Nursing, Poverty and Healthcare

Introduction

Healthcare and poverty are two interrelated topics. Healthcare is directly dependent on the level of poverty within an area. It would be insincere to assert that poverty is the greatest threat to healthcare. Generally, poor people have to reckon with a myriad of illnesses as compared to wealthy people. People living in poverty often die at tender ages in comparison to wealthy persons (Beck, 1992).

This picture is replicated at national levels as can be witnessed from the national life expectancy rates. Healthcare can therefore not be studied without consideration of the impact of poverty on it. However, to effectively study the impact of poverty on healthcare, it is important to create a distinction between relative poverty and absolute poverty. The susceptibility of people subject to these two kinds of poverty ill health is dissimilar in a way. However, the general picture is similar. The poor regardless of their condition suffer several health problems.

According to the world health organization, approximately 1.2 billion people live in extreme poverty conditions across the globe (World Health Organization, 2009). This is based on the poverty threshold level of less than a dollar paper day. A threshold that many people are now questionnaire its capability to indicate poverty as a result of the changes in costs of living. The relation between poverty and ill-health emanates from the conditions that poverty subjects people to, as well as inaccessibility to health care facilities both in terms of costs and location.

Many people globally, live in environments where there is a lack of decent shelter, lack of water fit for consumption, and poor sanitation conditions. The world health organization has continuously dedicated resources to addressing this problem but still, the impact is too large to manage. The meager resources, therefore, have to be directed to areas of extreme need. Additionally, the organization helps in the design of policies that appropriately prioritize and respond to the needs of people in dire need of help.

Background information

On the 21st century eve, a shocking revelation was made; over one billion of the world’s population did not enjoy the benefits of economic prosperity accrued in the2oth century. This translated to approximately 20% of the global population living in conditions of absolute poverty (<$1 per day). Surprisingly, almost half the population lived on less than $2 per day ((World Health Organization, 2009; UNHCR, 2010).

The case was slightly different in sub-Saharan Africa where 50% live in absolute poverty (World Health Organization, 2009). This measurement is however based on income and perhaps evaluation beyond income would translate to an even larger percentage. Faltering social progress is a common occurrence in Africa in contrast to other global regions which have witnessed improved living conditions in recent times. The major dimension of poverty in Africa includes Social exclusion, human right abuse, gender inequalities, and poor health conditions (UNHCR, 2010).

The rise in poverty levels globally has been coupled with a similar rise in health-related problems. As much as generalization cannot be drawn about life expectancy and the level of poverty in various regions, generally, the expectancy remains relatively low in poverty-stricken areas. While life expectancy in tropical Africa is 51 years, in sub-Saharan Africa the case is different. Life expectancy is set at 47 years down from 45 years, 15years ago (World Bank, 2009).

The mortality and morbidity rate as a result of the disease remains relatively high more especially in sub-Saharan Africa where poverty remains a pervasive issue. According to WHO, approximately 14.5 million children die prematurely as a result of various diseases affecting sub-Saharan Africa. A large portion dies before their 5th birthday (World Health Organization, 2009). Various reports have emphasized that mortality rates in Africa are accelerated by parasitic infections due to the inability to control them. Other causes include respiratory infections like pneumonia, tuberculosis, and whooping cough as well as water-borne diseases e.g. dysentery, typhoid, and cholera.

Major causes of health deterioration in poor regions are, however, related to poor housing conditions, poor sanitation conditions, unavailability of proper waste disposal mechanism as well as water inadequacy. Most persons in poor regions lack proper latrines and often rely on water directly collected from the rivers (Shaw, Dorling & Davey, 2007). The conditions account for 50-90% of illnesses and deaths among the poor world population. According to Shaw, Dorling & Davey (2007), natural deficiencies, poor living conditions, and communicable diseases claim a big portion of health-related issues in poor regions. In areas where mortality and morbidity rates are high, poor nutrition, lack of proper hygiene, and basic needs are also recorded.

Research indicated theta as the debts owed by African countries rose from $61 billion in 1980 to approximately $2226 billion by the end of the last century; a similar increase was recorded in health deterioration (World Health Organization, 2009). The research indicates a robust link between poverty and health conditions. This explains the sharp attention shift to poverty as a factor within healthcare management. Both social and health scientists have delved into this area in an attempt to assist the level of correlation. This trend deviates from the norm where the two were independently handled and hence difficult to determine the correlation between them.

The world health organization is leading the pack in researching the role of poverty in changing healthcare conditions and using the same in designing a new health population (Beck, 1992). It is estimated that 975 infant mortality cases occur in underdeveloped regions. The leading causes of death are diarrhea, malnutrition, and respiratory infections. Though attributed to poverty and ignorance, various researches have pointed out that ignorance is a product of poverty in itself.

Regardless of the approach used in the measurement of poverty, it remains one of the most critical health risk factors. Persons earning less than $10000 in a year face three times riskier of dying from health-related problems as compared to those earning $30,000 over the same period within the United States (Black, Morris & Bryce, 2003; Brotherhood of St Laurence, 2002).

It generally implies that poverty breeds ill heath regardless of the dimension adopted in the analysis of the relation between the two. African countries are a clear representation of this factor. In an era where economic disparity is by far the largest, it offers good ground for investigation of the relation between the two, for instance, a comparison of urban and rural health trends reveals that the earlier where the average income is higher records better healthy than in rural settings (Stansfeld, 1999; Shaw, Dorling & Davey Smith, 1999)

The absolute poverty approach defines poverty based on the idea that individuals are poor if they have insufficient income to purchase some ‘objective’ minimum bundle of goods (Dorling & Davey Smith, 1999). According to Rowntree classifying families as poor is based on the condition that their total earnings are not sufficient enough to acquire minimal resources necessary to sustain their life. This definition is entrenched into the U.S poverty lines which are based on minima food budget settings. An appeal of that measure is that they represent a fixed benchmark against which progress can be made over time.

However, a major disadvantage of the approach is that it is extremely difficult to choose an objectively defined ‘minimum set of necessities’ (Dorling & Davey Smith, 1999). This means that the minimum standard will necessarily change over time. Absolute poverty is based on the capacity to survive. This implies having enough food to keep one healthy (Dorling & Davey Smith, 1999). A measure of absolute poverty is, therefore, almost entirely based on a person’s nutritional status. The implication is that when using this method, for example, those individuals unable to purchase enough food to meet their essential nutritional requirements are classified as poor.

On the other hand, the relative approach classifies individuals as poor if their income is significantly low compared to that of the persons around them.

Typically, it defines poverty about come median or equivalent income level settings. A major advantage of this approach is its simplicity and transparency. It requires no decision about what constitutes a minimum necessary basket.

According to Stansfeld (1999), relative poverty is defined relative to some generally accepted thresholds within the society. This definition exceeds the basis of biological needs alone. This is based on the notion of the existence of an acceptable living standard and life quality in a particular society. Poverty can therefore be said to occur when people are unable to adequately meet their basic needs include food and other necessary amenities. Such needs are important in enabling people to take their respective roles within society.

Thus, people are relatively deprived if they cannot obtain at all or sufficiently the conditions of life i.e. the diets, amenities, standards, and services that allow them to play the roles, participate in the relationships and follow customary behaviors which are expected of them by their membership of a society. People in such conditions are said to be living in poverty (Stansfeld, 1999).

Thus the relative approach to defining poverty shows that people realize their level of poverty only when they compare their socio-economic condition with an acceptable standard of living for the community in which they live. This explains the assertion that poverty as a relative concept appears only to require an appeal to common sense; hence the explanation given to the concept would vary from one geographical area to another.

Process overview

The focus group provides preliminary indications useful in mobilization of advocacy for poverty related issues within healthcare settings. Despite representation by a small sample of participants, the focus group highlights issues that both empirical and qualitative researches have cited. The focus group stresses the importance of stakeholders focusing on poverty as a preventive healthcare practice. The buck to improved healthcare stops with elimination of poverty within the affected areas. This is rather ideal.

This focus group is held amongst a group of persons who have had direct contact with persons suffering medical conditions as a result of poverty. The focus group meeting is centered on healthcare scenario which resulted from cases of poverty. The participants narrate some of the cases and cite factors which make them poverty related. The narrator opens the discussion by citing some interesting status about the poverty situation globally according to the world health organization. The participants raise important issues which touch on the impact of poverty to society’s accessibility to health.

The participants were anonymously selected from different regions and each had no prior knowledge or contact with the other. However, their contact with medical scenario made them share some common medical background. They therefore bear similar associations to the topic of study. It is vital to note that selection of anonymous individuals though was meant to ensure that the participants gave their honest opinions on the matter/topic. Though most researches recommend that various focus group meetings are held in order find divergent group’s opinions for comparison, the findings of this research are limited to two focus group meeting conducted on 3/9/11from 1:15-3:15 p.m., 11:15 p.m.-1:00 a.m. and on 3/10/11 as from 9:30-10:30 am amounting to a total time duration of 4hours and 45 minutes.

The group’s responses were guided by the moderaters, who provided the basic questions upon which discussions were founded. The focus group setting was in such a way that all the participants were made comfortable throughout the conversation. To further facilitate ease of discussion, comfortable chairs and refreshments were provided to the participants. Gender was an important factor and it was ensured that both female and male participants were availed.

Questioning Strategies

The focus group questioning involved clearly open-ended questions. The operator managed the group in such a way that the participants did not tire out of answering questions. Other than comfortable setting mentioned above, breaks were availed in between to ensure that the participants did not get over-exhausted. Questioning strategies thus focused on management of the process without losing focus of the information being sought. Krueger’s questioning approach was adopted by the moderator where sequential question was used as shown by the list below;

1. Introduction was done to make the members more free with each other and openly share ideas regarding the topic on health and poverty (everyone was given at least a single opportunity to give their views on every matter raised).
2. Once the participants had been introduced, the moderator presented an introductory statement/question which partly introduces those participants to the topic while at the same time opening up channels for discussions.
3. Transition questions are used every now then to move from one area to another as a means of helping the participants broadly view the topic and hence offer representative opinions.
4. There are set of predetermined key questions whose answers are considered fundamental to the final analysis of the focus group discussion outcome.
5. Ending questions is structured to facilitate summary presentations by each of the participants. Generally this part allows each participant to give a summary opinion of the points he/she had earlier stated.

The focus group will use structured questions whereby the moderators guide the discussion towards attaining opinions on the areas of interests. The focus groups meeting are basically based on a pre-set agenda. Under such an arrangement, the moderator used guided questions to get the group back on track in instances where it seems to deviate from the original topic or area of interest. However, when appropriate, the moderator leaves the conversation to naturally flow to ensure full and in-depth coverage of key questions of focus by the research.

Generally, strategies employed in questioning are critical in group management. Moderators often face difficulties managing groups if inadequate questioning strategies are employed. The need for moderators to be empathic and non-dominant over the group is also stressed. Adopting several questioning strategies is useful in gaining subtle influence of the group without necessarily taking over the discussion.

Methodology

Research outcomes are often as good as the strategies employed in conducting their research. No matter how good an analysis is conducted, the research cannot be concluded as being successful if it does not represent the actual situation it set out to investigate. This stresses the need to base each and every research on facts and not fictitious outcomes. The setting of the focus group directly influences the overall outcome of the research.

To effectively evaluate the topic, the following questioning approaches were adopted during the focus group;

• Leading questions are used to help the group delve into the topic in-depth.
• When group steers off the topic, steering questions are used to guide the group back on track.
• Factual questions are used in defusing issues that could spur emotional discussions.
• Anonymous questions are useful in generation of diverse opinions.

Research Questions

The set research questions put emphasis on establishing the effect of poverty on communities. Background information sought to address socio-economic status, health status, and healthcare access from the view of the participants. The questions formulated aimed to aid the respondents give their view on how poverty affects healthcare within the society.

The following research questions guided the findings of this paper;

1. What characteristics are associated with the poor within the community?
2. What are the leading causes of poverty within the society?
3. What common health problems are associated with society?
4. Which health facility provisions are available for those who fall ill yet have limited resources?
5. What should be done to improve the health of the poor in the society?

Objectives of the Survey

The research aimed to identify the link between poverty and health with regard to nursing care. The specific objectives of the study include the following;

• Examine the effect of poverty on healthcare provision
• Identify common diseases and their prevalent rates among the poor.
• Examine the linkages between poverty and health as demonstrated by the most prevalent diseases in their spatial perspectives.
• Analyze how poverty impacts access to health care facilities
• Identify appropriate approaches to curb the increasing health decay through appropriate poverty reduction strategies.

Conceptual Framework

Impact poverty assessment on health is dependent on comprehensive and comparative policy oriented framework which helps establish the interconnection between poverty and healthcare provision.

Hypotheses

The following hypothesizes formed basis for the research;

• Poverty is the prime cause of poor health amongst various communities.
• Adequate income and knowledge is fundamental to better healthcare amongst populations.
• Increased accessibility to healthcare facilities helps improve heath conditions.

Findings and discussion

From the focus group, a number of health determinants are discussed or cited by the participants. These are basically factors which affect people’s health in one way or another. These include their environment, income generated level of education, social relations, and genetics among others. When combined together, the affect of these factors is expended. Various researches show that people social places of living affect their health and longevity. Various studies further insist that poverty and social status are leading contributors in determination of a person’s health. In the opening part of the focus group, the moderator says,

“It’s a disease that zaps people’s energy. It dehumanizes them and it creates a sense in many of helplessness and a loss of control over their lives, yet we know that the poor share an unequal burden of ill health. The poor, constituting 20% of the world’s population die from a big percentage of worlds diseases. These include communicable diseases, as well as maternal and perinatal complications. All of those are essentially preventable. Poverty has been identified as a cause, an associated factor, a catalyst and a result of ill health, so it’s inextricably related to health. So today’s discussion will talk about the nurse’s role in fighting cancer, and from the demographics that those are just some basic information that I wanted to get from the class about your previous experience.”

At this point, the moderator has directly pointed towards the direction of the researches purpose. Essentially, he asserts that poverty in deed affects health to the negative and hence this will not be the focus of the discussion, instead the discussion will focus on various scenarios with which poverty affects health. He mimic’s the words of Hong who said that, “a Boston pediatrician emphasized level of a person’s income, lifestyle and race as important determinants of health in any social set-up. He asserted that, “tell me someone’s race; tell me their income; and tell me whether they smoke. The answers to those three questions will tell me more about their longevity and health status than any other questions I could possibly ask (2000).”

In a Stockholm research, pathways of disease vulnerability were identified as premised on social status of individuals (Robertson, Brunner, & Sheiham, 2008). Key determinants applied in their research include level of education, locality, education levels, empowerment, and exposure/susceptibility to disease also pointed out that, deterioration of the global environment and the ecological crises manifested as climate change, ozone depletion, degradation of food producing systems, depletion of fresh water sources, loss of biodiversity, the spread of invasive species, and chemical pollutants are threatening the biosphere and its capacity to sustain healthy human life (Hong, 2000).

A number of factors emerge within the focus group as to how poverty affects individual health. The male participant cites a number of scenarios which reflect a scenario of absolute poverty and hence inability to access. He says, “Well I would say things like that interferes in relation to the types of for example drinks or like polluted, poisoned or polluted things in the third world that ties, relationships sometimes with this type of disease, type of food with the like diabetes and hypertension may aggravate the disease if they had no access to the quality of food, or the awareness.” Basically, his statement summarizes a number of aspects through which poverty affect the health of individuals. It covers living conditions, accessibility to clean water, types of food afforded, and ignorance which is a product of lack of education.

The female participant further highlights more on the impact of poverty on a person’s health. In his case, the hospital admitted a woman who lived without any running water and electricity and yet she was pregnant, and for that matter, the seventh child, the others of whom the social services department had taken away. The woman was dirty and the nurses were reluctant to attend to her. This case raises several aspects; one is the willingness of the medic to assist the poor and two, the position to which poverty had driven the woman. She was more vulnerable to diseases and even death many times compared to another pregnant woman who had proper antenatal care, normal family life and access to all facilities necessary to facilitate human life.

A female participant further cites a case where poverty made several people end up as clients to the hospital. Poor and in need of something to live, they had engaged in activities which resulted into shooting or other forms of retaliatory attacks as a thief would expect. He says, “An entire unit, an entire unit in Phoenix where every one of those patients would’ve had a different outcome had they not been poor. I mean I stood at a patient’s window and watched someone rob the store across the street, and another time I stood there and watched a guy shoot somebody else. I mean it was a bad area of town…”he notes that threes persons, if not for poverty would not have ended in hospital beds as patients.

In another case emerging from the focus group, people have neglected their health and relegated it down the priority list given the level of poverty they suffer. They work as if nothing is wrong with them, even when their health is failing. As he puts it,

“But they didn’t seek health care at all. Health care sought them when they collapsed, and they didn’t have money. They didn’t prioritize health care because money was so limited and so we had an entire unit of people in renal failure because their diet consisted of primarily chips and beer and soda and they would come, diabetic, hypertensive in renal failure, and this was how they’d get diagnosed, come in DKA, so.”

The case highlights a new and important perspective of healthcare. People with diseases which require monitored guides find themselves unable to these due to resource limitations. They live on exactly those things which any medic would recommend them not to take. It raises the question of nutrition and its role in healthcare settings. Poverty in essence inhibits ability to manage some illnesses out of the clinical setting.

In reinforcing the points provided by the participant, the moderator seeks to strongly affirm the role of locality in individual health and he says, “Um hmm. And it was mentioned of a poor water supply, pollution and all those things. So context, the community context and what’s available is very important for their health. I think we probably could think of, you know if we continued to think about our clinical practices, we could think of a number of examples.” At this point he also directs the discussion towards the role of society in healthcare management and how an individual’s society status may affect his recovery status.

Another fundamental area highlighted is the inability of the poor to gain health insurance coverage. A participant provides a case scenario of a patient who was brought into the hospital but lacked insurance coverage to cater for his bills. This is summarized in his statement where she says, “I had a patient die directly because of poverty. The hospital discharged her too soon because she was uninsured, sent her home and she came back that night in sepsis and they didn’t admit her. By the time they got her up to my unit she was in septic shock and died shortly after. So yeah, and it was pretty clear that they just dumped her on the street.

Thousands of people die annually across the world on cases similar to this. Access to shelter is also cited as a key issue affecting health conditions of individuals and of concern to the health fraternity. Millions of people across the globe lack access to proper shelter putting their lives at risk. Disparity in healthcare provision, where some regions are able to care for a majority of its population while others are unable also arises. The issues highlighted within the focus groups reflect the findings of many other researches which have been previously conducted in relation to poverty and individuals health. They can be categorized and summarized as below;

Nutrition and Health

Nutrition is an important connector of poverty and ill health. Nutrition is a key component of health. Many children cross the globe die yearly due to malnutrition cases. This is more pronounced in the developed countries where poverty is part f life. Patients suffering from diet stringent ailments have also found themselves unable to meet the diet requirements imposed by their illnesses and have ultimately found vulnerable to recurrence of their ailments. Nutritionists and health researchers stress the importance of focusing on preventing the risk of chronic diseases development among the poor, more so considering the escalated costs of managing such (UNHCR, 2010).

Nutrition is therefore critical to healthy living. Micronutrient malnutrition (deficiencies of vitamin A, iodine, and iron) affects about two billion person’s worldwide (UNHCR, 2010). Iron supplements are believed to enhance both intellectual and motor ability of infants. However, not all families have access to such supplements. Additionally, despite the proven ability enriched educational programs to ameliorate malnutrition problems, very few people live in areas where such programs are offered (Graham, 2009).

Hygiene and Health

Poor sanitation conditions are a major concern to health providers. As shown in the focus group where a woman suffers the risk of loosing her child due to the condition she has had to live in during her pregnancy. It is of fundamental importance to note that poor hygiene is associated with a myriad of illnesses. In a research by Graham (2009), it was established that diseases like buruli ulcer and diarrhoeal diseases were common in rural communities where there is poor access to safe water, unsanitary conditions, inappropriate waste disposal methods, lack of education and information and restricted access to health care services (Graham, 2009).

These findings are replicated by the findings of this focus group which emphasize that poor hygienic conditions have resulted into various clinical cases which would have otherwise been avoided if the victims had access to enhanced hygienic conditions.

Education and Health

Ignorance is severally mentioned indirectly or indirectly during the focus group as causal factors fro various clinical situations. Education has been found to play a significant role in reducing health decay within a household. Higher level of education has the potential of impacting nutrition, hygiene, housing condition and more significantly access to organized health service facilities and thereby reducing ill health. Poverty leads to poor access to proper education which negatively impacts the health status of the poor.

Access and Utilization of Healthcare Facility

Poverty limits access to healthcare facilities. This may be geographically of r even financial. As discussed in the focus group setting where people simple fail to prioritize their health due to lack of finance, the same is reflected throughout the globe. Utilization of health facilities ameliorates the effects of ill health. Nursing mothers who seek pre-natal and ante-natal care from health professionals stand the chance of improving the health conditions of their children (WHO, 2009). The review on utilization of healthcare facilities helped the study to identify poverty related factors that impact access and utilization of health services and the likely consequences on health conditions of people.

Housing and Health

Housing poverty introduced by United Nations Commission on Human Settlement (UNCHS) Global Report on Human Settlements 1996, highlighted that that, “individuals and households who lack safe water, secure and healthy shelter with basic infrastructure such as pipe borne water and adequate provision for sanitation, drainage and the removal of household waste could have poor health” (UNHCR, 2010). Proliferation of slums is a result of housing shortage across major cities in the world. They form the hub of worlds poor and likewise world’s diseases. In these slums, hunger is increasingly becoming an urban problem, and policy makers have shifted focus on housing as a prime determinant of health. The same is highlighted in focus group discussion.

Conclusion

The findings of this research reflect the situation of health across the globe. However, both participants are in agreement that the situation can be improved if people from all quarter poll resources together and collaborate for the benefit of ensuring that even the poor gets as much medical attention as the rest of the population. Healthcare provision should not be purely left to the government but rather non-governmental and religious institutions as well as other interest groups should come in to bridge the gap that respective governments are unable to fill. The moderator’s summary touches on almost all areas covered by the discussion.

Basically, it highlights the effect of poverty on healthcare and the possible directions towards solution of the same. It would be vital to mention that poverty is not a choice. In most cases people are born in absolute poverty and lack the platform to bridge the divide in which they grow. However, opportunities exist and those who take them are able to eliminate the baggage of poverty. Perhaps it’s a high time that organizations focusing on management of healthcare and more so preventive healthcare engage in poverty reduction initiatives as form of preventive healthcare.

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