Recognizing and Responding to Poverty in College Students: What Can Nurses Do?

Until recently, college students were often viewed as a population for whom poverty was not a relevant issue...Until recently, college students were often viewed as a population for whom poverty was not a relevant issue, but research shows that an alarming number of students are experiencing basic needs insecurity (Baker-Smith C., et al., 2020). Low-income students may also experience insufficient quantity of food and/or inconsistent housing, as well as other non-medical factors that can affect health outcomes. These social determinants of health (SDOH) include:

• Economic: employment, food insecurity, housing instability, poverty
• Education: early childhood development, enrollment in higher education, high-school graduation, language, and literacy
• Health and Health Care: access to health services, access to primary care, health literacy
• Neighborhood and Built Environments: access to food that supports health, crime and violence, environmental conditions, quality housing
• Social and Community Context: civic participation, discrimination, incarceration, social cohesion (CDC, 2021)

Poverty in college students should therefore be recognized as an important contributing factor to students’ health and well-being, as well as issues of health equity.

...it is necessary for college students to have enough food to eat and a safe place to live before pursuing higher-level learning and self-actualization...Many people have heard the cliché about poor college students surviving on ramen noodles, but poverty in college can have a dramatic impact on not only students’ physical and mental health, but also on their academic success. Maslow (1943) described a hierarchy of needs, which shows the importance of satisfying basic physiological necessities such as food, sleep, and shelter before attending to higher needs such as friendship, sense of connection, self-esteem, and self-actualization. Accordingly, it is necessary for college students to have enough food to eat and a safe place to live before pursuing higher-level learning and self-actualization so that they have better chances of succeeding in their educational endeavors.

There is an increasing awareness of the prevalence and detrimental effects of poverty on health and academic performance, but more can be done to recognize and respond to it in college students. Although interventions such as food pantries and meal vouchers exist, they may not be consistently implemented across university campuses. Moreover, stigma, or embarrassment, is associated with a need for additional help (Meza et al., 2019), which may cause students to hide or downplay the severity of their situation. In this article, we provide an overview of how poverty affects college students and how these students can be supported. We will look at the role of students, educators, and advanced practice registered nurses, and make recommendations about responding to poverty in college students. Finally, we will present an exemplar of how one nursing school faculty and staff are responding to food insecurity experienced by their students.

Food and Housing Insecurity in College students

In the United States, in 2021, almost 38 million people lived in poverty and struggled to fulfill their most basic human needs such as food, water, sanitation, education, and healthcare (Creamer et al., 2022). Food insecurity, defined as a “household-level economic and social condition of limited or uncertain access to adequate food,” (USDA ERS, 2023, section 2) affects over 13 million American households. Of those households, over five million experience very low food security (Coleman-Jensen et al., 2022). Very low food security results in disrupted eating patterns, such as skipping meals, and reduced food intake due to lack of money (USDA ERS, 2022).

There is often an overestimation of how much a student can pay paired with an underestimation of living costs...Many students enroll in college courses to increase opportunities related to economic and social mobility. However, financial aid alone has not been sufficient to contend with the rising cost of college tuition. There is often an overestimation of how much a student can pay paired with an underestimation of living costs; this leaves many students without much-needed support (Broton & Cady, 2020; Freudenberg et al., 2019). The average cost at a four-year public institution has increased by an average of 9% annually, resulting in a rise of 179.2% over the last two decades; college costs far outpace the rate of inflation (Hanson, 2002). To save money, students may decelerate or enroll in courses part-time. However, evidence shows that taking more than four years to complete an undergraduate degree is associated with lower post-college earnings (Witteveen & Attewell, 2021).

...a change in demographics from students who graduated from high school and immediately enrolled full-time in college to more non-traditional students also contributes to poverty in this group.In addition to rising costs, a change in demographics from students who graduated from high school and immediately enrolled full-time in college to more non-traditional students also contributes to poverty in this group. According to United States Government Accountability Office ([USGAO]; 2018), in 2016, 71% of college students were considered as non-traditional, defined as having at least one of the following characteristics: (1) financially independent from parents, (2) has at least one dependent, (3) is a single caregiver, (4) lacks traditional high school diploma, (5) has delayed college or is enrolled part-time, or (6) is employed full-time during the year.

Over the past decade, there has been an increase in low-income students enrolling in college courses: in 2016, 31% of college students were from low-income backgrounds, compared to 21% in 1996 (Fry & Cilluffo, 2019). To cover their basic needs, low-income students may have to work multiple jobs, skip meals, and take personal loans which further exacerbates inequities for these students; such complexities leave this group of students at a dramatic disadvantage.

Since Chaparro et al. (2009) published the first manuscript detailing food insecurity in college students, the conversation has begun at many higher education institutions. Now, it is widely recognized that college students are experiencing poverty, often including food insecurity, which was brought to the forefront particularly during the COVID-19 pandemic with the closing of campuses and limited dining services. The reality is that an estimated 41% of college students have had or are currently experiencing food insecurity (Nikolaus et al., 2020). Evidence shows that students most at risk of experiencing food insecurity are first-generation students, students from lower income households, students who have reported disabilities (Olfert, Hagedorn, et al., 2021), and non-traditionally aged students (Phillips et al., 2018). Importantly, college students of color are disproportionally affected by food insecurity. One study showed that Black first-generation college students had 296% higher odds of experiencing food insecurity compared to White first-generation students (Olfert, Hagedorn, et al., 2021). Transgender and non-binary students also have high prevalence of experiencing food insecurity compared to their cisgender peers (Laska et al., 2021).

In addition to food insecurity, poverty may contribute to a lack of required necessities for college, including housing, clothing, school supplies, and access to healthcare. Students may also experience “period poverty,” or the inability to afford menstrual hygiene products, which has been associated with depression in a national sample of 471 college-attending women (Cardoso et al., 2021). Indeed, 14.2% experienced period poverty, with 10% of women having experienced it each month.

The inability to secure stable shelter is associated with not only depression, but also acute stress, social isolation, and suicidal ideation.Housing insecurity and homelessness are also of concern for our impoverished students. Housing insecurity relates to concerns about affordability, crowding, and quality, while homelessness is not having a definitive place to sleep, including “couch surfing” with friends or staying in a shelter. Researchers at one large university found that 43.9% of their sample had experienced housing insecurity at least once, and 14.6% had experienced homelessness (Kornbluh et al., 2022). The inability to secure stable shelter is associated with not only depression, but also acute stress, social isolation, and suicidal ideation (Hallett & Freas, 2018).

In addition to the inability to secure basic needs such as food, menstrual hygiene supplies, and housing, poverty impacts students’ academic success. A hungry student will have difficulty learning; students are unable to concentrate in class and retain information, which in turn jeopardizes the ability to succeed in their courses and earn their degrees (Hege et al., 2021). Students who experience food insecurity are more likely to have poor sleep quality and are more likely to have a grade point average <3.0 when compared to food-secure students (El Zein, 2019). The more a student struggles with basic needs security, the worse their reported grade point average, level of anxiety about academic performance, and frequency of absences (Maguire & Crutchfield, 2020).

In addition to academic concerns, poverty also negatively impacts college students’ well-being. Students who are severely food and/or housing insecure are more likely to have experienced poor mental and physical health (Maguire & Crutchfield, 2020). A national survey of community college students investigated the relationship between basic needs insecurity and mental health and found that students who experience basic needs insecurity are more likely to report anxiety, depression, and suicidal ideation than their peers who are able to secure their basic needs (Broton et al., 2022).

Students also felt the need to binge if they were eating in the dining hall, especially if they had meal plans with fewer meals per day.Poverty and resulting food insecurity impacts eating behaviors as students may skip meals or eat less-expensive, highly processed or fast food, or foods high in fat which can lead to an increased risk of obesity, lower intake of produce, and poor health (Morales & Berkowitz, 2016). Students also felt the need to binge if they were eating in the dining hall, especially if they had meal plans with fewer meals per day (Nikolaus et al., 2019). In the next section, we will outline strategies to address and reduce poverty in college students, and the resulting mental and physical health effects, to provide a framework for recognition and action.

Current Interventions to Support Students Experiencing Poverty

An increased awareness paired with availability of resources can contribute to normalizing asking for help...Researchers, administrators, and students have called for action. Many universities have created resources to help students who are experiencing poverty. An increased awareness paired with availability of resources can contribute to normalizing asking for help, thus potentially decreasing stigma and hesitancy to reach out. A recent study explored a sample of 488 United States postsecondary institutions to evaluate resources for students’ basic needs and found that 88% of institutions offered at least one resource; food resources such as a campus pantry or meal sharing program are offered more frequently than housing-specific resources such as emergency housing (78% and 39%, respectively; Speirs et al., 2022). Despite intervention availability, students’ lack of knowledge about resources may result in less effectiveness for these measures. Moreover, if there is a lack of awareness, there may be less utilization (El Zein et al., 2018), leading to administrators believing that the issue is less severe than it actually is.

The campus milieu may also contribute to limited utilization of resources. Even when students are aware of available resources such as a campus pantry, concerns about social stigma may inhibit them from utilizing these options (El Zein et al., 2018; Weaver et al., 2021). To combat stigma and bring awareness to the urgency of this issue, many college administrators are acting to ensure that campus pantries are well-advertised with both locations and times that are accessible. Student-led pantries such as The Billiken Bounty (Saint Louis University, 2023) utilize social media to bring awareness to the issue of food insecurity, including frequent posts about hours of operation and easy menu options with ingredients that students can obtain from the pantry.

There are universities and colleges that utilize food sharing programs as well as campus gardens.Programs such as Swipe Out Hunger (2023) offer meal plan vouchers and allow students with extra meal plan “swipes” to share with others who are hungry. This program is also an excellent resource for referrals to initiate Supplemental Nutrition Assistance Program (SNAP) benefits. There are universities and colleges that utilize food sharing programs (Frank et al., 2021) as well as campus gardens. Some colleges set aside emergency funds (CCCSE, 2022) for students who are having trouble securing basic needs. Basic needs hubs can help students obtain food as well as short- and long-term housing while safe parking programs allow students to sleep in their car at a safe spot on campus with access to facilities and Wi-Fi (Wood, 2022).

Schools that use a proactive approach to ensure student awareness incorporate presentations during orientation, different methods of communication about resources, and even discussions with faculty so that they can better respond. It is paramount that nurses and educators make themselves aware of the available resources to proactively provide information and be ready to respond to a student’s disclosure.

Nurses on College Campuses

The roles of nurses on college campuses are many and varied; nurse faculty members might act as both educator and advocate. Advanced practice registered nurses (APRNs) are a mainstay of student health services. Since food insecurity, along with poverty, affects college students’ well-being, APRNs must be able to identify poverty, make appropriate recommendations, and address their students’ and patients’ basic needs. Still others are tasked with preparing APRNs, who are more likely than any other provider to practice in rural and underserved areas prone to the impact of poverty (Berhaus, 2019).

The Nurse as Educator and Advocate
Nursing faculty are tasked with serving their students’ individual learning needs, which are often viewed through the sole lens of academic achievement. However, nurse educators must consider that when students experience poverty, access to basic needs may be interrupted and poor academic performance may result (Meza et al., 2019, Silva et al., 2017). In order to best support the academic success and overall wellness of students, faculty must take an active approach in conveying an open and supportive learning environment in the classroom or clinical space.

An example of how faculty can promote wellness within their own classrooms could be incorporating a syllabus statement about basic needs security.It is crucial that nurse educators recognize the significant impact of poverty and food insecurity on our students’ lives and normalize the idea that they may need help. An example of how faculty can promote wellness within their own classrooms could be incorporating a syllabus statement about basic needs security. These statements may increase college students’ awareness and knowledge about resources that are available to them, and decrease the stigma associated with poverty and hunger (Goldrick-Rab, 2020). Below is an example of a faculty syllabus statement:

Any student who has difficulty accessing sufficient food to eat every day, or who lacks a stable place to live, and believes this may impact their performance in the course is urged to contact the Dean of Student Services. If you are comfortable doing so, please notify me so that I may assist you with finding resources to the best of my ability (Goldrick-Rab, 2020, viii).

Nursing students experience multiple competing and intersecting demands, including transitions of time, spaces, priorities, roles, and focus. Transition of focus requires shifting focus from self to the art of caring for others. During their education, students learn about hierarchy of needs (Maslow, 1943); and how to assess and advocate for patients, identify patient support systems, and provide patient education about nutrition. All of these components may also allow students to reflect on their own ability to secure basic needs.

Actively learning about poverty could enable student-to-student intervention...Faculty may employ experiential learning such as a poverty simulation (Turk & Colbert, 2018) and other activities like cognitive rehearsal in which a student mentally prepares to discuss poverty and potential resources. Such pedagogies may increase future caregivers’ knowledge, empathy, confidence, and competence in screening, detecting, and responding to poverty in their patients. Actively learning about poverty could enable student-to-student intervention (Cockerham et al., 2021), which could further assist with normalizing the conversation about poverty in college students. As an example, the practice of screening may help nursing students recognize potential for food insecurity in themselves and their peers, and thus increase utilization of resources. These valuable educational experiences should not stop at the undergraduate level. APRNs must also receive educational experiences that will foster an understanding of caring for all vulnerable populations who may experience poverty.

The Nurse as Advanced Practice Nursing Program Faculty
Regardless of the practice setting, those living in poverty and with limited resources expend excessive time and energy as they attempt to manage their lives, sometimes hour-by-hour (Lucas et al., 2019). However, APRNs may need added awareness of what poverty is and how to assess patients for insecurities associated with being poor, including an individual and community assessment to determine needs and available resources to fill in gaps.

As academic nursing rises to meet advancements with the incorporation of the American Association of Colleges of Nursing (AACN, 2021) Essentials for advanced-level nursing education, a natural curricular opportunity presents to address patient vulnerabilities embedded within the SDOH (CDC, 2021). This approach supports emerging APRNs with foundational underpinnings, and in best-case scenarios, clinical experiences that allow them to scaffold their knowledge and practice expertise in the evaluation and management of poverty in their patients. Incorporating an enhanced focus on the SDOH into population health course content ensures that students have a consistent foundational lens in which to approach other disparities as well.

The Nurse as a Healthcare Provider
University health services might consider adding a screening tool to their intake or patient health history form.Nurses and APRNS are an integral part of the healthcare team at many university student health centers and as such must remember that significant mental and physical health concerns are associated with food and housing insecurity. Kornbluh (2022) recommended that college health clinics serve as screening and recommendation locations. University health services might consider adding a screening tool to their intake or patient health history form. An example of a widely used, valid, and specific food security screening tool is the two-item Hunger Vital Sign screener (Hager et al., 2010) developed for families with children, and validated in adults by Gundersen et al. (2017). The student will answer “often true”, “sometimes true”, or “never true” to the following questions:

• “Within the past 12 months, (I/we) worried that (my/our) food would run out before (I/we) got money to buy more”
• “Within the past 12 months, the food (I/we) bought just didn’t last and (I/we) didn’t have money to buy more”

An intervention described as “screen and intervene” (Vineis, 2020) was implemented at a student health clinic. Staff and clinicians at the student health clinic felt that they were able to administer the simple two-item screening survey very quickly and easily. In the same study, staff and clinicians felt that the screening and referral initiative was a valuable addition, met a previously unmet need, and helped to promote awareness about this issue. The healthcare team identified that the program helped to promote students’ physical health and wellness (Vineis, 2020), which aligned well with their university mission.

The healthcare team identified that the program helped to promote students’ physical health and wellness, which aligned well with their university mission.Recognizing that a larger number of students act as caregivers for a child than ever before (USGAO, 2018), screening may benefit more than just the student. Such interventions may not only start the conversation about potential food and housing insecurity, but also increase referrals, which in turn may help students eliminate food insecurity and poverty. To reach that goal, we must raise awareness of resources; it is not enough to simply screen.

Exemplar: Faculty at One School of Nursing Respond to Poverty

Faculty at one school of nursing responded to poverty and food insecurity in students with the creation of a mini food pantry. In January 2022, our school of nursing faculty at a mid-sized, private, religious university recognized an increase in food insecurity among students, both during the pandemic and following it. Students were approaching the Office of Student and Alumni Affairs (OSAA) to seek support, describing an inability to secure enough food to eat.

The pantry, which is stocked on average 2-3 times per week, supplies a variety of food items and enables students to have basic necessities for meals.The mini pantry, which has been well-received and widely utilized, is conveniently situated in the student lounge, a common area accessible to students at all times. The pantry, which is stocked on average 2-3 times per week, supplies a variety of food items and enables students to have basic necessities for meals. There are also nutritious snacks to supplement their intake if their funds are low or if a student did not have time to prepare a lunch while balancing numerous demands on their time. The pantry also provides hygiene supplies to students. This includes established “menstruation stations” which provide supplies to individuals who may be in need within all bathrooms in the school of nursing. Items that are consistently available in the mini pantry include:

• Non-perishable foods, including proteins, vegetables, pasta, rice, cereals, and soups
• Basic kitchen items such as vegetable oil, salt and pepper, and can openers
• Quick snacks such as granola bars, crackers, and squeezable applesauce
• Health and beauty aids such as soap, shampoo, deodorant, toothbrushes, and toothpaste
• Menstrual hygiene supplies

Through the generosity of faculty, staff, and alumni, students working with the OSAA can “shop” from a backstock of food and hygiene items to fill an immediate need for their room or homes.

In an effort to destigmatize the conversation around food insecurity, the focus is on keeping food insecurity part of everyday discussions.In an effort to destigmatize the conversation around food insecurity, the focus is on keeping food insecurity part of everyday discussions. Students are sent regular emails and social media reminders about the available resources. Pamphlets and brochures are available around the school with information on how to secure resources privately if that is preferred. Each semester, faculty and staff collect and donate items, and the students themselves help support their peers in need and keep the food pantry replenished. Additionally, many faculty members have actively embraced this culture of caring by placing snacks on their desk or a table in their office for students to access during meetings and office hours.

...the students themselves help support their peers in need and keep the food pantry replenished.In addition to faculty, staff, and students, other efforts ensure sustainability for the mini pantry. Annually, there are two drives to collect items for the food pantry. The most recent graduating senior class raised money for the food pantry as part of their class gift. To ensure sustainability, the alumni association holds a food drive to benefit the food pantry as part of their annual Homecoming celebration, and there are plans to create a fundraising campaign for the School of Nursing Food Pantry.

Often, students are not aware of other resources such as scholarships, grants, or even community resources that may be available to them through the school of nursing or the university. The OSAA works closely with the founding faculty member to ensure they are meeting students’ basic needs. They also discuss and provide additional assistance for students in need who may experience food insecurity more consistently.

Students who receive these resources are very grateful and have often commented about the helpfulness of the mini pantry. We have received comments from students that the mini pantry and the other resources available to them at the school of nursing make them feel cared for and loved. Although the food pantry has had a great impact on the students in the school of nursing, it is clear that this model can be duplicated; another school in the university has also started a food pantry.

Recommendations

Healthcare providers, educators, and administrators must look for ways to mitigate the potentially harmful impacts of identified SDOH (CDC, 2021; Thimm-Kaiser et al., 2023). Universities and colleges can assist with SDOH capital, namely resources that affect health outcomes, of which education, food security, and quality housing are key factors. Institutions should look to mitigate exposure to the health risk of poverty, and assist with resilience, described as collective action to reduce harmful impact and improve the ability of individuals and communities to thrive.

...it is especially important to develop interventions that will address structural inequities.Recognizing the complex interrelationships of the SDOH (CDC, 2021), it is especially important to develop interventions that will address structural inequities. Many actions can be taken at the institutional, school, practice, and individual levels to recognize and respond to poverty in college students. The following are examples to begin or enhance your current efforts:

• Increase the awareness of students’ basic needs insecurity as a serious concern.
• Amplify the voices of students who experience poverty to faculty senate and administration.
• Focus on clear and consistent advertisement of student resources, including the sharing of this information with faculty and academic advisors.
• Normalize asking students if they are having difficulty with basic needs, especially with students who have academic difficulty or miss a large number of classes.
• Consider incorporating screening or surveying to determine severity of basic needs insecurity at your university or college.
• Make healthy snacks available during office hours and in areas such as Student Health Services and counseling centers.
• Know what to do if a student reveals that they are experiencing poverty – it is not enough to screen, taking the next steps is crucial!
• Make referrals to student services to ensure a multidisciplinary approach.
• Incorporate a basic needs security syllabus statement.
• Build educational experiences that allow for APRN students to gain an understanding of caring for all vulnerable populations who may experience poverty.
• Build partnerships with community organizations to increase food and housing security interventions.
• Conduct research about the effects of poverty on college students, especially much-needed intervention studies.

Conclusion

There is growing awareness of the detrimental effects of poverty in college students, and together we (i.e., nurses, educators, and administrators) must work to actively respond to student poverty. We must educate pre-licensure nursing students, and our APRN students, about how to assess food insecurity. They must be prepared not only to screen for potential concerns, but also to provide resources.

Poverty has a detrimental impact on college students’ academic performance as well as their mental and physical health.Poverty has a detrimental impact on college students’ academic performance as well as their mental and physical health. We must work to address these issues. We can start by normalizing the conversation so that students feel comfortable sharing their concerns with us. Concerns that today extend beyond the perennial “broke college student” perception – indeed, poverty is a social determinant of health that can significantly and adversely impact the lives of college students.

Authors

Amber L. Kolesar, PhD, RN, CNE, CCRN
Email: kolesara@duq.edu
ORCID ID: https://orcid.org/0000-0002-1506-4803

Amber Kolesar joined Duquesne University in 2016 and she currently serves as the Director of the Second-Degree BSN Program. She earned a BSN and MSN from Duquesne University and recently earned a PhD from Saint Louis University Trudy Busch Valentine School of Nursing. Her dissertation was a qualitative study that explored the lived experience of food insecurity in college students. Dr. Kolesar is certified as a nurse educator and a critical care nurse. She facilitates global health immersions for students to Central America. She is also an active volunteer with local food security initiatives, and is the founder of a student pantry in her school of nursing.

Angela Karakachian, PhD, RN
Email: Karakachiana@duq.edu
ORCID ID: https://orcid.org/0000-0002-2654-5098

Dr. Angela Karakachian received a BSN from Saint Joseph University Beirut-Lebanon in 1998. During the same time, she also received a BSN in France. Dr. Karakachian found her passion in nursing when she worked at Children's Hospital of Pittsburgh in the Allergy and Immunology unit. In 2012, she received a master’s degree in nursing education from the University of Phoenix. Dr. Karakachian joined Duquesne University in 2014. In Spring 2020, Angela earned a PhD in Nursing at Duquesne University. Her research interest is nurses' moral distress, in general and as they provide care to victims of child abuse.

Jessica Devido, PHD, CPNP
Email: devidoj@duq.edu
ORCID ID: https://orcid.org/0000-0003-2979-509X

Dr. Jessica Devido is an Associate Professor at Duquesne University School of Nursing. As a board-certified pediatric nurse practitioner and former labor and delivery nurse, her career has focused on improving maternal-child health (MCH) outcomes among vulnerable populations. She has built a community-engaged program of research that seeks clinical solutions for MCH equity. As a nationally selected Josiah Macy Faculty Scholar, Dr. Devido has developed and directs, along with a team of birthing experts, the MCH Equity Fellowship, a program designed for undergraduate pre-licensure nursing students to promote equity, cross-cultural sensitivity, and collaboration with community stakeholders.

Denise Lucas, PhD, FNP-BC, CRNP, FAANP
Email: lucasd2495@duq.edu
ORCID ID: https://orcid.org/0009-0005-5718-8280

Dr. Denise Lucas transitioned from an acute care clinical expert to a family nurse practitioner caring for underserved individuals in free clinic settings. She has a special interest in chronic illness, social determinants of health, and resources identified by patients other than money. She has established a faculty practice that welcomes advanced practice nursing students to gain a deep understanding of the complexities in caring for underserved individuals.

Kate DeLuca, EdD, MBA
Email: deluca899@duq.edu

Dr. Kate DeLuca serves as the Associate Dean for Student and Alumni Affairs at the Duquesne University School of Nursing. Dr. DeLuca completed dual degrees at Duquesne University, a Bachelor of Arts in Political Science and a Bachelor of Science in Business Administration. She went on to complete an MBA at Duquesne and earned a doctorate in education in the Higher Education Management program at the University of Pittsburgh. Dr. DeLuca joined the Duquesne University School of Nursing in 2004 and has served in various capacities, including the Graduate Academic Advisor. She has also been successful in the development and implementation of several new initiatives to enhance the student experience.