Editorial – Gregory Lewis, MD

Social Determinants of Health – Poverty – Editorial Series Part III

Social Determinants of Health (SDoH) are the conditions under which people are born, grow, live, work and age¹.  They have a larger role on population health than more traditional factors like genetics, behavior and health care².  Examples include socioeconomic status, education, employment, social networks, racism, discrimination, residential location, and housing and food security.  These upstream factors create the structure for health inequalities.  This is the third part of an editorial series on SDoH, today focused on poverty.

The CDC defines poverty as a condition in which “a person or group of people lack human needs because they cannot afford them”.  Other definitions to note are near poor or low income [<200% Federal Poverty Level (FPL)], poor (<100% FPL) and deep poverty (<50% FPL)³.  In 2013, 14.5% US citizens fell below the 100% FPL and 40% below the 200% FPL⁴.  In 2018 there was some improvement, with 11.8% of US citizens below the 100% FPL⁵.  This equates to just over 38 million people. Based on a report from County Health Rankings 2020, 17% of California children live in poverty (national average 18%)⁶.  There is a disproportionate impact on American Indian and Alaska Native, Black and Hispanic children.

Poverty impacts birth weight, infant mortality, language development, chronic illness, environmental exposure, nutrition and injury.  Poverty in children impacts brain development and these children are at risk for inattention, impulsivity, defiance and poor peer relationships.  There is a significant economic cost to society with childhood poverty, secondary to the lifelong hardships associated with these issues³.  The AAFP notes that poverty is associated with an increased likelihood of the following:  lack of a safe neighborhood to play, limited education opportunities, limited access to medical and dental care, poor nutrition, suboptimal housing, and exposure to violence and toxins.  High levels of stress affect human development and physiology (both acute and chronic)⁴.  People living in poverty are also subject to other SDoH, including food insecurity, housing insecurity and loss of health care³. 

The AAFP has a position paper on Poverty and Health⁴.  The AAP recommends screening for poverty during health care visits, and also have a policy statement addressing such³.  WE CARE (Well Child Care, Evaluation, Community Resources, Advocacy, Referral, Education) is a clinic-based, 12-question, screening tool developed for pediatric settings.  WE CARE assesses needs in 6 domains:  parental educational attainment, employment, child care, risk of homelessness, food security, and household heat and electricity⁸.  Another available tool called PHATE assesses population health.  PHATE uses patient data from the PRIME Registry to assign a Community Vital Sign.  The dashboard can provide links to local resources based on a specific zip code⁹.  The AAFP has a tool “Neighborhood Navigator” as part of The EveryONE Project, to help providers connect patients with local programs⁷.  Note that screening for poverty may have unintended harms (feeling of stigmatism, frustration regarding community resources)¹⁰.

Government programs have a significant effect on family poverty, based on longitudinal studies that used the Supplemental Poverty Measure (SPM)³.  Earned income tax credit (EITC) is a federal tax credit that helps low-income families.  Child tax credits provide tax refunds to low-income working families.  Medicaid and the Children’s Health Insurance Program have provided access to health care.  Education programs like Head Start are community-based programs for low-income families.  The Supplemental Nutrition Program for Women, Infants and Children (WIC) is associated with decreased rates of prematurity, infant mortality and increased involvement in prenatal care³. 

Physicians can advocate for programs and policies to reduce the impact of adverse events and outcomes related to poverty.  The CAFP has been supportive of the expansion of full-scope Medi-Cal coverage to eligible young adults ages 19 – 25, premium assistance subsidies in Covered CA for individuals and families up to 600% FPL, and the extension of Medi-Cal eligibility from 60 days to 1 year for postpartum women diagnosed with a mental health disorder.  The AAP calls for advocacy with public policies that address protection and expansion for the funding of programs that help low-income families, support promotion of employment and increase parental earnings, ensure quality health care access, and improve community infrastructure (affordable housing, safe public spaces)³.

As Family Physicians, we are on the front line to have an impact on these upstream issues.  We have opportunities and platforms to advocate for social reform on many local, state and national levels.  We need to take action in our own practices and our communities.  Early detection and management of poverty-related disorders is an important component of general practice.  Create a practice sensitive to the issues and needs of families living in poverty, screen for SDoH, and be aware of community resources available to your patients and families.

1. American Academy of Family Physicians.  Social determinants of health policy.  https://www.aafp.org/about/policies/all/social-determinants.html
2. American Academy of Family Physicians.  Advancing Health Equity by Addressing Social Determinants of Health in Family Medicine (Position Paper).  https://www.aafp.org/about/policies/all/socialdeterminantofhealth-positionpaper.html
3. AAP COUNCIL ON COMMUNITY PEDIATRICS.  Poverty and Child Health in the United States. Pediatrics.  2016; 137(4): e20160339.  https://pediatrics.aappublications.org/content/137/4/e20160339
4. AAFP.  Poverty and Health – The Family Medicine Perspective (Position Paper).  2015 Congress of Delegates.  https://www.aafp.org/about/policies/all/policy-povertyhealth.html
5. United States Census Bureau. https://www.census.gov/topics/income-poverty/poverty.html 
6. County Health Rankings 2020.  https://www.countyhealthrankings.org/explore-health-rankings/measures-data-sources/2020-measures
7. Neighborhood Navigator (AAFP).  https://www.aafp.org/patient-care/social-determinants-of-health/everyone-project/neighborhood-navigator.html
8. Garg A, Butz AM, Dworkin PH, Lewis RA, Thompson RE, Serwint JR.  Improving the management of family psychosocial problems at low-income children’s well-child care visits: The WE CARE Project.  Pediatrics. 2007;120(3):547-558. PMID: 17766528. DOI: 10.1542/peds.2007-0398.
9. Bambekova PG, et al.  Integrating Community and Clinical Data to Assess Patient Risks with a Population Health Assessment Engine (PHATE).  J Am Board Fam Med. 2020; 33:  463–467. http://jabfm.org/content/33/3/463.full
10. UpToDate.