Poverty causes ill health and suffering throughout the world. Although commonly used as a term to describe those in financial hardship, no single definition is universally accepted (Francis-Devine, 2022). However, in the UK, it is understood by many to describe a situation where household income is 60% lower than the average (Francis-Devine, 2022). The financial hardship of poverty for many people in the UK, therefore, is set within a context of deprivation and loss, because individuals are unable to buy the things needed to function each day.
Historically, research and policy have helped us understand the wide-ranging risks to people's health that come with financial hardship, poverty, and associated deprivation. Poverty affects the location, condition and availability of our home, our ability to access good nutrition and the opportunities we have to engage with our community and sustain relationships with friends and family (World Health Organization, 1995; Dahlgren and Whitehead, 2006; Ministry of Housing, Communities, and Local Government, 2019; Marmot et al, 2020). Despite societal measures, including free health care, unemployment, and sickness benefit, provided through the NHS and the Welfare State, poverty and deprivation still causes some people to experience ill health and die younger than their more affluent counterparts (Marmot et al, 2020).
In the UK today, nearly 40% of the population are living in poverty because of low income (Francis-Devine, 2022). This means that nurses and midwives are likely to meet people experiencing poverty and deprivation as part of their everyday work and should be ready and able to help them access the assistance they need to overcome the associated challenges. The very nature of poverty and deprivation means that many of the signs and symptoms are invisible, so nurses and midwives need to communicate their knowledge and understanding in a professional and caring way.
Research shows that low income affects people in different ways (Table 1). Overall, a lack of income limits a person's spending power, as well as their ability to make choices about what to buy. The emotional and psychological drain of poverty means that it is closely aligned to mental health, particularly because of its associations with isolation and loneliness. Although poverty may affect people's emotions in different ways, many describe it in terms of how it makes them feel undervalued and cut off from society. In fact, up to 50% of people with a debt problem also have a mental health diagnosis, and 20% of people with a mental health problem are likely to have a debt problem (Money and Mental Health Policy Institute, 2019).
Table 1. How money influences health
| Pathway to poverty | Impact on health |
|---|---|
| Material | Money helps people to buy goods and services that improve health; the more money a family has, the more goods they can buy. They can also buy better quality goods. This is likely to positively impact their health. |
| Psychosocial | The stress associated with trying to manage on a low income is high. Research shows that stress increases when individuals compare themselves with others and see themselves at the bottom of the social ladder. The associated biochemical changes in the body mean that stress can damage systems and eventually cause ill health. |
| Behavioural | People on low incomes are more likely to adopt unhealthy behaviours such as smoking and drinking alcohol. However, those on higher incomes are more likely to be able to afford to pay for things that contribute to healthier behaviours. |
| Reverse causation (poor health leads to low income) | People who experience ill health may be living in poverty because they are prevented from taking up paid employment. If unwell during childhood, a person may be unable to maximise the potential from education and this will limit their employment opportunities and potential earnings in adulthood. |
Ill health throughout life can also play a major part in creating the financial insecurity that can lead to poverty. Ill health in adulthood may lead to unemployment and early retirement and thereby reduce potential earnings. Equally, poor health in childhood may reduce educational attainment, as well as employment and earning potential in adulthood. The intergenerational nature of poverty and associated social inequalities means that they are cyclical and often pass from parent to child (Benzal et al, 2014). It is important, therefore, to recognise the signs early to change the pattern of deprivation.
How can nurses and midwives promote financial wellbeing?
The invisibility of financial insecurity and poverty means that for best outcomes, nurses and midwives should not wait for the person to ask for help. Instead, they should talk to people in their care about money and finance. This is particularly important because research reminds us that people who are worried about their finances, or living in poverty, are unlikely to ask for help. Looking out for potential signs that someone is struggling financially can be a practical first step to take (Table 2). As the most trusted profession in society (Ipsos MORI, 2021), nurses and midwives can play a critical role in supporting people to gain access to information and services to help manage their concerns about money.
Table 2. Practical tips for spotting financial hardship
| Signs of financial hardship | What the signs could mean |
|---|---|
| Have you noticed the person has missed appointments? | Could it be because they can't afford the travel or parking costs? |
When visiting someone in their home:
|
The person may be unable to pay the heating costs. A home that feels cold and damp may suggest that the heating has not been used for some timeAbsence of cooking facilities may increase may suggest higher food costs if the person is reliant on ‘take-away’ meal sources. It may also suggest potential health concerns, because of the person's reliance on less nutritious food sourcesUnopened bills may suggest that the person is unable to pay. Research shows that many people try to ignore the problem and avoid asking for help. |
| Have they not picked up prescriptions? | The person may be unable to afford the cost of the prescription |
Asking about money as standard can help to reduce the shame and embarrassment people feel when they are struggling financially. If you are able to weave in asking someone if they have any money worries within your day-to-day interactions and normalise those conversations, people may be more likely to open up, and share their concerns. This could help you to signpost the person to the most appropriate kind of help.
Your role as a nurse or midwife does not include also becoming a money adviser. In fact, to provide any advice about financial matters you would need to be insured, trained, supervised, and regulated by the Financial Conduct Authority. Therefore, if you discover that someone you are working with is struggling financially, you should signpost to free, impartial sources of support, such as the Government-backed MoneyHelper service.
To support all health and care professionals to enhance their knowledge and to take greater action on key public health issues such as financial wellbeing, the Office for Health Improvement and Disparities has published free online e-learning resources as part of the All Our Health Programme (https://www.elfh.org.uk/programmes/all-our-health). The financial wellbeing resource aims to support professionals by providing bite-sized learning, which focuses on the evidence for what works, and provides links to helpful data sources, guidance, and further training resources.
Case Study
Mr Khan* lives with his wife and two young children, in a privately rented flat. His mental health has been a challenge for much of his adult life. In the last few years, it has become increasingly difficult to manage. Recently, he was made redundant following a restructure at work. Before that he was on long-term sick leave and had not worked for 12 months. Mrs Khan is a cleaner. She tends to work during the night after putting the children to bed. Ill health means that Mr Khan is unable to help with childcare responsibilities during her absence. She must rely on the neighbour to help care for the children while she is at work because all their immediate family live in Pakistan. Both Mr and Mrs Khan are frightened that they may lose their home. Their income was low before the redundancy, but now is even lower. For the last 3 months they have fallen behind on their rent payments and now are being threatened with eviction.
Although you have only known the family a few months, you can see a big change in Mrs Khan's health and wellbeing, and you are worried about how this is affecting the children. The school nurse team leader in your office told you that the head teacher is also worried because the children have been falling asleep in class and are often disruptive. The teacher said they frequently come to school asking for food because they are hungry, having not had any breakfast before leaving home.
As the community mental health nurse for Mr Khan, you can see that Mrs Khan looks very upset and you think she has lost a lot of weight. She tells you that she doesn't know what they will do if they lose their home. As she is finding it increasingly difficult to care for the children and Mr Khan and still go to work, she thinks that eviction is highly likely. She doesn't know who to ask for help. Today is the first time she has talked to you about their finances. With the threat of eviction looming, you feel you must do something to help. You know that you cannot provide any financial advice, but also know that you can signpost Mrs Khan to a service that can help her. After all, it must have taken a lot of courage to ask for help.
Having recently completed the e-learning module about financial wellbeing and mental health services, you know that help is available from the MoneyHelper service and that people can access the debt advice locator tool (https://tinyurl.com/2yr2xce5) using the internet or the telephone. Although there is no internet access in the home, Mrs Khan can telephone the service and talk to someone about the rent arrears.
As a mental health nurse, you can see that Mr Khan's deteriorating mental health is reaching a crisis point, which means you should also complete a referral to the Mental Health Crisis Breathing Space scheme (Mental Health UK, 2022). This scheme will help Mr Khan manage his debts. By pausing all enforcement action, the ‘breathing space’ provided will mean his family is less likely to lose their home and he can focus on his mental health recovery.
*This is an illustrative case study with fictitious patient names