The article by Fuller et al,1  which examines relationships between family material hardships, resilience, and suboptimal health care use, is a refreshing and constructive step forward in unpacking the relationship between family difficulties, ability to cope with those difficulties, and health care needs that both go unmet and are met through the less-desirable route of the emergency department (ED). Including children both with and without special health care needs, this article paves the way toward potential practical interventions to enhance family resilience and mitigate material hardships that could address the difficult problem of excessive ED use and, instead, point families toward care that meets their child’s needs in a more durable way.

In previous work,2  the authors added to the growing body of evidence3,4  linking material hardships with unmet health care needs and increased ED use for children with special health care needs (CSHCN). Here they go further, using data from the National Survey of Children’s Health to approach the following question: are these relationships affected by elements of family resilience and/or neighborhood support? Understanding these relationships might facilitate efforts to enhance resilience factors in addition to the more difficult work of alleviating material hardships.

The study defined material hardship as families having difficulty covering basic needs with their current income. It examined 2 aspects of resilience: family resilience, defined as talking and working together to solve problems, acknowledging a family’s own strengths, and staying hopeful; and neighborhood support, defined mainly by mutual assistance in times of need. Not surprisingly, it found that families of CSHCN were more likely to report material hardship; unfortunately, they were also less likely to report family resilience and neighborhood cohesion.

The outcomes of the study were parent report of unmet health care needs and the number of ED visits in the preceding 12 months. Again, it was no surprise to find that families of CSHCN reported higher odds of having unmet needs and more ED visits and that material hardship was associated with more ED visits for both CSHCN and non-CSHCN. Adding resilience factors to the mix, however, revealed some interesting relationships. In fact, although resilience factors were not associated on their own with decreased ED use for CSHCN, increased neighborhood cohesion negated the effect of material hardship on increased ED use. This relationship did not hold true for non-CSHCN.

Unmet health care needs had a different pattern. Both high family resilience and high neighborhood support were protective against unmet health care needs among families of CSHCN. Material hardship was associated with increased unmet needs among both CSHCN and non-CSHCN. Resilience factors did not modify this pattern, but both family resilience and neighborhood support partially mediated the association between CSHCN and unmet needs through reducing material hardship.

This study is unusual among secondary data analyses in that it points toward solutions to problems in addition to identifying the problems themselves. The new ideas here are that (1) enhancing resilience may contribute to more appropriate health care use generally and that (2) neighborhood support can play a role, specifically in decreased use of the ED. The authors speculate that the difference in the effect of resilience factors between the 2 outcomes might be due to ED visits being a more concrete reflection of the child’s medical condition, whereas unmet health care needs is more of a longer term problem with access to resources. If this is true, interventions to enhance resilience, such as strength-based approaches to care, and to promote community cohesion and resource connections, such as family-to-family partnerships, might begin to address the difficult triad of special health care needs, material hardship, and decreased resilience. The hard task now is to work with health care providers, families, and communities to test these ideas in real-world settings.

Opinions expressed in these commentaries are those of the author and not necessarily those of the American Academy of Pediatrics or its Committees.

FUNDING: No external funding.

COMPANION PAPER: A companion to this article can be found online at www.pediatrics.org/cgi/doi/10.1542/peds.2019-1975.

     
  • CSHCN

    children with special health care needs

  •  
  • ED

    emergency department

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Competing Interests

POTENTIAL CONFLICT OF INTEREST: The author has indicated he has no potential conflicts of interest to disclose.

FINANCIAL DISCLOSURE: The author has indicated he has no financial relationships relevant to this article to disclose.