Parental Cancer History and Its Association With Minor Children’s Unmet Food, Housing, and Transportation Economic Needs

Key Points Question What are the associations of parental cancer and minor children’s unmet economic needs related to inadequate food, housing, and transportation in the US? Findings In this cross-sectional study of 22 941 children aged 5 to 17 years, parental cancer was associated with food insecurity, unaffordability of housing and other monthly bills, and transportation barriers to medical care. Children with a parental cancer history and living in low-income families were especially vulnerable to unmet economic needs. Meaning These findings suggest that strategies to identify children with a parental cancer history and address their unmet economic needs are warranted.


Introduction
2][3] Child-rearing responsibilities may be a contributing factor to financial hardship among young adult cancer survivors. 4Previous research 5,6 found that parental cancer history was associated with worse health among children, including psychosocial and behavioral problems, poor mental health, and school absenteeism due to health problems.Parents with a cancer history may be forced to make trade-offs in allocating limited household financial resources between their own medical needs and basic economic needs of their family.
Raising a child has become more costly in recent years, especially with increasing prices of food, housing, child care, and education. 7Patient out-of-pocket costs for cancer treatments have also increased. 8Families with a parental cancer history may experience financial hardship for prolonged periods and struggle to maintain their standard of living, even years after diagnosis. 9However, little is known about the associations of parental cancer with their children's basic economic needs related to food, housing, and transportation.
In this cross-sectional study, we used nationally representative data to examine the financial implications of parental cancer on children's daily living necessities.With a growing interest in adding nonclinical services in medical insurance to address health-related social needs, 10 this study can help inform policies to screen for and address these children's unmet economic needs.

Methods
The 2013 to 2018 National Health Interview Survey (NHIS) was used to identify children aged 5 to 17 years with and without a parental cancer history.The NHIS is a cross-sectional, nationally representative household survey conducted annually in the civilian, noninstitutionalized population in the US, with the annual sample child response rate ranging between 63.4% and 70.7% during these years. 11Within each household, a sample child can be linked to a sample adult if the adult was identified as a parent for the child and lived in the same household.Parents with a history of cancer were defined as those who reported receiving a diagnosis of cancer or any malignant neoplasm (termed malignancy in the NHIS) by a physician or other health professional.This study does not require institutional review board review or informed consent because we used deidentified publicly available data, in accordance with 45 CFR §46.Because NHIS is crosssectional annual household survey data, there was no loss to follow-up of the survey respondents.
We followed the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) reporting guidelines. 12

Statistical Analysis
Children's unmet economic needs for daily living necessities included family-level food insecurity (ie, worry about food running out, food not lasting, and inability to afford balanced meals), parent's worry about paying monthly bills and housing-related costs, and delaying child medical care owing to lack of transportation (see the eTable in Supplement 1 for exact wording of questions and response options).We examined both unadjusted and adjusted associations of parental cancer and children's educational attainment in the family, and family income as a percentage of the federal poverty level (FPL).Both parent's and child's race and ethnicity were included in our study.Parent's race and ethnicity information was reported by the sample parent herself or himself, and the child's race and ethnicity information was reported by an adult in the family who had the most knowledge about the sample child's health and may not be the sample parent interviewed.All categories were classified by the NHIS.We used reported race and ethnicity information and grouped children and parents into 4 groups: Hispanic, non-Hispanic Black, non-Hispanic White, and Asian and others (ie, Hispanic Black, Native American and Alaska Native, multiple race, and unknown).We treated race and ethnicity data as a sociodemographic factor because previous literature has shown that it is associated with health disparities in the US. 13 Survey year and geographic region were also included in the multivariable models.

Discussion
In this nationally representative cross-sectional study, we found that children with a parental cancer history were more likely to experience food insecurity, unaffordability of housing and other living necessities, and transportation barriers to medical care compared with children without a parental cancer history.Moreover, non-Hispanic Black children, children whose parents had poor health, and children living in low-income families were more likely to experience food insecurity and parent's financial worry about paying monthly bills and housing costs.5][16][17] Our findings also suggest that efforts to identify children with a parental cancer history and screen for any unmet economic needs and connect them with relevant services are warranted.
The vulnerability of young adult cancer survivors to medical financial hardship is well documented. 2,3,18Their coping strategies for high out-of-pocket medical costs include delaying or forgoing medical care and prescription medication to save money. 1 This study expands the evidence base by examining the financial implications of parental cancer on children's daily living necessities.
Younger adult cancer survivors with children may have lower wealth accumulation and higher debt obligations (eg, paying off home mortgages and student loans) than their older counterparts, 9 which may force them to make trade-offs to provide sufficient housing, food, and child care for their children.A recent estimate from the US Department of Agriculture for annual costs of raising a child ranges from $15 438 to $17 375 in 2022, which represents a 23.3% increase compared with the year 2015. 19Another estimate shows that a middle income family is expect to spend, on average, $310 605 to raise a child born in 2015 until age 17 years. 20Because of the increasing of both cancer treatments and raising children, all family members of the young adult parents with a history of cancer may be particularly vulnerable to unmet economic needs.
Previous research 14 on parental cancer history found worse physical and mental health outcomes among minor children.However, the potential pathways for these associations were unclear.Our findings provide important perspectives for understanding the association of parental cancer with poor health among minor children.Food insecurity has been consistently associated with poor health among children. 21Compared with food-secure children, food-insecure children were more likely to have asthma, iron deficiency anemia, and tooth decay and to experience poor mental health, such as depression, anxiety, and suicide ideation. 21Poor living conditions, such as lead exposures or lack of adequate heating and cooling at home, may also cause illnesses among children. 22Combined with the finding of transportation barriers for child medical care, our study

JAMA Network Open | Public Health
Parental Cancer History and Children's Unmet Food, Housing, and Transportation Economic Needs The Centers for Medicare & Medicaid Services recently allowed states to apply for waivers to address health-related social needs in their Medicaid programs, including services related to food and housing, education, and employment, 10,23 which allows individual states to start experimental or pilot programs that provide nonmedical benefits to low-income populations under their Medicaid and Children's Health Insurance Program. 24,25For example, New Jersey, Arkansas, Massachusetts, and Oregon can now use Medicaid funds to assist beneficiaries with rent support or health-related home improvements, such as mold removal. 26Moreover, most of these states also developed foodas-medicine programs, which can also pay for nutritious food, including fruits and vegetables. 26Our results showed that parents with a history of cancer who are economically disadvantaged or have multiple comorbid conditions face high risks of food insecurity and housing instability, which inevitably affect their minor children and other family members.Therefore, children with a parental cancer history and living in states that applied and were approved for waivers may benefit from these initiatives.However, more than half of the states have not applied for these waivers to address health-related social needs.Evaluation of the effectiveness of these Medicaid pilot programs on addressing health-related social needs in children with a parental cancer history is warranted.

Limitations
This study has limitations.Measures of food insecurity and financial worry were self-reported by the sample adult.Lack of transportation for child medical care was obtained from an adult respondent in the family who is knowledgeable about the child's health, who may not be the sample adult.
Moreover, we do not have detailed cancer-related information, such as stage of diagnosis and type of treatments received for the parents' cancer.

Conclusions
In this cross-sectional study, parental cancer was adversely associated with children's daily living necessities, including food insecurity, housing unaffordability, and transportation barriers to medical care.Socioeconomically disadvantaged children with a parental cancer history are especially vulnerable.Efforts to identify children with a parental cancer history and develop strategies to mitigate their unmet economic needs are warranted.

Table 1 .
Characteristics of Minor Children Living in Families With and Without a Parental Cancer History, National Health Interview Survey 2013-2018 (continued) cThe number of chronic conditions was defined as the sum of the following conditions: that a respondent was ever told by a doctor or other health professional that they had arthritis, asthma, cancer, diabetes, emphysema, heart disease (angina, coronary heart disease, heart attack, or another heart condition or disease), high cholesterol, hypertension, stroke, and cancer.dBody mass index is calculated as weight in kilograms divided by height in meters squared.

Table 2 .
Associations of Parental Cancer History With Food Insecurity, Unaffordability of Monthly Bills and Housing, and Lack of Transportation for Child Medical Care, National Health Interview Survey 2013-2018 b See the eTable in Supplement 1 for exact wording of questions and response options.

Table 3 .
Adjusted Results of Characteristics Associated With Unmet Economic Needs Among Children Living in Families With a Parental Cancer History, National Health Interview Survey 2013-2018 Parental Cancer History and Children's Unmet Food, Housing, and Transportation Economic Needsprovides evidence that can inform interventions to identify and mitigate the negative associations of parental cancer on children's health, as well as their basic economic needs for daily living.
a See the eTable in Supplement 1 for exact wording of questions and response options.bThefoodinsecuritysummary measure included any family-level food insecurity (ie, worry about food running out, food not lasting, and unable to afford balanced meals).cThefinancial worry summary measure included 2 parent's financial worry measures (ie, worry about paying monthly bills or housing-related costs).d All statistical tests were 2-sided, and all P values were f Body mass index is calculated as weight in kilograms divided by height in meters squared.JAMA Network Open | Public Health JAMA Network Open.2023;6(6):e2319359.doi:10.1001/jamanetworkopen.2023.19359(Reprinted) June 22, 2023 7/10 Downloaded From: https://jamanetwork.com/ on 09/17/2023