The Healthy People 2020 Social Determinants of Health topic area is organized into 5 place-based domains:
- Economic Stability
- Health and Health Care
- Neighborhood and Built Environment
- Social and Community Context
Poverty is a key issue in the Economic Stability domain.
The prevalence of poverty in the United States is an important public health issue. In 2015, approximately 43 million Americans lived in poverty.1 Although the U.S. Census Bureau uses “a set of dollar value thresholds that vary by family size and composition to determine who is in poverty,”2 poverty may be defined in a number of different ways, particularly by socioeconomic status (SES).3, 4
Socioeconomic status can be determined by a family's income level, education level, and occupational status.3 In spite of the differences in definition between poverty and socioeconomic status, researchers agree that there is a clear and established relationship between poverty, socioeconomic status, and health outcomes5, 6—including increased risk for disease and premature death.7
Many factors can contribute to inequitable access to resources8 and opportunities, which may result in poverty.7, 9 10 Marital status, education, social class, social status, income level, and geographic location (e.g., urban vs. rural) can influence a household's risk of living in poverty.1, 7, 11–14 For example, in 2012, 17.7% of people in rural areas were living in poverty, compared to 14.5% of people in urban areas.15, 16 Racial and ethnic minorities are more likely than non-minority groups to experience poverty at some point in their lives.9, 17 In addition, children from families that receive welfare assistance are 3 times more likely to use welfare benefits when they become adults than children from families who do not receive welfare.12 Studies also report that migrant status18 is a risk factor for poverty.9, 19–21
Residents of impoverished neighborhoods or communities are at increased risk for mental illness,22, 23 chronic disease,17, 24 higher mortality, and lower life expectancy.7, 8 Some population groups living in poverty may have more adverse health outcomes than others. For example, the risk for chronic conditions such as heart disease, diabetes, and obesity is higher among those with the lowest income and education levels.17 In addition, older adults who are poor experience higher rates of disability and mortality.25 Finally, people with disabilities are more vulnerable to the effects of poverty than other groups.25–27
Racial and ethnic minorities living in poverty (defined by socioeconomic status) may also have more adverse health outcomes.9 For example, a study of health outcomes among those living in poverty found that African American men are more likely to die from prostate cancer than any other racial group.28–30 The same study found that African American women are more likely to suffer from breast and cervical cancer than any other racial group.28
Similarly, racial and income-based disparities are found among children. One study found more than half of the children living in poverty had cavities, compared to one third of those living above the poverty level.31 The study also found that, of families living in poverty, Mexican American children had the highest prevalence of cavities.31 This high rate of cavities may be due, in part, to parents' lack of awareness of recommendations for early preventive oral health care.31 Cost may be another important factor as almost two–thirds of the parents in 1 study did not obtain dental care for their children due to cost.31
Strategies that aim to increase the economic mobility of families (for example, job training programs and Early Head Start) may help to alleviate the negative effects of poverty.32–34 In addition, social assistance programs are designed as a safety net for all U.S. citizens, but specifically benefit low-income individuals and families.35 An example of a social assistance program is the National School Lunch Program (NSLP). The NSLP has been found to reduce the “risk of experiencing food insufficiency” among low-income households with children.36 In order to reduce socioeconomic inequality, it may also be important to address factors that are associated with the health status of poor communities.32
Additional research is needed to increase the evidence base for what can successfully lessen the effects of poverty on health outcomes and disparities. This additional evidence will facilitate public health efforts to address poverty as a social determinant of health.
Disclaimer: This summary of the literature on poverty as a social determinant of health is a narrowly defined review that may not address all dimensions of the issue.i, ii Please keep in mind that the summary is likely to evolve as new evidence emerges or as additional research is conducted.
i Terminology used in the summary is consistent with the respective references. As a result, there may be variability in the use of terms, for example, black versus African American.
ii The term minority, when used in a summary, refers to racial/ethnic minority, unless otherwise specified.
1 Proctor BD, Semega JL, Kollar MA. Income and poverty in the United States: 2015. U.S. Census Bureau, Current Population Reports. Washington, DC: U.S. Government Printing Office; 2016. P60-256(RV). Available from: http://www.census.gov/content/dam/Census/library/publications/2016/demo/p60-256.pdf
2 DeNavas-Walt C, Proctor BD, Smith JC. Income, poverty, and health insurance in the United States: 2009. U.S. Census Bureau, Current Population Reports. Washington, DC: U.S. Government Printing Office; 2010. P60-238.
3 Cowan CD, Hauser RM, Kominski RA, Levin HM, Lucas SR, Morgan SL, Spencer MB, Chapman C. Improving the measurement of socioeconomic Status for the National Assessment of Educational Progress: A theoretical foundation. Jessup (MD): National Center for Education Statistics; 2012. Available from: https://nces.ed.gov/nationsreportcard/pdf/researchcenter/Socioeconomic_Factors.pdf
4 Thorbecke E. Multidimensional Poverty: Conceptual and measurement issues. In: Kakwani N, Silber J, editors. The many dimensions of poverty. New York (NY): Palgrave Macmillan; 2008. p. 3-20.
5 Wagstaff A. Poverty and health sector inequalities. Bulletin of the world health organization. 2002;80(2):97-105.
6 Brooks-Gunn J, Duncan GJ. The effects of poverty on children. Future Child. 1997;7(2):55-71.
7 Singh GK, Siahpush M. Widening socioeconomic inequalities in US life expectancy, 1980–2000. International Journal of Epidemiology. 2006;35(4):969-979.
8 Mode NA, Evans MK, Zonderman AB. Race, neighborhood economic status, income inequality and mortality. PLoS ONE. 2016;12;11(5):1-14. doi:10.1371/journal.pone.0154535
9 Williams DR, Mohammed SA, Leavell J, Collins C. Race, socioeconomic status, and health: Complexities, ongoing challenges, and research opportunities. Ann N Y Acad Sci. 2010;1186:69-101. Available from: http://www.bu.edu/sph/files/2015/08/NYASRACESES.pdf
10 The World Bank. (2016). Poverty. Retrieved from http://siteresources.worldbank.org/INTPOVERTY/Resources/335642-1124115102975/1555199-1124115187705/vol1.pdf
11 Meyer DR, Wallace GL. Poverty levels and trends in comparative perspective. In: Cancian M, Danziger S, editors. Changing poverty. IRP Publications 2009: University of Wisconsin-Madison, Institute for Research on Poverty conference; 2008. Available from: https://pdfs.semanticscholar.org/1e4b/6407e8e6d42f91854cd0ef1f87c171f3b1ec.pdf
12 Personal Responsibility and Work Opportunity Reconciliation Act of 1996, Title I, 104th Cong., 2nd Sess. (1997). Available from: https://www.gpo.gov/fdsys/pkg/BILLS-104hr3734enr/pdf/BILLS-104hr3734enr.pdf
13 Cherry D, Huggins B, Gillmore K. Children's health in the rural environment. Pediatric Clinics of North America. 2007;54(1):121-133.
14 Mood C, Jonsson J. The social consequences of poverty: An empirical test on longitudinal data. Social Indicators Research. 2016;127(2):633-652. doi:10.1007/s11205-015-0983-9
15 The intersection of rural poverty and federal human services programs. Policy Brief. Rockville (MD): National Advisory Committee on Rural Health and Human Services; 2014 Jan. Available from: https://www.hrsa.gov/advisorycommittees/rural/publications/ruralpoverty.pdf
16 Woolfolk, M. P., Sgan‐Cohen, H. D., Bagramian, R. A., & Gunn, S. M. (1985). Self‐reported health behavior and dental knowledge of a migrant worker population. Community dentistry and oral epidemiology, 13(3), 140-142.68. U.S. Department of Agriculture. (2006) Geography of Poverty. Available from https://onlinelibrary.wiley.com/doi/abs/10.1111/j.1600-0528.1985.tb00429.x
17 Braveman PA, Cubbin C, Egerter S, Williams DR, Pamuk E. Socioeconomic disparities in health in the United States: What the patterns tell us. Am J Public Health. 2010;100(S1):S188-S196.
18 Frisbie WP, Cho Y, Hummer RA. Immigration and the health of Asian and Pacific Islander adults in the United States. Am J Epidemiol. 2001;153(4):372-380.
19 Holmes SM. An ethnographic study of the social context of migrant health in the United States. PLoS Med. 2006;3(10). doi: 10.1371/journal.pmed.0030448
20 Frank A,McKnight R, Kirkhorn S, Gunderson P (2004) Issues of agricultural safety and health. Annu Rev Public Health 25: 225–245.
21 Slesinger D. Health status and needs of migrant farm workers in the United States: A literature review. J Rural Health. 1992;8(3):227-234.
22 Belle D. Doucet J. Poverty, inequality, and discrimination as sources of depression among U.S. women. Psychology of Women Quarterly. 2003;27(2):101-113.
23 Caughy MO, O’Campo PJ, Muntaner C. When being alone might be better: Neighborhood poverty, social capital, and child mental health. Social Science & Medicine. 2003;57(2):227-237.
24 Ward-Smith P. The effects of poverty on urologic health. Urologic Nursing. 2007;27(5):445-446.
25 Minkler M, Fuller-Thompson E, Guralnik JM. Gradient of disability across the socioeconomic spectrum in the United States. N Engl J Med. 2006;355:695-703.
26 Brucker DL, Mitra S, Chaitoo N, Mauro J. More likely to be poor whatever the measure: Working-age persons with disabilities in the United States. Social Science Quarterly. 2015;96(1):273-296. doi:10.1111/ssqu.12098
27 Rank MR, Hirschl TA. The likelihood of experiencing relative poverty over the life course. PLoS ONE. 2015;10(7):1-11. doi:10.1371/journal.pone.0133513
28 Ward E, Jemal A, Cokkinides V, Singh GK, Cardinez C, Ghafoor A, Thun M. Cancer disparities by race/ethnicity and socioeconomic status. CA: a cancer journal for clinicians. 2004;54(2):78-93.
29 Ries LAG, Harkins D, Krapcho M, Mariotto A, Miller BA, Feuer EJ, Clegg L, Eisner MP, Horner MJ, Howlader N, Hayat M, Hankey BF, Edwards BK, editors. SEER cancer statistics review, 1975-2003, National Cancer Institute. Bethesda (MD): 2005. Available from: http://seer.cancer.gov/csr/1975_2003/.
30 Singh GK, Miller BA, Hankey BF, Edwards BK. Area socioeconomic variations in US cancer incidence, mortality, stage, treatment, and survival 1975–1999. Bethesda (MD): National Cancer Institute. 2003. NCI Cancer Surveillance Monograph Series No. 4. NIH Publication No. 03-5417.
31 Edelstein BL, Chinn CH. Update on disparities in oral health and access to dental care for America's children. Acad Pediatr. 2009;9(6):415-419.
32 Yoshikawa H, Aber JL, Beardslee WR. The effects of poverty on the mental, emotional, and behavioral health of children and youth: implications for prevention. Am Psychol. 2012;67(4):272-84.
33 Riccio J, Dechausay N, Greenberg D, Miller C, Rucks Z, Verma N. Toward reduced poverty across generations: Early findings from New York City’s conditional cash transfer program. New York, (NY): MDRC; 2010.
34 Love JM, Kisker EE, Ross CM, Schochet PZ, Brooks-Gunn J, Paulsell D, Brady-Smith C. Making a difference in the lives of infants and toddlers and their families: The impacts of early Head Start. Princeton (NJ): Mathematica Policy Research; 2002.
35 Blank RM. Evaluating welfare reform in the United States. Journal of Economic Literature. 2002;40(4):1105-1166.
36 Huang J, Barnidge E. Low-income Children's participation in the National School Lunch Program and household food insufficiency. Social Science & Medicine. 2016;150:8-14.