Patients living in poverty can pose a challenge to medical professionals: Some go off their medication, others fail to report to physical therapy, many struggle to lose weight. To truly serve low-income patients, doctors and nurses have to do more than diagnose an illness. They must consider the factors that will help or hinder a patient’s ability to stick with a prescribed treatment.

“Poverty impacts decisions that we make,” said Adelita Cantu, associate professor in the School of Nursing at UT Health. She teaches population-focused health, which explores the social determinants of health.

Some diseases, such as diabetes, are more common in high-poverty populations. Stress and lack of healthy food options also contribute to illness and disease. Preventable illness, Cantu explained, is contextual, and income is a significant predictor of disease risk.

Once a semester, Cantu’s nursing students take on the roles of widows, teen parents, disabled workers, and single parents in an exercise designed to give them a glimpse into the lives of people struggling to make ends meet. Cantu wants them to see how scarcity of resources and compounding emergencies can make people in poverty more likely to become sick and less likely to adhere to a treatment plan.

“This clearly shows you how health becomes a lower priority” among low-income people, Cantu said.

The Missouri Community Action Poverty Simulation helps healthcare professionals understand the challenges low-income people face and the decisions they make as a result. This understanding can aid in building trust and cooperation between provider and patient, and can ultimately save lives.

“I don’t think we’re doing a good job if we don’t help our students understand the multitude of factors that are driving people into the sick role,” Cantu said.

In the role-playing exercise that began Jan. 9, students were divided into “families” of up to five members, their “homes” made up of an arrangement of folding chairs. Tables representing a grocery store, community services, a public school, a generic “employer,” a homeless shelter, and a jail lined the perimeter of the room. These community resources also included some common in low-income neighborhoods, like a pawn shop and a quick-loan office. 

The simulation covered four 15-minute “weeks” with a break in between so students could regroup. Along with their identities, “family members” were given a packet that contained items representing their cash, home goods, and transportation passes that represented the money and time necessary to get from place to place. In order to get from the school to work, for example, students had to use a transportation pass.

The first lesson learned was that money is not the only scarce resource among low-income people. Time is equally valuable.

Students in the role-playing exercise hurry to the job placement booth and line up and pay vital bills.
Students in the role-playing exercise hurry to the job placement booth and line up and pay vital bills. Credit: Scott Ball / San Antonio Report

When the whistle blew to start the first “week,” students got up and walked casually to their destinations. Lines formed. Resource characters, played by UT Health Science Center faculty, told students that they didn’t have proper paperwork. In some situations they gave students the run-around and created small bureaucratic nightmares.

By the second round, “week two,” students sprinted from their chairs when the whistle blew.

By week two, a growing number of participants populated the holding area for students taken from their homes. Brandy Gomez, 34, played the role of an 8-year-old who was left at home by mistake. Sydney Parker, 28, played a 9-year-old who regularly stayed home to watch her 1-year-old nephew. Parker’s family spent all of week two trying to get her back. 

“We went to social services, but they weren’t helpful,” said Alejandra Marquez, who played Parker’s 20-year-old single mother.

Trying to get her child back, Marquez had not had time to pay the bills, so now the family was scrambling.

As they faced the mounting pressure of time, the exercise also showed students how crime disproportionately affects people in poverty. Several students were mastering the simulation until a thief, played by Braulio Amazaga, stole their money, car titles, or home goods.

The simulation also showed how the elderly, a population the nursing students will serve more than any other, are among the most vulnerable to crime.

Amazaga “robbed” Erin Webb, who was playing an 85-year-old widow. She couldn’t find a job, was evicted by week three, and had to move in with another family. Two other single senior citizen characters decided to get married, because they felt they were at risk of being robbed living alone.

Students sit in jail as Braulio Amazaga (left), who portrayed a thief, points to a victim of his recent crime.
Students sit in jail as Braulio Amazaga (left), who portrayed a thief, points to a victim of his recent crime. Credit: Scott Ball / San Antonio Report

The exercise also showed how public and private institutions inadvertently contribute to the difficult choices people in poverty are forced to make. A school holiday meant families had to spend extra transportation passes to keep their school-age children with them. For patients, this might mean canceling medical appointments.

 At the pawn shop, “Big Dave,” played by Cantu’s husband John, shuffled through a pile of microwave, television, and stereo cards he had accumulated from students needing quick cash. “In real life, people do that,” he said.

Students soon realized how quick-cash options are necessary to meet urgent needs, but over time leave families with fewer resources. Prescription medicines, physical therapy, and preventive care start to seem like luxuries. 

UT Health staff turn over chairs, symbolizing students being evicted.
UT Health staff turn over chairs, symbolizing students being evicted. Credit: Scott Ball / San Antonio Report

By the fourth and final “week”, most families were behind on their bills. The game account keepers began “evicting” families by turning over their chairs. The homeless shelter only had a few available chairs left.

Guy Ferguson, 46, played a 57-year-old stroke victim whose family was evicted. Unable to help himself, he stood aside, homeless, while waiting for the exercise to end.  

“People were saying that [the exercise] is not realistic, but I said, ‘No, I’ve known a lot of people who live like this,’” Ferguson said.

After the exercise ended, Cantu pointed out that seeing the strengths and weaknesses of their patients’ problem-solving abilities will help future nurses prescribe more successful treatments.

In the immediate future, the program will help raise awareness of the populations the students will serve during clinicals, which take place from now until April. During the clinicals, students will be asked to reflect on the role-playing exercise and how it connected to real experiences with their patients.

Cantu believes the exercise gives students valuable insights, so valuable, in fact, that first-year medical students are participating in their own poverty simulation exercise.

Bekah McNeel is a native San Antonian. You can also find her at her blog,, on Twitter @BekahMcneel, and on Instagram @wanderbekah.