, and shelter. As discussed in Caring for Vulnerable Populations and Communities, the presence of children in a family is a financial burden on all the other members (de la Sablonnière, 2017).

Families in the cycle of poverty can have several disadvantages compared to families with financial stability. Some of these negative social determinants of health include

• low level of education,
• few marketable job skills,
• lack of transportation,
• frequent moves due to eviction,
• high levels of debt that can lead to recurrent bankruptcies,
• depression, and
• higher-than-average incidence of alcohol and substance misuse.

For impoverished families, the more of these factors are present, the more difficult it will be for them to improve their economic situation, even with the support of friends and family (Coughlin et. al, 2022). Breaking the cycle of poverty can be even more challenging for people who lack family support or live in remote and sparsely populated areas. This relative isolation is another barrier for individuals experiencing poverty to overcome. When thinking of positive predictive factors, or circumstances that help break the cycle of poverty, two that come at little cost are social support and social capital (Dickey et.al, 2022).

Social support is both actual and perceived support from a person’s social network, such as coworkers, friends, and family. Having a family member or neighbor who can babysit a sick child to prevent a caregiver from missing work is a form of social support; this allows the caregiver to avoid a day of lost wages, which might destabilize the household’s monthly finances. Social capital refers to resources accessed through social connections, or networking, which decrease barriers to health care. An individual notifying a friend about an opening at their workplace for a job with higher wages and/or benefits and providing the friend with a referral letter is an example of social capital in action. Unfortunately, when people are already living in an impoverished state, they often lack friends and acquaintances with significant social capital, and this creates barriers to economic support (Dickey et al., 2022).

Children living in poverty are more likely to experience malnutrition (due to a lack of quality foods), disease (due to poor sanitation and lack of immunizations), and reduced access to education (Sharfstein, 2021). Research shows that the effect of interventions aimed at childhood nutrition and early childhood education through programs like Head Start has increased the high school graduation rate of children impacted by these programs (Bitler & Figinski, 2019).

Community health nurses use policies and programs to improve childhood nutrition and to encourage early childhood education, well-child checks, and vaccinations. At the local level, improving childhood nutrition happens through food assistance programs, often called food pantries, and zoning policies that encourage the building of grocery stores in underserved areas to increase the presence of fresh foods and eliminate food deserts.

States can support families by providing supplemental funding to their Head Start centers, which provide children ages 3 to 5 with early educational interventions, free hot meals, and education and resources for caregivers. Children from infancy to age 3 can be enrolled in Early Head Start where available, which provides parents with a safe, no-cost alternative to paid childcare (U.S. Department of Health and Human Services [HHS], 2023).

At the national level, the Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) and the Supplemental Nutrition Assistance Program (SNAP) provide nutritional support for families. These programs provide healthy food needed for children’s growth and development and maintain nutritional health in adults (Benefits.gov, 2021). A recent evaluation of the effects of SNAP on child health has shown that the program has helped reduce child poverty and that without the support of SNAP as a primary food source for a family, twice as many children would live in deep poverty (Trisi & Saenz, 2020).