Public Health Nursing Vol. 9 No. 2, pp. 74-80 0737- 1209/92/$6.00 0 1992 Blackwell Scientific Publications, Inc.

The Concept of Poverty Patricia Carney, R.N., M.S.

Abstract Although poverty is one of the most familiar and enduring conditions known to humanity, it is an extremely complicated concept to understand. Some researchers view it as a reaction to the stress of being poor, whereas others perceive it as a process of adapting to the condition of poverty. Historical definitions are numerous, but can be classified as relating to either lack of financial income or lower social status. Numerous factors contribute to the concept of poverty, including political, economic, social, and cultural forces. The one that has consistently had the greatest effect on the evolving concept is the passage of time, which encompasses all these forces in a very intricate manner. This author explored the evolution of the concept of poverty to identify relevant themes for consideration in the public health nursing domain.

HISTORICAL ASPECTS OF POVERTY

Every nation has endured poverty in some segment of its population. The meaning of poverty differs greatly by culture, however. For example, in India and Japan the poor are greatly respected because of the political and religious systems that give meaning to their lives (Finney, 1969). Anglo cultures, however, have tended to view most aspects of poverty in a very negative light (Youings, 1984), and American culture has been influenced most by that attitude (Ferman, Kornbluh, & Haber, 1965). For this reason, this historical discussion focuses primarily on poverty in England and the United States. The word poverty is derived from the Old French word pov’rte and was incorporated into the English lanEven with more than 20 million Americans currently guage in 1175 A.D. The human condition of being poor living at or below the federally defined poverty level, can be traced to biblical times: “The rich man’s wealth the meaning of poverty is extremely difficult to delin- is his strong city, the ruination of the lowly is their poveate due to the social, political, economic, and espe- erty” (Proverbs 10: 15). Most historical definitions can cially cultural forces that influence the concept over be categorized as either sociocultural or economic (Ostime. A common problem frequently associated with ter, Lake, & Oksman, 1978). This is further exemplified poverty, regardless of definition, is compromised phys- by the Oxford English Dictionary’s primary definitions, ical or psychosocial health in the impoverished individ- which are the condition of having little or no wealth or ual. Lack of resources and options for coping lead to material possession, and the poor collectively or as a poor nutritional and other health habits that become ex- class. tremely difficult to change. An examination of English and American history ilNursing has been concerned with caring for the poor lustrates many political attempts to eradicate or control through its history. Issues affecting people in poverty poverty in society. As Figure 1 illustrates, cycles of poare no less complex today than they have ever been. litical consciousness regarding the plight of the poor This author examined the historical aspects and the have occurred consistently over time. Regardless of contemporary concept of poverty both in and outside how well-meaning and diligent the efforts may have the domain of nursing. The goal of this analysis was to been, attempts to control the poor or alleviate their achieve a more definitive understanding of both the con- plight often led to oppression and deprivation. This cept of poverty and implications for practice and cycle of political consciousness followed by attempts to research. eliminate poverty actually reinforced the condition over time. The first attempt to examine poverty outside the poPatricia Carney, R . N . , M . S . ; is a doctoral student, University litical realm was made by Sir Frederic Eden in 1797. of Washington, School of Nursing, Seattle, Washington. Eden examined the wages of laborers, the cost of food, Address corresDondence to Patricia Carney, R . N . , Universiiy . of . Washington, School of Nursing, SC-72, Sentile, WA 98117. and the conditions in British workhouses, but he was 74

Carney: The Concept of Poverty

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England

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924 Athelstane enacted, Englands first “Poor Law” decreeing that poor laborers must belong to a mannor ~~

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1700 Begging outlawed, Church reopens hospitals and organizes financial structure based on provate donations, which is still in place today.

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1392 Modern “Pmr Laws enacted giving responsibility

1380 Emancipation of Laborers

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1484 Creation of first

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1600 Church looses financial power almshouses and hospitals close

Roosevelt legislates “New Deal efforts, which improve minimum buying power of every family; Social Security also enacted

1980’s Reagan cuts

Figure 1. Historical attempts to eradicate or control poverty.

reluctant to define or estimate the extent of poverty at determination on the average income and spending of the time. It was not until the late 1800s that any major 30 London families. Later, he expanded his survey contribution to the definition was made, and it came throughout London and estimated that approximately from Liverpool businessman Charles Booth. Booth 18.2% fell into the “poor” category and 12.5 % were stratified people as the “poor” and the “very poor,” very poor (Webb, 1926). This represented 30.7% of the defined respectively as “those who have a sufficiently population in the city at the time. Seebohm Rowntree, an English Quaker, was greatly regular though bare income, such as 18 to 21 shillings per week” and “those whose means are insufficient . . . influenced by Booth’s work. Rowntree surveyed the according to the usual standard of life in this country” working class (those without servants), noting their (Fred & Elman, 1969, p. 44). Booth based his economic income, rent, housing conditions, and characteristics

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of the occupants. Through this work, he made a distinction between what he called primary and secondary poverty:

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Primary-“Families whose total earnings are insufficient to obtain the minimum necessaries for the maintenance of merely physical efficiency.” Secondary-“Families whose total earnings would be sufficient for the maintenance of merely physical efficiency were it not that some portion of them is absorbed by other expenditures, either useful or wasteful” (Holman, 1978, p. 5).

Rowntree subsequently saw the need to delineate the meaning of “physical efficiency.” To accomplish this he enlisted the help of nutritionists to estimate the intake required for prison inmates to work efficiently. They determined that 3500 calories would allow a man to produce “moderate work” (Rowntree, 1902). Rowntree then calculated how much food would be required to provide this caloric intake, and determined its cost based on the cheapest prices available. He also allowed for shelter, clothing, and fuel. His figures reflected that a significant percentage of the English population was poor: 15.46% of the working class and 9.19% of the whole population (Rowntree, 1902). Both Booth’s and Rowntree’s work had a significant impact in raising the consciousness of others about the extent of the problem. Their concept was later defined as subsistence or absolute poverty, which was considered to have three elements: a focus on physical efficiency rather than enjoyment of life or intellectual development, stringency in calculations with the mode of life this implied, and a view of poverty that was unrelated to the income of society as a whole (Holman, 1978). This concept (absolute or subsistence poverty) was disputed in the early 1900s as being too rigid (Townsend, 1973). Townsend felt that Booth and Rowntree used many arbitrary judgments to decide what particular items the impoverished would or would not have, such as haircuts, contraceptives, newspapers, and laundry services. It was noted during this time (1950s) that many more psychologic, social, and cultural factors were involved in determining individual and family needs than just those that had been considered physical. This recognition altered the methods used to examine poverty. In England thereafter, populations were studied based on their own individual spending habits, rather than the values imposed on them by others. Inadequacies of the subsistence concept of poverty contributed to the formulation of relative poverty. The term was first coined by Lafitte (1970), who defined poverty in the early 1900s as “a level of income suffi-

ciently low to be generally regarded as creating hardship, in terms of the community’s prevailing living standards, and so requiring remedial action on the part of public social policy.” This definition was thought to be capable of encompassing the majority of any given community at the time. To explain this rather disturbing point, the Social Science Research Council (SSRC) emphasized in its definition the existence of a distance between minority and average standards of a society in any given time: “It is the continually moving average standards of that community that are the starting points for an assessment of its poverty, and the poor are those who fall sufficiently far below these average standards” (Holman, 1978, p. 14). These definitions led the SSRC to identify four elements of the relative concept of poverty, which are a comparison between persons, concern with contemporary standards in a social environment, recognition of inequity in society, and dependence on value judgments regarding what is right or wrong (Holman, 1978). Therefore, the relative concept encompassed the influence of the environment and changing social standards. In the United States the association between relative poverty and inequality had significant political implications. One involved the belief that general improvement in the standard of living does not mean that a reduction in the poverty level will follow (Holman, 1978). The political discomfort related to this obvious societal gap caused many legislative bodies to be more influenced by the subsistence concept in appropriating funds and developing programs to assist the poor, which led to the development of the official “poverty level.” The use of income to identify the impoverished has caused great dissatisfaction with many sociologists, anthropologists, and public health officials, primarily because of the oppressive lifestyle it implies. Abel-Smith and Townsend redefined the concept in the late 1960s as “a variety of conditions involving differences in home and environment, material possessions and educational and occupational resources as well as financial resources” (Holman, 1978, p. 32). This definition led to the identification of many social deprivations in the poor, which also indicated that the solution to poverty would have to include much more than financial adjustment. This historical background provides some insight regarding the evolution of the concept of poverty in the United States. The interrelationships between the passage of time, different societal forces, and social strata can be seen in Figure 2. As illustrated, time both influences and is influenced by political, economic, social, and cultural forces. These forces influence each other, while they mediate and are mediated by the dominant strata in society (middle-, upper middle-income levels). The societal forces and the dominant strata influence

Carney: The Concept of Poverty

PPssingTime

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TABLE 1 . Summary of Culture of Poverty Behavioral Traits Classification of Traits

Social The Non-dominant strata in society (people in poverty)

Figure 2. Societal interrelationships influencing poverty.

the nondominant stratum (people in or near poverty). But as the arrows indicate, the nondominant stratum has no mediating influence on these interrelationships. CONTEMPORARY CONCEPTS OF POVERTY

The three current primary concepts of poverty are anthropologic or sociologic in origin: cultural, situational or structural, and adaptational (Holman, 1978; Valentine, 1968). These viewpoints are generally not considered to be theoretical frameworks due to their loose structure. In addition, they have not been intensively studied scientifically; rather they represent sets of observations about people living in poverty. The cultural concept was developed by anthropologist Oscar Lewis in 1959 when he identified the “culture of poverty.” He claimed that the poor were so alienated from the rest of society that they had developed and passed on to their children coping mechanisms so intensive as to constitute a culture within a culture (Lewis, 1966). Poverty, does not breed resentment, rather resignation to it enables people to live in it (Lewis, 1966). Therefore, Lewis viewed the culture of poverty as being primarily an adaptive process. He identified 62 specific behavioral traits, which can be summarized and categorized as economic, social, and psychologic (Table 1). Several social preconditions must exist for the culture of poverty to develop. These include a capitalistic society with a class structure in which the dominant class is upwardly mobile, significant unemployment or underemployment is present, and an association exists between low income and individual or class inferiority or inadequacy (Lewis, 1966). With the presence of these conditions, the culture of poverty would develop in approximately 20% of any population (Lewis, 1966).

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Psychologic

Other

Summary Description Unemployment and underemployment, low wages and unskilled occupations, absence of savings; chronic shortness of cash, pawning a n d o r borrowing at inflated interest rates, use of second-hand clothing and furniture, frequent daily food purchases in small amounts Crowded quarters with lack of privacy, free unions, with early initiation into sex, abandonment of women and children, maternal-centered families, political apathy and cynicism about government, low level of education and literacy, marginal relationships to organizations of the larger society, critical attitude toward beliefs and values of dominant social class High frequency of alcoholism, violence toward women and children, strong feelings of marginality, helplessness, dependency, inferiority, and fatalism; high tolerance for psychologic pathology Strong present-time orientation with little ability to deter gratification, attempts to use and integrate into a workable way of life the remnants of beliefs and customs of diverse origins

From Lewis (1969). Adapted with permission of the University of Kentucky Press and Mrs. Ruth M. Lewis, University of Illinois.

Lewis and others argued that a change in the condition of poverty would require an alteration in the cultural adaptive process outlined here. The situational or structural concept was originally developed by Karl Marx and Max Weber in the late 1800s (Waxman, 1983). This theory is based on a stratified society where the poor’s position at the bottom is maintained by the upper strata. Social, economic, and political inequities exist among the classes, with the pathology of the poor being due to the structure of the system rather than the subculture of the people. This perspective represents a reactive rather than adaptive process to social, economic, and political factors. Thus the values and behaviors of the impoverished are generated from external rather than internal influences. From this perspective, to alleviate poverty would require a change in the restrictive social culture (Waxman, 1983). The adaptational perspective is a combination of the cultural and situational. This integrated view was pro-

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posed in 1963 by Rodman. He acknowledged the social strata issues as being oppressive to the poor, but felt that some behaviors develop internally as adaptive responses to the condition of poverty. Rodman disagreed with Lewis’s view that the poor do not share the values of the larger society. Rather, he postulated that impoverished people indeed share these values generally but are unable to achieve their ambitions because of their low social status. The adaptational component involves what Rodman called the concept of “value stretch.” That is, the poor stretch or revise their middle-class value system in order to adapt to the barriers they experience in attempting to reach their goals (Rodman, 1963). This stretch notion prevents the poor from feeling continually frustrated in their attempts to live up to unattainable values. It should be noted that each of these views was developed using observational techniques. It is the presence or absence of the behaviors of people in poverty, together with applications of social theory, that led to the identification of these perspectives. The use of these techniques does not eliminate bias on the part of the observer, and therefore the concepts may not represent a completely valid view of poverty. Obtaining the perspective of impoverished people in theory development could provide extremely important information on the condition of poverty.

amined and measured, poverty itself has received limited attention. Pesznecker (1984) examined the literature and developed an interactive adaptational model of poverty that is based primarily on Rodman’s adaptational view (Fig. 3). Pesznecker identified some specific stressors that impoverished people experience in their day-to-day lives, and postulated that one develops health-promoting or health damaging-behaviors in response to these stressors. She theorized that poor people’s behavior responses are shaped by the interactions between individual or group factors and the environment, which are further mediated by public policy and social support. The stressors that she saw as affecting disadvantaged people were futility regarding employment opportunities, unsafe or inadequate housing, repeated exposure to crime or violence, and insensitive attitudes of social service and health agencies. The ability of the poor to cope also is a struggle due to the erratic and constant accumulation of stressors (Pesznecker, 1984). Pesznecker’s model was developed based on a synthesis of the adaptation perspective of poverty and the stress and coping literature. As discussed earlier, the adaptational viewpoint, as with the others, is based on the observation of behaviors, rather than an incorporation of poor people’s and observers’ combined perspectives. In addition, this model has been tested only to a

NURSING’S CONCEPT OF POVERTY An accepted association exists between the condition of Environmental Factors IndividuaUGroupFactors Early childhoodexperiences poverty and the physical and psychosocial health of the High life change Enduring life conditions Unique coping problems poor (Kosa, Antonovsky, & Zola, 1969). Put simply, the Multiple concurrent pmblcms Limited opportunity for mastery Individual poor are more likely to die at an earlier age and more Poor coping outcomes Institutional likely to endure acute or chronic illnesses than people with higher incomes. This phenomenon has been linked to the health-related behaviors of the poor and their lack of access to comprehensive health care in our society Mediating Factors (Aday, 1975). Public Policy Florence Nightingale (1894) claimed it was the nurse’s responsibility to educate the poor about the importance of sanitation and disease prevention. She was involved in developing legislation that improved England’s Poor Laws (1864) regarding the responsibility for the health of the poor. After these changes were made, she proposed the use of “district nursing” in London, and public health nursing was born. Throughout its history, nursing has been involved in the health care of the poor. Depression Sense of well-being Nurse researchers have studied many concepts related Anxiety Law self-esteem to poverty, such as hopelessness (Campbell, 1987), Low motivation High self-esteem Low p e i v e d self-efficacy powerlessness (Dykema, 1985), homelessness (Berne et al., 1990), self-neglect (Reed & Leonard, 1989), and bar- Figure 3. Adaptional model of poverty. Adapted by permisriers to health-related behavior (Tripp-Reimer, 1992). sion of Blackwell Scientific Publications from Pesznecker, Thus, whereas many related concepts have been ex- B. L. (1984, December).

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Carney: The Concept of Poverty 79

limited extent. There is no doubt that an understanding sive conditions of poverty. Until effective interventions of poverty is critical in examining issues affecting dis- can be identified, specific recommendations for public advantaged populations. health nurses are equivocal. Nursing is, however, in an excellent position, based on a long interactive history with disadvantaged people, t o work together with the CONCLUSION poor to bring about an understanding of the factors that Today, an estimated 21.4 million Americans are living at affect their adaptive behavior. Only when we underor below the poverty level, which is currently defined stand, respect, and assist in voicing the beliefs of imby the federal government as a gross annual income of poverished people can we intervene in a productive and $12,000 for a family of four (Flynt, 1988). Many more comprehensive manner. people are very close to this income level. The stressors the poor and near poor encounter every day are signifREFERENCES icant and contribute to altered physical and psychosoAday, L. A. (1975, June). Economic and non-economic barcia1 health. In practice, the focus should be on avoiding riers to the use of needed medical services. Medical Care, stigmatization of the poor, understanding the societal 8, 447-456. forces that influence their behavior, and acknowledging Berne, A. S., Dato, C., Mason, D. J., & Rafferty, M. (1990, these behaviors as coping strategies that contribute to Spring). A nursing model for addressing the health needs their survival. of homeless families. Image: Journal of Nursing ScholarPoverty is a continuously evolving and extremely ship, 22, 8-13. complex concept with intricate interactions occurring Campbell, L. (1987, February). Hopelessness: A concept analysis. Journal of Psychosocial Nursing, 23, 18-22. among social, cultural, political, and economic forces. Dykema, L. L. (1985, September). Gaventa’s theory of power The oppressive forces that have led to extreme depriand powerlessness: An application to nursing. Occupavation have been present for centuries and have tional Health Nursing, 33, 443-446. contributed to inconsistent and ineffective means of soEden, F. (1797). The state of the poor. Reprinted in 1928, A. cietal support. The chances of eliminating poverty comRoger (Ed.). London: Cross. pletely are highly unlikely, but a more comprehensive Ferman, L. A., Kornbluh, J.H., & Haber, A. (Eds.). (1965). understanding of the condition may be possible. Poverty in America. Ann Arbor: University of Michigan The author’s view, based on this broad literature rePress. view, is that an understanding of poverty can only come Finney, J. C. (Ed.). (1969). Culture change, mental health, from the disadvantaged population itself. Qualitative and poverty. Lexington: University of Kentucky Press. approaches that incorporate the perspectives on the in- Fred, A., & Elman, R. (Eds.). (1969). Charles Booth’s London. London: Hutchinson. formant, such as grounded theory, phenomenology, and Flynt, J. W. (1988). The culture of poverty in white Ameriethnography, would provide significant information on cans. American Cancer Society publication 2010. Atlanta: the poor’s view of the political, economic, social, and American Cancer Society. cultural forces that influence their behavior. The followHolman, R. (1978). Poverty: Explanations of social deprivaing are possible research questions. tion. London: Martin Robertson. Kosa, J., Antonovsky, A., & Zola, I. K. (Eds.). (1969). PovWhat public policy directions would most likely aid erty and health: A social analysis. Cambridge: Harvard the poor in overcoming the oppressive conditions in University Press. which they live? Lafitte, F. (1970). Income deprivation. In R. Holman (Ed.), What affect does extended unemployment have on Socially deprived families in Britain (pp. 7-50). London: Bedford Square Press. health? What social support networks influence the health- Lewis, 0. (1966, October). The culture of poverty. Scientific American, 215, 19-25. related behavior of the poor? Lewis, 0. (1969). A Puerto Rican boy. In J. C. Finney (Ed.), What cultural beliefs affect healthy lifestyle choices? Culture change, mental health, and poverty. Lexington: University of Kentucky Press. Some of these questions encompass the mediating Nightingale, F. (1894). Health teaching in towns and villages, factors (public policy and social support) identified by rural hygiene. London: Spottiswoode. Pesznecker in her adaptational model of poverty, and Oster, S. M., Lake, E. E., & Oksman, C. G . (1978). The defresearch in this area will test the construct of this inition and measurement of poverty: A review. Boulder, model. It is the view of this author that many intervenCo: Westview Press. tions, based on individual and community needs, will be Pesznecker, B. L. (1984, December). The poor: A population at risk. Public Health Nursing, 1 , 237-249. required to enhance adaptive responses to the oppres-

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Reed, P. G., & Leonard, V. E. (1989, October). An analysis of the concept of self-neglect. Advances in Nursing Science, 12, 39-53. Rodman, H. (1963, December). The lower class value stretch. Social Forces, 42, 205-215. Rowntree, B. S. (1902). Poverty: A study of town life. London: Macmillan. Townsend, P. (1973). The social minority (p. 25). London: Allen Lane. Tripp-Reimer, T. (1982, April). Barriers to health care: Variations in interpretation of Appalachian client behavior by

Appalachian and non-Appalachian health professionals. Western Journal of Nursing Research, 4 , 179-191. Valentine, C. A. (1968). Culture and poverty. Chicago: University of Chicago Press. Waxman, C. I. (1983). The stigma of poverty (2nd ed.). New York: Pergamon Press. Webb, B. (1926). My apprenticeship (pp. 103-166). London: Longmans. Youings, J . (1984). Sixteenth-century England. London: Penguin Books.