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Population Health for Nurses

8.1 Economic Stability

Population Health for Nurses8.1 Economic Stability

Learning Outcomes

By the end of this section, you should be able to:

  • 8.1.1 Discuss the relationship between poverty and economic insecurity.
  • 8.1.2 Describe the impact of employment on economic stability.
  • 8.1.3 Explain how housing instability contributes to economic insecurity.
  • 8.1.4 Describe the link between a person’s socioeconomic position and their health.

Economic stability in the context of the SDOH refers to the ability to access necessary resources and care to promote healthy living. It requires having a steady source of income with stable employment that is safe from occupational-related health risks. The necessary resources include the ability to afford quality housing in a safe neighborhood with access to clean air and water, transportation, and healthy food options.

In the context of an individual or a family, economic stability refers to a situation where the individual has a steady source of income and regular access to resources that are essential for a healthy life, such as food, clothing, housing, transportation, child care, and health insurance. A consistent income is one key to economic stability at the individual and family levels. Individuals with steady employment are less likely to experience economic insecurity (ODPHP, 2020a).

Consistently earning a living wage is another critical component of economic stability that directly correlates with what an individual can afford to live a healthy life. A living wage is one that affords a modest standard of living for the individual and family (Global Living Wage Coalition, 2018). The federal minimum wage is far below what is generally considered necessary for a family to survive; that is, it is less than a living wage (Glasmeier, 2023). The federal minimum wage rate has not kept pace with inflation and other cost-of-living adjustments that disproportionately impact Black, Indigenous, and people of color (BIPOC) individuals (Khan & Khattar, 2022). The last update to the federal minimum wage occurred in 2009, when it was increased to $7.25 per hour. Twenty states currently use the federal minimum wage. The ability to afford housing, food, child care, transportation, and health insurance affects an individual’s economic or financial stability (ODPHP, 2020a; Rural Health Information Hub [RHIhub], 2020a). A goal of Healthy People 2030 is to “help people earn steady incomes that allow them to meet their health needs” (ODPHP, 2020a, para. 1).

Poverty

Economic insecurity is when an individual or family cannot consistently afford housing, food, clothing, transportation, child care, or health care. Economic insecurity is directly linked to poverty, a state in which an individual lacks a socially acceptable amount of money or possessions (Merriam-Webster, 2023). In 2021, almost 38 million individuals, close to 12 percent of the population, lived in poverty in the United States (Creamer et al., 2022). Individuals and families living in poverty cannot afford the resources essential to living a healthy life (ODPHP, 2020a). Economic insecurity is also associated with unemployment, underemployment (willing but unable to find full-time work), and low-wage employment. Many individuals with stable work still do not earn enough income to afford the resources necessary for good health (ODPHP, 2020a). Almost one in every three individuals in the United States is considered economically insecure, with incomes below 200 percent of the federal poverty level (Langston, 2018). The groups most affected are BIPOC communities, which comprise slightly more than half of the individuals who are economically insecure (Langston, 2018).

The socioeconomic gradient is another term for the relationship between income and health, namely, the association between low socioeconomic position (SEP) and increased disease risk and premature death (Bonaccio, et al., 2020). SEP refers to one’s position in society based on social and economic factors of income, education, and employment. Individuals living with economic insecurity often cannot access resources that support healthy and quality living. These resources, along with economic stability, are what comprise the SDOH: stable housing, safe neighborhoods, access to healthy and affordable foods, and access to quality education. Living with economic insecurity makes it difficult to attain and sustain the determinants of health, thereby perpetuating a cycle of poverty, economic and housing instability, food insecurity, and a lack of access to educational and employment opportunities. This contributes further to income inequality and insecurity and results in a multitude of negative health outcomes (ODPHP, 2020b).

The U.S. Census Bureau (USCB) determines poverty levels by using a set of income thresholds that vary by family composition. If a family’s total income is less than the set family threshold, that family and each individual in it are considered to be living in poverty (USCB, 2023). The official poverty definition uses income before taxes and does not include noncash benefits such as public housing, food stamps, tax credits, and Medicaid benefits (USCB, 2023). In 2021, the federal designation of poverty for an individual was an income under $12,880 per year, and for a household (family of four) it was an income under $26,500 per year (ODPHP, 2020b). According to the U.S. Department of Housing and Urban Development (USDHUD), regardless of the location, a family of four with one adult employed full-time at the federal minimum wage rate is unable to afford fair-market rent for a two-bedroom apartment (Habitat for Humanity, 2023). Families who live in poverty cannot consistently afford quality housing, food, health care, and other necessities.

Poverty is cyclical and often persists for long periods of time. Research supports the concept of generational poverty, the phenomenon of persistent poverty and disadvantage where children who grow up poor, regardless of race, are more likely to be poor as adults (Wagmiller & Adelman, 2009). In many cases, the foundation of poverty can be traced to structural discrimination and racism that contribute to inequitable social and economic opportunities (ODPHP, 2020b). These deeply rooted practices and beliefs propagate the pervasive unjust treatment and oppression of BIPOC individuals (Braveman et al., 2022; see Structural Racism and Systemic Inequities). Individuals living in poverty or within impoverished communities lack equal access to the resources necessary for healthy living, such as safe, quality, stable housing and healthy food options. In the United States, BIPOC individuals living in rural areas and individuals living with disabilities are at higher risk for living in poverty.

Living in poverty has been directly linked with poor health outcomes. Those living in poverty or with limited finances may have difficulty accessing care due to the costs of health insurance, medications, and provider visits. Living in impoverished communities with limited access to healthy foods impacts health outcomes related to metabolic diseases, cardiovascular diseases, and diabetes. Living with the daily stressors of poverty and having to make difficult decisions such as pay the rent or purchase food increases stress levels and negatively affects mental and cardiovascular health while also negatively influencing health behaviors. Adults living in poverty are at higher risk for adverse health outcomes from smoking, substance use, and chronic stress. Poverty in childhood is associated with developmental delays, toxic stress, chronic illness, and nutritional issues. Mortality rates are higher and life expectancy is lower for impoverished individuals, families, and communities. In the United States, individuals who earn the top 1 percent of income (meaning they make more than almost everyone else) live 10 to 15 years longer than individuals who earn the bottom 1 percent of income (ODPHP, 2020b). For individuals living in poverty, economic insecurity is a constant health threat.

Employment

Employment is a main driver of individual economic stability. Stable employment is associated with lower levels of poverty and overall better health. A job’s demands, the work environment, compensation, and the security of the work all affect an individual’s health status (ODPHP, 2020u). Individuals may be out of the workforce (retired or unable to work), employed (working for pay), unemployed (not working but looking for work), or underemployed (involuntary part-time work, intermittent work, poverty-wage work). A lack of employment and underemployment are associated with poverty and economic insecurity. Studies have linked illness and premature death, and a delay or absence in receiving necessary medical care and prescriptions, with unemployment in adults (Kansas Department of Health and Environment, 2015). Individuals who are unemployed have higher rates of depression, anxiety, and low self-esteem along with a sense of demoralization. In addition to psychological harm, some of these individuals experience stress-related issues such as hypertension, heart disease, and arthritis and may also experience a stroke or myocardial infarction (ODPHP, 2020u).

An individual’s physical work environment is an important factor in their general health. Repetitive lifting, pulling, or pushing heavy items, exposure to chemicals, or loud noises can all cause significant injury and illness to workers (ODPHP, 2020u). Time off from work often follows an injury or illness, which can further tip an individual into economic insecurity. Highly demanding jobs, high levels of conflict within the workplace, long workdays, having multiple jobs, and working evening shifts are also associated with psychological stress. These workplace stressors place individuals at risk for depression, strained caregiver-child relationships, and unhealthy coping mechanisms such as misusing alcohol or smoking cigarettes (ODPHP, 2020u). Migrant workers are at particular risk; see Caring for Vulnerable Populations and Communities for more details.

Disparities in employment have been correlated with race and ethnic background, gender, and level of educational attainment (ODPHP, 2020u). These disparities negatively impact economic stability and further perpetuate the cycle of poverty. For example, BIPOC individuals are more likely to work in lower-paying blue-collar service jobs and environments with greater exposure to the environmental risk factors described above while White individuals are more likely to work in office jobs and assume managerial positions (ODPHP, 2020u). These exposures place BIPOC individuals at higher risk for injury, illness, anxiety, and depression (ODPHP, 2020u). While the pay gap between women and men in the United States has narrowed somewhat in recent years, in 2020, women earned 83 cents for every dollar earned by men (Wisniewski, 2022). This gap in pay equity between genders negatively affects the economic stability of women and families.

Educational level affects the type of work individuals engage in, the working conditions they experience, and compensation levels. Individuals with lower levels of education generally have fewer job choices and may be forced to accept undesirable positions and low wages. These individuals are more likely to have more physically demanding jobs that may expose them to harmful toxins (ODPHP, 2020u). Many factors may contribute to lower educational attainment, including growing up in poverty with unequal access to educational opportunities.

The Opportunity Atlas

At this interactive website, The Opportunity Atlas, you can click on a map to find out which U.S. neighborhoods offer children the best chance to rise out of poverty. You can trace the roots of today’s affluence and poverty back to the neighborhoods where people grew up. The atlas allows users to search by location, outcome, and demographic group.

Explore the atlas, and then respond to the following questions.

  1. What question(s) did you use to explore the Atlas?
  2. What do the areas where household income at age 35 is highest seem to have in common? What about those areas where household income is lowest? And what about those where income falls somewhere in the middle? Thinking about other aspects of these regions, consider what it is about the regions—based solely on geography—that might relate to these outcomes.
  3. Pick one of the articles on the map (indicated by an open book icon) and explore what you find at that link. How does this add to your understanding of poverty and opportunity?

Housing Instability

Affordable housing is another driver of economic stability, whereas housing instability is correlated with economic insecurity. Individuals and families who encounter difficulty paying rent, live in overcrowded residences, move frequently, or spend a large part of their household income on housing are experiencing housing instability.

Households are cost burdened if they spend more than 30 percent of their income on housing, and they are severely cost burdened if they spend more than 50 percent on housing (ODPHP, 2020s). After paying rent, these households are left with little to spend on other necessities such as food, clothing, utilities, and health care. BIPOC households are almost twice as likely as White households to be cost burdened (ODPHP, 2020u). In 2019, there were over 37 million cost-burdened households in the United States, almost 18 million of which were severely cost burdened. Cost-burdened households are at risk for housing instability (ODPHP, 2020u). Substandard or inferior housing is associated with health risks such as asthma, allergies, mental health conditions, and respiratory illnesses related to vermin, mold, water leaks, and inadequate heating and cooling systems (CDC, 2009).

Interactivity: Spent

In the interactivity Spent, you begin by losing your job, life savings, and house. Down to your last $1,000, you must make it through the month by making a series of difficult decisions as you watch your savings dwindle. While this activity is set up as a game, poverty is not something you can simply stop playing, and many Americans make decisions like those in this interactive simulation daily to survive.

Walk through the interactivity, and then respond to the following questions.

  1. What factors did you weigh as you decided how to spend your money?
  2. What, if anything, surprised you as you made your choices?

Being cost burdened puts individuals and families at risk for foreclosure or eviction. Renters who are evicted or forced to move often relocate to poorer and less safe neighborhoods (ODPHP, 2020u). Researchers have correlated children who experience multiple housing moves in a year with poor physical health and lack of consistent health insurance coverage. If families must move frequently, building community relationships and attachments is more difficult. Community attachments can be protective for individuals experiencing adversity. For example, research has indicated that individuals living in higher-income areas report better health than those living in lower-income areas (ODPHP, 2020u).

Severe housing instability may result in homelessness, a state where individuals lack a nighttime residence (Figure 8.3). The USDHUD Annual Homelessness Assessment Report to Congress found that an estimated 582,500 individuals were experiencing homelessness on a single night in 2022 (USDHUD, 2022). This equates to 18 of every 10,000 individuals in the United States experiencing homelessness. Compared to the overall U.S. population, BIPOC communities continue to be overrepresented among the population experiencing homelessness (USDHUD, 2022). Individuals experiencing homelessness have an increased risk of premature death. In Massachusetts, the mortality rate of individuals ages 25 to 44 experiencing homelessness was approximately ten times higher than that of the general population. A study of individuals experiencing homelessness in the New York City shelter system found that over 50 percent had a substance use disorder, 17 percent had hypertension, 17 percent had asthma, and 35 percent were experiencing major depression, correlating the negative impact of housing instability with homelessness. Children who are homeless are at risk of cognitive and mental health problems, asthma, physical injury and assaults, and poor school performance. Housing instability has broad implications for the development and future of these children (USDHUD, 2022). See Caring for Vulnerable Populations and Communities for more information about homelessness.

An individual sits on a street corner; the road is wet and there is a dusting of snow on the sidewalk. A sleeping bag and other personal effects surround the individual on the sidewalk.
Figure 8.3 An individual experiencing homelessness is at risk for health issues related to inadequate nutrition and exposure to violence, communicable disease, and weather. (credit: “homeless” by Golfeser/Flickr, Public Domain)

Theory in Action

Moving to Opportunity

Neighborhoods make a difference in the health and well-being of residents. In this video, Harvard professors Nathan Hendren and Edward L. Glaeser discuss the Moving to Opportunity (MTO) program, which assessed the outcomes of moving families with young children out of high-poverty housing projects into lower-poverty neighborhoods (ODPHP, 2020u). The program found that the children of families who moved to low-poverty neighborhoods before the age of 12 were more likely than children who didn’t move or children who moved after the age of 12 to go to college, have higher incomes, and live in better neighborhoods as adults. The women of these families also had improved health outcomes, with lower levels of obesity and diabetes (Abdul Latif Jameel Poverty Action Lab, n.d.).

Watch the video, and then respond to the following questions.

  1. According to the research presented, where in the United States do children have the best chance of upward mobility? Where do they have the worst chance? Why do you think this is so?
  2. Why do you think children who were under age 12 when their families moved to neighborhoods with lower poverty rates fared better economically as adults than children who were older when they moved to these same neighborhoods?

Case Reflection

Housing Instability

Read the scenario, and then respond to the questions that follow.

Serena Jordan is a 42-year-old woman who is married with three children, ages three, five, and nine. She works full-time as an administrative assistant at an insurance company. Her husband is a truck driver and is often gone for weeks at a time on the road. They do not have any family nearby, but they rent a second-floor apartment in an old three-family home and have made friends with the neighbors who live on the third floor. The neighbors, an older couple, sometimes help watch the children when Serena is in a pinch. Serena’s family lives paycheck to paycheck, and though she works 40 hours a week, Serena is always worried about being able to pay the bills. Currently, she earns $13/hour, and her husband brings home a salary of $50,000/year, but with the three children, day care expenses, rent, grocery bills, car payments, and medical bills, it never seems to be enough. The family spends almost $2,000 a month on rent, leaving them cost burdened.

  1. Why do you think many people in the United States are experiencing similar situations to those Serena and her family are experiencing?
  2. What are some interventions the community health nurse can do to assist Serena and her family?

The Role of the Nurse in Addressing Economic Instability

Nurses need to assess for poverty in all their clients, regardless of appearance or health insurance status. This assessment can be a written questionnaire or an in-person conversation. It might be as simple as asking, “Do you sometimes have to skimp on purchasing groceries to pay your rent? Do you feel you have all the resources necessary?” Often, nurses do not want to ask these questions in case a client answers “No,” as they do not have a solution or they feel the problem is too big for one person to solve. However, the first step in the nursing process is always assessment. Nurses need to be able to ascertain this information as a part of the total health assessment to collect data and then formulate a plan. Nursing can significantly impact individuals, families, and communities living in poverty by raising awareness of the prevalence of poverty and its associated negative health outcomes. By raising awareness, nurses can advocate for allocating more resources, such as increased tax credits for families, free early education programs for young children, and better food assistance programs. Community health nurses who assess for housing instability and collect relevant data can intervene with referrals to housing support programs and subsidies that can provide low-income families with financial and housing assistance. Additionally, nurses can advocate for a living wage for everyone by promoting the health and societal benefits of improving conditions for impoverished communities.

Community health nurses can be essential in promoting safe physical work environments to address employment-related health disparities. Nurses should screen all their clients for physical and psychological work-related hazards to formulate an appropriate care plan. They can also work with local and state officials and business owners to advocate for employee benefits and resources such as health insurance, paid sick leave, and parental leave. Community health nurses can also advocate at the local, state, and federal levels for employment programs, free educational training programs, or degree programs for lower-income individuals who wish to further their education, obtain career counseling, and seek access to affordable, quality child care. Nurses specializing in occupational health often work in tandem with corporations to promote healthy work environments. Their role is to protect workers from physical injury related to repetitive lifting or poor ergonomic design and exposure to harmful chemicals and loud noises.

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