The Cognitive Burden of Poverty: a Mechanism of Socioeconomic Health Disparities

Living in poverty is strongly linked to poor health and premature death, a reality that manifests in a roughly 10-year difference in lifespan between those at the top and bottom of the U.S. income distribution.¹ Socioeconomic disparities in morbidity and mortality at least partially stem from flaws and structural inequities both within and beyond the healthcare system, but a significant portion is also attributable to a greater burden of modifiable risk factors among the poor, including excess weight, smoking, poor diet, physical inactivity, and other behavioral risk factors.^2–4

The current dialogue on strategies to promote health behaviors among the poor heavily (almost exclusively) focuses on proposals to eliminate systemic and environmental barriers to healthy eating, physical activity, and preventive services including vaccination and cancer screening. This focus is grounded in epidemiologic research highlighting the role of contextual factors, structural barriers, and discriminatory policies in health behaviors and health outcomes. Unfortunately, accumulating evidence indicates that piecemeal efforts at eliminating systemic and environmental constraints, such as building grocery stores in food deserts or renovating physical activity venues, rarely produce the expected gains in health behaviors.^5–9 These outcomes have been both disappointing and somewhat puzzling to public health advocates. Recent advances in the behavioral and cognitive sciences suggest that disrupting the link between poverty and health not only requires eliminating systemic and environmental barriers, but may also necessitate alleviating the cognitive burden of poverty.

Poverty is both a socioeconomic and a psychological phenomenon defined by scarcity of material resources, psychosocial resources, and time. Whereas well-resourced individuals have the means to prevent and eliminate many hassles and stressors from daily life, those experiencing scarcity frequently encounter a multitude of obstacles when performing basic tasks. For instance, buying groceries might necessitate decisions related to securing transportation, navigating a food desert, and deciding how to allocate a limited food budget, all considerations that are unnecessary for those of higher socioeconomic status. Social scientists have delineated causal loops in which socioeconomic adversity, and the associated lack of resources, makes many challenges facing the poor unsolvable. Being faced with unsolvable problems can trigger avoidance-based coping responses that are aimed at reducing stress, but ultimately result in the persistence of problems that elicit chronic stress and place demands on cognitive bandwidth until they are resolved.¹⁰ Consistent with this account, individuals living in poverty report experiencing more severe stress in daily life.¹¹

Emerging research suggests that daily experiences of stress, scarcity, and cognitive demands markedly influence cognition and decision-making.^12–14 Each of these exposures has been found to temporarily disrupt executive functioning, high-level cognitive operations mediated by the brain’s prefrontal executive systems such as planning, problem-solving, and future-oriented thinking. Within established behavioral models,¹⁵ executive functioning is central for supporting a healthy lifestyle that includes eating well, engaging in regular exercise, and overcoming temptation from the immediate reward provided by palatable but unhealthy foods, tobacco products, and alcohol. As neurocognitive resources are finite, the cognitive burden of poverty consumes the mental bandwidth needed for computationally intensive operations such as executive functioning. The result is that efforts to maintain a healthy lifestyle can be derailed.

Beyond temporarily disrupting executive functioning, there is evidence that the cognitive burden of poverty promotes a present-biased mindset that prioritizes one’s immediate needs over longer-term rewards.¹⁶ Present-biased thinking is likely adaptive in the context of poverty, where one’s immediate needs are often threatened and longer-term payoffs are unreliable. However, present bias can undermine health, as many health behaviors are essentially a series of intertemporal tradeoffs between sources of immediate gratification (e.g., junk food, cigarettes) and future health outcomes. A robust and continually growing literature links present-biased thinking to multiple facets of an unhealthy lifestyle, including substance abuse, poor diet, sedentariness, and obesity.^17–20 As present bias exhibits a strong socioeconomic gradient, it is well-positioned as a potential mechanism underlying socioeconomic disparities in health behavior.²¹

The fact that the cognitive burden of poverty contributes to socioeconomic health disparities in parallel with tangible constraints (Figure 1) provides a plausible explanation for why isolated efforts focused on eliminating specific systemic and environmental constraints have had disappointing outcomes. Such interventions may make living a healthy lifestyle less impossible for the poor, but not necessarily a higher priority relative to ongoing challenges. Entering a newly built supermarket with a present-biased mindset is unlikely to lead to healthy food purchases,²² and the existence of an affordable, nearby fitness center is unlikely to help one establish a physical activity routine if mental resources remain allocated to more pressing concerns. To maximize their impact, it is likely that systemic and environmental interventions must be coupled with strategies that alleviate poverty’s impact on cognition and decision-making.

Figure 1. Parallel pathways to socioeconomic health disparities.

Poverty is both a socioeconomic condition and a psychological phenomenon, and these facets affect health through distinct mechanisms. Public health approaches to reducing socioeconomic disparities have traditionally focused on addressing tangible consequences of poverty, including the impact of personal material disadvantage and systemic and environmental constraints on health behavior (solid lines). Far less effort has been directed toward alleviating the cognitive burden of poverty (dashed lines). Daily experiences of stress, cognitive demands, and scarcity lead to dynamic changes in executive function and present bias that have downstream effects on health behaviors. As the tangible and psychological components of poverty influence health in parallel, interventions that eliminate systemic and environmental constraints are likely necessary, but not sufficient, to reduce socioeconomic health disparities.

These strategies might take several forms. As a first step, advocacy efforts could incorporate reforms that mitigate the aspects of poverty that deplete cognitive resources. As depicted in Figure 2, it is possible to classify poverty-related exposures on two dimensions reflecting 1) their cognitive burden, and 2) the degree to which they represent a tangible, systemic/environmental constraint for a given health behavior. Some poverty-related exposures have a high cognitive burden, but may not directly constrain a specific health behavior in any tangible way (e.g., noise pollution, psychosocial stress, inflexible work arrangements associated with many low-wage jobs). Conversely, there exist many tangible constraints on health behavior that have a minimal cognitive burden, such as limited access to nearby physical activity venues or supermarkets. At the intersection of these dimensions lie tangible constraints on health behavior that also have a high cognitive burden. For example, an unsafe neighborhood is both a very real deterrent to outdoor walking, and also a major source of stress. Likewise, limited access to transportation poses a physical barrier to accessing preventive health services, and also begets a multitude of stressors and scarcity experiences in daily life that make preventive services a less urgent priority. Poverty-related exposures that represent both a tangible constraint and a significant source of cognitive burden are likely high-yield targets for reducing socioeconomic health disparities.

Figure 2. Hypothetical classification of poverty-related exposures on the dimensions of cognitive burden and potential to impose tangible constraints on health behavior.

The public health community is most familiar with aspects of poverty that contribute to socioeconomic health disparities by imposing tangible constraints on health behavior (localized in the lower-right quadrant). Yet, other aspects of poverty affect health behavior primarily by imposing a cognitive burden (upper-left quadrant), or represent both a source of cognitive burden and a tangible constraints on health behavior (upper-right quadrant). Though there is still a strong need for research characterizing the cognitive burden of various poverty-related exposures, interventions targeting poverty exposures along both dimensions will be needed to reduce socioeconomic health disparities.

Several types of intervention may hold promise for mitigating the impact of the cognitive burden of poverty on health. Commitment strategies are mechanisms that enable a person to overcome present bias by constraining their future choices to those in their best long-term interest.²³ For example, someone can restrict or disincentivize their own future engagement in unhealthy behaviors, thereby forcing/motivating their future self to engage in a healthier behavior, no matter how tempting the alternative may be at that time. Commitment strategies such as financial contracts for weight loss or smoking cessation, and opting in to programs where benefits (e.g., grocery discounts) are contingent on healthy behaviors (e.g., making healthful food purchases), are efficacious and have shown high acceptability.²⁴ There are various forms of commitment strategies with diverse potential applications to health behaviors, and their ability to have a long-term impact on socioeconomic health disparities has not yet been examined. There may also be potential benefit in redesigning processes to lower the cognitive burden of health-related decisions (e.g., decomposing large decisions into smaller ones, timing decision-making to occur when mental resources are preserved, eliminating time pressure). As examples, patients are more likely to schedule cancer screenings when offered a single fixed appointment time rather than multiple options.²⁵ Individuals also select higher quality health insurance when the number of available plans is limited and plan features are standardized, thereby minimizing cognitive demands when making plan comparisons.^26,27 Ultimately, the ideal approach for reducing socioeconomic health disparities would incorporate multiple strategies, spanning the socioecological spectrum from societal forces to individual level interventions, that are aimed at eliminating the root causes of poverty and also alleviating its cognitive burden for those affected.

Progress in addressing the cognitive burden of poverty has been limited by two factors. The first is the challenge of measuring the impact of poverty-related exposures on cognition and decision-making in real-world settings. Fortunately, this is becoming increasingly feasible through ambulatory assessment methods that include validated cognitive tasks administered on an individual’s mobile device.²⁸ These methods will be crucial for identifying the most cognitively burdensome aspects of poverty, and the optimal strategies to buffer against them. As research on this topic advances, it will be important to understand how the cognitive burden of poverty may vary across sociocultural groups. Sociological research suggests that the manifestations of stress, cognitive demands, and scarcity are influenced by cultural factors (e.g., which situations are stressful, which scarce resources are most valued).²⁹ It is also vital to recognize the intersectionality of different dimensions of marginalization. Poverty disproportionately affects Black, Hispanic, and Native Americans,³⁰ groups that have endured structural racism and sociopolitical marginalization across generations. Poverty is also entwined with other forms of disadvantage, including under-resourced neighborhoods, exposure to crime, and residential segregation.³¹ Empirical research examining the cognitive burden of poverty across sociocultural groups should be prioritized.

A second barrier to progress has been the collective discomfort this topic evokes in the public health community. The suggestion that cognitive processes, at the individual level, contribute to increased morbidity and mortality among the poor can risk being perceived as pejorative, victim-blaming, and discriminatory. A focus on cognitive mechanisms also carries the risk of appearing to minimize the importance of contextual drivers of socioeconomic disparities. Perhaps for these reasons, the public health community has been more comfortable limiting its advocacy to reforms that eliminate systemic and environmental constraints on health that are tangible and viewed as entirely extrinsic to the individuals they affect. However, striving to reduce the cognitive burden of poverty does not inherently disregard the importance of contextual factors, and should not be taken to present a false dichotomy that detracts from the importance of advocating for the comprehensive, multilevel reforms needed to prevent poverty in the first place. Public health advocates can and should aspire to minimize the existence of poverty while also seeking to alleviate its burden on those it currently affects.

Given the potential for misunderstanding, it is important to emphasize that the cognitive burden of poverty represents a mechanism, not a cause, of the relationship between poverty and health. Though it affects individual-level decision-making, it is as much a product of broad societal factors as individual-level financial insecurity (left side of Figure 1). The disrupted executive functioning and present-biased decision-making that result from stress, scarcity, and cognitive demands are not character flaws of the poor, but normal (sometimes adaptive) responses to living in an impoverished environment. Indeed, stress, scarcity, and cognitive demands impact decision-making in individuals across all socioeconomic strata. The relevant point is that these exposures are more pronounced in the daily lives of the poor. In distinction from earlier work linking childhood poverty to long-term neurodevelopmental outcomes, the impact of day-to-day stress, scarcity, and cognitive demands on cognition and decision-making are thought to be fleeting and reversible.^28,32 Therefore, pairing strategies to alleviate the cognitive burden of poverty with systemic and environmental reforms could potentially benefit even those who have endured chronic exposure to poverty.

With poverty, rather than individual decision-making, recognized as the true culprit in socioeconomic health disparities, it is hoped that the public health community will more freely engage in constructive dialogue focused on alleviating the cognitive burden of poverty. This dialogue would bridge two well-developed and complementary bodies of knowledge – public health research demonstrating the importance of context, and cognitive science delineating mechanisms of health behavior. Both perspectives will be needed to determine which aspects of poverty have the greatest influence on health behaviors, and ultimately, to identify comprehensive strategies that can close the socioeconomic mortality gap.