Hannah Zhu, Emma Sunderland, Akudo Okereafor, Guddi Singh

Introduction: How do I begin to help a family living in poverty?

Poverty can seem like a huge mountain of a problem and we can feel small and powerless against it. We see children living in poverty in A&E, clinic, inpatient wards and intensive care units EVERY day. We each have a key role in identifying and reducing the impacts of poverty for every child we see.  We need to treat their poverty as key risk factor for disease, if we want to improve their child’s quality of life and long-term health outcomes. Just as screening is important for other adverse risk factors like smoking or domestic violence, we must also screen for poverty. By identifying low-income families, we can connect them to community resources. Community support is vital to help increase participation, provide essentials and empower families to thrive together. 

“After all…it takes a village to raise a child”

How should I discuss poverty with my patients? 

“How do I ask sensitively? Do parents even want me to?”

By using a ‘framing statement’ like…

“Since the pandemic more parents are having difficulty paying bills and have worsening debts, is this something that has been worrying you?”

…you can reduce stigma and encourage parents and carers to trust you to divulge their struggles.

Talking about income is a delicate subject You cannot tell who lives in poverty by looking at them. Incorporating simple screening questions that ALL parents and carers are asked can help identify families who need help. Parents are often relieved that we recognise the impact of poverty on their family’s health and that we want to offer them assistance.

Another approach is to use the routine family and social history you ALREADY take to identify risk factors for poverty. These include:  families with three or more children, single parents, unemployment and/or parents with chronic physical or mental health conditions. If you’re familiar with the HEADS psychosocial assessment tool for adolescents you can adapt this to both identify and discuss the impact of poverty with families with children of all ages.

The adapted “HEADS” tool for poverty
Questions	Possible indicators for poverty
Home: Who lives at home with you? What is your house like?	– Chronic physical or mental health problems, >3 young children, single parent – Housing concerns: pests, leaks mould, cold, overcrowding
Employment/Education: Do you work? What is your job?How is your child doing at school?	-Unemployment/low income, asylum seekers, travellers. -Developmental delay, poor school attainment, poor attendance
Activities:  Do you have any hobbies? Have you been on holiday in the last year?	-Lack of disposable income for hobbies, holidays or transport -Social isolation
Diet:  What did you eat yesterday?In the last year, have you worried that your food would run out before you got money to buy more?	-Lack of (healthy) food, unable to afford fresh fruit and vegetables -Parents missing meals to feed children -Free school meals -Foodbank use
Safeguarding/Support: Have you ever had a social worker? Has anyone ever hurt or threatened you?	-Reasons for social worker could give insight into current and previous vulnerabilities. Consider what support they already have? Are they receiving benefits? -Physical, emotional, sexual abuse or neglect warrants further investigation and referral as per local pathways.

How can I help the child in poverty and their family?

Sometimes just being understanding of the family’s social and financial situation and empathetically managing their child’s healthcare in that context can be enough to transform the quality of the child’s care. 

There are other specific action you and your teams can take:

SIGNPOSTING parents/carers to services that focus on the social determinants of health is an increasingly important skill for all health professionals. This may involve directing them to: sources of financial support, both from the state (such as statutory benefits and social security entitlements) and third sector organisations (local food banks, childcare support, and other practical services). 

A useful repository of information to help families navigate available services can be found through UK Bill Help (www.billhelp.uk). 

ADAPT and ADOPT  this ‘1-2-3 fight inequality leaflet’ for local community resources.

EMPOWER FAMILIES and encourage their strengths on an individual level (personal resilience, knowledge and skills) or community level (family and social networks, schools and clubs, and third sector organisations).

“Mothers and fathers are raising respectful, eloquent young men and women, who, in reality, are part of a system that will not allow them the opportunity to win and succeed.” 

 Marcus Rashford. 

Case Study 2: James  Situation: James, 11, laceration to R ankle in A&E.   Background: James is 11 years old and has never had friends come over to his house because he is embarrassed that he shares a bedroom with his two younger sisters. He knows his parents can’t afford dinner for his friends if they did come so he plays outside most afternoons. Earlier, an older boy bought him chicken and chips and James had been bragging when he fell from the damaged fence in a small car park; his parents warned him not to go to the local park for fear of gangs.  Assessment: His father works two jobs and mother works part-time. They struggled last month to buy essentials as there was a leak in their flat and substantial repair cost.  Recommendations: Wound care PLUS give 1-2-3 resources leaflet. Tell them about local food banks and direct to Citizens’ Advice and debt advice help. James’ father apologises he’s getting upset and we acknowledge his challenges and offer encouragement. Food Bank also has budgeting workshops and ‘cooking on a budget’ sessions. Risk of grooming and criminal exploitation – highlight the contact number of local youth workers and warn about gangs and county lines risk.

Summary

As paediatricians, we meet and care for more and more families living in poverty every day. Being familiar with local and national poverty-busting resources and knowing how to offer them can provide practical and tangible help to families. Let’s empower parents to get the help their families deserve and help to break the cycle of poverty for future generations.

In the words of Michael,

“Why treat children only to send them back to the conditions that made them sick?” 

Key learning points

We all need to play our role in fighting child poverty. For every patient, we can:

• Screen – consider using a framing statement like: ““Since the pandemic more parents are having difficulty paying bills and have worsening debts, is this something that has been worrying you?”
  • Ask and listen – consider using our adapted HEADS for your social history (Home, Employment/Education, Activities, Diet, Safeguarding/Support)
  • Prescribe resources – consider 1. Income support 2. Providing essentials 3. Encouraging participation and improving quality of life.

FURTHER READING

If you found this blog useful you may be interested to read the following, upon which this blog draws:

Singh, G., & Zhu, H. (2020). Poverty in practice: using quality improvement in paediatrics to improve identification and support of families living in poverty. Archives of Disease in Childhood-Education and Practice.

Singh, G., Owens, J., & Cribb, A. (2018). Practising ‘social paediatrics’: what do the social determinants of child health mean for professionalism and practice?. Paediatrics and Child Health, 28(3), 107-113.

Singh, G., Zhu, H., & Cheung, C. R. (2020). Public health for paediatricians: Fifteen-minute consultation on addressing child poverty in clinical practice. Archives of Disease in Childhood-Education and Practice.

For an overview of poverty and health inequalities in the UK 

Michael Marmot, J. A. (2020). Health equity in England: The Marmot Review 10 years on. London: Institute of Health Equity.