- AAP —
- American Academy of Pediatrics
- SDH —
- social determinants of health
The adverse effects of poverty on health have been well documented. In response, pediatric clinicians have become increasingly focused on mitigating these effects on children’s health.1 In March 2016, the American Academy of Pediatrics (AAP) released the first-ever policy statement on poverty, calling for pediatricians to screen and address poverty and related social determinants of health (SDH).1 Recent research has developed an evidence base for strategies to address SDH in urban practices.2,3 Notably, poverty has grown by 66% in suburban communities over the past decade, double the rate in cities.4 However, comparatively little information is available for pediatricians on how to address poverty in the suburbs, where almost half of US pediatricians practice and where differences in infrastructure and resources may limit the generalizability of strategies successfully implemented in urban practices.5 This Perspective addresses barriers to and opportunities for pediatricians to better support suburban poor families.
Rise in Suburban Poverty
Forty-six million Americans, including 16 million children, live below the federal poverty level, or $24 230 for a family of 4. In the past decade, the suburbs have seen a larger increase in poverty than urban and rural areas.1 From 2000 to 2013, two-thirds of the increase in poverty in major metropolitan areas occurred in the suburbs (Fig. 1). The number of near-poor individuals (100% to 200% of the federal poverty level) also increased. Currently, more than half of poor and near-poor metropolitan area residents, 56% and 63%, respectively, live in the suburbs.4
The rise in suburban poverty began in the 1990s, but increased in the 2000s due to 3 main factors: population, housing, and labor market changes.4,6 From 2000 to 2013, the suburban population grew 3 times as fast as the urban population, in part from new immigrants moving directly to the suburbs in search of affordable housing and jobs. As a result, suburbs have become more demographically, culturally, and economically diverse.4,6,7
Regarding housing, rising home prices and gentrification in cities led many families to find more affordable housing in the suburbs.6 From 2004 to 2008, 73% of subprime loans in metropolitan areas were made in the suburbs. Following the 2008 subprime mortgage crisis and housing market collapse, the suburbs had nearly 75% of the foreclosures.4
Finally, labor market changes accompanied these shifts. During the 2000s, jobs moved outward from cities, and 43% of metropolitan area jobs were located more than 10 miles outside of downtown by 2010.4 Many of these jobs were in retail, manufacturing, and construction. These sectors were hardest hit by the Great Recession, resulting in substantial job losses for many suburban communities.6 Although new suburban jobs have been created as the economy has improved, many pay $20 000 or less annually, a salary too low to lift families from poverty.4
Unique Challenges Confronting the Suburban Poor
Low-income suburbanites confront challenges distinct to this setting. The first is the lack of access to safety net services. Food pantries and other resources are often less available in this setting,6,7 and as noted previously many suburbanites are newly poor or new immigrants and unaware of what services are available.4
Second is the relative lack of public transportation. Poor public transportation limits individuals’ access to safety net services and employment opportunities. Even if public transportation is available in low-income suburbs, only 25% of jobs are within a 90-minute public transit commute and 4% within a 45-minute commute.4
Third is the gap in public and private funding. The perception that poverty is only an issue for cities or rural areas has led to a lag in services in many suburban neighborhoods.4 Most programs (eg, food pantries) are located in inner cities, and these programs often receive available funding.6,7 Many suburban communities have not developed the infrastructure to address the local rise in poverty.
Implications for Pediatricians
The AAP recommends that pediatricians identify families in need, connect families to resources, and coordinate with community partners.1 Doing so in suburban practices may require approaches that differ from urban practices.
Screening Acceptability and Approach
In urban settings, parents have been accepting of SDH screening, and studies have evaluated the effectiveness of screening by using in-person, written, and electronic assessments.2,3 However, there have been no studies in suburban settings evaluating which screening strategies (in-person or electronic) are most effective in identifying SDH and acceptable to parents. Also, as many suburban communities have a limited number of resources, providers may not be aware of them or comfortable discussing unmet social needs in this setting. In addition, suburban practices, as do some urban practices, generally lack social workers or volunteers who could assist in screening or identifying resources. Research is needed to determine which screening strategies are most efficient and acceptable for families and providers.
Effectiveness of Referrals
Addressing SDH in urban clinics has been shown to improve the food assistance, housing, and job training families receive,2,3 but more work is needed to determine how referrals can most effectively and efficiently address SDH in suburban settings. First, research is needed to determine what resources (eg, food or childcare assistance) suburban families most need. With the increase in near-poor residents, many families may not qualify for benefits (eg, the Supplemental Nutrition Assistance Program), and best practices for addressing the unmet needs of families who do not qualify for benefits remains unclear. Second, further work is needed to determine how suburban practices should connect families to resources. Providing lists of local resources (eg, food pantries) is an effective strategy for urban practices,2 but may not effectively address families’ needs if there are not enough local resources available or the resources available are not accessible by public transportation. Testing whether practices can connect families to services that deliver food (eg, the Feeding America Mobile Food Pantry Program) may be important. Increasingly powerful geographic information systems also could be used to determine where resources exist, the transportation routes to connect families to them, and where new resources are needed.
Steps Practices Can Take
Although future research is needed to determine the most effective screening and referral methods to address families’ needs in suburban practices, there are steps that pediatricians could take now to mitigate the effects of suburban poverty on child health. First, pediatricians could take steps to promote literacy, through formal or informal Reach Out and Read programs, to help mitigate the effects of poverty on child development. Second, posting information on resources within offices and developing signage encouraging families to discuss unmet social needs would signal to families that the office is willing to address these problems. Finally, if clinicians began to identify the specific unmet needs of families, they would have first-hand knowledge of how these issues affect families and where gaps in services exist. With this knowledge, practices could advocate locally, for example by partnering with local law practices, or at the state and national levels, including in partnership with the AAP.
Although almost half of pediatricians practice in suburban settings, many clinicians are unaware that poverty has grown substantially in suburban communities. Implementation of the AAP recommendations is an important step in addressing suburban poverty, yet questions remain regarding how to most effectively and efficiently address suburban families’ needs. As research and program development efforts continue to define ideal strategies for addressing suburban poverty, pediatricians can take steps now to improve resources and outcomes in this setting.
- Accepted September 1, 2016.
- Address correspondence to Deepak Palakshappa, Department of Pediatrics, The Children’s Hospital of Philadelphia, 34th St and Civic Center Blvd, CHOP North-1455, Philadelphia, PA 19104. E-mail:
FINANCIAL DISCLOSURE: The authors have indicated they have no financial relationships relevant to this article to disclose.
FUNDING: This project was supported by the Edmond F. Notebaert Endowed Chair in Pediatric Research.
POTENTIAL CONFLICT OF INTEREST: The authors have indicated they have no potential conflicts of interest to disclose.
- Council on Community Pediatrics
- Kneebone E,
- Berube A
- Murphy AK,
- Allard SW
- Felland LE,
- Lauer JR,
- Cunningham PJ
- Copyright © 2016 by the American Academy of Pediatrics