Relationships Between Material
Hardship, Resilience, and Health
Anne E. Fuller, MD, MS,a,bArvin Garg, MD, MPH,cNicole M. Brown, MD, MPH, MHS,bYorghos Tripodis, PhD,d Suzette O. Oyeku, MD, MPH,bRachel S. Gross, MD, MSe,f
BACKGROUND:Material hardship has been associated with adverse health care use patterns for
children with special health care needs (CSHCN). In this study, we assessed if resilience factors were associated with lower emergency department (ED) visits and unmet health care needs and if they buffered associations between material hardship and health care use for CSHCN and children without special health care needs.
METHODS:A cross-sectional study using the 2016 National Survey of Children’s Health, restricted
to low-income participants (,200% federal poverty level). Separately, for CSHCN and children without special health care needs, weighted logistic regression was used to measure
associations between material hardship, 2 resilience factors (family resilience and
neighborhood cohesion), and 2 measures of use. Moderation was assessed using interaction terms. Mediation was assessed using structural equation models.
RESULTS:The sample consisted of 11 543 children (weighted:n= 28 465 581); 26% were
CSHCN. Material hardship was associated with higher odds of ED visits and unmet health care needs for all children. Resilience factors were associated with lower odds of unmet health care needs for CSHCN (family resilience adjusted odds ratio: 0.58; 95% conﬁdence interval: 0.36–0.94; neighborhood cohesion adjusted odds ratio: 0.53; 95% conﬁdence interval: 0.32–0.88). For CSHCN, lower material hardship mediated associations between resilience factors and unmet health care needs. Neighborhood cohesion moderated the association between material hardship and ED visits (interaction term:P= .02).
CONCLUSIONS:Among low-income CSHCN, resilience factors may buffer the effects of material
hardship on health care use. Future research should evaluate how resilience factors can be incorporated into programs to support CSHCN.
WHAT’S KNOWN ON THIS SUBJECT:For children with special health care needs (CSHCN), material hardship is associated with more emergency department visits and greater unmet health care needs, leading to higher health care costs, and potentially reﬂecting poorer child health.
WHAT THIS STUDY ADDS:Resilience factors, including high family resilience and neighborhood cohesion, were unique buffers in the setting of material hardship for CSHCN only. Resilience factors could be considered in designing programs to support CSHCN.
To cite:Fuller AE, Garg A, Brown NM, et al. Relationships Between Material Hardship, Resilience, and Health Care Use.Pediatrics. 2020;145(2):e20191975
aDivision of Paediatric Medicine, Department of Paediatrics, Hospital for Sick Children, University of Toronto,
Toronto, Ontario, Canada;bDivision of Academic General Pediatrics, Department of Pediatrics, Albert Einstein
College of Medicine, Children’s Hospital at Monteﬁore, Bronx, New York;cDivision of General Pediatrics,
Department of Pediatrics, Boston Medical Center and Boston University School of Medicine, Boston, Massachusetts;dDepartment of Biostatistics, School of Public Health, Boston University, Boston, Massachusetts; e
Division of General Pediatrics, Department of Pediatrics, School of Medicine, New York University and New York City Health and Hospitals/Bellevue, New York, New York; andfDepartment of Population Health, School of
Medicine, New York University, New York, New York
Dr Fuller conceptualized and designed the study, conducted the analyses, and drafted the initial manuscript; Drs Garg and Oyeku conceptualized and designed the study; Drs Brown and Gross conceptualized and designed the study and reviewed the analyses; Dr Tripodis assisted on the analyses and reviewed the analyses; and all authors reviewed and revised the manuscript, approved theﬁnal manuscript as submitted, and agree to be accountable for all aspects of the work.
Poverty is a well-established cause of adverse child health outcomes.1 Material hardship, deﬁned as difﬁculty meeting basic needs, including food, shelter, and utilities,2 is a poverty-related risk that can have negative effects on child health extending beyond income.3–8In addition, special health care needs can add further risk. Children with special health care needs (CSHCN) are deﬁned as children who have a chronic physical, developmental, behavioral or emotional condition and require health care services beyond what is typically required.9 Overall, 20% of children in the United States have special health care needs.10Families of CSHCN face increasedﬁnancial burdens,11and CSHCN may be particularly
vulnerable to the effects of material hardship.
Despite having multiple risk factors, including material hardship and special health care needs, some children have positive, resilient outcomes. Resilience is deﬁned as
“positive adaptation in the context of signiﬁcant risk or adversity.”12 Family- and neighborhood-level resilience factors have been shown to promote better health outcomes for children with a variety of special health care needs, with a focus on condition-speciﬁc outcomes.13To our knowledge, no studies to date have examined resilience factors for a broader scope of chronic health conditions or speciﬁcally compared CSHCN and children without special health care needs (N-CSHCN).
Broadening the scope of conditions is important, given that children with diverse medical and social risks show greater health care use overall.14,15 There is evidence that CSHCN reporting material hardships have higher rates of emergency
department (ED) visits and greater unmet health care needs.16Research examining resilience factors that may promote optimal health care use among children with and without
special health care needs is limited. Toﬁll these gaps, we sought to determine if low-income children with and without special health care needs have similar rates of material hardship and resilience factors and if there were different associations between resilience factors and health care use, including ED visits and unmet health care needs. To assess whether resilience factors act as buffers in the setting of material hardship, we investigated whether associations between resilience factors and health care use were related to material hardships. We hypothesized that resilience factors would mitigate the effects of material hardship and be associated with fewer ED visits and lower unmet health care needs. This may occur directly by reducing material hardship (through mediation) or indirectly by reducing the
consequences of material hardship (through effect modiﬁcation).
We conducted a cross-sectional study using the 2016 National Survey of Children’s Health (NSCH)10to measure differences in risk and resilience factors between children with and without special health care needs and to investigate whether resilience factors at the family and neighborhood level could promote optimal health care use.
Data Source and Study Sample
The NSCH is a population-based survey of parents or primary caregivers about child health and use of health services as well as family and community characteristics. Details of the design and
implementation of this survey are available through the Maternal Child Health Bureau: https://mchb.hrsa. gov/data/national-surveys/data-user.17The database consists of ∼50 212 children aged 0 to 17.10This is a publicly available national data set administered by the Census
Bureau on behalf of the National Center for Health Statistics, Centers for Disease Control and Prevention. All data were collected in the NSCH.
Our study included CSHCN and N-CSHCN who have complete survey data for the main study variables. Given low rates of material hardship in participants who did not report low income (11.9% compared with 41.8% of low-income participants), we restricted our sample to children with a family income of,200% of the federal poverty level.18The Albert Einstein College of Medicine Institutional Review Board found the study exempt from human subject review.
Special health care needs status was deﬁned using the 5-item screener (CSHCN Screener) from the National Center for Health Statistics.10This screener is used to address functional limitations or need for services due to a medical condition. The questions ask if the child (1) receives
prescription medication; (2) receives more medical care, mental health care, or educational services than is usual for a child their age; (3) is limited in their ability to do the things most children of the same age can do; (4) needs or gets special therapy; or (5) has any kind of emotional, developmental, or behavioral problem for which he or she needs treatment.9A second subset of questions inquires if this is related to any medical, behavioral, or mental health condition and if the problem is expected to last for.12 months. Afﬁrmative responses to any of the questions along with the associated subquestions indicated a CSHCN.
food or housing?”This single question, included in the survey as a measure of adverse childhood experience,19was selected because it reﬂects the deﬁnition of material hardship and speciﬁcally mentions the most commonly studied material hardships: food and housing
insecurity. Responses included never, rarely, somewhat often, or very often. We created a dichotomous variable deﬁned as never or rarely versus somewhat often or very often.
Family resilience was measured by using 4 questions:“When your family faces problems, how often are you likely to do each of the following: (1) talk together about what to do, (2) work together to solve our problems, (3) know we have strengths to draw on, (4) stay hopeful even in difﬁcult times.”Responses were measured via a 4-point Likert scale, with responses of none of the time, some of the time, most of the time, or all of the time. We created a 3-category variable on the basis of the NSCH codebook from the Data Resource Center for Child and Adolescent Health,10and then for our analysis, we dichotomized the variable, deﬁning high family resilience as a response of most or all of the time to all 4 questions.
Neighborhood cohesion was measured by using 3 questions:“To what extent do you agree with these statements about your neighborhood
or community: (1) people in this neighborhood help each other out, (2) we watch out for each other’s children in this neighborhood, and (3) when we encounter difﬁculties, we know where to go for help in our community.” Responses were measured on a 4-point Likert scale, with responses of deﬁnitely agree, somewhat agree, somewhat disagree, or deﬁnitely disagree. We created a dichotomous variable on the basis of the NSCH codebook, deﬁning high neighborhood cohesion as children whose parents reported“deﬁnitely agree”to at least 1 item and at least
“somewhat agree”or“deﬁnitely agree”to the other 2 items.
Our dependent variables were 2 measures of health care use: ED visits and unmet health care needs. ED visits were measured by using the following question:“During the past 12 months, how many times did this child visit a hospital emergency room?”A dichotomous variable was created, deﬁned as no visits or$1 visit. Unmet health care needs were measured by using the following question:“During the past 12 months, was there any time when this child needed health care but it was not received?”A dichotomous variable was created, deﬁned as no unmet need or any unmet need.
Child and parent sociodemographic characteristics were collected in the NSCH. For children, these were age (years), sex, race and ethnicity (non-Hispanic white, non-(non-Hispanic African American, Hispanic or Latino, or other), and insurance type (public only, private only, combination of public and private, uninsured, and other). For parents, these were age (years), education (high school, more than high school), any parent working (no, yes), and parent marital status (married, single).
We used descriptive statistics to calculate means and proportions of characteristics of our study population. We usedx2tests for categorical variables and Mann-Whitney tests for continuous variables, because these were not normally distributed, to compare CSHCN and N-CSHCN with respect to each resilience factor, material hardship, and health care use outcome as well as study covariates. We also tested bivariate relationships between our independent and dependent variables. We used logistic regression models to measure associations between independent and dependent variables and special health care needs status. We then used logistic regression models to measure associations between material hardship as our independent FIGURE 1
variable and each health care use outcome as the dependent variable, with separate models for CSHCN and N-CSHCN. We developed similar models for each resilience factor as the independent variable. Finally, we created a set of models including each resilience factor and material hardship. For these models, we tested
for effect modiﬁcation using interaction terms and stratiﬁed models by the resilience factor for those with interaction termP,.05. If there was no evidence of effect modiﬁcation, we examined for evidence of mediation, which we suspected when there was
a statistically signiﬁcant association
between a resilience factor and the outcome, between material
hardship and the outcome, and between the resilience factor and material hardship. All logistic regression models were adjusted for child age, sex, insurance type, and ethnicity and parent age, education, employment status, and marital status. We tested for mediation using generalized structural equation models with linearized coefﬁcients,20adjusting for covariates that were signiﬁcantly associated with outcomes in logistic regression models. Figure 1
summarizes the analysis plan. Established survey weights from the National Center for Health Statistics were used for all analyses.
Signiﬁcance was assessed at a 2-tailedaof .05. Statistical analyses were performed using Stata (v 14.2, College Station, TX).21
Our study sample consisted of 11 543 children, representing an estimated 28 465 581 children in the United States with household income
,200% of the federal poverty level. Of these, 2998 (26%) screened positive for special health care needs. Table 1 shows sample characteristics. Compared with those without special health care needs, CSHCN were more likely to be male, have public health insurance, and to have parents report that they are not employed or that there is no parent working outside the home.
Material Hardship, Resilience Factors, and Health Care Use for N-CSHCN and CSHCN
After adjustment for covariates, CSHCN reported higher odds of material hardship (odds ratio [OR]: 1.61; 95% conﬁdence interval [CI]: 1.35–1.94) and lower odds of both family resilience and neighborhood cohesion (OR: 0.76; 95% CI:
TABLE 1Participant Characteristics
Full Sample CSHCN Status
n= 11 543 (Weighted
n= 28 465 581)
N-CSHCN (n= 8545)
CSHCN (n= 2998)
n(Weighted %) n(%) n(%)
Age in y, median (IQR) 9 (5–14) 9 (4–13) 11 (7–15) Sex
Male 5904 (50.7) 4198 (49.1) 1706 (56.9)
Female 5639 (49.3) 4347 (50.9) 1292 (43.1)
Non-Hispanic white 6573 (37.0) 4774 (55.9) 1799 (60.0) Non-Hispanic African American 1247 (18.4) 861 (10.1) 368 (12.9)
Hispanic 2176 (35.1) 1716 (20.1) 460 (15.3)
Other 1574 (9.5) 1194 (13.9) 353 (11.8)
Public insurance only 5957 (58.9) 4160 (48.9) 1797 (59.9) Private insurance only 3837 (22.6) 3118 (36.5) 719 (24.0) Public and private 823 (6.8) 537 (6.3) 286 (9.5)
Uninsured 762 (9.6) 603 (7.1) 159 (5.3)
Other or not speciﬁed 164 (2.1) 127 (1.5) 37 (1.2) Parent
Parent age in y, median (IQR) 39 (32–47) 39 (32–47) 41 (34–49) Parent education
High school or less 4585 (43.0) 3403 (39.8) 1182 (39.4) Some college or more 6958 (57.0) 5142 (60.2) 1816 (60.6) Any parent working
No 2112 (20.1) 1324 (15.5) 788 (26.3)
Yes 9431 (79.9) 7221 (84.5) 2210 (73.7)
Parent marital status
Married 7740 (66.0) 5976 (69.9) 1764 (58.8)
Single 3803 (34.0) 2569 (30.1) 1234 (41.2)
Main study variables Material hardship
Somewhat or very often 4908 (41.3) 3233 (37.8) 1675 (55.9) Never or rarely 6635 (58.7) 5312 (62.2) 1323 (4431) High family resilience
Yes 8660 (74.0) 6590 (77.1) 2070 (69.1)
No 2883 (26.0) 1955 (22.9) 928 (30.9)
High neighborhood cohesion
Yes 5816 (55.4) 4492 (57.6) 1324 (44.2)
No 5727 (44.6) 4053 (47.4) 1674 (55.8)
Any ED visit
Yes 2763 (26.4) 1758 (20.6) 1005 (33.5)
No 8780 (73.6) 6787 (79.4) 1993 (66.5)
Any unmet health care need
Yes 508 (5.0) 230 (2.7) 278 (9.3)
No 11035 (95.0) 8315 (97.3) 2720 (90.7)
0.63–0.92 and OR: 0.73; 95% CI: 0.61–0.87, respectively) compared with N-CSHCN. CSHCN were also more likely to report an ED visit (OR: 2.24; 95% CI: 1.83–2.71) or an unmet health care need (OR: 4.25; 95% CI: 3.05–5.94) compared with N-CSHCN (Table 2).
Resilience Factors and Health Care Use
Direct associations between resilience factors and use for N-CSHCN and CSHCN examined separately are found in Table 3. The only direct associations were found for CSHCN and unmet health care needs. CSHCN who reported high family resilience and neighborhood cohesion had lower odds of unmet health care needs (OR: 0.58; 95% CI: 0.36–0.94 and OR: 0.53; 95% CI: 0.32–0.88, respectively).
Resilience Factors, Material Hardship, and ED Visits
Material hardship was associated with higher odds of an ED visit for both N-CSHCN (OR: 1.54; 95% CI: 123–1.93) and CSHCN (OR: 1.37; 95% CI: 1.02–1.87) (Table 3). We found evidence of effect modiﬁcation of
the association between material hardship and ED visits by neighborhood cohesion among CSHCN only (interaction term:P= .02). We therefore stratiﬁed this model and found that material hardship was associated with higher odds of ED visits only among those with low neighborhood cohesion (OR: 1.75; 95% CI: 1.17–2.6) and was nonsigniﬁcant for those with high neighborhood cohesion (OR: 0.94; 95% CI: 0.62–1.42) after adjustment.
Resilience Factors, Material Hardship, and Unmet Health Care Needs
Material hardship was associated with higher odds of unmet health care needs for both N-CSHCN (OR: 3.14; 95% CI: 1.86–5.32) and CSHCN (OR: 2.71; 95% CI: 1.52–4.85) (Table 3). We found no evidence of effect modiﬁcation of this association by resilience factors. Path analysis was used to investigate whether lower material hardship mediated the association between resilience factors and lower unmet health care needs. Figure 2A demonstrates the associations between family resilience, material hardship, and
unmet health care needs. Four standard criteria for mediation were met: (1) higher family resilience is associated with lower unmet health care needs, (2) higher family resilience is also associated with lower material hardship, (3) material hardship is associated with higher unmet health care needs, and (4) the association between family resilience and unmet health care needs is attenuated after adjustment for material hardship (indirect effect coefﬁcient:20.01;P= .01). Figure 2B demonstrates similar associations for neighborhood cohesion (indirect effect coefﬁcient:20.01;P= .008).
In this study of low-income parents of children with and without special health care needs, we found that parents of CSHCN were more likely to report material hardship, less likely to report resilience factors, and more likely to report an ED visit or unmet health care need. However, although material hardship was associated with adverse health care use patterns for all children,resilience factors were related to better outcomes only for CSHCN. Among CSHCN, the association between material hardship and ED visits was moderated by neighborhood cohesion: this association was found only for CHSCN with low
neighborhood cohesion. In addition, associations between both resilience factors and unmet health care needs were partially mediated by lower material hardship for CSHCN. Part of the association between resilience factors and lower unmet health care
TABLE 2Comparing CSHCN to N-CSHCN: Material Hardship, Resilience Factors, and Health Care Use CSHCNa
aORb 95% CI
Material hardship, yes 1.61 1.35–1.94
Family resilience, high 0.76 0.63–0.92
Neighborhood cohesion, high 0.73 0.61–0.87
ED visit,.1 2.24 1.83–2.71
Unmet health care need, yes 4.25 3.05–5.94
aCompared with N-CSHCN.
bAdjusted OR; adjusted for child age, sex, insurance type, and ethnicity and parent age, education, employment status,
and marital status.
TABLE 3Resilience Factors and Health Care Use
ED Visits Unmet Health Care Need
N-CSHCN CSHCN N-CSHCN CSHCN
aORa 95% CI aORa 95% CI aORa 95% CI aORa 95% CI
Material hardship 1.54 1.23–1.93 1.37 1.02–1.87 3.14 1.86–5.32 2.71 1.52–4.85 Family resilience 0.96 0.74–1.25 1.01 0.72–1.41 0.86 0.48–1.12 0.58 0.36–0.94 Neighborhood cohesion 1.06 0.85–1.32 0.76 0.55–1.04 0.80 0.42–1.54 0.53 0.32–0.88
needs was through reduced material hardship.
Even in the setting of multiple risks, we identiﬁed family and
neighborhood resilience factors associated with better health care use outcomes for CSHCN. The
mechanisms of these factors are likely varied. Supports may be material (such as child care), emotional (reducing stress), or informational (such as resource navigation),22and resilience factors likely provide support in multiple ways. Our study broadens previous research that is condition speciﬁc, showing that family and community factors were associated with better child health outcomes in studies investigating speciﬁc conditions, including attention-deﬁcit/hyperactivity disorder,23autism,24diabetes,25and mental illness.26By demonstrating differences between CSHCN and N-CSHCN, this study adds to our understanding of possible
mechanisms of these protective factors. In the setting of special health care needs, families may engage in recruiting supports through family interactions or seeking neighborhood resources, and so these factors are more active. Because there is greater adversity, there may be greater opportunity for resilience factors to have effects.
We found that neighborhood cohesion modiﬁed the association between material hardship and ED visits, whereas for unmet health care needs, reduced material hardship mediated the effects of family resilience and neighborhood cohesion. One notable difference between the 2 outcomes is that ED visits may be a more-concrete reﬂection of the child’s medical condition, whereas unmet health care needs may be addressed by increasing access to resources. There may be factors associated with high neighborhood cohesion that are
associated with better child health, or families living in more-cohesive neighborhoods may have access to health care resources that mitigate the need for ED visits. Resilience factors may provide access to more material resources, directly reducing material hardships. Alternatively, there may be unmeasured shared characteristics of families with high resilience factors that are also associated with lower material hardship and reduced unmet health care needs.
This study has important implications for better understanding the
mechanisms of risk and resilience factors for children with and without special health care needs with respect to health care use, a potentially important marker of health status. Understanding these implications can help inform interventions that capitalize on family and
Interventions that actively bolster family strengths while working concomitantly on addressing challenges have shown promise in improving child outcomes. Examples include the Incredible Years program and The Family Check-Up, which address the roles of risk and protective factors, and have shown better behavioral health outcomes for children in low-income families.27,28 These interventions are parenting focused and likely improve family resilience, so they potentially could be applied to broader special health care needs, although tailored interventions may be needed for different conditions. A
comprehensive literature review revealed that community development programs, such as rental assistance, neighborhood watch programs, and access to child care, can improve child health.29 However, few interventions directed at CSHCN intervene at the
neighborhood level, which could optimize scalability and reach. FIGURE 2
This study had several strengths. This was a nationally representative data set with a large sample size. We identiﬁed factors at the family and neighborhood level that may promote more optimal health care use outcomes. It is possible that this was through directly reducing material hardship or through other pathways. More research is needed to better understand the mechanisms of these associations. However, our study had several limitations. We restricted our sample to participants reporting low income, soﬁndings may not be generalizable to other groups. In future studies, researchers could consider comparing low-income children to those who are not low income. We also did not distinguish between different types of special health care needs, and so it is possible that there are differential effects on
these subgroups that were not identiﬁed. This study relied on self-reported data. Measures should be comparable to other studies using the NSCH but were not validated instruments. This was a cross-sectional study, and so we cannot infer direction of relationships. Finally, the constructs examined are complex, and there are likely other important factors involved that have not been measured.
In summary, in this study of low-income CSHCN and N-CSHCN, we found that resilience factors,
speciﬁcally high family resilience and neighborhood cohesion, were related to better health care use outcomes in the setting of material hardship for CSHCN only. Theseﬁndings indicate
an important opportunity for further research examining how these resilience factors and other strengths of families of CSHCN can buffer the unique stressors they face and also point to an opportunity for clinicians to work with families to identify strengths and leverage these to promote better outcomes for vulnerable children.
CI: conﬁdence interval CSHCN: children with special
health care needs ED: emergency department N-CSHCN: children without special
health care needs NSCH: National Survey of
Children’s Health OR: odds ratio
Accepted for publication Oct 24, 2019
Address correspondence to Anne E. Fuller, MD, MS, Division of General Paediatrics, Department of Paediatrics, Hospital for Sick Children, University of Toronto, 555 University Ave, Toronto, ON M5G 1X8, Canada. E-mail: email@example.com
PEDIATRICS (ISSN Numbers: Print, 0031-4005; Online, 1098-4275).
Copyright © 2020 by the American Academy of Pediatrics
FINANCIAL DISCLOSURE:The authors have indicated they have noﬁnancial relationships relevant to this article to disclose.
FUNDING:Supported by the National Institutes of Health and National Center for Advancing Translational Science Einstein-Monteﬁore Clinical Translational Science Award (grant UL1TR001073). Funding sources had no role in the design, collection analysis or interpretation of data, or in the decision to submit for publication. Funded by the National Institutes of Health (NIH).
POTENTIAL CONFLICT OF INTEREST:The authors have indicated they have no potential conﬂicts of interest to disclose.
COMPANION PAPER:A companion to this article can be found online at www.pediatrics.org/cgi/doi/10.1542/peds.2019-3694.
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DOI: 10.1542/peds.2019-1975 originally published online January 16, 2020;
and Rachel S. Gross
Anne E. Fuller, Arvin Garg, Nicole M. Brown, Yorghos Tripodis, Suzette O. Oyeku
Relationships Between Material Hardship, Resilience, and Health Care Use
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DOI: 10.1542/peds.2019-1975 originally published online January 16, 2020;
and Rachel S. Gross
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Relationships Between Material Hardship, Resilience, and Health Care Use
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