Introduction
The experience of poverty represents a significant public health issue. As of 2013, approximately 30.6 million adults and 14.7 million children in the United States were living in poverty (DeNavas-Walt et al.
2014). Poverty disproportionately affects females (DeNavas-Walt et al.
2014; Entmacher et al.
2014), with 25.2 million females living in poverty in the United States as of 2013, compared to 20.1 million males (DeNavas-Walt et al.
2014). Women of certain racial/ethnic groups (Hispanic, Native American and black) and age groups (younger cohorts) are more likely to experience poverty (DeNavas-Walt et al.
2014; Entmacher et al.
2014).
The experience of poverty can affect women’s emotional wellbeing. Women are more likely than their male counterparts to report stress in their life caused by the economy or money (American Psychological Association). Furthermore, women who experience poverty, including economic hardship, are more likely to experience depression (Manuel et al.
2012). Depressive symptoms are also likely to be higher among certain subgroups of low-income women. For example, in a sample of African American, single mothers receiving welfare, 40% reported depressive symptoms severe enough to meet diagnostic criteria for clinical depression (Coiro
2001). This result has been duplicated in recent qualitative research indicating that difficulties with emotional wellbeing are often exacerbated in samples of low-income, minority women, as many do not have health insurance or report concern that their healthcare provider may hold discriminatory beliefs (Lazear et al.
2008).
Poverty’s pernicious impact on infants and children has been well documented (Brooks-Gunn and Duncan
1997). Disturbances in the emotional wellbeing of mothers, such as those caused by anxiety and depressive symptoms and disorders, are associated with an increase in infants born at lower birth weight, shorter gestation, and overall adverse effects on fetal/infant development, as compared to mothers without these symptoms (Schetter and Tanner
2012). Children living in poverty are also more likely to have mothers who are experiencing depressive symptoms or high degrees of perceived stress (Berger et al.
2009), and higher psychological distress among parents living in poverty is associated with poorer psychological outcomes, including internalizing and externalizing behaviors, among children (Robila and Krishnakumar
2006). Additionally, social capital, including trust and participation, is restricted in low-income families, which has been found to affect children’s outcomes, including their mental health and behavior (De Silva et al.
2005; Parcel and Menaghan
1993).
Currently, the United States determines whether an individual is in poverty using income thresholds, which take into account the size of families and the age of individuals within these families (United States Census Bureau
2014). Though the use of income as a standard for poverty determination is widespread, some researchers have examined material hardship in relation to poverty, which includes concerns such as food insufficiency and utility disconnection, and found these measures to be more targeted measures of both deprivation and health outcomes (Beverly
2001; Gershoff et al.
2007; Heflin and Iceland
2009). Given these emerging conceptualizations of poverty, and their importance to maternal and child health, there is a growing need to operationalize poverty in order to tailor interventions for families to actual reported needs of families living in poverty.
While previous research has focused on specific aspects of poverty pertaining to low-income women, such as marriage and emotional health (Coiro
2001; Edin
2000; Edin and Reed
2005; Gibson-Davis et al.
2005), these studies for the most part have not looked specifically at how poverty affects parenting practices, but rather note there is a main effect of income on overall quality of parenting and self-reported parental efficacy (Waldfogel et al.
2010). As such, this study aimed to (1) operationalize poverty specific to a sample of low-income mothers, (2) examine how mothers describe sources of stress related to poverty, and (3) explore how the experience of poverty affects women’s parenting practices.
Methods
Procedures
The New Haven Mental health Outreach for Mothers (MOMS) Partnership, a collaborative of agencies dedicated to improving the wellbeing of women and families, conducted a needs assessment with a sample of parenting women between January of 2011 and June of 2015. This needs assessment was structured into six sections: (1) About Yourself, (2) Housing, (3) Your Family, (4) Basic Needs, (5) Your Physical Health and Emotional Well Being, and (6) Motherhood and Personal Goals, which were designed to capture systematic information specific to low-income parenting women, including information about their financial situation and their current sources of stress. The needs assessment consisted of both open- and close-ended questions, allowing for both qualitative and quantitative data analysis to occur.
Women were recruited for this needs assessment by community mental health ambassadors (CMHAs) who were women who lived in the local community and were chosen for their familiarity with local neighborhoods. CMHAs underwent extensive mental health and community training. For information on training procedures, please see (Smith and Kruse-Austin
2015). CMHAs initiated recruitment activities in settings typically frequented by parenting or pregnant women. Additionally, systematic recruitment activities took place in a number of community locations, including schools, stores, and parks, in an effort to recruit individuals evenly in neighborhoods throughout the community. CMHAs used standardized language for recruitment activities.
Participants were eligible to participate in the study if they met the following criteria: (1) were female, (2) lived in the urban city where the study took place, (3) were at least 18 years old, (4) were pregnant, parenting or served as the primary caregiver for a child who was under the age of 18, (5) were able to provide written informed consent, and (6) spoke Spanish, English or Farsi.
Upon establishing eligibility, needs assessments were administered by a trained CMHA who had undergone at least 2.5 days of training and had conducted both practice and supervised surveys. All women completed the assessment in person, and when needed, research staff members were available to read questions or to help with their interpretation of questions.
Ethics
Approval for this study was obtained from the Yale University Institutional Review Board (IRB) and from the IRBs of organizations involved with the MOMS Partnership. CMHAs obtained written informed consent from all study participants and participants were given the right to skip questions within the needs assessment. Women were compensated for their time with a $10 gift card.
Additionally, the authors of this manuscript hold no conflicts of interest related to this research and are responsible for all content in this manuscript.
Data Analysis
Quantitative Data Analysis
Data were restricted to those women who had completed the survey between January of 2013 and the beginning of June of 2015 to ensure consistency of measures across survey versions. Univariate analyses were conducted on variables related to the demographic characteristics, clinical characteristics, and basic needs of parenting women. Several questions related to basic needs were specific to diaper use. As diaper use is not applicable to older children, a subset of data were taken for basic needs questions related to diaper use with parents that had children under 4 years of age. SAS 9.4 was utilized for all statistical analyses.
Qualitative Data Analysis
Qualitative data analysis centered on the question, “What are the current stressors in your life?” All answers to this question were compiled (n = 436), and a coder trained in qualitative coding methodology independently coded these responses using principles of thematic analysis (Braun and Clarke
2006). Specifically, inductive analysis was utilized for its more data-driven nature (Braun and Clarke
2006). First, the researcher read and re-read all responses to become familiar with the data (Braun and Clarke
2006). Responses were then coded into broad themes and thematic maps were created to visualize and make connections between themes (Braun and Clarke
2006). As coding progressed, responses were categorized into sub-themes, with all themes and sub-themes given a corresponding definition to ensure consistency in coding. Upon completion of initial coding, this researcher entered all data into ATLAS.ti, and a second researcher, also trained in qualitative coding, was given a subset of 20% of responses to code. Researchers compared their codes on these responses and had an initial agreement of 76.7%, with Cohen’s Kappa calculated to be 0.73, indicating good inter-coder reliability (Altman
1991). Upon completion of inter-coder reliability measures, remaining discrepancies were discussed and codes were revised as necessary until consensus was reached. Lastly, key words used by parenting women within each theme were identified by the primary coder. A search function assisted in the calculation of the frequencies of key words.
Discussion
Overview
This research provides a base for understanding poverty specific to low-income parenting women in several ways. We were able to quantitatively operationalize poverty specific to a sample of low-income mothers, examine how mothers describe sources of stress related to poverty, and explore how the experience of poverty affects women’s parenting practices.
Operationalizing the Experience of Poverty Among Parenting Women
First, we found that parenting women described the supports that were critical to helping them meet their basic needs. Among urban, African American and Hispanic mothers living in high poverty, we found that the most critical supports women described were SNAP (food stamps), WIC, and TANF.
Additionally, in spite of the fact that such a high percentage of our women received benefits such as SNAP and TANF, many women still experienced difficulty obtaining basic needs related to parenting, such as food, diapers, and clothing. Difficultly obtaining basic needs is a risk factor for chronic mental health challenges for both mother and child. For example, food insecurity has been associated with an increased likelihood of mental health conditions among mothers, with those described as being food insecure having a prevalence of generalized anxiety disorder or a major depressive episode 13.4% higher than those described as fully food secure (Whitaker et al.
2006). Furthermore, women who report the need for mental health services are more likely to report the need for diapers (Smith et al.
2013). Difficulty meeting basic needs has also been associated with a number of adverse child outcomes. For example food insecurity is related to increased externalizing and internalizing symptoms in children (Slopen et al.
2010).
The difficulty that low-income parenting women face obtaining basic needs and the frequency with which low-income parenting women are also connected to healthcare providers through pediatric well child visits, prenatal and postpartum care, and through schools or early childcare settings, presents a potential opportunity for healthcare providers, educators and child caregivers to screen for unmet basic needs and to ensure institutions (healthcare, education and early childhood care) are connected to community agencies providing basic needs supports. For example, these screenings could occur in the context of Head Start programs, which could be doubly beneficial, given that these programs are associated with an increase in educational attainment for some parents (Sabol and Chase-Lansdale
2015). We suggest an additional method whereby this might occur.
A Basic Needs-Informed Curriculum, has been developed by the National Diaper Bank Network and the MOMS Partnership to train professionals on the importance of addressing basic needs for families (Goldblum and Smith
2015). One aim of this program is that healthcare and social service professionals will have the capacity to have conversations with low-income individuals about basic needs and form connections with community agencies to partner around increasing a family’s ability to meet their basic needs (Goldblum and Smith
2015). Healthcare providers, early childcare workers and social service employees could all benefit from the basic needs curriculum. Over 330 individuals have been trained to date on this curriculum (Smith et al.). Early results suggest this curriculum is effective in helping individuals understand basic needs, including how they can affect families and stress levels, and in helping individuals understand the way they or their organization can support individuals experiencing difficulty obtaining basic needs (Smith et al.).
Terminology Frequently Used by Parenting Women in Relation to Poverty
Second, we describe how mothers talk about issues of poverty and basic needs using the terms they use as compared to terms that may be frequently used by social service and healthcare providers. We found mothers frequently talked about “bills,” “money,” “jobs,” “work,” “housing” and “transportation,” rather than talking about “poverty,” “at risk” or “low-income,” words commonly used by researchers and practitioners. Given the importance of these terms in describing stress, it is critical that healthcare providers incorporate these terms into clinical assessments with low-income, parenting women. Matching clinical language with terms that patients and clients utilize themselves has been found to improve patient satisfaction (Williams and Ogden
2004), which could increase the likelihood that individuals will continue with treatment and follow medical advice. It is especially important that the terminology and experiences of low-income women are incorporated into training curriculums for healthcare providers, as recent research has demonstrated that medical residents have limited knowledge of underserved populations, as well as limited confidence in their knowledge (Wieland et al.
2010). Further, fewer than 15% of students at one medical school had knowledge of programs for low-income individuals, such as WIC (Doran et al.
2008).
Qualitative Investigation of the Role of Poverty in Parenting Practices
Third, women described how poverty directly negatively impacted their ability to provide the quality of parenting they wanted to achieve, primarily through restricting the amount of time they could spend with their children and in limiting their ability to provide experiences to their children. This finding is in keeping with past literature which has shown that parental monitoring may be eroded in the contexts of high poverty (Costello et al.
2003). Further, research has shown that social capital is critical for child development and outcomes (De Silva et al.
2005; Furstenberg Jr and Hughes
1995; Parcel and Menaghan
1993). However, this might be restricted among low-income parenting women and families, unless these individuals are tied to community institutions that can serve as resource brokers, defined as “organizations that have ties to businesses, nonprofits, and government agencies rich in resources and that provide their patrons with access to these resources” (Small
2006). The MOMS Partnership currently serves as a resource broker for low-income, parenting women.
Limitations
Several limitations must be considered when interpreting the results of this study. First, study participants were selected from a single, urban city. Thus, results may not be generalizable to all parenting women living in poverty, such as those living in rural areas. For example, while the terms identified in our study provide a start for providers who serve low-income, parenting women in an urban setting, they are likely not generalizable given our sample. Second, all survey information was obtained via self-report, and thus we are not able to ascertain if women completely comprehended all of the questions. While we attempted to minimize this concern by allowing women to skip questions, this resulted in a higher percentage of missing data for certain questions, although we did not observe systematic patterns of missing responses.
Future Research
Future research should further expand on the operationalization of poverty amongst parenting women. Specifically, research is needed in diverse regions of the United States, such as rural settings, and in partnership with low-income parents themselves to increase effectiveness of research design and community benefit that accounts for the context of poverty and the mechanisms by which material hardship specifically impacts parenting outcomes. Additionally, further qualitative research is necessary to examine how parenting practices are affected by the experiences of poverty among racial and ethnic subgroups, as this research has high potential for tailoring interventions. Lastly, the development of curriculums for healthcare providers using language frequently used by low-income women should be considered and efficacy of such a curriculum should be established.