Children, Poverty and Burden of Disease: Impacts on Community Health Centers
Children, Poverty
and Burden of
Disease:
Impacts on
Community Health
Centers
Prepared by: Washington Association of Community
and Migrant Health Centers, Karie A. Nicholas, G.C.,
M.A., 2016
Children, Poverty and Burden of Disease: Impacts on Community Health Centers
Table of Contents
Introduction .................................................................................................................................................. 1
Background/Problem .................................................................................................................................... 1
Population Distribution .............................................................................................................................. 1
Income Distribution ................................................................................................................................... 2
Associations between income and disease ........................................................................................... 2
Asthma ...................................................................................................................................................... 3
Demographics and Disparities, Asthma ................................................................................................ 3
Costs of Asthma ................................................................................................................................... 4
Obesity ...................................................................................................................................................... 4
Generational Risk .................................................................................................................................. 5
Immunization ............................................................................................................................................. 5
Trauma and Injury ..................................................................................................................................... 6
Unintentional Injury .............................................................................................................................. 6
Intentional Injury ................................................................................................................................... 7
Solutions .................................................................................................................................................... 7
Conclusions ............................................................................................................................................... 7
List of Figures
Figure 1 - Children and Adults as % of total Population of Washington by Race ...................................... 1
Figure 2 - Children and Adults as % of total Population of Washington by Ethnicity ................................ 2
Figure 3 - Comparisons of Children % of Patients and Populations ........................................................... 2
Figure 4 - New Current Cases of Asthma for CHC Patients Due to Population
Increase Assuming Historic Population Growth Rates ............................................................... 3
Figure 5 - Demographic Comparison of CHC Patient Populations to Overall Population by Race ............. 3
Figure 6 - Demographic Comparison of CHC Patient Populations to
Overall Population by Ethnicity .................................................................................................. 4
Children, Poverty and Burden of Disease: Impacts on Community Health Centers
INTRODUCTION
Figure 1
This report examines the most current reported data
on population and burden of disease both nationally
and in Washington State for the years 2014-2016. It
includes additional current research on specific
health issues which identify and clarify the burden of
disease for low-income populations and Community
Health Centers and their patients.
Population distribution and Income distribution
were examined to identify the proportion of risk
factors for CHCs. Four health topics were chosen:
Asthma,
Obesity,
Immunizations,
and
Trauma/Injury. Asthma and Obesity were chosen
because of high morbidity, increasing prevalence
and strong associations with poverty. Trauma and
Injury were chosen because of high morbidity and
mortality. Finally, Immunization was selected to
examine the challenges of preventative care
measures in juvenile populations for CHC’s and the
impacts on the general population.
Methodology: A review and basic statistical analysis
of major reporting entities including the CHC, WHO,
US Census and Washington State Department of
Health was completed for specific demographic
measures. A literature review using the terms
obesity, children, population, income, poverty,
historical, Washington State, US, Asthma, trauma
and injury for the years 2014-2016.
BACKGROUND/PROBLEMS
POPULATION DISTRIBUTION


AIAN
Asian
Black
Adults as a
percent of total
Children as a %
of total




NHPI
Two or
more
White
Population Distribution of children age 0-18
by ethnicity is: Hispanic 21%, other 17%.
(Kids Count Data Center, 2016).
In 2015 children ages 0-18 who lived at or
below the Federal poverty level made up
18% of the population living in Poverty in
Washington State. (Poverty Rate by Age.
Washington State, 2015. State of Health
Facts. , 2016)
The proportion of the Washington State
Population who were 0-18 in 2015 was
22.5% or 1,613,328 individuals; by
comparison children Age 0-18 make up 32%
of CHC patients. 19.83% of all children in
Washington State received care at a CHC in
2015. (United States Census Bureau
QuickFacts Washington, 2015) (HRSA, 2015)
Children age 0-18 make up 60.6% of the
Hispanic population, 22.7% of the nonHispanic White population and 35.7% of all
other demographics combined.
Washington State Population growth rate is
expected to increase by 50% from 8.21 in
2015 to 12.23 in 2016 and is due mainly to
migration from California, Oregon and
Texas, although births have also been on the
rise since 2014. (2016 Populations Trends ,
2016)
Population distribution of children age 0-18
by race is: White 57%, Black 5%, American
Indian/Alaska Native 1%, Asian 7%, two or
more races 8%, Native Hawaiian/Pacific
Islander 1%.
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Children, Poverty and Burden of Disease: Impacts on Community Health Centers
Figure 2
Adults as
a percent
of total
Children as
a % of total
Children as a
proportion of
race/ethnicity
Hispanic
Non-Hispanic white
Other
Summary
The number of children in Washington State has
risen since 2014 and will have an impact on Medicaid
expansion. The large the largest proportions and
growth rates are in minority communities and are
due to migration from other states and a slight rise
in the birth rate. Many more children than adults are
likely to come from racially and ethnically diverse
households, which is likely to have a greater
proportional impact on Community Health Centers
(CHCs).
INCOME DISTRIBUTION
 In 2015 there were 311,400 children ages 0-18
in Washington State who lived at or below the
Federal Poverty Level (FPL). (Poverty Rate by
Age. Washington State, 2015. State of Health
Facts. , 2016)
 11% of Washington’s total population lives at or
below the FPL. In contrast, 65% of Community
Health Clinic patients live at or below the FPL
and another 23.3% were between 101-200%
FPL. In other words, CHCs treat a substantially
larger proportion of poor individuals relative to
the general population. (Poverty Rate by Age.
Washington State, 2015. State of Health Facts. ,
2016) (HRSA, 2015)
 The proportion of children living in poverty as a
percent of the total population is nearly equal to
the proportion of children served by CHC’s as a
percent of the total population.
Figure 3
100%
80%
60%
40%
20%
18.0%
0%
32.2%
4.4%
4.3%
Children as a Children as a CHC patients Children in
percent of percent of age 0-18 as a poverty as a
the total CHC patients percent of % of the total
population
total
population
population
Associations between Income and Disease
Low income is associated with higher rates of many
health conditions, both infectious and chronic. Some
disease which have strong associations with poverty
are flu, asthma, poor diet, obesity, emotional or
behavioral issue, and trauma related injury and
death.
The relationship between income, income inequality
and disease is complex, cumulative and multigenerational. Some of the exposures which
influence the relationship between poverty and
disease for children are chronic stress (for both
parents and children) which can affect development
and immune functions, exposure to environmental
pollutants, poor nutrition, and exposure to physical
hazards (other than pollutants). (Van Eenwyk &
Brandt, 2013)
Summary
Poverty has strong associations with health
outcomes. A large portion of individuals and children
in poverty receive care for prevention and chronic
conditions at Community Health Centers creating a
disproportionate burden of disease for CHCs.
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Children, Poverty and Burden of Disease: Impacts on Community Health Centers
ASTHMA
Washington State should expect to see an increase
in Asthma cases due to up-swings in population
growth. Community Health Centers, in particular,
should see average increases of 92 to 114 current
asthma cases per year in children due to population
growth alone if population growth rates continued
at the same rates for the period of 2010-2015
(2.09% for under 18, 1.71% for under 5, and 6.9% for
the overall population). Since 71 percent of
Washington’s growth rate is expected to come from
migration* (2016 Populations Trends, 2016), a
conservative estimate using national rates for new
migrates projects a similar overall growth rate, but
more increases in the age 5-11 group.
*primarily from California, Oregon and Texas.
information: The percent of CHC patients under 18
is currently 32% compared to the general population
which is 22%; CHCs treat a larger proportion of
minority populations compared to the general
population (see demographic charts); poor and
minority communities often have increased risk of
social and health issues with well-established
associations to the development of Asthma, such as
work, housing quality, stress and obesity. (Racial
Disparities in Childhood Asthma, 2016)
Figure 5
Demographic Comparison of CHC
Patient Populations
to Overall Population by Race
2%
1%
8%
4%
5%
Asian
Figure 4
New Current Cases of Asthma for CHC
Patients Due to Population Increase
Assuming Historic Population Growth Rates
200
180
160
140
120
100
80
60
40
20
0
Age 0-4 Age 12- Age 5- All Age Boys
17
11
<18
<18
girls
<18
New Current Cases Assuming National Rates for
Migrants
New Current Cases Assuming Washington Rates for
Total Population
Demographics and Disparities, Asthma
However, the population growth rate for 2015 was
8.21% and is estimated to be 12.23% in 2016, which
would increase current case rates regardless of
whether they follow the current prevalence trend
for Washington State or the National Trend. (2016
Populations Trends, 2016) Due to demographic
difference between CHC patient populations and the
general population, an assumptions about an
increasing burden of Asthma for Community Health
Centers should be made based on the following
6%
Black
2%
2%
Two or more
7%
9%
56%
White
80%
AI/AN
Washington State’s
CHC Population
NH/PI
Washington State Population
A Key finding from Washington State Department of
Health’s report on the Burden of Asthma in 2013
were that “Non-Hispanic Native American (11
percent) and non-Hispanic Black (11 percent) youth
report higher asthma rates than other racial/ethnic
groups. Similar to adults, youth of Asian (6 percent)
or Hispanic (any race, 7 percent) descent report
lower asthma rates than other racial/ethnic groups,
except Pacific Islander”. (The Burden of Asthma in
Washington State, 2013)
Figure 6
Demographic Comparison of CHC Patient
Populations to Overall Population by Ethnicity
12%
35%
62%
70%
Hispanic
Non-Hispanic white
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Children, Poverty and Burden of Disease: Impacts on Community Health Centers
Cost of Asthma in Children
 “Approximately 8% of all children (0-17 years) in
Washington State have asthma (Washington
State Department of Health and the Washington
Asthma Initiative, 2005).
 A study by Davies and Hauge found that “the
‘best estimate’ of the annual costs of childhood
asthma
attributable
to
environmental
contaminants in Washington State is $48.9
million in 2004$ (comprising $34.1 million in
direct health care costs and $14.8 million in
indirect costs), with a range of $16.3 – 57.1
million.” (Davies & Hauge, 2005)
 Factors which should also be considered in
determining the cost of childhood Asthma
include increasing costs of medication, school
days missed, ER visits and associated health
issues such as depression and chronic
bronchitis.
Summary
The prevalence of Asthma in children is higher
among ethnic and racial minorities and in poorer
populations. These demographics make up a larger
portion of patients served by Community Health
Center and they are becoming an increasingly larger
portion of the total Washington State Population.
OBESITY
 Percent of children (ages 10-17) who are
overweight OR Obese in Washington State
26.2%. (Kaiser Family Foundation State
Health Facts, 2016)
 According to the CDC the prevalence of
obesity for children age 2-19 for the years
2011-2014 was about 17% and the
prevalence was higher among non-Hispanic
whites, non-Hispanic blacks and Hispanics
than among non-Hispanic Asians. (Ogden,
Carroll, Fryar, & Flegal, 2015)
 The general state population obesity rate is
26.4% for adults, 14.0% for 2-4 year olds
from low income families and 11% for 10-17
year olds in the general population.
(Washington State DOH, 2016)
 Between 2008 and 2011 obesity in children
ages 2-4 from low income families had a
statistically significant decline, from 14.4%
to 14.0%. (Robert Wood Johnson
Foundation, 2015)
Community Health Centers serve a larger portion of
Hispanic/Latinos
and
non-Hispanic
blacks
populations in Washington State, as well as lowincome non-Hispanic Whites and other low income
groups, compared to the overall state population.
(See Population Demographics) What this means for
CHC’s is that they treat a large proportion of the
population in Washington at greater risk for obesity
than private health care. Of those patients at CHC’s
in 2015, 71.30% of children and adolescents age 317 had a measurement of BMI percentile and
counseling on nutritional and physical activity
document in 2015 in an effort to mitigate obesity
into adulthood.
Generational Risk
A recent, global literature review in The Lancet
noted that “increasing evidence suggests that
exposure to maternal obesity also leads to an
increased risk of disease in off spring. Observational
studies have provided evidence for associations
between maternal obesity and an increase in their
off spring’s risk of obesity, coronary heart disease,
stroke, type 2 diabetes, and asthma”. (Godfrey,
2016) Godfrey et al. further note that these
increased risks are lifelong for the children and
have “profound public health implications”.
(Godfrey, 2016) This suggests that there could be
substantial benefit in curbing childhood obesity,
and substantial cost savings given numerous causal
associations with other chronic diseases, by
emphasizing weight loss interventions for women
of child-bearing age.
Summary and Recommendations


Because Obesity has a strong association
with many other chronic conditions
throughout and individuals lifetime, a
recommendation for more robust data
collection on obesity prevalence is
warranted.
A second recommendation is a more
focused effort to curb obesity for women
of child-bearing age because of the
generational risk of obesity and the health
issues, for both the mother and the child,
that have potential life-long consequences.
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Children, Poverty and Burden of Disease: Impacts on Community Health Centers
IMMUNIZATIONS
Even as late as 1980’s Influenza and Pneumonia still
topped the list for causes of death for children ages
5-14 in Washington State. In the 1950 some of the
top causes of death for children were Influenza,
Meningitis, Tuberculosis, Measles and Rheumatic
fever. (DOH, 2015) The World Health Organization
reports that “there has been a 99% decrease in
incidence for the nine diseases for which vaccines
have been recommended for decades, accompanied
by a similar decline in mortality and disease
sequelae.” (Andre, et al.)
The authors further assert that vaccination is a cost
effective, safe and socially beneficial investment
which reduces inequity, empowers women, protects
against bioterrorism, promotes economic growth
and promotes peace. (Andre, et al.) For more
information on the success of vaccines go to:
https://ourworldindata.org/vaccination/#reductio
n-of-cases-and-deaths-of-vaccine-preventablediseases-in-the-united-states-after-theintroduction-of-the-vaccine-max-roserref
The mean vaccination rate for CHC’s is 65.52%, 95%
CI (.5636, .7467). This indicates that CHC’s are doing
at least as well as the state average in vaccination
rates for their patients. However, CHC’s also face
substantial challenges to completing vaccination
schedules on time, including lack of transportation
for patients, incomplete medical records, and
patients who were previously uninsured.
Unvaccinated children are more likely to be male,
white, from higher income households, have a
married mother with a college education and have 3
or fewer siblings. (Omer, 2012) Since CHC
demographics vary greatly from the demographic
group described above, the barriers to full
vaccination for CHC patients are more likely to be
structural, social determinants of health rather than
medical, religious, or philosophical.
aimed at combatting social determinants of health
are likely to improve vaccination rates for CHCs.
TRAUMA AND INJURY
While the overall rate of death and death due to
unintentional injury has declined drastically for
children in Washington State, trauma and injury
remains the number one cause. Unintentional
trauma death and injury includes events such as
drowning, poisoning (including food poisoning),
motor vehicle accidents, falls, burns, choking,
suffocation, and playground injuries. Intentional
trauma death and injury events includes events like
suicide, homicide and child abuse. In Washington
State 27-43% of all deaths of children between the
ages of 1-19 are caused by unintentional injury,
another 7-10% are cause by assault, and 12-14% of
deaths for ages 5-19 are caused by suicide.
Unintentional Injury


Unintentional Injury is the number one
cause of death for children ages 1-adult
(age 24).
o Drowning is the leading type of
unintentional injury death for
children age 1-4.
Motor vehicle accidents are the leading
type of unintentional injury death for
children age 5-adult (age 24). (National
Center for Injury Prevention and Control,
2014)
Intentional Injury
 Suicide is the number two cause of death
for children age 10- adult (age 24).
 Homicide, including firearms death, is the
third leading cause of death for children
age 1-4 and 15-adult (age 24). (National
Center for Injury Prevention and Control,
2014)
Summary and Recommendations
Community Health Centers do as well as the state
average in completing recommended childhood
vaccinations while facing large challenges in the area
of social determinants of health. More resources
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Children, Poverty and Burden of Disease: Impacts on Community Health Centers
Leading Causes of Mortality in Children of
Washington State:



Ages 1-4
Leading cause: unintentional injury
Third most common cause: homicide
Ages 5-14
Leading cause: unintentional injury
Third most common cause: suicide
Fourth most common cause: assault
(homicide)
Ages 15-19
Leading cause: unintentional injury
Second most common cause: suicide
Third most common cause: assault
(homicide) (Washington State DOH, 2014)
A recent report in the Lancet describes the
magnitude of the problem in the overall population,
noting that trauma accounts “for over half of deaths”
in people younger than 45 and costs $600 billion
dollars a year. (The Lancet, 2016)
Although we found little research in the US or in
Washington State on the relationship between
poverty and injury, a large body of global research
shows a clear correlation between poverty and
mortality and morbidity from injury for children. A
2014 study in the journal Pediatrics on child abuse
and neglect assessed the relationship between
poverty and maltreatment at the county level. The
study found that child maltreatment was associated
with unemployment, poverty, and Medicaid use and
that “higher income inequality across US counties
was significantly associated with higher county-level
rates of child maltreatment. The findings contribute
to the growing literature linking greater income
inequality to a range of poor health and well-being
outcomes in infants and children”. (Eckenrode,
Smith, McCarthy, & Dineen, 2014)
Because this study was done at the county level,
maltreatment cannot necessarily be correlated with
household incomes at the individual level. Rather,
this study suggests that poverty is a community level
exposure risk and maltreatment may include things
like bullying, gang violence, inadequate childcare, or
even police brutality. It does also not suggest that
Medicaid use is causal, but correlative, where the
correlation may be that families on Medicaid are less
likely to be able to move from high risk areas. Finally,
this study specifically looks at income inequality and
suggested that not just poverty, but wider gaps in
income equality is a risk factor.
SOLUTIONS
More robust state-wide and clinic level research
needs to be done to identify the burned of disease
for Community Health Center patients, particularly
for diseases with strong associations to poverty, race
and ethnicity.
A focus on preventive care should include funding
and education for curbing obesity in women of childbearing age and pregnant women.
Because of high environment risks to health, housing
and transportation should be considered to part of a
healthy community and accounted for accurately
when determining funding for Community Health
Centers.
CONCLUSION
Ethnic and Racial minorities make up a
disproportionate percent of the population in
Washington State under 18 years old, compared to
adult population, and are also disproportionately
represented in the Community Health Centers
patient population. Individuals living in poverty are
disproportionally represented among CHC patients
and carry a larger burden of disease associated with
poverty. Diseases and conditions such as Asthma,
Obesity, and Trauma/Injury have a large impact on
the morbidity and mortality of children in
Washington State and disproportionately affect lowincome and minority children. Immunization has a
tremendous impact on overall community health
and Community Health Centers continue to provide
coverage at the same rates as the State population
in spite of structural and resource challenges.
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Children, Poverty and Burden of Disease: Impacts on Community Health Centers
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