8.1 Economic Stability

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.

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).

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.

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)

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.