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Improving the health of mothers living in poverty

By: Amie Koch, DNP, RN, FNP-C, ACHPN

Implementing nurse-led healthy lifestyle classes.


  • Mothers experiencing poverty likely have a history of trauma, so healthcare providers should use trauma-informed care.
  • Nurses can collaborate with mothers experiencing homelessness and implement healthy lifestyle classes to improve mothers’ health perceptions.
  • When mothers living in homelessness participate in evidence-based, trauma-informed, healthy lifestyle classes with a nurse, their depression, distress, and anxiety levels may decline.

The number of homeless in the United States may appear to be declining, but the count doesn’t include families staying with friends, relatives, or in transitional housing. According to the U.S. Interagency Council on Homelessness, approximately 58,000 families (including 109,719 children) are homeless in America on any given night. In 2017, families with children under 18 represented one-third of all people experiencing homelessness.

Social determinants keep people in the generational cycle of poverty. Unstable residences, frequent moves, housing in dangerous neighborhoods, low education levels, employment and food insecurity, childcare and transportation stressors, and history of trauma or abuse contribute to poor physical and mental health. Single mothers and mothers who live with poverty have limited access to healthcare services, including mental health support. Healthy lifestyle classes—such as the ones described in this article—and support by healthcare professionals can help improve not only a mother’s health, but also her children’s.

Healthy lifestyle class content

I developed an evidence-based healthy lifestyle curriculum for mothers living in poverty based on major themes identified in a literature review of health risk factors for this patient population. The classes, which are for women only and are divided into four sections, take a trauma-informed approach. (See Trauma-informed care.) They provide support and encouragement to build healthy relationships and healthy lifestyles.

Class 1: I CAN be healthy.

Class 1 focuses on topics related to a healthy lifestyle, including sleep, stress, developing daily healthy behaviors, medication and treatment adherence, what to do when sick, and how to determine the appropriate level of health services needed (primary care provider, urgent care, emergency department). Basic child-development concepts and positive parenting strategies also are discussed.

This class uses an activity-based learning strategy, which includes an interactive healthy behaviors bingo game to help participants recall concepts discussed in class. The activity also is an icebreaker that encourages participant interaction. A trusting and relaxed learning environment is established at the conclusion of this initial session.

Trauma-informed care

Nurses practicing trauma-informed care are aware of the high rates of trauma (including living in poverty) and its long-term consequences. They assume anyone they encounter may have experienced trauma. In addition, they:

  • emphasize physical, psychological, and emotional health while helping clients develop a sense of empowerment and control
  • acknowledge trauma’s impact no matter how long ago it occurred
  • are intentional about telling clients what they’re doing, so clients can have a say in their care
  • inform clients that they can say “stop” at any time
  • establish a safe and trusting environment to facilitate communicating and learning.

Class 2: Cardiovascular health

Topics in this class include the relationship of stress, exercise, and nutrition to heart health. Cardiovascular disease, hypertension, atrial fibrillation, and stroke are discussed, as are warning signs of a heart attack or stroke and what to do. Group discussion focuses on the importance of a heart-healthy lifestyle for mothers and their children. Each participant’s blood pressure is measured, and information is provided about local exercise facilities and programs, affordable ways to get physically fit, stress reduction, and how to get children interested and involved in fitness.

Class 3: Emotional and mental health

This session includes information and discussions about violence, trauma, domestic abuse, history of abuse, substance use, posttraumatic stress disorder, mental health, anxiety, and depression. When appropriate, mothers with substance use disorder are encouraged to seek assistance, but stress and homelessness create challenges to addressing this issue.

Class discussions cover topics such as support versus social isolation, negative thinking, and the long-term effects of trauma. To help mothers build their self-esteem and self-worth, they journal to identify personal strengths and weaknesses and likes and dislikes.

Class 4: Nutrition

The objectives of the fourth class include providing education about obesity, food insecurity, what a healthy plate looks like, and how what we eat affects our bodies, minds, and finances. The class also teaches mothers how to influence their children’s health with the food they eat. Information on local food banks, food programs, and local farmers’ markets is presented.

Class impact

The mothers completed the Four-Dimensional Symptom Questionnaire (4DSQ) before and after the four sessions. Depression, distress, and anxiety scores decreased after completing the classes, although the mothers’ average depression score remained higher than the general population norm of 20%.

I was able to address specific health issues during the classes. For example, in the cardiovascular health class, I identified new-onset hypertension in one mother and helped her schedule an appointment with a primary care provider. In addition, I confirmed existing hypertension in two mothers who were no longer taking medication because they couldn’t afford or access healthcare. I referred them to the local low-income health clinic to follow up with a primary care provider and obtain medication.

Participants also reported positive outcomes, including:

  • increased confidence in managing their health and making healthy lifestyle choices for themselves and their children
  • improved communication with their children
  • positive changes from week to week (for example, getting children to bed earlier on school nights and increasing school attendance)
  • better nutrition (for example, getting children to eat vegetables or to drink water or milk instead of soda or sweet tea for dinner)
  • healthier breakfast choices for themselves and their families
  • enjoyment of the classes and a desire to continue to meet after the series concluded.

The nurse-led classes made space for mothers to bond. Mothers shared their experiences (including what they were cooking for their families and where they went for medical or dental care) with the group, reflecting a high level of trust among participants. They expressed feeling happy about belonging to a group and organized a walk together to get exercise. Participants reported increased cohesiveness as the classes continued, as well as decreased feelings of isolation.

Recommendations for nurses

Healthy lifestyle classes meet the Institute for Healthcare Improvement Triple Aim: improve population health, improve the patient experience, and reduce overall healthcare costs. Consider offering consistent, consecutive nurse- or nurse practitioner–led classes with small groups of mothers to help improve their overall health and that of their children. Look for libraries, community centers, homeless shelters, or health clinics to hold the classes, and tailor them to highlight services available in the community where the mother lives. Use these programs as opportunities to create partnerships between community agencies and local nursing schools. Programs and policies you create for families experiencing homelessness should prioritize health and wellness more than rapid rehousing because improved health may contribute to family stabilization.

Current healthcare and housing policies, the education system, employment opportunities, and the pervasiveness of abuse and intimate partner violence have contributed to the poor health of vulnerable women experiencing homelessness or poverty. States that have expanded Medicaid services have taken a step toward positive change for mothers living in poverty, but more must be done to support them. Other programs that can help include educational assistance, full-time employment with a living wage, expanded opportunities for safe and adequate housing, and emotional support at the community level. Nurses who practice consistent support and advocacy can serve as leaders in improving the health of mothers in poverty.

Amie Koch is an assistant professor at Duke University School of Nursing in Durham, North Carolina, and a family nurse practitioner for adult and pediatric palliative care and hospice at Transitions LifeCare in Raleigh, North Carolina.


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