Chapter 25: Poverty, Homelessness & Mental Health Risks

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Welcome back to the Deep Dive.

Our mission here is, well, it's pretty simple.

You bring us the stack of sources, the textbook chapter, the research that you need to get your head around and we pull out the absolute crucial knowledge for you.

And today's mission is a really important one.

We're focusing on the core concepts for community and public health nursing.

Specifically, we're diving deep into how nurses care for the most vulnerable populations in the United States.

Right.

And the central theme that connects everything we're looking at today is this idea of vulnerability and these deep health inequities.

Exactly.

And they are almost entirely driven by the social determinants of health.

It's a term you hear a lot, but it's just it's about where people are born, where they grow up, where they live, work and age.

Those factors are powerful.

They really are.

We're not just looking at a single disease here.

We're looking at the whole context.

In the chapter we're tackling today, it breaks this down by looking at four specific groups.

Yes, four groups that face just magnified challenges because of cultural attitudes, systemic barriers, you name it.

We're talking about the poor, the homeless, pregnant teens and people living with mental illness.

And the sources are so clear that for any nurse going into this field, the work has to start internally.

You have to look in the mirror first.

That's the absolute starting point.

You have to examine your own values, your own judgments, maybe biases you don't even know you have about these groups.

Only then can you really, you know, systematically and fairly identify what they need, what the barriers are, what the barriers are and what essential services they require.

It's a huge task.

And it requires what the text calls a multi -dimensional approach, which means you're looking at everything, the biological, psychological, social, cultural, environmental, comic, even spiritual factors, all of it.

Yeah.

If you just focus on, say, an infected foot, but you miss the fact that the person has no clean water or a safe place to sleep, you failed that patient.

It's the difference between treating a symptom and treating a whole person who's stuck in a really complex and often failing social system.

That's it.

Exactly.

So today we're going to unpack each of these vulnerable groups one by one.

We'll start with poverty, then move through homelessness and teen pregnancy.

And we'll wrap up with a close look at mental illness and the practical toolkit nurses need.

Okay.

Let's start with poverty because even defining it isn't simple.

The federal government uses two different measures and a nurse really needs to know the difference.

Why two?

Well, it's about function.

They serve different purposes.

So first you have the poverty thresholds.

These come from the U .S.

Census Bureau, and they're mostly for statistical use.

So for tracking trends, for research, looking back.

Exactly.

It's a retrospective tool for calculating the official national poverty rate.

But then you have the one that's immediately actionable for a nurse.

The federal poverty guidelines.

Precisely.

Those are issued every year by the Department of Health and Human Services, the USDHHS.

And their one and only purpose is to determine financial eligibility for critical programs.

So things like Medicaid, CHIP.

Medicaid, CHIP, savings on marketplace health insurance.

If a nurse is trying to get a family connected to care, this is the number they need to know right now.

And these numbers aren't set in stone.

They change every year.

Right.

They're updated annually based on the Consumer Price Index, or CPI.

The CPI basically just tracks inflation,

the average change in prices for a whole basket of goods and services.

Food, housing, gas.

All basics.

So as the cost of living goes up, the poverty line goes up with it to reflect that reality.

And when you look at the scope, the statistics are pretty stark.

They show exactly who is being hit the hardest.

Oh, absolutely.

The overall poverty rate in 2018 was about 11 .8%.

But that number hides some really big disparities.

For kids, it's much higher.

Much higher.

For children under 18, it was 16 .2%.

It makes them the poorest age group in America.

And you see with race and gender, too, higher rates for women and much higher for African Americans and Hispanics.

At its core, it just means you don't have enough money for the basics.

The sources also break down the experience of poverty into a few different types, which helps a nurse understand a client -specific situation.

Yeah.

You have to know what you're looking at to tailor your help.

First, there's persistent poverty.

This isn't just a temporary setback.

We're talking about families who stay poor for long, periods.

It often gets passed down through generations.

And then there's a term for the environment itself.

That's neighborhood poverty.

This is when you have whole geographic areas, a neighborhood, a few city blocks where poverty is just concentrated.

You see it in the dilapidated housing, the high unemployment.

The environment itself is working against your client's health.

And the last one, multi -generational poverty often overlaps with the others.

It does.

This is that deep -seated poverty you see in specific minority groups where historical and systemic barriers have just locked in that disadvantage for generations.

Think about African Americans in the rural south or American Indians on reservations.

And for a nurse, the imperative here is to just accept and respect that reality, right?

Not to judge it.

Exactly.

You have to understand how that deep life situation shapes their choices and their health,

not impose your own ideas on them.

Which is a good lead -in to the causes.

The text lists this huge tangled web of factors.

You really can't pin it on any one thing.

No, it's fundamentally systemic.

You've got huge economic shifts like job outsourcing, a move from stable industrial jobs to less stable service jobs.

Things that leave people without a high school degree behind.

Then you have things like more female -headed households, weak child support enforcement.

Exactly.

And inadequate education, poor job skills.

All these things weave together and make it hard to climb out.

And this is where the conversation shifts from sociology to biology.

The actual physical impact of poverty, especially through this mechanism called toxic stress.

This might be the most important thing to understand about poverty's effect on kids.

Absolutely.

We know poverty is tied to just awful health outcomes.

Higher rates of chronic illness, shorter life expectancy.

But for children, the constant high -level stress of it all, the chaos, the instability, it keeps their body's stress hormones firing constantly.

Cortisol, adrenaline, all of it.

So their body is in a constant state of fight or flight that never turns off.

That's it perfectly.

It's called allostatic load.

And this chronic hyper -vigilant state, especially when it happens during those key developmental windows, it actually affects the physical development of the child's brain.

Specifically, the prefrontal cortex.

The part that controls planning, impulse control.

Right.

All the executive functions, the constant flood of cortisol literally remodels the brain.

So you end up with poor impulse control, difficulty self -regulating.

They struggle in school.

They might make poor choices later.

And that leads to unhealthy coping mechanisms as they get older.

That's the devastating long -term hit.

It can lead to smoking, substance abuse, core diet, all things that increase their risk of getting sick and dying at a much younger age.

Toxic stress is a measurable physical process.

Given how biological that damage is, what can nurses actually do?

How do you buffer a brain that's under that kind of attack?

The number one buffer is a stable, supportive relationship with an adult.

That relationship acts as a shield against all the chaos in their environment.

And the source mentions a really specific and kind of surprising intervention.

Right.

Breastfeeding.

Yes.

The text highlights breastfeeding, especially with skin -to -skin contact, as a powerful tool against toxic stress.

When a mother does skin -to -skin, her own calming hormones go up and simultaneously lowers the infant's cortisol levels.

It reduces their physiological stress load.

Instantly.

It induces calm.

So we always talk about breastfeeding for nutrition, for immunity, but for a kid in a high -stress environment, its role in regulating hormones might be the most important thing it does.

That's a huge reframing of that intervention.

It really is.

And you see it in programs like the Nurse Family Partnership, the NFP.

They have nurses do long -term home visits with new low -income moms.

They support breastfeeding.

They help with parenting.

They help create that stable relationship that buffers the child's developing brain.

So that really brings it all back to the nursing role.

You're addressing the biological impact of an economic reality.

Okay.

So moving from poverty, let's look at a state that's so often linked to it.

Homelessness.

Right.

And homelessness, like poverty, is really complex.

You can't just have one approach.

The official HUD definition is simple.

It's just a person who lacks a fixed, regular, and adequate nighttime residence.

But to actually help someone, the nurse needs to know what kind of homelessness they're dealing with.

The sources break it into three categories.

Yes.

And these are crucial for assessment.

First is transitional homelessness, which you might also hear called crisis poverty.

This is usually triggered by a single catastrophic event.

Like a job loss and an eviction at the same time.

Or a house fire, a sudden illness.

They usually have a short shelter stay.

They're highly motivated, and they can often get back into housing with a little short -term help.

They're the biggest group in terms of turnover in the shelter system.

They have the people who are kind of stuck in a loop.

That's episodic homelessness.

These are people cycling in and out of being homeless.

They're often younger, and they're usually dealing with chronic unemployment and co -occurring issues like mental health problems or substance abuse.

And the last group, which is smaller, but often needs the most help.

That's chronic homelessness.

This is someone who has been homeless for a long time, a year or more, or had multiple episodes.

And they also have a disabling condition,

usually a serious mental illness or chronic physical problem.

These are often older individuals, and they're the ones who really need permanent supportive housing.

The sheer numbers are staggering.

The 2019 data said around 568 ,000 people were homeless on a night.

And what really stood out to me was the number of unsheltered people.

It's huge.

37 % were unsheltered.

That's over 200 ,000 people living on the streets, in parks, in cars.

And that has a profound impact on their health.

And again, you see that African Americans are consistently and deeply overrepresented in this population.

The sources also point to some specific groups who are at really high risk.

Let's start with families, because I think that breaks the stereotype a lot of people have.

It does.

Homeless families are usually headed by a single mom with a couple of kids.

She's often fleeing domestic violence, and she's carrying a much higher burden of medical and mental health issues than housed women.

And the number of homeless youth is just shocking.

27 % of the total homeless population is under 25.

What's driving that?

It's often about broken relationships,

family instability, lack of social support.

But a huge distressing factor is SOGI sexual orientation and gender identity expression.

Around 40 % of unaccompanied homeless youth identify as LGBTQ.

So they've likely been rejected by their family.

Yes.

And they're afraid of the formal systems like child welfare or the justice system, so they try to stay hidden.

Then there are homeless veterans.

We hear about programs targeting them, and it seems like there has been some success, but they're still so vulnerable.

They are.

The numbers have gone down a bit, which is a rare good news story, thanks to programs like the VA's SSVF for rapid rehousing and HUD VHH for permanent supportive housing.

But what are their main health challenges?

They have extremely high rates of other problems.

About half have a serious mental illness, and 70 % have substance use issues.

A lot of it is connected to combat PTSD or traumatic brain injury.

So a nurse has to know that and screen for it.

And the last group, the most vulnerable of all, homeless older adults.

The stats here are just grim.

They're tragic.

The life expectancy for a chronically homeless person is just 44 years.

44.

That's a life expectancy you'd see in a developing nation.

44.

Wow.

That just says everything about the impact of these social determinants.

They suffer from so many untreated chronic conditions, TB, severe hypertension, arthritis, because they don't have continuity of care.

By the time they show up in an ED, the disease is in an advanced stage.

And the environment of homelessness itself creates specific health problems.

It's a feedback loop.

It is.

Their care is almost always crisis oriented, happening in the emergency department, which is the most expensive and least effective way to manage health.

They have exposure related illnesses, hypothermia, heat stroke, infestations,

respiratory problems like TB and crowded shelters.

And you mentioned something like peripheral vascular disease from just standing all day.

Absolutely.

From standing or sitting on hard surfaces for hours, it ruins your circulation.

Their nutrition is terrible.

Lots of high sodium, high fat, fast food.

And trauma is constant.

It could be a major wound or just a small cut that turns into a major infection because they can't keep it clean.

With all of that going on, that daily fight for survival, things like healthy people, 20, 30 goals, they must seem like a total luxury.

They are.

You can't expect someone to manage a complex insulin regimen when they don't know where their next meal is coming from or they're going to sleep.

They might not have an ID.

They can't get transportation.

They're embarrassed.

Health promotion is a luxury.

Survival is the priority.

And I can only imagine how COVID -19 amplified all of this.

It was a nightmare.

The very basics of prevention, social distancing, hygiene were impossible in a crowded shelter.

It put this population at extreme immediate risk.

This all paints a very stark picture, but let's shift to a population where, if we get it right, prevention can break that cycle of poverty and poor health.

Pregnant teens.

Yes, adolescent pregnancy is such a critical public health issue because it's a real pivot point.

It can lock young parents and their kids into a cycle of poverty and poor education that impacts two generations at once.

But the sources did point to some good news here, some positive trends in behavior.

They did.

The data shows a pretty significant linear drop in the number of young people initiating sex between 2005 and 2015.

So it seems like some of the education around delaying sex is working.

But when teens do become sexually active, what's the gold standard for protection now?

The recommendation is dual protection.

That means using two methods at once,

ideally a hormonal method.

And the best ones are long acting, reversible contraception or LARC, like an IUD or an implant plus a condom.

Why LARC specifically?

Because they're just so effective and they take user error out of the equation.

ACOG and other not just a first pregnancy, but also rapid repeat pregnancies.

So in the clinic, when you're talking to a teen, the approach has to be different.

They're often anxious, maybe embarrassed.

The very first thing a nurse has to do is create a safe, nonjudgmental space, build that trust.

And when you're talking about sensitive stuff, you use neutral words instead of do you have an STD?

You might ask, have you noticed any change in your typical vaginal discharge?

The source also says to let the teen use their own words.

Yes, you let them use their own language, even if it's, you know, crude or not medically correct.

Once you have that trust, then you can gently teach them the right terms.

But if you show shock or judgment, you've lost them.

They'll shut right down.

And the legal side of this is so tricky, confidentiality, consent.

It's a minefield for nurses.

It's a huge area of risk.

State laws on a minor's right to consent for contraception or just says, whatever your state law is, that's the rule.

So there's no national standard to fall back on.

You have to know your local cold.

Exactly.

A nurse in a teen clinic needs to have a cheat sheet on their state specific consent laws.

And for abortion, it's even more state dependent.

Often it requires parental notification.

And that fear of a parent's reaction is the number one reason teens delay getting care.

The text also talks about the adolescent mindset, that sense of invincibility.

It's a huge factor.

They have this feeling that they're unique, that the bad things, the poverty dropping out of school won't happen to them.

They think they can do it all, even though the data overwhelmingly shows that's not the case.

Let's talk about the young men involved, the issue of paternity.

Right.

Paternity or legal fatherhood is really complex when you're not married.

And interestingly, while teen pregnancy rates have dropped, the percentage of teenage fathers has actually gone up.

So what are the challenges for the young father and how does the nurse bring him into the picture?

Teen fathers often have their own challenges, delinquency, substance use.

The nurse really has to acknowledge and support the young man, talk about his concerns, money,

school, where he's going to live.

And getting paternity legally established is critical for the mother to get any kind of assistance like TNF or Medicaid.

And I imagine there's a big emotional barrier for him too.

Oh, absolutely.

A lot of young men get pushed out by the mother's family.

And so they might seem like they don't care when really they just feel helpless or ashamed.

The nurse can be that bridge, helping him understand his rights and responsibilities.

So when a teen does become pregnant, she's automatically considered a high risk obstetrical client.

Why is that?

The risks just compound.

There's poverty, late prenatal care, and a big one is violence.

Teens are much more likely to experience violence during pregnancy than adult women.

A nurse has to screen for violence at every single visit.

No exceptions.

And the biggest physical risks for the baby are low birth weight and prematurity.

That's the major threat to the infant.

They're much more likely to have a baby under 5 .5 pounds or born before 37 weeks.

Those babies are at higher risk for all kinds of long -term problems.

The number one intervention is getting them into prenatal care as early as possible.

And nutritionally, the teen's body is trying to do two things at once, grow herself and grow baby.

It's a massive double burden.

Her own adolescent growth spurt is happening at the same time.

So the nurse has to really focus on weight gain, 25 to 35 pounds is the recommendation.

And for a really young teen, say 14, she might actually need to gain more than an adult to have a healthy baby.

The text points to one specific nutritional problem as being the most Iron deficiency anemia.

It's super common because of poor diet and the high demand of pregnancy.

And it's a big risk factor for prematurity and low birth weight.

So the nurse has to hammer home the importance of prenatal vitamins with iron and educate them on iron rich foods.

Beyond the physical stuff, the nurse also has to prepare them for the reality of being a parent.

Yes, a lot of teens think they're ready because they babysat, but they are not prepared for the reality.

And the sources are clear.

Abusive parenting is more likely when parents don't understand normal child development.

So the nurse has to teach them the basics and continually assess for child abuse risk.

And finally, advocating for their education is key to breaking that cycle.

This is a huge advocacy role for the nurse.

Federal law says schools can't kick students out for being pregnant or parenting.

The nurse's job is to make sure the stays in school and gets the accommodations she needs.

Okay, let's transition now to our final vulnerable population.

Individuals with mental illness, which is just a massive public health concern.

Let's start with some definitions.

Right.

So mental illness is kind of an umbrella term for all diagnosable mental disorders.

But SAMHS makes a key distinction between any mental illness, AMI, which is any disorder that meets the criteria in the DSM -5.

And serious mental illness, SMI.

Exactly.

And the difference with SMI is all about function.

It's a disorder that causes serious functional impairment, meaning it gets in the way of major life activities.

The prevalence is just huge.

Nearly half of all people in the US will have a mental illness at some point.

And you can't talk about mental illness without talking about comorbidity, especially with substance use disorders.

No, you can't.

Millions of adults have a mental illness and a substance use disorder at the same time.

And that makes treatment so much harder, often one masks the other, or treating one makes the other worse.

You have to treat the whole person.

To understand how we got to the current crisis, especially with so many people with mental illness being homeless or in jail, we have to look back at deinstitutionalization.

Right.

Deinstitutionalization was this huge movement to get patients out of the big old state psychiatric hospitals and back into the community.

It was driven by a few things, new psychotropic drugs that worked, states wanting to save money, and a civil rights push for treatment in the least restrictive environment.

So the idea was good, but the source says the implementation was bankrupt.

What went wrong?

Everything, basically.

The community -based services that were supposed to support these people, the housing, the job training, the case management,

they just weren't there.

The funding never came.

Families were left to cope on their own, totally unprepared.

So these very vulnerable people were just released with no safety net.

Tragically, yes.

Many ended up in nursing homes that couldn't handle them, or critically, they ended up on the streets or in the criminal justice system.

Jails and prisons have become our country's de facto mental hospitals.

And the community mental health centers were supposed to be that safety net, right?

They were, but they were under -resourced.

They could do some outpatient stuff, but they didn't have the intensive wraparound services people needed.

The whole system was just hollowed out.

Let's focus now on the specific populations at risk, starting with children and adolescents.

Kids are so vulnerable.

It's a mix of biological factors and environmental risks like violence, abuse,

and family dysfunction.

And the result is just tragic.

Suicide is the second leading cause of death for kids and young adults aged 10 to 24.

Is there a gender difference there that's important for a nurse to know?

Yes, there is.

Males complete suicide more often, usually with firearms.

Females have more suicidal thoughts and non -fatal attempts, often using poisoning.

Both demand immediate targeted intervention.

So the nursing role is all about screening and collaboration.

Absolutely.

The Healthy People 2030 goals are all about increasing depression screening for this group.

And you have to get all the systems, schools, social services, the justice system working together.

Moving to adults, it seems like stress is the big trigger.

It is.

The stress of juggling all these roles, worker, parent, caregiver, plus economic uncertainty can just break down a person's mental stability.

The rates of anxiety disorders are incredibly high, over 31 percent lifetime prevalence.

And what's the nurse's role here, especially since so many adults don't seek out a psychiatrist?

The key is that primary care is often the only place they go.

So nurses in primary care clinics are on the front lines.

They're perfectly positioned to use screening tools for depression, anxiety, and substance abuse.

Early detection is everything for suicide prevention.

And finally, older adults.

This is a group whose mental health needs are often just dismissed as a normal part of getting old.

Right.

And that's just wrong.

Depression is absolutely not a normal part of aging, but they have high rates of it, especially in long -term care.

And of course, there are dementia -related issues.

And they process medications differently, which is a big risk.

Huge risk.

Their liver and kidney function has changed so they can overdose more easily or have bad side effects.

And sometimes their depression doesn't look like sadness.

It looks like physical complaints, chronic pain, stomach problems.

So it gets missed.

And isolation is a huge factor.

Profound.

Loneliness from losing a spouse or friends.

And they tend to underuse the mental health system because of stigma.

So the nursing role is about health promotion in places like senior centers and supporting the family caregivers, who are also a huge risk for burnout and depression.

And before we move to interventions, we have to mention cultural diversity.

It's so critical.

Nurses have to be aware that different cultures see mental illness differently.

It might be seen as a spiritual problem, not a clinical one.

And that affects if they seek care, how they talk about it.

You need culturally competent interpreters and you have to avoid stereotypes.

Okay, so this has all been building toward the what do we do about it part.

The three levels of prevention are the absolute foundation for a public health nurse.

They are primary, secondary and tertiary.

It's the framework for everything.

You have to know if you're trying to prevent the problem, catch it early or manage it long term.

Let's run through some primary prevention examples.

This is about stopping the problem before it even starts.

Right.

Targeting the root causes.

So that's advocating for affordable housing, job training programs.

For teens, it's accessible birth control and safe sex education.

For mental health, it's teaching stress reduction to the general population.

No secondary prevention examples.

This is all about screening and early intervention.

Exactly.

This is screening for TB in a homeless shelter or screening for diabetes and high blood pressure.

It's providing emergency housing to stop someone from becoming chronically homeless.

It's a nurse in a primary care clinic screening for depression and starting treatment right away.

And finally, tertiary prevention examples.

This is for people who already have a chronic condition.

This is all about rehabilitation and maximizing their function.

So psychosocial rehab programs for people with SMI, comprehensive case management for the chronically homeless, harm reduction things like needle exchanges and long term drug treatment.

This is where political advocacy often comes into.

This brings us to the core of the nurse's actual practice, the client centered care strategies.

And it starts, like you said at the beginning, with self -awareness.

It has to.

Before you can do anything else, you have to ask yourself the hard questions.

Do I secretly believe poor people are lazy?

Do I think people with mental illness are just manipulative?

If you haven't done that internal work, your body language, your tone of voice,

it will give you away.

Once that's done, it's all about building trust, which must be so hard with people who have been let down by every system imaginable.

So hard.

So creating trust means being incredibly reliable.

If you say you're going to call them back, you call them back.

Even if it's just to say, I don't have the answer yet, but I'm still working on it.

That simple act can be revolutionary in their chaotic world.

And that goes hand in hand with showing respect and avoiding assumptions.

Yes, showing respect means truly listening and avoiding assumptions means being a detective.

If a mom misses an appointment, don't just label her non -compliant.

Find out why.

Was it because she had no bus fare?

Was her other child sick?

You solve that barrier first.

The nurse also has to be this master coordinator connecting all the dots of a really fragmented system.

They're the ultimate case manager.

Coordinating a network of services means, you know, every food bank, every legal aid clinic, every housing program in your area, you are the link.

And you also identify the gaps and advocate to get them filled.

And you have to advocate for the services themselves to be more accessible.

Right.

Advocating for accessibility means pushing for clinics to have evening hours, to be on a bus line.

A service that's impossible to get to is not a service at all.

And even in a crisis, you're always trying to weave in prevention.

Always.

Focusing on prevention means every interaction is a chance to teach about immunizations, nutrition, safe sex.

It's a chance to do quick screening.

It's about breaking the cycle for the next generation.

The last skill is maybe the most delicate.

Knowing when to help and when to step back to preserve their autonomy.

This is the art of it.

Balancing autonomy.

The text calls it knowing when to walk beside the client and when to encourage the client to walk ahead.

Sometimes you absolutely have to step in and make the appointment because they're too overwhelmed.

But other times, you give them the phone number and let them make the call.

Exactly.

You empower them.

If you take away their power to make decisions, you're just perpetuating the very system that's harming them.

You have to respect their right to self -determination.

And for the nurse doing this incredibly draining work, the final piece of advice is about themselves.

Self -care.

It is not a luxury.

It is mandatory.

You cannot pour from an empty cup.

This work demands you find a source of strength and renewal for yourself because your clients are often looking to you for hope.

You have to find what recharges you and make time for it.

When you look at all these issues together, poverty,

homelessness, teen pregnancy, mental illness, it can feel overwhelming.

But the practice of public health nursing is what ties it all together.

It's about mastering that assessment of a person's needs within this huge context of systemic disadvantage.

It's about coordinating resources, using prevention, and just holding on to that radical compassion.

That's how you begin to restore dignity.

And that idea of restoring dignity brings me back to that strategy you mentioned,

balancing autonomy.

The source talks about the choice between walking ahead of a client and dictating care versus walking beside them and offering support.

So here's the final thought.

For these populations who have so little control over their own lives, whose days are dictated by policies and crises, how does that simple choice, the choice to walk beside them and empower them to lead, how does that fundamentally change the entire relationship and maybe lead to more sustainable health outcomes for everyone?

That's it for this week's Deep Dive.

We hope you feel thoroughly informed and ready to apply these vital concepts.

We'll see you next time.