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Learning from Low-Income Families and Their Providers the Weight of Social Determinants of Health

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Thistle Elias, Sarah Papperman and Tammy Thomas

Submitted: 06 January 2026 Reviewed: 15 January 2026 Published: 25 March 2026

DOI: 10.5772/intechopen.1014634

Social Determinants of Health IntechOpen
Social Determinants of Health Edited by Ronald J. Ozminkowski

From the Edited Volume

Social Determinants of Health [Working Title]

Dr. Ronald J. Ozminkowski and Associate Prof. Rashid Menhas

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Abstract

Most nonbiological determinants of health impact US families differently, depending on caregiver income. Low-income families served through Early Head Start programs experience innumerable stressors while raising children. Families manage challenges imposed by costly childcare, unaffordable and low-quality housing, lack of transportation, food deserts, community violence, costly health care, and more. Focus groups with caregivers and home visitors (HVs) in three urban regions and three regions outside of a midsized city reveal the frustrations, as well as the resilience and persistence, of caregivers trying to meet the needs of their families despite structural and social determinants that present unending challenges. Across multiple years of participatory evaluation with local sites of this federally funded program, the authors have learned of the challenges local low-income families confront, in particular with housing, transportation, food, and childcare. The HVs, committed to supporting families, experience similar frustrations navigating systems of insufficient resources, express compassion, and demonstrate tenacity in their efforts to help families. This work centers the voices of caregivers and HVs to share their perspectives and to challenge us to consider intervention points.

Keywords

  • social determinants of health
  • structural determinants of health
  • low-income families
  • poverty
  • home visiting
  • community-engaged research

1. Introduction

Families of young children face many social and structural factors impacting health. For low-income families in the US, determinants such as housing, transportation, childcare, and food access present significant barriers to optimal health and well-being. National and local statistics demonstrate the context within which families are navigating depressed wages, high housing costs, transportation challenges, childcare, insurance, and health care costs. Through studies conducted in 2020 and 2025 with low-income parents and Early Head Start (EHS) home visitors (HVs), this research team heard first-hand accounts of what caregivers encounter in their efforts to locate and access sufficient resources to raise their families. (In this document, we will use “parent” and “caregiver” interchangeably to mean the same parenting provider role.) Local EHS participant perspectives from one mid-Atlantic county reflect the challenges documented nationally and contribute the human stories behind the statistics. While "social determinants of health" (SDOH) is commonly used terminology, the authors include the term “structural” throughout this work to remind the reader that these determinants are often built, bureaucratic, and concretely changeable.

2. Poverty – impacting options

Financial resources significantly determine options for families’ quality of life. Since 2019, American household costs, such as groceries, rent, and childcare, have increased at rates outpacing earnings [1, 2]. The national minimum wage ($7.25 per hour) has remained static since 2010, and 20 states’ minimum wages are at or below this federal minimum, including the state of this study [3]. The US federal poverty level (FPL) is used to determine eligibility for a range of services and benefits, and in 2024, it was $31,200 for a family of four [4]. Poverty rates nationally and locally average just above 1 in 10 residents, and more than 1 in 7 children live at or below the FPL [5]. This varies by state, with some states’ poverty rates as high as 1 in 4 children living in poverty and a few states with child poverty rates as low as 1 in 13, based on the FPL. However, the FPL does not reflect sufficient income for people to meet their basic needs, necessitating additional ways of measuring poverty [2, 6]. Beginning in 2010, the US Census Bureau began reporting the Supplemental Poverty Measure (SPM) in an effort to better reflect household needs, including food, clothing, shelter, utilities, telephone, and internet [7]. Calculated by this approach, the 2024 SPM shows one in eight US households living in poverty [8]. Past survey data show that over two in five parents (44.3%) of children under age three struggle to pay for one or more necessities, such as health care, food, or housing expenses [9]. For many low-income households, financial stress is common, as caregivers aim to meet the needs of their families – in particular, housing, food, transportation, childcare, and health care.

2.1 Housing

Housing – including cost and quality – is a key determinant of physical and psychological health [10] and the largest expense for American households [11]. Nearly one in three American households (31.3%), and half of all renters, are “cost-burdened,” meaning they spend more than 30% of household income on housing expenses [12]. Recently, over eight million American households (the highest number on record) had “worst case housing needs,” meaning they made less than 50% of the area median income and “pay more than half their income toward rent, live in severely inadequate conditions, or both.” This figure includes 2.6 million families with children [13]. The lack of affordable housing is pervasive; there is no American state or city with enough affordable and available housing for renters earning less than 30% of the area median income [14]. Locally, in order to spend less than 30% of earnings on the average fair-market two-bedroom apartment, a person in this region would need to earn $24.62 per hour [15], nearly four times the state minimum wage [3].

2.2 Transportation

Transportation is both a significant expense for low-income families and critical for accessing other determinants of health, including food, childcare, and employment, and the lack of it can act as a “barrier multiplier,” worsening challenges for families [16]. Transportation barriers can impede access to physical and mental health services, resulting in missed appointments, delayed and foregone medical and pharmacy care – especially in underserved communities [16]. While Americans, on average, spend 15% of household income on transportation, the poorest quintile of households (earning less than $25,000/year) spends an average of 30% of after-tax income on transportation. The lowest-income households with at least one vehicle spend even more, putting 38% of their income toward transportation [17]. However, households below 200% of the FPL in the USA are more than three times as likely to not have access to a personal vehicle (19%) compared to those above 200% of the FPL (5%) [18].

2.3 Food access

Access to food, via affordability and proximity, is another determinant of health, presenting significant structural challenges for low-income families. The United States Department of Agriculture defines households as food insecure if they had times during the year in which they were “uncertain of having or unable to acquire enough food to meet the needs of all their members” due to limited resources [19]. In 2023, over 1 in 10 (13.5%) American households (18 million) were food insecure, including nearly one in five (17.9%) households with children (6.5 million) [19]. Food insecurity for the state and county of this study is similar to national statistics [20, 21]. While the prevalence of food insecurity has increased across households, the burden is felt especially among children, single parents, and in rural and city households [21]. Food insecurity numbers are not surprising when considering the cost of food compared to wages. The US Department of Agriculture’s most conservative monthly food spending plan, the “Thrifty Food Plan,” provides budget guidelines for food to account for 30% of a low-income household's income. The plan estimates an average cost for a family of two adults and two toddlers (under three years old) in 2025 at just under $850 per month [22], which corresponds with food costs just under 30% of the gross income of two parents working full-time at the federal minimum wage ($7.25 per hour) [3]. Of course, actual food costs depend on location and the types of food outlets available. Poorer communities (both rural and city) and communities of color are more likely to have limited food access for multiple reasons, including more convenience stores in poorer neighborhoods, lack of reliable transportation for many low-income families, and larger grocery stores with lower prices located in wealthier communities [23, 24]. Assisting households experiencing food insecurity, the Supplemental Nutrition Assistance Program (SNAP) is the largest US nutrition assistance program, providing benefits to an average of 12% of residents [23]. SNAP benefits have been proven to provide critical support to families [19, 25, 26], reduce food insecurity [27, 28] as well as reduce poverty, freeing up resources for other needs [29, 30]. Nonetheless, analysis of United States Census data reveals that in 2022, more than two-thirds of people reporting food insecurity in their households did not receive SNAP benefits, and among those who did, a third indicated ongoing inability to access sufficient food due to lack of resources [26]. As of 2024, over 41 million people received SNAP benefits, more than a third (38%) of them under the age of 17, and 1 in 10 under the age of five [23].

2.4 Childcare

Childcare represents a significant expense for families with small children and also determines caregivers’ ability to work. Between 1990 and 2010, childcare costs increased while many workers’ earnings stayed the same, leading some households to spend more on childcare than any other expense [31]. According to a United States Department of Labor news release from 2024, many American families face childcare prices that are higher than the cost of rent [32]. Nationally, in 2022, families spent 8.9%-16% of their income on childcare [32]. For a single minimum wage worker, however, the expense for one infant in center-based care would cost well over half of their income nationwide [33]. In the county of this study, home-based infant care (often less expensive than center-based care) is estimated to cost over $10,000 annually in 2024, which is 8.8% of the median household income and over two-thirds of the income of a single minimum wage worker [3, 34]. If we use the US Department of Health and Human Services guidance that affordable childcare should consume less than 7% of household income, childcare for infants is affordable to fewer than one in five (17.7%) families in this state [33].

2.5 Health care access

Access to health care in the USA is determined by the ability to afford out-of-pocket expenses for care and medications, co-pays and deductibles, insurance status, proximity to health care, and having transportation to access care. As a percentage of family income, health care costs range from 16% (for high-income households) to 34% (for low-income households) [35]. In 2010, before the introduction of the Affordable Care Act (ACA), approximately 48 million people in the USA were uninsured, significantly impeding their access to health care [36]. The ACA, among many things, expanded Medicaid coverage to include over 20 million people who were neither poor enough to qualify for federal health insurance previously nor able to afford it if their employer didn’t offer it [37]. Still, in 2023, over 27 million (8%) Americans were uninsured, despite nearly three-quarters of them being in households with at least one member working full-time [38]. In 2025 polling, 75% of uninsured people indicated delaying or foregoing care due to cost (as did 37% of those insured) [39]. One in four survey respondents (insured and uninsured) in the 2022 KFF Health Care Debt Survey indicated having unpaid medical or dental bills they were unable to pay [39], and health care debt continues to be the leading cause of personal bankruptcy in the USA [40].

3. Early head start and home visiting

EHS, a 1995 national expansion of the United States Head Start Program, provides critical services to low-income families with children aged zero to three years and pregnant mothers [41, 42]. These services are designed to nurture healthy attachments between caregivers and their children, help children meet developmental milestones, and build their school readiness. Services are delivered either as home-based services utilizing HVs, center-based services, or through family childcare services [43, 44]. HVs with EHS work directly with families in their homes by providing individualized services to infants and toddlers, engaging with caregivers, and facilitating access to community resources in order to promote children’s social, emotional, physical health, and cognitive development [42, 43]. An early, rigorous, nationwide evaluation of EHS demonstrated extensive benefits for children and families, based on a model that is responsive to families’ needs and the variability of environments [45].

Family Foundations Early Head Start (FF EHS) is a nonprofit organization in the mid-Atlantic region of the USA, which provides an average of 300 families annually with EHS home visiting and additional supportive services across six regions of one county – three within and three outside of a midsized city [42, 46]. FF EHS uses an infant mental health focus (emphasizing the importance of healthy social and emotional development in early childhood) and a relationship-based approach (emphasizing building nonjudgmental, supportive connections with caregivers) to provide all of their services [42].

4. Methods

Each year, this evaluation team works with FF EHS leadership, including coordinators of six FF EHS sites in the county, to determine foci for continuous quality improvement efforts. In two of these years (2020 and 2025), the team explored families’ experiences with social and structural determinants of health. In 2020, this was done via focus groups with caregivers. FF EHS refers to adults in parenting roles as “caregivers” to acknowledge the range of family members who may be involved in meeting young children’s needs; in this document, we will use the terms “parent” and “caregiver” interchangeably to mean the same parenting provider role. Over several months in 2020, this team held focus groups with caregivers from each of the six FF EHS sites, with a total of 69 caregivers (including five fathers) of children under three years old. Two of the six groups included informal interpreting for a few parents by other parents (Nepali, Bhutanese, Somali parents), and two included formal interpreters for a few parents (Arabic and Spanish-speakers), with additional time allotted to accommodate interpretation. Focus groups explored topics including community resources families used and requested most frequently, barriers to families accessing needed resources, supports families have and need more of, and the impact of FF EHS on families’ resources and supports.

In January 2025, the evaluation team returned to related topics, holding three focus groups, with each group incorporating HVs from two sites, totaling 19 HVs. These focus groups addressed topics including what HVs were seeing among families (such as how parents were managing costs of living, particularly food and housing), stressors for parents and their children, ways that FF EHS is assisting, and what kinds of additional help are needed to support families.

Focus groups were recorded, transcribed by an outside service, and coded inductively line-by-line by pairs of coders, including authors (TE and TT) paired with one staff member and one graduate student. For both years of exploration, approval from the team’s institutional review board was granted. The team utilized a grounded theory approach to analysis, emphasizing finding new insights from the data rather than working with a predetermined theory or framework [47, 48]. Codes were determined and refined in an iterative process, with all decisions documented in order to help ensure the credibility, confirmability, and dependability of the analysis and findings [49]. Representative quotes of caregivers/parents (parent) and HVs were selected to illustrate thematic findings. All findings were shared in aggregate, without identifiers, with FF EHS leadership for their use in ongoing quality improvement efforts and required reporting to federal funders. In keeping with best practices of community-engaged research (and participatory evaluation) [50, 51], findings each year were also shared with the FF EHS parent leadership group in a presentation, including an extensive question-and-answer session, and the formal report was made available upon request to parents and HVs.

5. Findings from two years of study with EHS families and HVs

Parents and HVs shared numerous challenges faced by low-income families around social and structural determinants of health – food, transportation, childcare, and housing in particular. Notably, problems with one often led to or exacerbated problems with another.

5.1 Problem – being low income

Largely, the challenges that participants describe are directly associated with low wages, which directly affect major categories of need as described, but also basics. As one HV summarized, “They often don’t have enough for simple things like a seasonal change of clothes, basically.”

For many families, problems are layered and can multiply quickly.

Sometimes I have to put money towards my rent, and I couldn’t buy diapers at the time, and stuff like that. Or like I said, the transportation to even get there to where I have to go … (Parent)

A lot of families, they’ll have a problem, and then it’ll just snowball, and then they’re like, ‘I don’t know what to do after this.’ (HV)

Some families, they want to go back to school, but they feel that they can’t afford to go back to school, which stops their growth for investment and employment. (HV)

Yeah. I think that for the majority of our families, it’s not like one specific stressor. I think it’s like cumulative multiple stressors at the same time. You can’t get employment because you can’t get transportation there and you don’t have childcare. Or you can’t find new housing because you’re backed up on this utility, and now you can’t be transferred. It’s kind of things building on top of each other. (HV)

Some parents work two jobs to make ends meet. Others weigh the benefits of extra income against potentially losing assistance. For caregivers, increasing income can actually decrease financial stability; as one HV says, “It’s a rock and a hard place.”

5.2 Food access

Participants describe a wide range of difficulties that caregivers face in accessing affordable and quality food for their families, even with food assistance. Caregivers budget, make cuts in other expenses, plan meals, and shop for shelf-stable items to best cope with food costs, as well as anticipate the timing of any benefits. Parents and HVs describe families challenged to afford sufficient food for their families, even with federal public assistance resources such as the SNAP (also referenced informally as “food stamps”) and Women, Infants, and Children (WIC).

I have a few families that are struggling with it, and then they’ll run out of food stamps at the end of the month. And then the food bank, they don’t have transportation, so it’s difficult for them to get to food banks. So I know they’re doing lots of pasta and canned foods to make it kind of through the month. (HV)

I think a lot of my families have similar issues where they’re not feeling like they get as much with their food stamps. So towards the end of the month, it’s a bit of a struggle. (HV)

I made too much to get food stamps by maybe $6 and it’s like, I need help with food because the way the economy is. As soon as I pay my bills I got to buy food and then after that I don’t have nothing for myself. I can’t get my baby shoes or whatever the case may be. (Parent)

5.2.1 Food banks/pantries – limitations

Parents are challenged by food banks’/pantries’ operating hours, limitations in their service areas, distances to food pantries, and transportation. For many families, access to food pantries is complicated by locations that are not accessible by public transportation and parents who do not have access to a vehicle. Families juggle resources to have enough food, managing long waits at food pantries, food pantry closures, and challenges in accessing pantries.

They get food stamps, but they’re running out of food before the end of the month. And then they have to wait until the new food stamps come out. So they’re utilizing the food banks more. Those type of things. Because the cost of food, for one, and then by the middle of the month, they ran out of food. (HV)

[At the food pantry] in the summer, people would come hours early, four or five hours, to try to get in line. (HV)

Pantries run out of food if parents can’t get there early enough, as described in this exchange among parents:

[Parent 1] Also, when you get there– if you’re not there at 6 o’clock in the morning for it to open, you could be one of the last ones and they run out of food.

[Parent 2] That early? Two hours before it opens?

[Parent 3] Yeah.

5.2.2 Food access tied to transportation

Families faced consistent challenges accessing food without private transportation or reliable public transportation. Families are offered boxes of produce, “but you have no way to get back,” (Parent)

Some can, if the food banks are close enough to walk. They’ll get themselves there. But … a few of my families, especially that have multiple kids, transportation is a little bit more of a struggle for them to find a ride, find a ride that’s big enough for them and all their kids to go too. (HV)

You have really heavy boxes of food. It’s not feasible if you don’t have a car. You’re not going to be able to take a bus and carry these giant boxes of produce on the bus. (HV)

Some areas are very isolated, without public transportation or a grocery store, but then some families end up relocated there due to limited housing elsewhere:

[It’s] a food desert, and there’s just nothing there. (HV)

In [community name] we don’t have nothing. You could ride down blocks and blocks [here] and see abandoned houses, abandoned stores, abandoned churches. (Parent)

It’s really not the easiest place to live. I mean there is bus service, but it takes forever to get anywhere, it’s so isolated … How are you going to get them to the grocery store? Are you going on the bus with a baby and go get all your groceries? … It’s just a lot to live out here for anybody that doesn’t have especially their own transportation. (HV)

6. Transportation – cost and availability

Parents specifically spoke to numerous challenges with transportation – affecting their ability to access food, childcare, and other resources. Changes in public transportation, particularly bus schedules and reduced routes, make travel with children more difficult. Many communities served by FF EHS lack bus lines. Bus schedules and the complexity of parents’ work and preschool schedules make it impossible for some children to attend preschool programs. As one parent shared,

I see a lot of kids, they are really poor, that are at home because their parents cannot take the bus. (Parent)

When buses were unavailable, parents resorted to walking with their children to needed resources. In many communities, navigating narrow streets presented parents with safety concerns. The cost of transportation was described across focus groups as being a significant concern, especially given that some locations require multiple buses to reach, as this exchange between parents shows:

[Parent 1] I think the biggest barrier is transportation because not a lot of people have transportation. And not a lot of people have the money to invest in the buses.

[Parent 2] Oh, yeah. It is expensive.

[Parent 1] –$2.75 just to ride the bus.

[Parent 2] I take two buses.

[Parent 1] And some people have three or four buses.

[Parent 2] That’s $15 debt.

Given that many regional programs and resources are housed in one major downtown area, and the parking downtown is markedly expensive, even parents with vehicles indicate that they have to take the bus.

I cannot drive there. I have to take a bus to go there. And there’s two buses going and two buses coming back which is going to cost you $10, $12. (Parent)

For families outside of the city in particular, the lack of transportation options exacerbated the challenges of accessing needed services, as this parent exchange suggests:

[Parent 1] We’re like the country. Because even though we’re a city, nobody really knows about us. We don’t have resources. Half the stuff they do in [nearby city], and the services and programs they have in [the city]–

[Parent 2] I can’t get all the way down here.

[Parent 1] We can’t. Yeah. We’re stuck here.

Transportation challenges combine with limitations in childcare when parents need to access resources, such as personal health care appointments.

I have a family who I have to arrange transportation [for] and accompany her to medical appointments with the children because she has no family close to even watch her two older girls for two hours so she can get to a prenatal appointment. (HV)

7. Childcare – cost and availability

HVs describe significant challenges families face when trying to find affordable, accessible, quality childcare.

I see childcare waiting lists are very long, and it has been harder to get subsidized tuition for childcare. Most of the families do not utilize childcare outside of using family friends or just not working. Oh, yeah. I think that is a tremendous challenge for so many people. (HV)

I have some moms who want to go back to work, but then they’re also either scared to leave their child with strangers, or like [HV name] said, childcare is really expensive. So it’s been like a really big burden on them. They’re not sure what to do, and they feel like really stuck. (HV)

I have a few families that are struggling with childcare. They need childcare to go to work to pay their astronomical rent, but there’s either no places that are within their area or places that they don’t really feel are trustworthy to send their kids or places that are reasonably priced that they would feel comfortable sending their kids. (HV)

When caregivers’ work hours are not “typical,” there are greater challenges in finding available childcare, which, in turn, can compromise their ability to work.

Especially for families who work irregular hours, either unpredictable hours, or weekends, or nights, or long days. It’s very hard to find childcare outside of your typical work hours … I mean, I have families that won’t send their kids to the Head Start classroom because it’s not long enough hours. But I have many who are having trouble finding childcare that works for them mostly because of their work hours. (HV)

If they can’t get childcare, they just don’t show. They just don’t go to work. And then they have trouble keeping the job. And it makes them look really irresponsible from the employer’s perspective. ‘You said you’d show up on Thursday’, but when their childcare falls through, they don’t show up. So then they have trouble sometimes keeping those jobs because of childcare. (HV)

Exchange between HVs:

[HV1] I have two families that are struggling with childcare, and the daycares– they’re two separate daycares, but they are closing often. And the parents want to both work, and they don’t work because they have to call off for the daycare. And then even transportation from home to the daycare and to work, because they take the bus, is difficult because they have to give themselves so much extra time. And then I have one family that works second shift, and that’s really difficult to find childcare.

[HV2] Yeah. I’ll add to that because I mean, unfortunately, a lot of the families we work with have an education that doesn’t allow for standard 9:00 to 5:00 jobs or 9:00 to 6:00 jobs even. And so it means that they’re going to be taking those jobs, a lot of security jobs. I mean, we probably all have a couple families working security. I have a mom that’s a fill-in nurses’ aide kind of thing. So she’ll work overnight. If you’re dependent on childcare, those childcare situations are really few and far between. You really need a support system for that.

Families manage these childcare challenges in a variety of ways. Some parents forgo work to stay home with their children, some parents have older children watch younger siblings so they can work, some parents take turns caring for their children, and several parents bring their children to work with them. Sometimes these approaches work, and sometimes parents lose their jobs when childcare falls through.

8. Housing – availability and quality

Among all determinants brought up by participants, none was more complex and impactful than housing. HVs and families described significant housing challenges across the region, including high costs, low availability (including subsidized Section 8 housing), low quality (in both private and public housing), and long waits for subsidized housing. Due to limited options, families “make-do” (HV), rotating stays with family members and staying in circumstances they wouldn’t otherwise choose.

As one HV summed up, “housing is in crisis.”

For me, the most consistent kind of across-the-board issue I’m seeing for a lot of families is housing. It seems to be a really big issue, both finding it and affording it. (HV)

Accessing housing is almost impossible. The waiting lists are all very, very long. I had a family that– she was on every single list, and she, two years in, was still bouncing around from one family member to another. And she wasn’t the only one. It seems like I keep hearing that story. (HV)

It’s just so much harder to find some type of help for us whenever we need it as being single fathers. It’s really hard. I had five of my kids before, and it was hard. I was house hunting with my kids, and it was hard. I couldn’t find too much of anything for them. (Parent)

8.1 Low quality housing

Some families are managing poor-quality and unsafe housing, as exemplified in this exchange among HVs:

[HV6] [There was not] a fire extinguisher provided. So there’s a lot of just, I think, small things, too, that they’re just not maintaining, and it’s creating safety issues.

[HV7] … [One place] that had two fire extinguishers that were both expired and four smoke alarms. There was just a hole in the wall. There was nothing. And fortunately, we have that stuff at our office that we’re able to give to them … But it’s like at the same time, “Why is that happening?” It shouldn’t be on us. That should be on the landlord. That’s unsafe.

[HV4] Yeah. I have similar experience in terms of the quality of housing. There’s one family I just saw the other day. They had a main door to the building. [Management] just took the door off, so there was just cold air flowing in when you have babies on this first floor. There’s just no door. And it’s just so sad the disregard for humanity that you see.

Families don’t have many housing options as rents rise and the quality of what they can afford declines. Home Visitors described families dealing with mice and bug infestations, water leaks and mold, poor air quality, and lack of maintenance, all of which impact their quality of life and health. One HV shared that a family’s bedroom ceiling completely collapsed, and “they were no longer able to sleep in the bedroom.”

Housing is less than suboptimal in terms of the conditions, leaking roofs and stuff, but they can’t afford to find other housing. (HV)

I do have a few that the housing situations that they are in is kind of like a slumlord situation, and they’re not really doing anything about it. And so like the one family, any time they shower, do laundry, flush a toilet, anything like that, do dishes, her whole first floor floods. (HV)

“The living conditions in her building are terrible, and the maintenance people know about it and they are refusing to fix it. So the whole unit is just living with mice, bed bugs. There’s always just things going on … It’s just not a good living condition for young babies, especially. There’s been times where her heat hasn’t been working, and [management] just take their time.” (HV)

HVs described multiple families repeatedly moving around the county, trying to find more affordable, quality housing.

I just have one family that comes to mind in particular … it just seems they go from a bad situation to worse. There’s a lot of lead in the one home that they were living in. So they moved to a different house and the heat didn’t work. The vents that cover the heating system-they were all rusted and cracked, and the landlord wasn’t doing anything, and their rent is astronomical … they’re just kind of in over their head. They’re struggling. How they’re handling it, I’m honestly not sure, but they are. They just keep going from bad situation to worse renting and living conditions. (HV)

8.2 Housing scams

Due to the scarcity of affordable housing, families are vulnerable not only to living in subpar conditions but also to being cheated. As one HV noted, “a lot of people have been scammed.”

I had a situation where a family gave the landlord the money and he reneged, he pulled out, and he didn’t give her money back. He only gave her half of her money back that she put in. So it’s things like that … A lot of families just go by word of mouth, like, “Oh, I talked to such and such, and I gave them money” with no documentation. (HV)

A family applied for a house and was accepted and paid the application fee. And then when it came time to sign the lease, the company disappeared. The family has been left without permanent housing and is living separately among relatives. A lot of housing places are telling people that they can move in in a month, and then, a year later, they still haven’t moved. (HV)

9. Resources for families to meet needs

While access and affordability of housing, food, transportation, and childcare are perpetual challenges impacting low-income families, parents described benefiting from community-level resources they pursued on a case-by-case basis. As FF EHS HVs learned of reliable resources, they aimed to share this information with other HVs and caregivers. Among these are gas and electric utility assistance programs, community-based organizations that can assist with housing advocacy, and others that sometimes help with rent. As this parent describes one local organization:

They’ll help you with your rent, electric, gas. Like I said, it all depends on what– I don’t know personally what other stuff they have, but me, at the time that I needed them, it was mostly for rent. (Parent)

Parents and HVs described local county government housing resources as the most frequently used by families, including a program that provides information about housing availability, as well as city government housing programs that assist with obtaining driver’s licenses and job searches. Parents identified several local organizations that provide families with assistance for critical children’s supplies.

We go there once a month and get diapers and clothes. And they have formula. (Parent)

9.1 Challenges with resources

Even with HV assistance, not all resources that families need are accessible.

I had this one family where I called around to like three different diaper banks, and they were completely out of diapers. (HV)

A lot of service providers are not consistent at all. They cancel constantly. (HV)

Participants discussed how eligibility rules, unwieldy processes, and unresponsive organizations can impede parents’ ability to obtain necessary resources. Parents and HVs described ongoing challenges such as extensive paperwork, age or income eligibility requirements, lengthy waiting times and waitlists, and the frustration of not having calls to resource programs returned. Many housing and employment resources are not available to parents with a history of incarceration. Some resource programs are unavailable to working parents who marginally exceed income limits. HVs can provide invaluable assistance in navigating these systems.

Because there’s that person that answers the phone that will ask you questions to eliminate you from whatever you’re calling to get. It’s like that’s their job is to ask you the questions so that they can eliminate you from the program. (Parent)

9.2 Early Head Start support

In addition to assisting parents in navigating systems and identifying community resources, HVs provide home-making supports when possible, including kitchen boxes with utensils and crockpots, as well as home inspections and supplies for child safety.

They help a lot, too. Especially with the safety of your house, whenever you didn’t have anything, they ask you “Do you need this baby gate?” [EHS] helps with a lot of stuff. (Parent)

Like a fire extinguisher, and other things like that. (Parent)

Additionally, participants noted the critical help of FF EHS transportation assistance in getting children to doctor’s appointments and helping families attend EHS socialization opportunities and parent meetings.

10. The lived experience of unmet needs – and policy opportunities

Through this research, caregivers and HVs revealed a multitude of challenges related to social and structural determinants of health for low-income families. This aligns with research finding that low-income parents of young children put tremendous effort into identifying resources and trying to navigate systems in an effort to meet their children’s needs [52]. For many FF EHS families, there is a layering of challenges that reinforce one another and make the resolution of one difficult (or impossible) without the resolution of another. Families without reliable transportation struggled to access grocery stores or food pantries; families trying to find affordable housing found themselves forced to move to areas further away from food and social service resources, or staying in communities that no longer had resources, often also without public transportation; and families with low-wage jobs, unable to afford reliable, quality childcare, found their ability to work threatened. Not surprisingly, research suggests that individuals with two or more unmet needs may experience “more stress, depressive symptoms, sleep problems, chronic disease,” and poorer self-rated health compared to individuals with one or no unmet social needs, emphasizing the importance of the “dynamic relationships among social needs” [53]. The challenges that these families navigate underscore the importance of considering vulnerability beyond income alone [54], examining the complex and inter-related nature of social determinants, as well as “the need for multifaceted approaches to social needs interventions” [55].

Parents spoke extensively about the challenges of transportation, particularly in getting to food and other needed resources, especially for families with small children or those living in geographically isolated areas. This aligns with studies suggesting that transportation insecurity is a “barrier multiplier,” exacerbating challenges with other determinants of health, including access to affordable housing, medical care, preschool programs, food assistance, childcare, and home visiting services [16]. As such, efforts to address SDOH need to prioritize “high-quality, safe, and sustainable means of transportation to connect people with resources and with one another” [56].

Participants shared multiple challenges that caregivers face in accessing food, trying to stretch financial resources and food benefits to ensure they have enough food until the end of each month, and ultimately needing to utilize food pantries – often with some difficulty – to feed their families. When costs rise and wages remain stagnant, public assistance resources that provide monthly food benefits to families in need become even more essential. SNAP benefits for healthy food access have been well established to provide invaluable support to families [23, 25, 26]; however, these benefits are currently in jeopardy [57].

Parents’ difficulties finding and affording quality childcare were significant, given the high cost of care, parents’ low wages, and their concerns about the quality of care. Parents’ options were limited, and their stress was high. What our participants shared matches state-wide data indicating that fewer than one in five families (17%) are able to find affordable childcare [33]. To help meet the needs of working families, there have been many calls for paid parental leave and universal childcare [9, 25, 58], as well as calls to improve the childcare sector nationally with “substantial government investment to function adequately and eventually prosper” [59]. Notably, of 41 wealthy countries within the Organisation for Economic Co-operation and Development (OECD), the USA is the sole country without a national paid leave policy [58, 60].

Participants, in particular HVs, shared a long list of housing-associated stressors they recognize among the hundreds of families they collectively see. These included finding affordable housing (given both low wages and rising housing costs), living far away from resources (including food stores and pantries), and an overwhelming number of families living in unsafe and unhealthy housing with unresponsive management. This matches national data indicating that housing costs as a proportion of income are unduly burdensome for low-income caregivers, requiring parents to compromise on housing quality and location and do without other necessities in order to have shelter [12, 13]. Calls for increased utility assistance [25] and rental assistance [13] aim to provide some relief to financially stretched families.

To most broadly reduce housing challenges, researchers have proposed a range of policy initiatives aimed at improving housing availability and affordability. Promising proposals include using “zoning reforms to encourage multifamily housing development” [15], incentivizing new development near public transit and rent stabilization [25], repairing existing affordable units [15, 25], and working more broadly with local governments toward “removing barriers that drive up housing costs” [13]. Logically, either regulatory incentives or penalties to affect the responsiveness of property managers at the county or municipal level could also make a significant positive impact on the conditions in which low-income families are raising children.

Participants in these focus groups were not asked about health care access as a focus of this work; EHS parents largely qualify for public health insurance (Medicaid), and FF EHS offers mental health resources for caregivers. Transportation and childcare challenges were described as hindrances to accessing all resources, including health care appointments. In a review of over 400 studies since Medicaid expansion under the Affordable Care Act, most evidence shows increased financial security among low-income populations, as well as improved access to and affordability of care, use of health care services, and self-reported health [61]. Evidence is mixed about the impact on health outcomes [61]. While families with Medicaid coverage do not need to budget financial resources for healthcare, they continue to struggle with other costly determinants of health. Currently, Medicaid programs are facing significant reductions at the federal level [39], which will also reduce SNAP food benefits for recipients covered by Medicaid, including many EHS families [26].

Arguably, policy initiatives could significantly impact the lives of these families by addressing income directly, benefiting parents who simply do not have enough money for necessities [53]. Evidence of reduced “poverty and food hardship” during the COVID-19 pandemic, due to child tax credits and disbursement of cash support to families, suggests these high-level policy approaches can benefit families [62] fairly quickly. Suggestions have included raising the federal minimum wage [25], tying it to the rate of inflation, adjusting state minimum wages to match cost-of-living variability, as well as providing guaranteed income [63] and cash transfer programs [54], all designed to directly reduce poverty. Support for small businesses that shift to pay higher wages could be facilitated through policy efforts [63]. Additionally, expanding social safety nets [54] and public assistance benefits to close the minimum-to-living wage gap could make a significant and meaningful impact on families where caregivers are making choices about whether to increase income at the expense of needed benefits [63].

11. Conclusion

Low-income parents are working hard to meet the needs of their young children but confront persistent problems with social and structural determinants of health. EHS parents and HVs spoke about the layering and interrelatedness of these challenges, particularly with food access, transportation, childcare, and housing, which make life more difficult for families. Listening to the voices of parents and HVs serving low-income families allows us to better understand the experiences behind the statistics and invites us to think creatively about interventions with individual families, the community organizations that serve them, and policy implications.

Acknowledgments

The authors would like to acknowledge the critical role and support of Chris Dunkerley, Director of Family Foundations EHS, for his dedication to the staff and families of FF EHS, ongoing quality improvement of services, support of this evaluation project, and sharing of these findings. We also want to acknowledge the tireless work of FF EHS Site Coordinators, staff and parent leadership, and HVs committed to the health and well-being of the families they serve. Finally, we acknowledge the significant role of doctoral student Ashwini Chaudhari in assisting with data analysis through the second year of this project and the support of the Family Foundation Consortium of Public Education for this evaluation project.

Conflict of Interest

The authors declare no conflicts of interest

Gratitude

The authors thank the families and HVs of FF EHS for sharing their perspectives and stories, and for trusting us with their reporting.

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Written By

Thistle Elias, Sarah Papperman and Tammy Thomas

Submitted: 06 January 2026 Reviewed: 15 January 2026 Published: 25 March 2026

© 2026 The Author(s). Licensee IntechOpen. This content is distributed under the terms of the Creative Commons Attribution 4.0 International License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

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