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Healthy Families in Hard Times: Solutions for Multiple Family Hardships


June 2010

Executive Summary

Low-income families with young children often face what can seem like a never-ending cycle of hardships. Basic necessities, such as stable housing, heat, lights and enough nutritious food, can become competing demands that are endlessly traded off against one another. The current recession has only made things worse. For low-income households, hardships rarely occur in isolation. Families stretched to pay the rent often struggle to put nutritious food on the table. Those threatened with utility shut-off may have trouble paying the rent. Limited resources to meet basic household needs means constant juggling of the family budget. Often children in the family, especially the youngest, suffer most because their health is vulnerable to even the briefest experience of hardship.

Recent research by Children’s HealthWatch shows that very young children in families that experience multiple hardships — in this case, not enough nutritious food, inadequate or inconsistent access to utility service, and unstable housing — suffer negative health effects, many of which can have life-long consequences. Not surprisingly, as the number and severity of the hardships increase, so too do the risks to children’s health and development.

The research shows that nutrition, housing and utility support programs, such as SNAP (formerly food stamps), WIC, housing subsidies and utility assistance through the Low-Income Home Energy Assistance Program (LIHEAP), can be effective in offsetting some of the impact of these hardships. Compared to children in low-income families receiving no benefits, children in households receiving WIC, SNAP and a housing subsidy, with or without LIHEAP, were more likely to meet the criteria for being a “well” child, less likely to have been hospitalized since birth and less likely to be at risk for developmental delays. In short, these programs help protect young children against the worst impacts of multiple hardships.

As unemployment remains at record high levels, the number of families in need continues to grow. Children cannot wait for the recession to end. Their bodies and brains are growing now. Leadership in Congress is needed to move from a system in which each benefit program has different eligibility criteria, screening requirements and recertification procedures to an efficient system designed to improve the health of America’s most vulnerable children.

Measuring and Understanding the Impact of Hardship

Over the past decade, Children’s HealthWatch has monitored the impacts of material hardships and public policies on young children’s health using data collected from household-level surveys in five U.S. cities. Mothers of children under 36 months old are surveyed in hospital emergency departments and primary care clinics in Baltimore, Boston, Little Rock, Minneapolis, and Philadelphia. Data are collected on:

  • Food insecurity

    Families lack consistent access to sufficient healthful food for all family members to enjoy active, healthy lives.
  • Housing insecurity

    Families move frequently, crowd into living quarters that are too small, or double up with another family for financial reasons.
  • Energy insecurity

    Families lack consistent access to sufficient household energy (electricity, gas, heating oil) to ensure healthy and safe conditions in the home.

As of December 2009, 21 percent of the 33,588 families interviewed by Children’s HealthWatch over 10 years were food insecure, 27 percent were energy insecure and 41 percent were housing insecure. Our research has shown that each of these material hardships is associated with negative impacts on children including poor health, increased hospitalizations, iron deficiency anemia and increased risk for developmental delays.

We know these insecurities have real and costly implications for our country. Food insecurity, for example, increases the chances that a child will need special education, which doubles the cost of educating that child. Food insecurity has been found to be associated with a 13 percent drop in reading and math scores by third grade for those who are food insecure in kindergarten. Food insecure children have higher rates of mental health issues and a greater likelihood of exhibiting negative classroom behaviors.

To understand the impact of multiple hardships on children’s health, Children’s HealthWatch developed a multiple hardship index combining measures of food, energy and housing insecurity. Using the index, we found that a little more than one-third (37 percent) of our sample of low-income families experienced no hardship, more than half (57 percent) experienced moderate hardship, and a smaller percent (6 percent) experienced severe hardship. It is important to note that because the index measures the impact of three very specific categories of hardship — food, energy and housing insecurity — a finding of no hardship does not mean a family is not struggling. Rather it simply indicates they do not suffer any of these three particular hardships.

Our research found that family hardship varied by race, education, employment and whether the mother was born in the U.S. or not.


  • Whites had higher rates of no hardship than Blacks or Latinos.
  • Latinos had the highest rates of moderate and severe hardship.


  • Those with the least education (some high school or less) had the highest rates of hardship.


  • Those who were unemployed had higher rates of hardship than those who were employed.

U.S. born v. Non- U.S. born

  • Families in which the mother was not born in the U.S. had higher rates of hardship than those born in the U.S

Calculating a Family Hardship Score

Step 1

Families are assigned a score of 0, 1 or 2 for each component (food, energy and housing insecurity) depending on how they respond to a set of questions. They receive a score of 0 if they do not experience insecurity for that component, a score of 1 if they experience moderate insecurity for that component and a score of 2 if they experience it at a severe level.

Step 2

Their scores are summed across the three components to arrive at a total hardship score. A family’s level of hardship is then characterized by their total score.

  • A total score 0 - No Hardship
  • A total score of 1-3 - Moderate Hardship
  • A total score of 4-6 - Severe Hardship

Children Suffer When Families Experience Multiple Hardships

To better understand the impact of hardship on young children, we developed a composite indicator of child “wellness” based on children’s height and weight, health, history of hospitalizations and risk of developmental delay. We then looked at the association of hardship with wellness and found that higher hardship scores were associated with decreased odds of wellness. We also found that children in families suffering hardship are more likely to be at risk of developmental delay than children in families with no hardships.

Children with moderate hardship (v. those with no hardship) were:

  • 11% less likely to be classified as well
  • 21% more likely to be at risk for developmental delay

Children with severe hardship (v. those with no hardship) were:

  • 35% less likely to be classified as well
  • 120% more likely to be at risk of developmental delay 

Multiple Hardships Require Integrated Solutions

For most low-income families, the only real solution to long-term multiple hardships is employment that pays a livable wage and provides health benefits. As our research shows, those who were unemployed and those with the lowest levels of education were more likely to experience hardship. Unfortunately, children’s bodies and brains cannot wait for the economy to generate better-paying jobs. They are growing now and unless they receive the nutrition they need, many will suffer life-long health and development consequences. Given sustained high rates of unemployment, nutrition programs, such as SNAP and WIC, and programs that provide housing and home energy assistance are more critical than ever.

Public policies and public assistance programs exist to address each of the family hardships we examined. SNAP, WIC and other child nutrition programs are designed to address food insecurity and nutrition issues. Housing subsidies are designed to increase affordability and reduce housing insecurity. LIHEAP is designed to assist families struggling to pay utility bills. Unfortunately, these programs are too often planned and implemented in isolation.

Equally important, many families that are eligible for these benefits do not receive them. Few, if any, discretionary programs are funded at levels that allow them to reach the majority of eligible families. As shown in the chart below, only 9 percent of those eligible for public housing and only 15 percent of those eligible for Housing Choice (Section 8) vouchers receive them. Even in SNAP, which is an entitlement program, participation among eligible households is only 66 percent. 

National Participation Rates Among Eligible Households

Program Percentage of Eligible Households Participating 
Public Housing 9%
Housing Choice 15%
SNAP 66%

Can Multiple Benefits Offset the Impact of Multiple Hardships?

Because, as the research shows, these hardships often occur in combination, public assistance programs need to work together to support families more effectively. We know that individually, nutrition, housing and energy assistance programs are effective in offsetting individual hardships. What has not been looked at before now, however, is whether multiple benefits can offset the impact of multiple hardships.

Children’s HealthWatch examined the child health and development outcomes associated with four public assistance programs (SNAP, WIC, LIHEAP and housing subsidies). These outcomes included: wellness; fair/poor health; hospitalizations since birth; risk of underweight; risk of overweight; and risk of developmental delay. We found that among the low-income families monitored by Children’s HealthWatch, those that received any benefits were better off than those that received none, although not all the findings were statistically significant. For most outcomes, those receiving multiple benefits were markedly better off. Specifically, children in families receiving WIC, SNAP and a housing subsidy, with or without LIHEAP, benefitted the most. In comparison to those receiving no benefits, they were:

  • More likely to be classified as “well”
  • Less likely to have been hospitalized since birth
  • Less likely to be at risk for developmental delays


American public policy is crafted in silos yet the needs of our nation’s most vulnerable families and their young children cut across Congressional committees and administrative agencies. Families with very young children need more efficient access to the programs for which they are eligible. By strengthening individual programs and improving coordination across programs, we will improve the health of our nation’s youngest children.

Improve Access

  • Increase regular coordination across agencies such as Health and Human Services, the Departments of Agriculture, Housing and Urban Development, and Labor in order to better serve low-income families.
  • Streamline program access by expanding categorical eligibility and single point-of-entry programs and by increasing direct certification (cross-program automatic enrollment for eligible families). There should be ‘no wrong door’ for accessing benefits. Streamlining access and improving coordination will reduce administrative expenses.
  • Improve outreach and awareness to ensure that all families receive the benefits for which they are eligible.

Invest in Strong Nutrition Programs

  • Invest in a strong and well-funded reauthorization of child nutrition programs to ensure that the broadest spectrum of low-income children receive the high-quality nutritional assistance they need to be healthy.
  • Ensure that SNAP benefits are adequate to purchase a healthy diet. Research by Children’s HealthWatch in Boston and Philadelphia has shown that families receiving the maximum SNAP benefit in those cities in 2008 would have had to spend, on average, an additional $2,520 and $3,165, respectively, to purchase the government’s Thrifty Food Plan (the national standard for a nutritious diet at a minimal cost).

Expand Housing and Energy Assistance Programs

  • Expand the availability of housing subsidies which currently reach only a very small proportion of eligible families. Given the cost of housing, a housing subsidy can make a huge difference in a family’s financial situation. 
  • Increase funding for LIHEAP which currently reaches just 17 percent of eligible families.