Income

What Is It?

This focus area measures the percent of children in poverty, as defined by the federal poverty threshold. This measure provides information about a community’s ability to meet basic needs necessary to maintain health. Poverty is commonly considered insufficient income to meet the needs for food, clothing, and shelter. [3]

Why Do We Measure It?

Income and financial resources have long been understood as important to health, so that individuals can obtain health insurance, pay for medical care, afford healthy food, safe housing, and access to other basic goods, at least until a certain income threshold is achieved.[4] A 1990s study showed that if poverty were considered a cause of death in the U.S., it would have ranked among the top 10 causes of death .[5]

There are many ways to measure the effects of income on health, each with numerous pros and cons. For example, measures of relative income may be more revealing in developed countries, where absolute levels of income have exceeded a minimum threshold above material scarcity. [6] But relative measures of income, such as income inequality, may be inappropriate for smaller, sub-national or sub-state regions; deprived areas may have poorer health not because of inequalities within them, but because they are poor relative to the wider society. [7]

While negative health effects resulting from poverty are present at all ages, children in poverty face greater risks.[3,8] Children face greater morbidity and mortality due to greater risk of accidental injury and lack of health care access.[8] Children’s risk of poor health and premature mortality may also be increased due to the poor educational achievement associated with poverty.[3] Early (or prenatal) poverty may result in development damage. Children’s age-five IQ correlates more with family income that with maternal education, ethnicity, and single female-headed household.[8] In addition, residence in a poor neighborhood (regardless of family poverty status) can result in negative health consequences, “including all-cause mortality, self-rated health and medical conditions, disease incidence, incidence of severe childhood injury, depression, intimate partner violence, health behaviors such as physical activity level, and alcohol-related problems.”[9]

Measurement Strategies

Researchers have used various strategies to measure poverty, including relative versus absolute measures of poverty (state-reference poverty levels versus the federal poverty standard), indicating severity of poverty, such as “near poverty” or “extreme poverty,” and differentiating the population under measurement (total population versus children in poverty). Hillemeier et al. found that state-referenced poverty was not significantly associated with mortality or infant mortality, but poverty defined by the federal standard did correlate to these mortality measures.[10] One disadvantage of a relative poverty measure is that it would not result in increased poverty levels if incomes overall tended to decrease, as during a recession.[11] In considering degrees of poverty, researchers have found that extreme poverty has particularly deleterious effects on children’s prospects for a healthy life and is less sensitive to economic changes than poverty or near-poverty.[9] Finally, measuring children in poverty is an upstream measure in reference to future generations, but at the same time it is a downstream measure for the current generation. “Without a healthy and happy start in life, children growing up in poverty are likely to fall into the same cycle of economic hardship as their parents.”[12]

What Is the County Health Rankings Measurement Strategy?

The County Health Rankings uses data on children in poverty from the Census’ Current Population Survey (CPS)   Small Area Income and Poverty Estimates (SAIPE).

Measure Strengths & Limitations

Children in poverty captures an upstream measure of poverty that assesses both current and future health risk. Because it is benchmarked to federal poverty thresholds, it is an absolute measure of poverty, and a more effective predictor of adverse health outcomes. Children are at greater risk for poverty, so this measure is more sensitive to changes in poverty levels.

Headcount measures of poverty alone, however, do not account for the level of economic deprivation, and greater deprivation is correlated with worse health outcomes.[11] Wagle recommends a multi-dimensional approach to assessing poverty, looking at economic well-being, capability, and social inclusion as three separate dimensions of poverty. “Although these dimensions are highly interrelated, a lack of perfect predictability indicates the urgency for using all three.”[13] Instability of income may also be a significant predictor of morbidity, mortality, and childhood education achievement, which requires longitudinal data.[5]

References

[1] Brunner E. Socioeconomic determinants of health: Stress and the biology of inequality. Br Med J. 1997;314:1472.
[2] Wilkinson RG. The Impact of Inequality: How to Make Sick Societies Healthier. New York, NY: The New Press; 2005.
[3] Brooks-Gunn J, Duncan GJ. The effects of poverty on children. Future Child. 1997;7(2):55-71.
[4] Subramanian SV, Kawachi I. Income inequality and health: What have we learned so far? Epidemiol Rev. 2004;26:78-91.
[5] Krieger N, Williams DR, Moss NE. Measuring social class in US public health research: Concepts, methodologies, and guidelines. Annu Rev Public Health. 1997;18:341-378.
[6] Wilkinson RG. Socioeconomic determinants of health: Health inequalities: relative or absolute material standards? Br Med J. 1997;314:591.
[7] Pickett, K. E. & Wilkinson, R. G. Inequality: an underacknowledged source of mental illness and distress. The British Journal of Psychiatry, 197. 2010: 426-428.
[8] Aber JL, Bennett NG, Conley DC, Li JL. The effects of poverty on child health and development. Annu Rev Public Health. 1997;18:463-483.
 [9] Wen M, Browning CR, Cagney KA. Poverty, affluence, and income inequality: Neighborhood economic structure and its implications for health. Soc Sci Med. 2003;57:843-860.
[10] Hillemeier MM, Lynch J, Harper S, Raghunathan T, Kaplan GA. Relative or absolute standards for child poverty: A state-level analysis of infant and child mortality. Am J Public Health. 2003;93:652-657.
[11] Blank RM. Presidential address: How to improve poverty measurement in the United States. J Policy Anal Manage. 2008;27:233-254.
[12] Annie E. Casey Foundation. Reduce Poverty and Promote Opportunity. Baltimore, MD: Annie E. Casey Foundation; 2009. Issue Brief, January 2009.
[13] Wagle UR. Multidimensional poverty: An alternative measurement approach for the United States? Soc Sci Res.2008;37:559-580.