The shiny picture of the American dream sometimes belies underlying struggles. This may be especially true in suburban communities, where demographic shifts in the last decade have left growing numbers of families experiencing poverty or near-poverty conditions in which they struggle to pay the bills. And that has serious implications for children’s health.
Cornerstone recently sat down with Deepak Palakshappa, MD, an attending physician at Children’s Hospital of Philadelphia who conducts research on ways to address food insecurity —the inability to afford sufficient, quality food to sustain a healthy lifestyle —in families seen in pediatric practices.
Dr. Palakshappa, an instructor in General Pediatrics at the Perelman School of Medicine at the University of Pennsylvania, and faculty member in CHOP’s PolicyLab and Center for Pediatric Clinical Effectiveness (CPCE), recently co-authored a Perspective article in Pediatrics about the implications of suburban poverty for pediatrics with his research collaborator, Alex Fiks, MD, MSCE, associate director for outpatient research activities at CPCE, co-medical director of CHOP’s Pediatric Research Consortium, faculty member in PolicyLab, and an assistant professor of Pediatrics at the Perelman School of Medicine.
The edited conversation, about these concerns and the possibilities for the pediatric health system being a stronger support for families with social needs in the suburbs, follows below.
Some people may think of poverty as only a social or economic issue, and not a health issue. Can you tell us a little bit about why it is a health issue in general, and for children in particular?
The association of poverty and negative health outcomes has been longstanding. There’s been lots of literature about it, originally from the Whitehall studies of the 1960s and 70s that found that lower-income, working-class people had higher rates of cardiovascular disease than wealthier workers. There’s been an even greater recognition in the last decade about the social context in which individuals live and how it affects their health, an idea that is broadly called social determinants of health. The concept encompasses where we’re born, and where we live and work, and how that impacts children and adults’ health.
Essentially, poverty is thought to lead to negative impacts on potentially all aspects of life. In children in particular, it’s been found to have physical effects, acting through food insecurity. Children have higher rates of parental-reported poor health, iron-deficient anemia, some aspects of obesity, higher rates of asthma, and also psychosocial behavioral problems. It further leads to lifelong consequences because it has effects on academic performance and future education levels. Truly, poverty affects all aspects of children’s lives and leads to lifelong disparities in health.
How did you and Dr. Fiks end up writing the Pediatrics perspective piece?
There’s been growing recognition of a rise in suburban poverty. Poverty has increased by about 66 percent in the suburbs in the last decade, and that’s about double the rate in inner cities. While that was going on, the American Academy of Pediatrics released a policy statement in March recommending that pediatricians screen and address some of these poverty risk factors in clinics. We saw that a lot of pediatricians don’t recognize that there’s this rise in suburban poverty. There’s been growing literature written about the rise in suburban poverty, but there has not been much about how this rise impacts pediatric clinical care. A lot of the literature around food insecurity and social determinants of health has focused on low-income urban areas, with a little bit on rural areas. While our own work has focused on food insecurity screening, we were also thinking about screening for all social determinants of health. We saw that as an opening to raise the discussion of what we do with it and what it means for suburban sites.
What should people know about this overall trend of rising suburban poverty?
Right now there are more people living below the federal poverty line in suburban communities than there are in urban communities, the result of a trend over this last decade. The thought is that it’s due to three or four major factors, including faster U.S. population growth in the suburbs compared to urban areas. This includes new immigrants from other countries moving to the suburbs, bypassing the cities in search of more affordable housing and jobs during this time. There was also a move of gentrification in cities, which led a lot of people to move to the suburbs to find more affordable housing. Another factor was when the housing bubble burst, leaving people who bought homes near the top of the market suddenly in bad shape. And finally was the recession. In the early 2000s, a lot of jobs had moved out to the suburbs, and a lot of people followed those jobs. When the great recession happened, a lot of those people lost those jobs, and that was compounded by the housing crash.
What are the big-picture research needs for pediatrics professionals to understand and address suburban poverty for the health of children?
The big picture is that we need to build on the current body of research focused on screening and addressing poverty and poverty risk factors which mostly deals with urban areas. I think there’s probably some differences in infrastructure and resources in suburban locations, and some of the studies focused on the urban sites may not translate in particular to the suburban sites. For example, there may be fewer food pantries in the suburbs, and they don’t necessarily have infrastructure like public transportation to get people to those resources.
The big picture needs: First, how should screening be done in the practices? A lot of the studies that looked at how you should screen, particularly asking families if they want a written questionnaire or an electronic one, was done in urban areas. It’s largely an open area. What do parents want, what do clinicians want, and what is the most effective way to identify families either struggling from food insecurity, housing insecurity, or other social issues that impact health?
Another need is to figure out the most effective methods to connect people to resources. One of the big studies in urban practices has been something called WE CARE. WE CARE is a study in Boston where the clinics use a screener and resource packet that they give out to families. In that setting, they found that about 30 to 40 percent of people ended up getting a new resource that they hadn’t had, such as childcare assistance, housing, or job training. I’m not sure how well that’s going to be able to translate to suburban sites.
What have you done so far in your research in this area?
My most recent research with Alex has begun to make inroads with these needs with a specific focus on screening for food insecurity in the suburban sites. Because this hasn’t been looked at much, we’re trying to see what is the prevalence of it, how will it work in clinics, and how we connect those families to resources. We just finished that study and are about to submit the manuscript soon.
At the end of the study, interestingly enough, all six practices that were kind enough to want to participate in the study all wanted to continue to screen. The clinicians and staff there all recognize that this is an important issue that we should be addressing and doing something about. We’re thankful to the providers who participated in the study for their willingness to take part and for their interest in continuing to address this need.
We ended up putting together a resource packet for the clinics to help families facing food insecurity. Finding the resources was itself a challenge. It took a lot of searching different websites, such as the local department of public health websites. We broke it down by county, and each county has variable availability of food banks and food pantries. I think it’s tough for a lot of people to find this type of help when they are in need.
What can pediatric practices do now to help families in the suburbs who may be experiencing poverty?
Here at CHOP, the resource guide we created for food insecurity is available now to practices that weren’t in the study. We’re working to get it into Epic so all the CHOP practices can pull it up electronically, but in the meantime people can reach out to me and ask for it. We actually combined the urban resource guide and the suburban resource guide into one large food resource guide, but it’s broken down by county so people can find the county they need.
More broadly, the policy statement from the AAP included a lot of recommendations, some of which I think could be used in suburban practices. One example is implementing Reach Out and Read, a national organization that has been found to improve developmental outcomes in children. In addition, simple forms of acknowledgement, like putting up signage on the bulletin boards telling you the WIC Office number, are at least a good start to show you recognize the issues that poor individuals in the suburbs face.
I think advocacy is also important. Pediatricians, nurses, nurse practitioners, and everyone, all have the ability to advocate, locally, statewide, and nationally, to bring up these issues. Having that one-on-one connection to families gives them a lot of insight that policymakers and other groups may not have. Say, “Hey, we’re seeing these issues of food insecurity. We’re seeing these issues of people struggling to pay for childcare. We see how these issues affect families and affect their health.” Make that known when it might not be known.
Any final thoughts?
From a big, broad, thousand-foot view, the questions we need to ask are what is the health system’s role, and what is the most effective role of the health system in addressing the social determinants of health? Clearly, they impact health. Clearly, if you want to try to improve patients’ health, that’s an area that healthcare ideally should get into. But what is the most effective means that the health system can utilize in addressing these needs?
I think we are building recognition of the need to integrate the health system in working across sectors to address these social determinants, including nonprofit, government, and for-profit businesses. At the same time, we have to recognize that it isn’t just an urban issue. It’s an everyone issue. That might change how the health system approaches it. That might change how a lot of people should approach it.