Social Determinants of Kidney Health: Focus on Poverty.

Abstract

Introduction Poverty is arguably one of the most significant social conditions of the 21st century. For the first time in over 20 years, global extreme poverty is expected to increase in the year 2020. Fueled by the coronavirus disease 2019 pandemic, preliminary estimates for 2020 project that an additional 88 million to 115 million people worldwide will be pushed into extreme poverty, bringing the total to above 700 million people (1). Poverty is one of the largest domains of the social determinants of health (SDoH) and undergirds the confluence of adverse social disadvantage. The SDoH include a range of factors apart from medical care that can be influenced by social policies that can significantly shape health and health outcomes (e.g., health insurance and access to care, low educational attainment, housing insecurity, and unemployment). The effect of historical and persistent inequities is reflected in the marked social gradient in the incidence of chronic diseases, such as CKD, CKD risk factors (e.g., hypertension, diabetes, obesity, and cardiovascular disease), and CKD outcomes (2). These inequities have been further highlighted by coronavirus disease 2019 and the disproportionately high rates of infection, hospitalization, and mortality in communities burdened by the direct and indirect effect of adverse SDoH (3). The purpose of this commentary is to highlight the significant influence of poverty on the prevention, progression, and treatment of CKD and to encourage the nephrology community to broaden the utilization of community partners as part of building a more socially aware health care workforce to improve patient well-being. In 2019, the federal poverty level was defined as an annual household income below $25,750 for a family of four. However, poverty is more than just low income. Poverty is typically characterized in three different ways: (1) economic well-being most often linked to income; (2) capability to navigate society as a function of an individual’s education or health status; or (3) social exclusion as a result of institutional behaviors, practices, and policies (4). Thus, relevant to health, a state of poverty is characterized not only by limited access to health care, but also one’s worldview and how one navigates in society (4). Moreover, the additional chronic stress associated with navigating basic needs in a state of poverty can limit cognitive processing and the ability to perform implementation tasks (5), such as following provider recommendations. Thus, the impact of poverty on both the physical and psychologic aspects of a person can play an important role in the many dimensions associated with the development and progression of CKD (Figure 1) (4,6). Within the health care system, several federal and state initiatives have been launched to focus on social needs. Models under the Centers for Medicare & Medicaid Services Innovation, Medicaid delivery system and payment reform initiatives support patient screening and provide referrals for social needs. Directly engaging and partnering with social service agencies and community-based organizations that are long-standing trusted members of local communities may also serve as an effective channel to expand the health-related workforce to be uniquely positioned to improve CKD outcomes.