SOCIOECONOMIC STATUS AND POVERTY 101

What are we talking about when we talk about socioeconomic status and poverty? 

Socioeconomic status: Socioeconomic status (SES) measures people’s combined social and economic position. SES is typically grouped into three vague categories: low, middle and high. These levels correlate with income, education level, and social prestige. SES is also associated with factors such as occupation, housing, resources, and generational wealth [1]. 

Poverty: Poverty refers to the lack of resources needed to maintain a decent standard of living. People experiencing poverty may lack access to basic needs such as the need for food, water, shelter, education, sanitation, or health care [2]. As of 2022, the World Bank defined the income line for global extreme poverty to be less than or equal to $2.15 per person per day [3]. With this definition, approximately 10% of the world lives in extreme poverty [4]. Social and political factors can influence poverty, as certain populations are more likely to benefit from historical advantages. Women, children, racial minorities, immigrants, sexual and gender minorities, and those with disabilities disproportionately bear the burden of poverty in the United States [5,6].

Why do socioeconomic status and poverty matter in healthcare?

SES strongly influences both physical and mental health. People living in poverty or with a lower SES may have increased health vulnerabilities due to stress, malnutrition, lack of access to health care, poor health literacy, or other factors. Accordingly, lower SES is associated with increased chronic illness, poorer disease outcomes, and premature mortality [7]. Strong evidence also suggests the existence of an SES gradient for conditions such as cardiovascular diseases, diabetes, arthritis, and poor birth outcomes [8]. Poverty contributes to many communicable diseases through factors like unsafe housing conditions, malnutrition, poor water quality, and exposure to toxins [9]. Due to the high costs of health care, individuals experiencing poverty may also avoid seeking health care, or lack transportation to health care facilities [10]. 

People of color, immigrant families, single-parent households, and other marginalized communities are especially likely to experience poverty. The combined burden of being a minority and experiencing poverty is a strong social determinant of health. Chronic stress from poverty, power imbalances, and discrimination increases mental illness and suicide rates [11]. The prejudice of medical professionals can also increase health disparities. Physicians are often more directive toward clients of a low SES, as well as giving them less time and information about their treatment. Moreover, many physicians share the common but false belief that people in poverty are less deserving of care. These types of attitudes can make patients feel stigmatized or ashamed, another very real barrier to accessing care [12]. 

What do we know about socioeconomic status and poverty in medical and health professions education?

Health professions education neglects teaching about poverty and may perpetuate biases toward patients in poverty. Many residents do not feel comfortable caring for people experiencing poverty, and many hold negative preconceptions about low SES patients, including that they will be difficult to deal with or that they care less about their health than wealthier patients do. Accordingly, a study of major barriers to care for those in poverty found these barriers included physicians’ ignorance of the determinants of health associated with low income [13]. Education related to the intersection of poverty and other social forces like racism is even more lacking [14].

Part of the issue is that SES strongly impacts educational opportunities and outcomes. Students living at or near the poverty line are underrepresented in medical and health professions graduate education. Between 1988 and 2017, the top two household-income quintiles contributed 73-79% of all matriculants to medical school [15]. Within medical schools, students reporting lower household incomes are less likely to be members of Alpha Omega Alpha, a medical honor society [16]. Given that poverty and structural barriers prevent diversity and equity in medical education, we must find ways to alleviate poverty and uplift disadvantaged students–which can also decrease the stigma surrounding poverty in medicine. How does the Bias Checklist address disability and ableism in health professions education content?

How does the Bias Checklist address socioeconomic status and poverty in health professions education content?

The Bias Checklist first asks: 

  • “Does the content include any mention of poverty or socioeconomic status?”

If you answer no, you will be prompted to consider whether your content should mention poverty or socioeconomic status.

Below are some examples of common ways in which bias, shame, stereotype and stigma toward poverty and low socioeconomic status can manifest in health professions education content:

  • Presenting race as a risk factor for disease occurrence or outcome without explaining the role of poverty, access to healthcare, etc.

  • Presenting poor people as lazy or lacking in character

  • Any comment about this subject that is meant to elicit laughter

Last, the Checklist asks: 

  • “Could the content be perceived as promoting stereotypes, bias, shame or stigma?”

What can we do to address this problem?

  • Example: Some Bias Checklist submissions deal with homelessness. These submissions point to a pattern of linking homelessness with HIV. As both homelessness and HIV are highly stigmatized, consistently describing them together can further stigmatize them. Test questions and vignettes should be revised to avoid a pattern of disproportionately describing patients who are unhoused as having HIV.

Where can I go to learn more? 

I learn best by…

Reading

  • The Death Gap: How Inequality Kills by David A. Ansell, MD

  • The Broken Ladder: How Inequality Affects the Way We Think, Live, and Die by Keith Payne

  • Priced Out: The Economic and Ethical Costs of American Health Care by Uwe Reinhardt

  • Fiscella, Kevin, et al. (2004). Health Disparities Based on Socioeconomic Inequities. Academic Medicine 79(12), 1139-1147.

Watching

Listening

NEED A CONSULTATION?

The following people have identified themselves as experts in socioeconomic status and poverty and are willing to be contacted with questions regarding your content.

  • Contact list coming soon!

HAVE SOMETHING TO ADD? 

Email us at biaschecklist@gmail.com with any of the following:

  • Recommendations for additional important content to include above, or suggested corrections or clarifications → use the subject header “Socioeconomic Status and Poverty 101 - Correction”

  • Suggestions for additional questions to add to the Bias Checklist → use the subject header “Socioeconomic Status and Poverty 101 - Checklist Question”

  • Suggestions for additional resources for learning more → use the subject header “Socioeconomic Status and Poverty 101 - Learn More”

  • Examples of curricular bias, including before and after versions of content → use the subject header “Socioeconomic Status and Poverty 101 - Example”

  • Your name, credentials, affiliation, area(s) of expertise, and brief biography or summary of qualifications if you are willing to serve as an expert consultant → use the subject header “Socioeconomic Status and Poverty 101 - Consultant”

References

  1. Easterbrook, Matthew, et al. (2023). Introduction to the special issue: nuances of social class and socioeconomic status. International Journal of Social Psychology, 1-6. https://www.tandfonline.com/doi/abs/10.1080/02134748.2023.2239577

  2. Habitat for Humanity. (2017). Relative vs Absolute Poverty. Retrieved September 12, 2023, from https://www.habitatforhumanity.org.uk/blog/2018/09/relative-absolute-poverty/

  3. World Bank Group. (2022, September 14). Fact sheet: An adjustment to global poverty lines. World Bank. Retrieved March 30, 2023, from https://www.worldbank.org/en/news/factsheet/2022/05/02/fact-sheet-an-adjustment-to-global-poverty-lines 

  4. McCoy, D. (2017). Critical Global Health: Responding to Poverty, Inequality and Climate Change. International journal of health policy and management, 6(9), 539–541. https://doi.org/10.15171/ijhpm.2016.157

  5. Shrider, Emily, & Creamer, John. (September 12, 2023). Poverty in the United States: 2022. United States Census Bureau. Retrieved September 13, 2023, from https://www.census.gov/library/publications/2023/demo/p60-280.html

  6. Institute for Research on Poverty. (June 2021). The Complexity of LGBT Poverty in the United States. University of Wisconsin-Madison. Retrieved September 12, 2023, from https://www.irp.wisc.edu/resource/the-complexity-of-lgbt-poverty-in-the-united-states/

  7. Gallo, L. C., et al. (2009). Socioeconomic Status and Health: What Is the Role of Reserve Capacity? Current Directions in Psychological Science, 18(5), 269–274. https://doi.org/10.1111/j.1467-8721.2009.01650.x

  8. Adler, N. E., & Ostrove, J. M. (1999). Socioeconomic status and health: what we know and what we don't. Annals of the New York Academy of Sciences, 896, 3–15. https://doi.org/10.1111/j.1749-6632.1999.tb08101.x

  9. Beech, B. M., et al. (2021). Poverty, Racism, and the Public Health Crisis in America. Frontiers in Public Health, 9(699049). https://doi.org/10.3389/fpubh.2021.699049

  10. Wolfe, M. K., et al. (2020). Transportation Barriers to Health Care in the United States. American Journal of Public Health, 110(6), 815–822. https://doi.org/10.2105/AJPH.2020.305579

  11. Knifton, L., & Inglis, G. (2020). Poverty and mental health: policy, practice and research implications. BJPsych bulletin, 44(5), 193–196. https://doi.org/10.1192/bjb.2020.78

  12. Loignon, Christine. (2014). Medical residents reflect on their prejudices toward poverty. BMC Medical Education, 14(1050). https://bmcmededuc.biomedcentral.com/articles/10.1186/s12909-014-0274-1

  13. Wallace, Erik A., et al. (2013). An Experiential Community Orientation to Improve Knowledge and Assess Resident Attitudes Toward Poor Patients. Journal of Graduate Medical Education, 5(1), 119-124. https://doi.org/10.4300/JGME-D-12-00015.1

  14. Klein, Melissa, et al. (2021). Poverty Related Education in Pediatrics. Academic Pediatrics, 21(8S), S177-S182. https://doi.org/10.1016/j.acap.2021.02.006

  15. Youngclaus, J., & Roskovensky, L. (2018). An updated look at the economic diversity of US medical students. AAMC Anal Brief, 18(5), 1-3.

  16. Nguyen, M., et al. (2021). Association of Socioeconomic Status With Alpha Omega Alpha Honor Society Membership Among Medical Students. JAMA Network Open, 4(6). https://doi.org/10.1001/jamanetworkopen.2021.10730

contributing writer(s)

Katie Faroukh, MD Candidate

Sophie Pollack-Milgate, BA

last updated October 4, 2023