Ameliorating poverty-related communication and swallowing disabilities: Sustainable Development Goal 1

Abstract

Purpose

More than 700 million people globally are still living in extreme poverty. No poverty (Sustainable Development Goal 1, SDG 1), is considered to be the greatest global challenge. This paper aims to outline the effects of poverty on communication and swallowing disabilities across the lifespan and steps to take for its amelioration.

Result

Poverty and disability are in a vicious cycle with each being a cause for and a consequence of the other. Poverty has incontrovertible and significant ramifications for communication and swallowing disabilities across the lifetime from pregnancy to old age. The individual, family and social burden and costs of these disabilities have lifelong economic and social consequences.

Conclusion

Considering poverty is a known and important determinant of communication and swallowing disabilities, the most potent weapon is to focus on preventing and ameliorating poverty-related communication and swallowing disabilities in children. A call to action is issued to speech-language pathologists to take steps towards this goal. This commentary paper focusses on Sustainable Development Goal of no poverty (SDG 1) and also addresses zero hunger (SDG 2), reduced inequalities (SDG 10), and climate action (SDG 13).

Keywords:

• Sustainable Development Goals (SDGs)
• no poverty (SDG 1)
• zero hunger (SDG 2)
• reduced inequalities (SDG 10)
• climate action (SDG 13)
• communication disability
• swallowing disability

Seven years ago, the United Nations proposed 17 Sustainable Development Goals (SDGs) (United Nations, 2015) that every country will be expected to work towards achieving by 2030. Many of these goals relate to ensuring healthy lives (ending poverty, improving the environment), equitable education, inclusive societies and combatting climate change. Of these goals, no poverty (SDG 1), is considered to be the greatest global challenge (United Nations, 2015).

More than 700 million people worldwide are still living in extreme poverty, with the COVID-19 epidemic significantly increasing the numbers (United Nations, 2021). Extreme poverty is currently measured as people living on less than US$1.90 a day (United Nations, 2015). Poverty exists in every country in the world in 2021, ranging from 82.3% in South Sudan to around 12–14% in Canada and Australia (World Population Review, 2022). This paper aims to outline the effects of poverty on communication and swallowing disorders and swallowing disorders and to provide strategies to use this evidence to take action and educate relevant professionals and organisations and to advocate for individuals with communication and swallowing disorders living in poverty.

Whilst poverty is multidimensional, it

entails more than the lack of income and productive resources to ensure sustainable livelihoods. Its manifestations include hunger and malnutrition, limited access to education and other basic services, social discrimination and exclusion, as well as the lack of participation in decision-making (United Nations, 2021).

From this description, ameliorating poverty is also closely aligned to zero hunger (SDG 2), reduced inequalities (SDG 10) and climate action (SDG 13). It is apparent that the impact of poverty on individuals is closely aligned to that of disability. Poverty and disability are interconnected, with each being a cause for and a consequence of the other, thereby setting up a vicious cycle (Elwan, 1999). Over a billion people worldwide live with some form of disability and 80% of people with disabilities live in least developed countries (World Health Organization, 2021). Poverty therefore is a major threat and strongly linked to people with disabilities (Banks et al., 2017), including those with communication and swallowing disorders.

Climate change (climate action SDG 13) is an additional factor relating to poverty. Climate change is the defining issue for health systems in the 21st century and will directly affect the health of all individuals (World Health Organization, 2016). It is defined as “the long-term change in the average weather patterns that have come to define Earth’s local, regional and global climates” (NASA, 2020). Poverty and climate change intersect significantly; the people whose health is being harmed first and most by climate change are the people living in poverty who are least able to protect themselves and their families (World Health Organization, 2016). The effects of climate change on individuals will depend on poverty levels, geographic location, educational level, health status, health and general infrastructure and the robustness of the economy (UNDESA, 2020). Escalating temperatures, air pollution, extremes of precipitation and more frequent natural disasters are directly and indirectly (e.g. food and water insecurity, air- and water-borne diseases, forced migration) implicated in the incidence, development, and exacerbation of communication and swallowing disorders (Sherratt, 2022).

Poverty, communication and swallowing disorders through the life cycle

Poverty at every stage of life is associated with the onset and exacerbation of communication and swallowing disorders and it also affects assessment and treatment.

Pregnancy, birth and infancy

Issues in pregnancy and birth have known association with factors related to poverty. Weck, Paulose, and Flaws (2008) found that preterm birth, low birth weight and intrauterine growth restriction are strongly linked to factors associated with poverty (poor nutrition, inadequate prenatal care, infections, level of home and air pollutants, maternal education level, exposure to stress, prenatal heat exposure, heavy metal and pesticide exposure). Babies born prematurely or of low birth weight may have an increased risk of autism, developmental communication and swallowing disorders, cerebral palsy, cognitive delays and attention deficit hyperactivity disorders, as well as feeding and swallowing difficulties (Clark & Sand-Loud, 2018).

Furthermore, poverty-related factors in prenatal development and childhood have been increasingly related to adverse health outcomes later in later life and are a strong predictor of heart disease, hypertension and stroke in adulthood (Raphael, 2011; Weck et al., 2008), with the associated risks of aphasia, apraxia, dysarthria and dysphagia. The risks linked with childhood poverty and social inequality may also affect memory and cognition in midlife and older adults (Trani, Moodley, Maw, & Babulal, 2022).

Childhood

Early adversity due to poverty has profound consequences for speech and language development and school readiness. These poverty-related factors are both home-based (maternal education, access to resources and experiences, quality of parent-child interaction, caregiver distress and depression, nutritional deficiencies, indoor pollution from cooking fuel) and community-based (access to clean water and sanitation, food insecurity, air pollution, community resources, educational spending levels, healthcare facilities, crime and violence) (Justice et al., 2019; Romeo et al., 2018; Sania et al., 2019). The effects of poverty on children’s language skills are apparent as early as two years of age, with a one standard deviation difference to those children in advantaged homes (Justice et al., 2019). Researchers have found that poverty-related factors (low birth weight, premature birth, access to health care and education, community-level resources) were associated with an increased risk of autism spectrum disorders (King & Bearman, 2011; Midouhas, Yogaratnam, Flouri, & Charman, 2013).

The effects of childhood poverty on language development are life-lasting. In the school years, poverty may lead to learning delays and disorders, school dropout, school failure, diminished cognitive processing, impaired self-regulation skills, reduced behavioural control and deficits in motor and visuo-spatial abilities (Radesky, Carta, & Bair-Merritt, 2016; Sania et al., 2019). Disparities in language may increase across the educational years and have lifelong social and economic consequences. Language difficulties may affect career prospects (and therefore income), social relationships and mental health and are associated with early pregnancy, early marriage, substance abuse, antisocial behaviour and poorer health (Larson, 2007; Ribeiro et al., 2022; Shaw, Mendelsohn, & Morris, 2021).

Childhood communication and swallowing disorders incur significant healthcare costs, both to families and to government (Le et al., 2017; Sciberras et al., 2015). Patterns of service utilisation varied by child age, with up to 21% of Australian families of children with communication and swallowing disabilities accessing health services, with an annual cost ranging between A$612 to A$992 (Le et al., 2017). Access to services also depends on families’ capacity to pay, waiting times and availability of services (Le et al., 2020). Costs, availability and access to health care in general and specifically speech-language pathology makes treatment mostly impossible for those living in poverty and in least developed countries (Wylie, McAllister, Davidson, & Marshall, 2018). Also, indirect costs (related to employment and workforce participation) are estimated to equate to a lifetime cost of A$21.677 (US$14.28) billion for these children in Australia (Cronin, Reeve, McCabe, Viney, & Goodall, 2020).

Adulthood

In addition to early experiences, poverty and the related environmental factors are associated with communication and swallowing disorders in adulthood. The incidence of stroke is rising in least developed countries, which have 86% of global stroke deaths and almost seven times higher burden of disability adjusted life years (Feigin et al., 2021). Individuals living in poorer regions have a higher risk of stroke and were twice as likely to have a severe stroke (Lloyd-Sherlock, 2010). Not only do these individuals have limited access to health care, their access to rehabilitation is often minimal; the World Health Organization estimates that there are fewer than 10 rehabilitation practitioners per million people in least developed countries (World Health Organization, 2017) and speech-language pathology services are sparse (Sherratt, 2021; Wylie et al., 2018).

Poverty is also implicated in other communication and swallowing disorders in adulthood. The incidence of laryngeal cancer (laryngectomy, voice disorders, dysphagia) is higher in lower-income and low educational level populations (Markou et al., 2013). At least 60% of individuals with all-cause dementia live in least developed countries where these adults have a higher level of multidimensional poverty (Trani et al., 2022). Exposure to pollution, extreme heat and infectious diseases and pesticides make those living in poverty at risk of dementia, Parkinson’s disease, stroke and cognitive decline (Sherratt, 2022). Reduced access to health care means that many individuals living in poverty do not receive the necessary or appropriate treatment for stroke, hearing loss, cancer and other communication and swallowing disorders.

The role of speech-language pathology

The facts about poverty and its association with communication and swallowing disorders can be overwhelming for the speech-language pathology profession with its dominant focus on traditional therapeutic management rather than prevention. However, prevention is reflected in the breadth of professional practice of speech-language pathology (American Speech-Language-Hearing Association, 2016; Speech Pathology Australia, 2015) and is an integral part of other health services (Shaw et al., 2021). Increasing the focus of services on prevention depends on placing it more prominently within the continuum of service delivery. The most effective health care systems offer a balance between both prevention and clinical treatment (Wylie et al., 2014). With increasing caseloads and restricted budgets, our profession will need to adopt a public health framework to maintain its relevance (Law et al., 2013). Central to this framework is an understanding of the social and environmental determinants underpinning health and the need for equity in health services.

Considering poverty is a known and established determinant of communication and swallowing disorders across the lifespan, the most potent plan of action is to focus on preventing and ameliorating poverty-related communication and swallowing disabilities in children. Various early intervention programs focussing on child communication and swallowing disorders have been implemented globally, with many having a positive effect (e.g. see Davies et al., 2021; Law et al., 2017). The following challenges are a call to action to speech-language pathologists.

The first and most important action is to engage with and recruit colleagues to become better informed on the nature and long-term effects of poverty on communication and swallowing disorders, associated healthcare costs and potential prevention strategies, and to use this knowledge to advocate for prevention-related action from relevant organisations as well as local and national health departments (American Speech-Language-Hearing Association, 2022). Speech-language pathologists could work alongside charities that focus on global poverty-related issues to assist them to raise awareness and potentially garner additional funding. Empowering speech-language pathologists to provide key messages and information could support the incorporation of a more holistic public health approach to communication and swallowing disorders, with an emphasis on prevention, within professional associations (Law et al., 2013). Speech-language pathologists can participate in community engagement with, and advocate for, the implementation of high-quality early education opportunities to children affected by poverty and/or their parents (Davies et al., 2021; Elmquist et al., 2021). Those who teach or mentor student speech-language pathologists have the opportunity to extend the integration of principles of public health into their educational programs (McAllister et al., 2013; Wylie et al., 2014).

Research is needed to more closely establish the links between specific poverty-related factors and communication and swallowing disability. Additional analyses could determine the efficacy and cost-effectiveness of prevention of child communication and swallowing disabilities compared to treatment. There is a significant need to develop, test and ascertain which early intervention programs are more effective in which populations and who can be trained to implement them. Research is also required to determine population needs and service availability in all countries (McAllister et al., 2013) and to ascertain service utilisation and healthcare costs for communication and swallowing disorders associated with poverty.

Summary and conclusion

Poverty is a known and major determinant of communication and swallowing disorders, many of which arise from its effect on pregnancy and early childhood. The focus of our efforts should be on the prevention and amelioration of poverty and thereby its substantial effects on communication and swallowing disorders over the lifespan. Speech-language pathology has a pivotal role in advocating for and integrating public health initiatives in communities where poverty persists.

Declaration of interest

The author reports no conflicts of interest. The author alone is responsible for the content and writing of this article.