Dynamics of Financial Hardship in the United States: Health and Retirement Study 2006-2016.

The purpose of this study was to examine the temporal trends and dynamics of financial hardship among older adults in the U.S. between 2006 and 2016 using the Health and Retirement Study. Sample included a total of 13,537 eligible person observations with a median age of 68 years. Financial hardship included measures of difficulty paying bills, food insecurity, taking less medication due to cost, and ongoing financial strain. Regression analyses were performed using a three-wave quadrennial model to estimate the prevalence of financial hardship over time, to explore temporal patterns and identify persistent hardship. Findings reveal that 51% of respondents who experienced food insecurity at one or more waves were transient. This pattern was similar to respondents who experienced ongoing financial strain (52% transient). Respondents who reported difficulty paying bills (68%) and reduced medications due to cost (62%) were also transient. Significant predictors across all four domains of financial hardship include age, years of education, marital status, self-rated health. Being African American was positively associated with reduced medication use and food insecurity. This study provides insight into the temporal dynamics of financial hardship in later life. It also highlights the contiguous, intermediate and transient nature of financial hardship among older adult populations.

The price of mental well-being in later life: the role of financial hardship and debt.

OBJECTIVE: This study investigated the associations between various financial hardship and debt indicators and mental health status among older adults. METHODS: Using data from the Health and Retirement Study (HRS), we considered the association between different forms of financial hardship and debt of those who were identified as having high levels of depressive symptoms (N = 7678) and anxiety (N = 8079). Financial hardship indicators: difficulty paying bills, food insecurity, and medication need; debt indicators: credit card and medical debt. Associations were tested using multiple logistic regression analyses and are reported as relative risk (RR) ratios and 95% confidence intervals (CIs). RESULTS: Participants who had difficulty paying bills were more likely to have high levels of depressive symptoms (RR = 2.06, CI = 1.75-2.42, p < 0.001) and anxiety (RR = 1.46, CI = 1.02-2.05, p < 0.001) compared to those who did not have financial difficulty. Similarly, medical debt was associated with depressive symptoms (RR = 1.43, CI = 1.14-1.74, p < 0.01) and anxiety (RR = 1.20, CI = 0.96-1.50, p < 0.01). Credit card debt was not significantly associated with either mental health outcome. CONCLUSION: Indicators of financial hardship and medical debt were associated with depressive symptoms and anxiety in a cohort of older adults. In contrast, the influence of credit card debt appeared to be more complex and vary by individual. These findings indicate that doing without meeting personal salient needs has a particularly adverse effect on psychological well-being.

Tobacco cessation and household spending on non-tobacco goods: results from the US Consumer Expenditure Surveys.

OBJECTIVES: To estimate the impact of tobacco cessation on household spending on non-tobacco goods in the USA. METHODS: Using 2006-2015 Consumer Expenditure Survey data, 9130 tobacco-consuming households were followed for four quarters. Households were categorised during the fourth quarter as having: (1) recent tobacco cessation, (2) long-term cessation, (3) relapsed cessation or (4) no cessation. Generalised linear models were used to compare fourth quarter expenditures on alcohol, food at home, food away from home, housing, healthcare, transportation, entertainment and other goods between the no-cessation households and those with recent, long-term or relapsed cessation. The full sample was analysed, and then analysed by income quartile. RESULTS: In the full sample, households with long-term and recent cessation had lower spending on alcohol, food, entertainment and transportation (p<0.001). Recent cessation was further associated with reduced spending on food at home (p<0.001), whereas relapsed cessation was associated with higher spending on healthcare and food away from home (p<0.001). In the highest income quartile, long-term and recent cessations were associated with reduced alcohol spending only (p<0.001), whereas in the lowest income quartile, long-term and recent cessations were associated with lower spending on alcohol, food at home, transportation and entertainment (p<0.001). CONCLUSIONS: Households that quit tobacco spend less in areas that enable or complement their tobacco cessation, most of which may be motivated by financial strain. The most robust association between tobacco cessation and spending was the significantly lower spending on alcohol.

Mechanisms of the Effect of Involuntary Retirement on Older Adults' Self-Rated Health and Mental Health.

This study examined mechanisms of the effect of involuntary retirement on self-rated health and mental health among adults aged 50 or older. Using two waves of the Health and Retirement Study (2006 and 2010), we selected a sample of 1,195 individuals working for pay at baseline who responded to a lifestyle questionnaire in both waves. Regression-based path analyses were conducted to test the mediating effects of financial control, positive and negative family relationships, and social integration on the relationship between involuntary retirement and self-rated health and mental health. Results of mediation analyses indicated that transition to involuntary retirement was directly negatively associated with subsequent self-rated health and indirectly negatively associated with mental health via perception of less financial control. Voluntary retirement was indirectly positively associated with both self-rated and mental health via perception of more financial control. No significant direct or indirect effects of retirement were found when retirement was measured with an aggregate measure without specifying its voluntariness. Findings emphasize the importance of specifying the voluntariness of retirement and recognizing the heterogeneity in the mechanisms of involuntary and voluntary retirement.

Racial and ethnic diversity in senior centers: comparing participant characteristics in more and less multicultural settings.

The 2008 Health Indicators Project surveyed a probability sample (N = 1,870) of New York City senior center participants. Attendees of racially and ethnically diverse and nondiverse senior centers were compared across 5 domains: demographics; health and quality of life; social support networks; neighborhood perceptions and engagement; health service access/utilization. Although homogeneous and diverse center participants demonstrate similar health and quality-of-life outcomes, those from diverse centers demonstrate greater risk of social isolation, receive less family support, and more likely seek medical care from hospitals or community clinics. Implications and future directions for research, practice and policy are discussed.

Inequality and the association between involuntary job loss and depressive symptoms.

Although socioeconomic status (SES) has been to shown to be associated with susceptibility to involuntary job loss as well as with health, the ways in which individual SES indicators may moderate the job loss-health association remain underexplored. Using data from the Americans' Changing Lives study, we estimate the ways in which the association between job loss and depressive symptoms depends on five aspects of SES: education, income, occupational prestige, wealth, and homeownership. Our findings indicate that higher SES prior to job loss is not uniformly associated with fewer depressive symptoms. Higher education and lower prestige appear to buffer the health impacts of job loss, while financial indicators do not. These results have a number of implications for understanding the multidimensional role that social inequality plays in shaping the health effects of job loss.

Environmental factors associated with primary care access among urban older adults.

Disparities in primary care access and quality impede optimal chronic illness prevention and management for older adults. Although research has shown associations between neighborhood attributes and health, little is known about how these factors - in particular, the primary care infrastructure - inform older adults' primary care use. Using geographic data on primary care physician supply and surveys from 1260 senior center attendees in New York City, we examined factors that facilitate and hinder primary care use for individuals living in service areas with different supply levels. Supply quartiles varied in primary care use (visit within the past 12 months), racial and socio-economic composition, and perceived neighborhood safety and social cohesion. Primary care use did not differ significantly after controlling for compositional factors. Individuals who used a community clinic or hospital outpatient department for most of their care were less likely to have had a primary care visit than those who used a private doctor's office. Stratified multivariate models showed that within the lowest-supply quartile, public transit users had a higher odds of primary care use than non-transit users. Moreover, a higher score on the perceived neighborhood social cohesion scale was associated with a higher odds of primary care use. Within the second-lowest quartile, nonwhites had a lower odds of primary care use compared to whites. Different patterns of disadvantage in primary care access exist that may be associated with - but not fully explained by - local primary care supply. In lower-supply areas, racial disparities and inadequate primary care infrastructure hinder access to care. However, accessibility and elder-friendliness of public transit, as well as efforts to improve social cohesion and support, may facilitate primary care access for individuals living in low-supply areas.

The influence of neighborhood factors on the quality of life of older adults attending New York City senior centers: results from the Health Indicators Project.

PURPOSE: To examine the association between self-assessed quality of life (QOL) and perceived neighborhood safety, social cohesion, and walkability among older adults in New York City (NYC). METHODS: We used data from the 2008 Health Indicators Project, a cross-sectional survey of 1,870 older adults attending 56 NYC senior centers. QOL, a binary measure, was created by dichotomizing a 5-point Likert-scaled global assessment. Neighborhood safety, social cohesion, and walkability were multi-component scale variables that were standardized due to varying response metrics. Multivariate binomial logistic regression analysis was performed on 1,660 participants with complete data. RESULTS: After adjusting for covariates, QOL was significantly associated with neighborhood safety and social cohesion. A one-standard deviation increase in neighborhood safety and social cohesion increased the log odds of having higher QOL by 30% (odds ratio (OR) = 1.30; 95% confidence interval (CI) = 1.14, 1.48; P ≤ 0.001) and 36% (OR = 1.36; 95% CI = 1.16, 1.59; P ≤ 0.001), respectively. Higher QOL was not significantly associated with neighborhood walkability. CONCLUSION: The results of this study underscore the need for initiatives that focus on enhancing age-friendly neighborhood features in large urban centers such as NYC and beyond.

Linking neighborhood characteristics to food insecurity in older adults: the role of perceived safety, social cohesion, and walkability.

Among the 14.6% of American households experiencing food insecurity, approximately 2 million are occupied by older adults. Food insecurity among older adults has been linked to poor health, lower cognitive function, and poor mental health outcomes. While evidence of the association between individual or household-level factors and food insecurity has been documented, the role of neighborhood-level factors is largely understudied. This study uses data from a representative sample of 1,870 New York City senior center participants in 2008 to investigate the relationship between three neighborhood-level factors (walkability, safety, and social cohesion) and food insecurity among the elderly. Issues relating to food security were measured by three separate outcome measures: whether the participant had a concern about having enough to eat this past month (concern about food security), whether the participant was unable to afford food during the past year (insufficient food intake related to financial resources), and whether the participant experienced hunger in the past year related to not being able to leave home (mobility-related food insufficiency). Unadjusted and adjusted logistic regression was performed for each measure of food insecurity. Results indicate that neighborhood walkability is an important correlate of mobility-related food insufficiency and concern about food insecurity, even after controlling the effects of other relevant factors.

The impact of occupation on self-rated health: cross-sectional and longitudinal evidence from the health and retirement survey.

BACKGROUND: The objective of this study is to estimate occupational differences in self-rated health, both in cross-section and over time, among older individuals. METHODS: We use hierarchical linear models to estimate self-reported health as a function of 8 occupational categories and key covariates. We examine self-reported health status over 7 waves (12 years) of the Health and Retirement Study. Our study sample includes 9,586 individuals with 55,389 observations. Longest occupation is used to measure the cumulative impact of occupation, address the potential for reverse causality, and allow the inclusion of all older individuals, including those no longer working. RESULTS: Significant baseline differences in self-reported health by occupation are found even after accounting for demographics, health habits, economic attributes, and employment characteristics. But contrary to our hypothesis, there is no support for significant differences in slopes of health trajectories even after accounting for dropout. CONCLUSIONS: Our findings suggest that occupation-related differences found at baseline are durable and persist as individuals age.

Investment in online self-evaluation tests: A theoretical approach.

BACKGROUND: Large-scale traumatic events may burden any affected public health system with consequential charges. One major post-disaster, expense factor emerges form early psychological interventions and subsequent, posttraumatic mental health care. Due to the constant increase in mental health care costs, also post-disaster public mental health requires best possible, cost-effective care systems. Screening and monitoring the affected population might be one such area to optimize the charges. METHODS: This paper analyzes the potential cost-effectiveness of monitoring a psychologically traumatized population and to motivate individuals at risk to seek early treatment. As basis for our model served Grossman's health production function, which was modified according to fundamental concepts of cost-benefit analyzes, to match the basic conditions of online monitoring strategies. We then introduce some fundamental concepts of cost-benefit analysis. RESULTS: When performing cost-benefit analyses, policy makers have to consider both direct costs (caused by treatment) and indirect costs (due to non-productivity). Considering both costs sources we find that the use of Internet-based psychometric screening instruments may reduce the duration of future treatment, psychological burden and treatment costs. CONCLUSION: The identification of individuals at risk for PTSD following a disaster may help organizations prevent both the human and the economic costs of this disease. Consequently future research on mental health issues should put more emphasis on the importance of monitoring to detect early PTSD and focus the most effective resources within early treatment and morbidity prevention.

Use of preventive care by the working poor in the United States.

OBJECTIVE: Examine the association between poverty and preventive care use among older working adults. METHOD: Cross-sectional analysis of the pooled 1996, 1998 and 2000 waves of the Health and Retirement Study, a nationally representative sample of older community-dwelling adults, studying self-reported use of cervical, breast, and prostate cancer screening, as well as serum cholesterol screening and influenza vaccination. Adults with incomes within 200% of the federal poverty level were defined as poor. RESULTS: Among 10,088 older working adults, overall preventive care use ranged from 38% (influenza vaccination) to 76% (breast cancer screening). In unadjusted analyses, the working poor were significantly less likely to receive preventive care. After adjustment for insurance coverage, education, and other socio-demographic characteristics, the working poor remained significantly less likely to receive breast cancer (RR 0.92, 95% CI, 0.86-0.96), prostate cancer (RR 0.89, 95% CI, 0.81-0.97), and cholesterol screening (RR 0.91, 95% CI, 0.86-0.96) than the working non-poor, but were not significantly less likely to receive cervical cancer screening (RR 0.96, 95% CI, 0.90-1.01) or influenza vaccination (RR 0.92, 95% CI, 0.84-1.01). CONCLUSION: The older working poor are at modestly increased risk for not receiving preventive care.

The prediction of criminal recidivism: the implication of sampling in prognostic models.

BACKGROUND: Instruments based on actuarial forensic risk assessment models are sensitive to the calibration sample, and the inclusion criteria for the subjects of a study population will influence the features of the resulting model. If the same instrument is used in populations that are not part of the calibration sample, the discriminative validity of the instrument is jeopardized; thus the definition of the calibration sample is very important. The aim of this study was to examine how sensitive prognostic models are to the calibration sample. METHOD: Two samples (N = 773) of offenders sentenced to at least 10 months in prison for a violent or sexual offense were used in this study. The "sanction sample" (recruited during August 2000, N = 515) consisted of all violent and sexual offenders actively administrated by the Criminal Justice System of Zurich, Switzerland. The "verdict sample" (recruited over two years, N = 258) included all offenders convicted in the Canton of Zurich during a two-year period. Both samples were unbiased, since all subjects that met the study criteria were included. In the first analysis, differences between the two samples were shown with respect to socio-demographic, criminological, and psychiatric variables using bivariate logistic regressions. In the second analysis, recidivism was estimated separately for both samples, using a logistic regression model as a function of a set of psychiatric, socio-demographic and criminological variables. RESULTS: Bivariate logistic regression showed that different risk factors for recidivism existed for both samples. CONCLUSION: Forensic risk assessment models are very sensitive to the calibration sample. There is strong evidence that, even when index-offenses and the socio-cultural background are the same, risk factors for recidivism differ depending on the stage of the judicial process in which the subjects are (e.g. whether a subject is indicted, on conditional release, on parole, or no longer under the supervision of a parole board). Unfortunately, none of the currently available actuarial risk assessment instruments that have been validated in European countries consider the different stages of the judiciary process.

The effects of economic deprivation on psychological well-being among the working population of Switzerland.

BACKGROUND: The association between poverty and mental health has been widely investigated. There is, however, limited evidence of mental health implications of working poverty, despite its representing a rapidly expanding segment of impoverished populations in many developed nations. In this study, we examined whether working poverty in Switzerland, a country with substantial recent growth among the working poor, was correlated with two dependent variables of interest: psychological health and unmet mental health need. METHODS: This cross-sectional study used data drawn from the first 3 waves (1999-2001) of the Swiss Household Panel, a nationally representative sample of the permanent resident population of Switzerland. The study sample comprised 5453 subjects aged 20-59 years. We used Generalized Estimating Equation models to investigate the association between working poverty and psychological well-being; we applied logistic regression models to analyze the link between working poverty and unmet mental health need. Working poverty was represented by dummy variables indicating financial deficiency, restricted standard of living, or both conditions. RESULTS: After controlling other factors, restricted standard of living was significantly (p < .001) negatively correlated with psychological well-being; it was also associated with approximately 50% increased risk of unmet mental health need (OR = 1.55; 95% CI 1.17-2.06). CONCLUSION: The findings of this study contribute to our understanding of the potential psychological impact of material deprivation on working Swiss citizens. Such knowledge may aid in the design of community intervention programs to help reduce the individual and societal burdens of poverty in Switzerland.

The persistence of depressive symptoms in older workers who experience involuntary job loss: results from the health and retirement survey.

OBJECTIVES: The purpose of this study was to investigate the association between involuntary job loss among workers nearing retirement and long-term changes in depressive symptoms. METHODS: Analyzing data from the first four waves (1992-1998) of the Health and Retirement Survey, we used longitudinal multiple regression in order to assess whether involuntary job loss between Wave 1 and Wave 2 was associated with depressive symptoms at Wave 3 and Wave 4. The study sample included 231 workers who had experienced job loss in the Wave 1-Wave 2 interval and a comparison group of 3,324 nondisplaced individuals. We analyzed the effect of job loss on depressive symptoms both in the full study sample and in subsamples determined by wealth. RESULTS: Among individuals with below median net worth, Wave 1-Wave 2 involuntary job loss was associated with increased depressive symptoms at Wave 3 and Wave 4. We found no effect of involuntary job loss for high net worth individuals at the later survey waves. DISCUSSION: Our findings identify older workers with limited wealth as an important group for which the potential effect of involuntary job separation in the years preceding retirement is ongoing (enduring) adverse mental health.

From adversary to partner: have quality improvement organizations made the transition?

OBJECTIVE: To describe the perceived impact of the Centers for Medicare and Medicaid Services Quality Improvement Organizations (QIOs) on quality of care for patients hospitalized with acute myocardial infarction, in the context of new efforts to work more collaboratively with hospitals in the pursuit of quality improvement. DATA SOURCE: Primary data collected from a national random sample of 105 hospital quality management directors interviewed between January and July 2002. STUDY DESIGN: We interviewed quality management directors concerning their interactions with the QIO interventions, the helpfulness of QIO interventions and the degree to which they helped or hindered their hospital quality efforts, and their recommendations for improving QIO effectiveness. PRINCIPLE FINDINGS: More than 90% of hospitals reported that their QIO had initiated specific interventions, the most common being the provision of educational materials, benchmark data, and hospital performance data. Many respondents (60%) rated most QIO interventions as helpful or very helpful, although only one-quarter of respondents believed quality of care would have been worse without the QIO interventions. To increase QIO efficacy, respondents recommended that QIOs appeal more directly to senior administration, target physicians (not just hospital employees), and enhance the perceived validity and timeliness of data used in quality indicators. CONCLUSIONS: Our study demonstrates that the QIOs have overcome, to some degree, the previously adversarial and punitive roles of Peer Review Organizations with hospitals. The generally positive view among most hospital quality improvement directors concerning the QIO interventions suggests that QIOs are potentially poised to take a leading role in promoting quality of care. However, the full potential of QIOs will likely not be realized until QIOs are able to engender greater engagement from senior hospital administration and physicians.

The burden of symptoms among community-dwelling older persons with advanced chronic disease.

BACKGROUND: Little is known about the frequency and range of symptoms experienced by community-dwelling older persons with advanced chronic disease who are not enrolled in hospice. The objectives of our study were to determine (1) the prevalence of a range of symptoms among older persons with advanced chronic disease and (2) whether the prevalence of symptoms is similar across diagnoses. METHODS: This was a cross-sectional study of the symptoms reported by 226 community-dwelling persons 60 years or older with advanced chronic obstructive pulmonary disease (COPD), cancer, or congestive heart failure (CHF). Symptoms were assessed using the Edmonton Symptom Assessment System. RESULTS: Virtually all participants (86%) experienced at least 1 symptom that rated moderate or severe, and most (69%) experienced 2 or more symptoms. The symptoms reported by the greatest proportion of participants were limited activity (61%), fatigue (47%), and physical discomfort (38%). Participants with COPD had a higher unadjusted mean +/- SD number of moderate or severe symptoms (3.3 +/- 2.1) than did participants with cancer (2.6 +/- 1.8; P = .03) or CHF (2.0 +/- 1.7; P<.001). After we adjusted for sociodemographic factors, compared with participants with CHF, participants with cancer experienced 38% (95% confidence interval, 9%-75%) more moderate or severe symptoms and participants with COPD experienced 71% (95% confidence interval, 37%-114%) more moderate or severe symptoms. CONCLUSIONS: Most community-dwelling older persons with advanced COPD, cancer, or CHF experienced multiple moderate or severe symptoms. The clinical care of community-dwelling older persons with advanced chronic illnesses would be enhanced by the identification and alleviation of the range of symptoms they experience.

Ownership status and patterns of care in hospice: results from the National Home and Hospice Care Survey.

BACKGROUND: The number of for-profit hospices increased nearly 4-fold over the past decade, more than 6 times the growth of nonprofit hospices. Despite this growth, the impact of ownership on hospice care is largely unknown. We sought to assess differences in the provision of services to patients of for-profit and nonprofit hospices. METHODS: Using the 1998 National Home and Hospice Care Survey, we examined services used by patients (N = 2080) cared for by 422 hospices nationwide. We used multivariable ordered logistic and logistic regression to assess the effect of profit status on service use, adjusting for potentially confounding patient and organizational characteristics. We calculated point estimates adjusted for sampling weights and standard errors adjusted for the clustering of patients within hospices. RESULTS: In ordered logistic models controlling for organizational and patient factors, patients of for-profit hospices received a significantly narrower range of services (adjusted odds ratio [OR], 0.45; 95% confidence interval [CI], 0.22-0.92) than patients of nonprofit hospices. This result is driven by patients of for-profit hospices receiving significantly fewer types of hospice services that federal regulations term "noncore" or more discretionary services (adjusted OR, 0.34; 95% CI, 0.15-0.75). CONCLUSION: The pattern of care differs in for-profit and nonprofit hospices. As the industry develops a substantial for-profit presence, it is critical for clinicians and other healthcare professionals to be alert to the potential impact of profit status on the care their patients receive.

Achieving goals in geriatric assessment: role of caregiver agreement and adherence to recommendations.

OBJECTIVES: To determine predictors of recommendation adherence and goal attainment of family caregivers of patients at a geriatric assessment center. DESIGN: One-year prospective cohort study. SETTING: Outpatient geriatric assessment center in Connecticut. PARTICIPANTS: Two hundred consecutive new patients and their family caregivers. MEASUREMENTS: : Family caregivers were interviewed after geriatric assessment to ascertain their treatment goals for the patient. Medical records were reviewed to identify treatment recommendations. Family caregivers were interviewed 1 year later to assess adherence to recommendations and attainment of goals. RESULTS: Follow-up interviews were completed with 176 (88%) family caregivers. Common recommendations pertained to physician referral (71%), medications (46%), counseling/education (31%), diagnostic tests (30%), residential planning (26%), healthcare planning (21%), and community services (21%). Goal attainment was reported in 44% to 67% of the patient cases, depending on goal category. Caregiver agreement with recommendations predicted adherence to recommendations (adjusted relative risk (ARR)=1.99, 95% confidence interval (CI)=1.04-5.92) after adjusting for available clinical and demographic factors. In addition, adherence to recommendations predicted goal attainment in adjusted analyses (ARR=1.70, 95% CI=1.09-2.64). CONCLUSION: This study revealed a broad range of treatment recommendations in geriatric assessment and suggests that agreeing with recommendations can promote adherence and that adherence can promote goal attainment. Taken together, the results imply that articulating shared treatment recommendations may improve the quality of health care.