AAFP Paper Offers Family Medicine Approach to Poverty

September 09, 2015 09:20 am Chris Crawford

Poverty is an "insidious, self-perpetuating problem that affects generations of families" and can be an obstacle to patients' health. This is according to a recent paper the AAFP published online that addresses how family physicians can mitigate the effects of poverty on health by understanding each patient's challenges and coping strategies, and knowing what community resources are available to support them and improve health outcomes.

[Young, impoverished girl sitting on concrete steps]

The CDC defines poverty as a condition in which "a person or group of people lack human needs because they cannot afford them."

In the United States in 2014, the federal poverty line was $12,316 for an individual younger than age 65 and $24,418 for a family of four. Cited in the paper, the American Community Survey found that 14.5 percent of U.S. citizens fell below the poverty line in 2013 and that youth, racial and ethnic minorities, those without a high school diploma and the unemployed had the highest rates of poverty.

"Low-income status" describes individuals and families whose annual income is less than 200 percent of the federal poverty level. Nearly 40 percent of U.S. citizens meet this definition.

The paper explains that poverty and low-income status are associated with a variety of adverse health outcomes, including shorter life expectancy, higher rates of infant mortality and higher death rates for the 14 leading causes of death.

Health Effects of Poverty

Paper author Patricia Czapp, M.D., of Annapolis, Md., told AAFP News that being poor does not guarantee a patient will have a poor health outcome but it does mean that the patient statistically is more likely to be exposed to adverse environmental factors that impact his or her health.

Story highlights
  • The AAFP recently published a paper online on how family physicians can mitigate the effects of poverty on health by understanding patients' challenges and coping strategies, and knowing what community resources are available.
  • The paper explains that poverty and low-income status are associated with a variety of adverse health outcomes, including shorter life expectancy, higher rates of infant mortality and higher death rates for the 14 leading causes of death.
  • An earlier paper described poverty as a "risk regulator" because it affects both the likelihood that a patient will have risk factors for disease as well as his or her ability to prevent and manage disease.

"Those factors might include lack of a safe neighborhood in which to grow, play and work; limited educational opportunities; limited access to preventive medical and dental care; poor nutrition; suboptimal housing; and exposure to violence and toxins," she said. "These factors all stack up. You can see why the average life expectancy is so much shorter in lower-income neighborhoods and why poverty is a generational problem, a cycle from which it is difficult for the individual to break free."

These factors can create high levels of stress for patients, which Czapp said affects human development and physiology in acute and chronic ways, even beginning in utero with issues such as cardiovascular dysregulation and impaired brain development. As a result, chronic disease is likely to develop earlier and more often in populations affected by poverty.

"Awareness of this phenomenon helps us intervene earlier to prevent, recognize and address chronic disease in individuals so that we can lessen the probability of late-stage complications and disability that arise from unrecognized and/or untreated disease," Czapp said.

Poverty as a 'Risk Regulator'

Czapp explained that a 2006 paper(www.ncbi.nlm.nih.gov) authored by T.A. Glass and M.J. McAtee first described the concept of poverty as a "risk regulator" because it affects both the likelihood that a patient will have risk factors for disease as well as his or her ability and opportunity to prevent and manage disease.

"Thinking of poverty as a risk regulator rather than a rigid determinant of health frees us from the notion that there is nothing we can do for the impoverished patient, that our efforts will not affect his or her ultimate health outcome," she said. "So we can stop throwing up our hands and instead use them to do good work. In fact, we can boost the patient’s 'host resistance' to poverty by making it easier for him or her to maintain health despite adverse circumstances."

The AAFP's paper offers many practical approaches to helping impoverished patients, from simple compassion and understanding, to forming realistic care plans and advocating for social change.

What Family Physicians Can Do

Strong primary care teams in the patient-centered medical home setting are critical in caring for low-income patients as these patients often have higher rates of chronic disease and difficulty navigating health care systems, the paper said.

Czapp said it's important to first figure out these patients' priorities before trying to address their health issues.

"Don’t lecture to him about using his insulin appropriately until you’ve helped him get the electricity turned back on in his dwelling," she offered, for example.

Czapp also said it’s very important for family physicians to remember to celebrate small successes with their low-income patients.

"The patient who wasn’t using his insulin at all is now reliably giving himself one shot a day. Acknowledge that success as the leap of progress it is and build on it. Inspire confidence in the patient," she said.

Czapp recommends family physicians avoid unintentionally shaming these patients by prescribing medications they can't afford or sending them to multiple offices for testing or consultations when they might not have adequate transportation.

"Their budgets and jobs may not allow them to do this," she said. "Rather than disappoint you and themselves, these patients will just disappear instead."

Working With Newly Insured Low-income Patients

In many states, the Patient Protection and Affordable Care Act has expanded Medicaid, allowing more low-income individuals and families to become insured for the first time. Patients who had never been insured before likely received care only in emergency departments and could use extra guidance navigating the health system, Czapp said.

Low-income patients' new insurance coverage grants them access to care but they might not understand what primary care and family physicians can offer them, what a referral entails or how appointments are made, copays are paid or medication is refilled.

"For the novice, this can be a humiliating and bewildering process to navigate, and it is so important that we and our staff react with compassion and understanding to help the newly insured learn what it means to be a patient within a medical home," Czapp said. "If we don’t do this, they will revert to their previous pattern of behavior of using the emergency department, because that’s the (only but inappropriate) medical home they know."

Supportive Resources

Busy family physicians don't need to struggle in isolation to mitigate the effects of poverty on their patients, Czapp said.

National resources that can help to support low-income families include

  • Reach Out and Read,(www.reachoutandread.org) a program that helps clinicians provide books for parents to take home to read to their children. Studies have shown that Reach Out and Read improves children’s language skills.
  • 2-1-1,(www.211.org) a free, confidential service that patients or staff can access 24 hours a day by phone. Community resource specialists can connect patients to resources such as food, clothing, shelter, utility bill relief, social services and employment opportunities.
  • The National Domestic Violence Hotline,(www.thehotline.org) a resource staffed 24 hours a day by trained advocates who are equipped to provide confidential help and information to patients who are experiencing domestic violence.

Local resources often also are available to provide material needs to patients and families.

"No one is expected to tackle this alone," Czapp said. "My own experience in providing care for a marginalized, low-income population in a patient-centered medical home has convincingly shown me the healing powers of compassion and community collaboration."

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