Financial strain and social support as moderators of the relationship between living alone and depressive symptoms in older people.

This study investigated the moderating effect of financial strain or social support on depressive symptoms among older people living alone in Taiwan. Data were collected from the "Taiwan Longitudinal Study on Aging (TLSA)," which included 1513 participants aged 65 and over, among them, 153 (10.1%) were living alone, while 1360 (89.9%) were living with others. Measurement tools included the Depression scale (CES-D), financial stress scale, social support scale, ADL scale, IADL scale, and stress scale, with Cronbach's α coefficients were 0.85, 0.78, 0.67, 0.91, 0.90, and 0.70 respectively. Hierarchical multiple regression was used to examine the moderator effect. The findings revealed that (1) Financial strain was found to moderate the relationship between living alone and depressive symptoms, acting as a promotive moderator among older men living alone. For older women, financial stress does not moderate the relationship between living alone and depressive symptoms. However, financial strain was also identified as a significant factor associated with depressive symptoms among older women living alone. (2) Social support does not moderate effect on the relationship between living alone and depressive symptoms in older men or older women. These results underscore the importance of considering financial stress in mental health policy development by government agencies. It is imperative to address the unique challenges faced by older individuals living alone, particularly in relation to financial strain, in order to promote their mental well-being.

Assessing the influence of rural residence and economic distress on lower extremity risk stratification among diabetic foot ulcer patients utilizing the Wound, Ischemia, and Foot Infection (WIfI) classification system.

OBJECTIVE: Diabetic foot ulcers (DFU) are a major sequela of uncontrolled diabetes with a high risk of adverse outcomes. Poor DFU outcomes disproportionately impact patients living in rural and economically distressed communities with lack of access to consistent, quality care. This study aimed to analyze the risk of geographic and economic disparities, including rural status and county economic distress, on the disease burden of DFU at presentation utilizing the SVS WIfI classification system. METHODS: We conducted a retrospective review of 454 patients diagnosed with a DFU from 2011 to 2020 at a single institution's inpatient and outpatient wound care service. Patients >18 years old, with type II diabetes mellitus, and diabetic foot ulcer were included. RESULTS: ANCOVA analyses showed rural patients had significantly higher WIfI composite scores (F(1,451) = 9.61, p = .002), grades of wound (F(1,439) = 11.03, p = .001), and ischemia (F(1,380) = 12.574, p = .001) compared to the urban patients. Patients that resided in at-risk economic counties had significantly higher overall WIfI composite scores (F(2,448) = 3.31, p = .037) than patients who lived in transitional economic counties, and higher foot infection grading (F(2,440) = 3.02, p = .05) compared to patients who lived in distressed economic counties. DFU patients who resided in distressed economic counties presented with higher individual grades of ischemia (F(2, 377) = 3.14, p = .04) than patients in transitional economic counties. Chi-Square analyses demonstrated patients who resided in urban counties were significantly more likely to present with grade 1 wounds (χ2(3) = 9.86, p = .02) and grade 0 ischemia (χ2(3) = 16.18, p = .001) compared to patients in rural areas. Economically distressed patients presented with significantly less grade 0 ischemia compared to patients in transitional economic counties (χ2(6) = 17.48, p = .008). CONCLUSIONS: Our findings are the first to demonstrate the impact of geographic and economic disparities on the disease burden of DFU at presentation utilizing the SVS WIfI classification system. This may indicate need for improved multidisciplinary primary care prevention strategies with vascular specialists in these communities to mitigate worsening DFU and promote early intervention.

Financial hardship among patients suffering from neglected tropical diseases: A systematic review and meta-analysis of global literature.

INTRODUCTION: Neglected tropical diseases (NTDs) mainly affect underprivileged populations, potentially resulting in catastrophic health spending (CHS) and impoverishment from out-of-pocket (OOP) costs. This systematic review aimed to summarize the financial hardship caused by NTDs. METHODS: We searched PubMed, EMBASE, EconLit, OpenGrey, and EBSCO Open Dissertations, for articles reporting financial hardship caused by NTDs from database inception to January 1, 2023. We summarized the study findings and methodological characteristics. Meta-analyses were performed to pool the prevalence of CHS. Heterogeneity was evaluated using the I2 statistic. RESULTS: Ten out of 1,768 studies were included, assessing CHS (n = 10) and impoverishment (n = 1) among 2,761 patients with six NTDs (Buruli ulcer, chikungunya, dengue, visceral leishmaniasis, leprosy, and lymphatic filariasis). CHS was defined differently across studies. Prevalence of CHS due to OOP costs was relatively low among patients with leprosy (0.0-11.0%), dengue (12.5%), and lymphatic filariasis (0.0-23.0%), and relatively high among patients with Buruli ulcers (45.6%). Prevalence of CHS varied widely among patients with chikungunya (11.9-99.3%) and visceral leishmaniasis (24.6-91.8%). Meta-analysis showed that the pooled prevalence of CHS due to OOP costs of visceral leishmaniasis was 73% (95% CI; 65-80%, n = 2, I2 = 0.00%). Costs of visceral leishmaniasis impoverished 20-26% of the 61 households investigated, depending on the costs captured. The reported costs did not capture the financial burden hidden by the abandonment of seeking healthcare. CONCLUSION: NTDs lead to a substantial number of households facing financial hardship. However, financial hardship caused by NTDs was not comprehensively evaluated in the literature. To develop evidence-informed strategies to minimize the financial hardship caused by NTDs, studies should evaluate the factors contributing to financial hardship across household characteristics, disease stages, and treatment-seeking behaviors.

An analysis of financial hardship faced by patients with First Episode Psychosis, and their families, in an Indian setting.

BACKGROUND: The economic burden of psychotic disorders is not well documented in LMICs like India, due to several bottlenecks present in Indian healthcare system like lack of adequate resources, low budget for mental health services and inequity in accessibility of treatment. Hence, a large proportion of health expenditure is paid out of pocket by the households. OBJECTIVE: To evaluate the direct and indirect costs incurred by patients with First Episode Psychosis and their families in a North Indian setting. METHOD: Direct and Indirect costs were estimated for 87 patients diagnosed at AIIMS, New Delhi with first-episode psychosis (nonaffective) in the first- and sixth month following diagnosis, and the six months before diagnosis, using a bespoke questionnaire. Indirect costs were valued using the Human Capital Approach. RESULTS: Mean total costs in month one were INR 7991 ($107.5). Indirect costs were 78.3% of this total. Productivity losses was a major component of the indirect cost. Transportation was a key component of direct costs. Costs fell substantially at six months (INR 2732, Indirect Costs 61%). Respondents incurred substantial costs pre-diagnosis, related to formal and informal care seeking and loss of income. CONCLUSION: Families suffered substantial productivity loss. Care models and financial protection that address this could substantially reduce the financial burden of mental illness. Measures to address disruption to work and education during FEP are likely to have significant long-term benefits. Families also suffered prolonged income loss pre-diagnosis, highlighting the benefits of early and effective diagnosis.

COVID-19-Related Financial Hardship Is Associated With Depression and Anxiety in Substance Use Treatment Across Gender and Racial Groups.

ABSTRACT: Many individuals lost their employment during the COVID-19 pandemic and experienced financial hardship. These experiences may increase risk for co-occurring conditions, including substance use disorders (SUDs) and related symptoms of depression and anxiety. This study aimed to examine the associations between COVID-19-related financial hardship and/or job loss and co-occurring symptoms, across gender and racial groups. Respondents (N = 3493) included individuals entering SUD treatment in the United States in March-October of 2020. Results demonstrated that COVID-19-related financial hardship and unemployment in the household was associated with greater depression and anxiety severity among people in SUD treatment (p's < 0.05). Our findings highlight financial hardship and loss of employment as risk factors for co-occurring depression and anxiety. However, additive effects between marginalized identity status and COVID-19 economic hardship on co-occurring symptoms were not observed.

A systematic review on the relationship between socioeconomic conditions and emotional disorder symptoms during Covid-19: unearthing the potential role of economic concerns and financial strain.

BACKGROUND: Covid-19 has disrupted the lives of many and resulted in high prevalence rates of mental disorders. Despite a vast amount of research into the social determinants of mental health during Covid-19, little is known about whether the results are consistent with the social gradient in mental health. Here we report a systematic review of studies that investigated how socioeconomic condition (SEC)-a multifaceted construct that measures a person's socioeconomic standing in society, using indicators such as education and income, predicts emotional health (depression and anxiety) risk during the pandemic. Furthermore, we examined which classes of SEC indicators would best predict symptoms of emotional disorders. METHODS: Following PRISMA guidelines, we conducted search over six databases, including Scopus, PubMed, etc., between November 4, 2021 and November 11, 2021 for studies that investigated how SEC indicators predict emotional health risks during Covid-19, after obtaining approval from PROSPERO (ID: CRD42021288508). Using Covidence as the platform, 362 articles (324 cross-sectional/repeated cross-sectional and 38 longitudinal) were included in this review according to the eligibility criteria. We categorized SEC indicators into 'actual versus perceived' and 'static versus fluid' classes to explore their differential effects on emotional health. RESULTS: Out of the 1479 SEC indicators used in these 362 studies, our results showed that 43.68% of the SEC indicators showed 'expected' results (i.e., higher SEC predicting better emotional health outcomes); 51.86% reported non-significant results and 4.46% reported the reverse. Economic concerns (67.16% expected results) and financial strains (64.16%) emerged as the best predictors while education (26.85%) and living conditions (30.14%) were the worst. CONCLUSIONS: This review summarizes how different SEC indicators influenced emotional health risks across 98 countries, with a total of 5,677,007 participants, ranging from high to low-income countries. Our findings showed that not all SEC indicators were strongly predictive of emotional health risks. In fact, over half of the SEC indicators studied showed a null effect. We found that perceived and fluid SEC indicators, particularly economic concerns and financial strain could best predict depressive and anxiety symptoms. These findings have implications for policymakers to further understand how different SEC classes affect mental health during a pandemic in order to tackle associated social issues effectively.

Prevalence of and Factors Associated with Financial Toxicity After Pancreatectomy and Gastrectomy.

BACKGROUND: Financial toxicity (FT) refers to the adverse impact of cancer treatment costs on patients' experiences, potentially leading to poor adherence to treatment and outcomes. However, the prevalence of FT among patients undergoing major upper gastrointestinal cancer operations, as well as factors associated with FT, remain unclear. METHODS: We conducted a cross-sectional study by sending the Comprehensive Score for financial Toxicity (COST) survey and Surgery-Q (a survey specifically developed for this study) to patients who underwent gastrectomy or pancreatectomy for malignant disease at our institution in 2019-2021. RESULTS: We sent the surveys to 627 patients and received responses from 101 (16%) patients. The FT prevalence (COST score <26) was 48 (48%). Patients likely to experience FT were younger than 50 years of age, of non-White race, earned an annual income <$75,000, and had credit scores <740 (all p < 0.05). Additionally, longer hospital stay (p = 0.041), extended time off work for surgery (p = 0.011), and extended time off work for caregivers (p = 0.005) were associated with FT. Procedure type was not associated with FT; however, patients who underwent minimally invasive surgery (MIS) had a lower FT probability (p = 0.042). In a multivariable analysis, age <50 years (p = 0.031) and credit score <740 (p < 0.001) were associated with high FT risk, while MIS was associated with low FT risk (p = 0.024). CONCLUSIONS: Patients with upper gastrointestinal cancer have a major risk of FT. In addition to predicting the FT risk before surgery, facilitating quicker functional recovery with the appropriate use of MIS is considered important to reducing the FT risk.

Long COVID and financial outcomes: evidence from four longitudinal population surveys.

BACKGROUND: Long-term sequelae of COVID-19 (long COVID) include muscle weakness, fatigue, breathing difficulties and sleep disturbance over weeks or months. Using UK longitudinal data, we assessed the relationship between long COVID and financial disruption. METHODS: We estimated associations between long COVID (derived using self-reported length of COVID-19 symptoms) and measures of financial disruption (subjective financial well-being, new benefit claims, changes in household income) by analysing data from four longitudinal population studies, gathered during the first year of the pandemic. We employed modified Poisson regression in a pooled analysis of the four cohorts adjusting for a range of potential confounders, including pre-pandemic (pre-long COVID) factors. RESULTS: Among the 20 112 observations across four population surveys, 13% reported having COVID-19 with symptoms that impeded their ability to function normally-10.7% had such symptoms for <4 weeks (acute COVID-19), 1.2% had such symptoms for 4-12 weeks (ongoing symptomatic COVID-19) and 0.6% had such symptoms for >12 weeks (post-COVID-19 syndrome). We found that post-COVID-19 syndrome was associated with worse subjective financial well-being (adjusted relative risk ratios (aRRRs)=1.57, 95% CI=1.25, 1.96) and new benefit claims (aRRR=1.79, CI=1.27, 2.53). Associations were broadly similar across sexes and education levels. These results were not meaningfully altered when scaled to represent the population by age. CONCLUSIONS: Long COVID was associated with financial disruption in the UK. If our findings reflect causal effects, extending employment protection and financial support to people with long COVID may be warranted.

Financial toxicity in gynecologic oncology: a multi-practice survey.

BACKGROUND: Financial toxicity is associated with worse cancer outcomes, including lower survival. OBJECTIVE: To characterize the prevalence of, and patient risk factors for, financial toxicity among gynecologic oncology patients in a multi-site health system. METHODS: We identified patients seen in University of Pennsylvania gynecologic oncology practices between January 2020 and February 2022 with a patient portal account. We sent a survey to all alive patients twice between March and April 2022, including the 11-item Comprehensive Score for Financial Toxicity (COST) tool. We compared differences between patients reporting high (COST score <26) and low financial toxicity (COST score ≥26) in Χ2 and regression analyses. RESULTS: Of 8239 patients, 6925 had a portal account, and 498 completed the survey for 7.2% response rate. 44% had a COST score <26, indicating financial toxicity. Patients with high financial toxicity were more likely to be younger (mean age 54 vs 60), have cervical cancer (10% vs 4%; p=0.008), be privately insured (71% vs 57%; p=0.003) or have Medicaid (7% vs 3%; p=0.03), or be unemployed (18% vs 3%; p=<0.001), and less likely to be white (79% vs 90%, p=0.003) than those with low financial toxicity. Patients with Medicare were less likely to experience financial toxicity than privately insured patients (RR=0.59, 95% CI 0.37 to 0.95). CONCLUSION: In this study of patients with gynecologic cancer or pre-cancer, 44% had financial toxicity. Financial toxicity was higher in patients who were younger, did not identify as White, and had private insurance. Targeted measures to address financial toxicity are needed to minimize disparities in patient burden of cancer treatment.

The invisible scars: Unseen financial complications worsen every aspect of long-term health in trauma survivors.

BACKGROUND: Trauma survivors are susceptible to experiencing financial toxicity (FT). Studies have shown the negative impact of FT on chronic illness outcomes. However, there is a notable lack of data on FT in the context of trauma. We aimed to better understand prevalence, risk factors, and impact of FT on trauma long-term outcomes. METHODS: Adult trauma patients with an Injury Severity Score (ISS) ≥9 treated at Level I trauma centers were interviewed 6 months to 14 months after discharge. Financial toxicity was considered positive if patients reported any of the following due to the injury: income loss, lack of care, newly applied/qualified for governmental assistance, new financial problems, or work loss. The Impact of FT on Patient Reported Outcome Measure Index System (PROMIS) health domains was investigated. RESULTS: Of 577 total patients, 44% (254/567) suffered some form of FT. In the adjusted model, older age (odds ratio [OR], 0.4; 95% confidence interval [95% CI], 0.2-0.81) and stronger social support networks (OR, 0.44; 95% CI, 0.26-0.74) were protective against FT. In contrast, having two or more comorbidities (OR, 1.81; 95% CI, 1.01-3.28), lower education levels (OR, 1.95; 95% CI, 95%, 1.26-3.03), and injury mechanisms, including road accidents (OR, 2.69; 95% CI, 1.51-4.77) and intentional injuries (OR, 4.31; 95% CI, 1.44-12.86) were associated with higher toxicity. No significant relationship was found with ISS, sex, or single-family household. Patients with FT had worse outcomes across all domains of health. There was a negative linear relationship between the severity of FT and worse mental and physical health scores. CONCLUSION: Financial toxicity is associated with long-term outcomes. Incorporating FT risk assessment into recovery care planning may help to identify patients most in need of mitigative interventions across the trauma care continuum to improve trauma recovery. Further investigations to better understand, define, and address FT in trauma care are warranted. LEVEL OF EVIDENCE: Prognostic and Epidemiological; Level III.

Mental Health Among Puerto Rican Adolescents Living in the United States During the COVID-19 Pandemic.

OBJECTIVES: The present study examined how different family level (family financial stress, family violence) and individual (food insecurity, gender, race) determinants of health were associated with mental health among Puerto Rican adolescents living in the U.S. during the COVID-19 pandemic. METHOD: A sample consisting of 119 Puerto Rican adolescents, aged 13 to 17, was collected via Qualtrics Panels between November 2020 and January 2021. We examined the association between family financial stress experienced during the pandemic and psychological distress. We also evaluated whether the association between family financial stress and psychological distress was moderated by family violence, food insecurity, and the participant's gender and race. RESULTS: Findings showed that food insecurity positively predicted psychological distress. Results also showed that participants' race moderated the association between family financial stress and psychological distress. Specifically, we found that while there was a significant positive association between family financial stress and psychological distress among Puerto Rican adolescents who identified as a racial minority, this association was nonsignificant among White Puerto Rican adolescents. CONCLUSION: Our research highlights the significant role of COVID-19 related family financial stress and food insecurity on Puerto Rican adolescents' poor mental health during the COVID-19 pandemic.

The relation between economic stressors and higher education students' mental health during the initial outbreak of the COVID-19 pandemic.

AIMS: The COVID-19 pandemic has had a large impact on the financial situation of higher education students, disproportionately affecting students with a low socioeconomic status (SES). This raises the question of whether economic stressors related to COVID-19 have aggravated existing socioeconomic inequalities in mental health. This study examined the relationship between economic stressors and students' depressive symptoms, and the role of students' SES and countries' socioeconomic conditions. METHODS: Data from the COVID-19 International Student Well-being Study was used for multilevel analyses, with depressive symptoms as dependent variable. Three indicators measured SES: educational level of the parents, ability to borrow money from their social network, and struggling with financial resources prior to COVID-19. RESULTS: Students with a low SES had more depressive symptoms, and those not able to borrow money and with parents without higher education were more exposed to a deterioration in their financial situation. Both economic stressors (reduction in working hours and a deterioration of their financial situation) were positively related to depressive symptoms. In addition, the positive relationship between a decrease in working hours and depressive symptoms was stronger in countries with a higher unemployment rate. CONCLUSIONS: We observed socioeconomic inequalities in students' mental health, which, in part, can be ascribed to a larger exposure to the economic stressors related to COVID-19 among students' with a low SES. The macroeconomic context also played a role, as the impact of a reduction in working hours on depressive symptoms was stronger in countries with poor economic conditions.

Health Care Spending, Use, and Financial Hardship Among Traditional Medicare and Medicare Advantage Enrollees With Mental Health Symptoms.

OBJECTIVE: We examined the differences in health care spending and utilization, and financial hardship between Traditional Medicare (TM) and Medicare Advantage (MA) enrollees with mental health symptoms. DESIGN: Cross-sectional study. PARTICIPANTS: We identified Medicare beneficiaries with mental health symptoms using the Patient Health Questionnaire-2 and the Kessler-6 Psychological Distress Scale in the 2015-2021 Medical Expenditure Panel Survey. MEASUREMENTS: Outcomes included health care spending and utilization (both general and mental health services), and financial hardship. The primary independent variable was MA enrollment. RESULTS: MA enrollees with mental health symptoms were 2.3 percentage points (95% CI: -3.4, -1.2; relative difference: 16.1%) less likely to have specialty mental health visits than TM enrollees with mental health symptoms. There were no significant differences in total health care spending, but annual out-of-pocket spending was $292 (95% CI: 152-432; 18.2%) higher among MA enrollees with mental health symptoms than TM enrollees with mental health symptoms. Additionally, MA enrollees with mental health symptoms were 5.0 (95% CI: 2.9-7.2; 22.3%) and 2.5 percentage points (95% CI: 0.8-4.2; 20.9%) more likely to have difficulty paying medical bills over time and to experience high financial burden than TM enrollees with mental health symptoms. CONCLUSION: Our findings suggest that MA enrollees with mental health symptoms were more likely to experience limited access to mental health services and high financial hardship compared to TM enrollees with mental health symptoms. There is a need to develop policies aimed at improving access to mental health services while reducing financial burden for MA enrollees.

Financial hardship among siblings of long-term survivors of childhood cancer: A Childhood Cancer Survivor Study report.

BACKGROUND: Siblings of children with cancer may experience adverse household economic consequences, but their financial outcomes in adulthood are unknown. METHODS: A total of 880 siblings (aged 18-64 years) of adult-aged childhood cancer survivors were surveyed to estimate the prevalence of financial hardship by three established domains (behavioral, material, and psychological). For individual financial hardship items matching the contemporaneous National Health Interview Survey or Behavioral Risk Factor Surveillance System, siblings were compared with the general population by calculating adjusted prevalence odds ratios (ORs) to sample-weighted responses. Multivariable logistic regression models examined associations between sibling characteristics and each hardship domain and between sibling hardship and survivors' cancer/treatment characteristics. RESULTS: Behavioral, material, and psychological hardship was reported by 24%, 35%, and 28%, respectively. Compared with national survey respondents, siblings were more likely to report worries about medical bills (OR, 1.14; 95% confidence interval [CI], 1.06-1.22), difficulty affording nutritious foods (OR, 1.79; 95% CI, 1.54-2.07), and forgoing needed medical care (OR, 1.38; 95% CI, 1.10-1.73), prescription medications (OR, 2.52; 95% CI, 1.99-3.20), and dental care (OR, 1.34; 95% CI, 1.15-1.57) because of cost. Sibling characteristics associated with reporting financial hardship in one or more domains included female sex, older age, chronic health conditions, lower income, not having health insurance, high out-of-pocket medical expenditures, and nonmedical/nonhome debt. No survivor cancer/treatment characteristics were associated with sibling financial hardship. CONCLUSIONS: Adult siblings of childhood cancer survivors were more likely to experience financial hardship compared with the general population. Childhood cancer may adversely affect entire households, with potentially lasting implications.

Association of Severe COVID-19 and Persistent COVID-19 Symptoms With Economic Hardship Among US Families.

Importance: Little is known about the association of severe COVID-19 and post-COVID-19 conditions with household finances. Objective: To examine associations between COVID-19 outcomes, pandemic-related economic hardship, and prepandemic socioeconomic status among families in the US. Design, Setting, and Participants: This cohort study used data from the Panel Study of Income Dynamics (PSID), a nationally representative, longitudinal study. Data included 6932 families active in the PSID in both 2019 and 2021. Exposures: Ordinal exposure categories were defined based on whether the reference person or spouse or partner reported a positive COVID-19 diagnosis and (1) persistent COVID-19 symptoms, (2) previous severe COVID-19, or (3) previous moderate, mild, or asymptomatic COVID-19. Families with no history of COVID-19 served as the reference group. Main Outcomes and Measures: Outcomes included whether a resident family member was laid off or furloughed, lost earnings, or had any financial difficulties due to the COVID-19 pandemic. Results: In this cohort study of 6932 families (772 Hispanic families [weighted, 13.5%; 95% CI, 12.4%-14.6%], 2725 non-Hispanic Black families [weighted, 13.1%; 95% CI, 12.3%-14.1%], and 3242 non-Hispanic White families [weighted, 66.8%; 95% CI, 65.2%-68.3%]), close to 1 in 4 (2222 [weighted, 27.0%; 95% CI, 25.6%-28.6%]) reported income below 200% of the US Census Bureau poverty threshold. In survey-weighted regression models adjusted for prepandemic sociodemographic characteristics and experiences of economic hardship, the odds of reporting pandemic-related economic hardship were 2.0 to 3.7 times higher among families headed by an adult with persistent COVID-19 symptoms (laid off or furloughed: adjusted odds ratio [AOR], 1.98 [95% CI, 1.37-2.85]; lost earnings: AOR, 2.86 [95% CI, 2.06-3.97]; financial difficulties: AOR, 3.72 [95% CI, 2.62-5.27]) and 1.7 to 2.0 times higher among families headed by an adult with previous severe COVID-19 (laid off or furloughed: AOR, 1.69 [95% CI, 1.13-2.53]; lost earnings: AOR, 1.99 [95% CI, 1.37-2.90]; financial difficulties: AOR, 1.87 [95% CI, 1.25-2.80]) compared with families with no history of COVID-19. Families headed by an adult with persistent COVID-19 symptoms had increased odds of reporting financial difficulties due to the pandemic regardless of prepandemic socioeconomic status (families with lower income: AOR, 3.71 [95% CI, 1.94-7.10]; families with higher income: AOR, 3.74 [95% CI, 2.48-5.63]). Previous severe COVID-19 was significantly associated with financial difficulties among families with lower income (AOR, 2.59 [95% CI, 1.26-5.31]) but was not significantly associated with financial difficulties among those with high income (OR, 1.56 [95% CI, 0.95-2.56]). Conclusions and Relevance: This cohort study suggests that persistent COVID-19 symptoms and, to a lesser extent, previous severe COVID-19 were associated with increased odds of pandemic-related economic hardship in a cohort of US families. The economic consequences of COVID-19 varied according to socioeconomic status; families with lower income before the pandemic were more vulnerable to employment disruptions and earnings losses associated with an adult family member's COVID-19 illness.

Income loss and subsequent poor psychological well-being among the Chinese population during the early COVID-19 pandemic.

BACKGROUND: The COVID-19 pandemic has had major ramifications for health and the economy at both the individual and collective levels. This study examined exogenous negative changes in household income and their implications on psychological well-being (PWB) among the Chinese population during the COVID-19 pandemic. METHODS: Data were drawn from the early China COVID-19 Survey, a cross-sectional anonymous online survey administered to the general population in China. Self-reported PWB was measured using a 5-point Likert scale with five questions related to the participants' recent psychological state. Hierarchical multiple linear regression was employed to examine whether income loss during the COVID-19 pandemic was associated with poor psychological health. RESULTS: This study included 8,428 adults, of which 90% had suffered from a moderate or severe loss of household income due to the early COVID-19 pandemic. Those who had experienced moderate or severe loss of income scored significantly lower on psychological well-being than those who did not experience income loss (19.96 or 18.07 vs. 21.46; P < 0.001); after controlling for confounders, income loss was negatively associated with PWB scores (moderate income loss: B = - 0.603, P < 0.001; severe income loss: B = - 1.261, P < 0.001). An interaction effect existed between the degree of income loss and pre-pandemic income groups. Specifically, participants in the middle-income group who had suffered severe income loss scored the lowest on PWB (B = - 1.529, P < 0.001). There was also a main effect on income loss, such that participants with varying degrees of income loss differed across five dimensions, including anhedonia, sleep problems, irritability or anger, difficulty with concentration, and repeated disturbing dreams related to COVID-19. CONCLUSIONS: Income loss during the pandemic has had detrimental consequences on psychological well-being, and the magnitude of the impact of income loss on psychological well-being varied according to previous income levels. Future policy efforts should be directed toward improving the psychological well-being of the economically vulnerable and helping them recover from lost income in the shortest time possible.

Association of Employment Disruptions and Financial Hardship Among Individuals Diagnosed with Cancer in the United States: Findings from a Nationally Representative Study.

Financial hardship (FH), defined as adverse patient effects due to cancer costs, is experienced by approximately half of individuals diagnosed with cancer. Many individuals diagnosed with cancer also experience disruptions with their employment. This study examines associations of employment disruptions and FH among a nationally representative sample of individuals diagnosed with cancer in the United States. We utilized 2016/2017 Medical Expenditure Panel Survey Experiences with Cancer data from individuals who worked for pay following cancer diagnosis. Employment disruption included taking extended paid time off work; switching to part-time/less demanding jobs; and/or retiring early due to cancer diagnosis/treatment. FH domains included: material (e.g., borrowing money/financial sacrifices); psychologic (e.g., worrying about medical bills/income); and behavioral (delaying/forgoing healthcare services because of cost). Multivariable logistic regression analyses determined associations of employment disruption and FH. Among 732 individuals with a cancer history, 47.4% experienced employment disruptions; 55.9% experienced any FH. Any FH was significantly more common among individuals with versus without employment disruptions across multiple measures and domains (68.7% vs. 44.5%; P value of difference <0.0001). Individuals with employment disruptions were more likely to have any FH [OR, 2.38; 95% confidence interval (CI), 1.62-3.52] and more FHs (OR, 2.76; 95% CI, 1.96-3.89]. This study highlights that employment disruptions are common and significantly associated with multiple domains of FH among individuals with a cancer history. Employer workplace accommodation, physician discussions regarding potential impacts of cancer care on employment, and other policies to minimize employment disruptions among individuals diagnosed with cancer may reduce FH in this vulnerable population. Significance: Individuals diagnosed with cancer may have employment disruptions; they may also develop FHs. People with cancer who have employment changes are more likely to also have FHs. Physicians and employers can help individuals with cancer through advancing planning, workplace assistance, and improved medical leave and insurance policies.

Historical Redlining, Socioeconomic Distress, and Risk of Heart Failure Among Medicare Beneficiaries.

BACKGROUND: The association of historical redlining policies, a marker of structural racism, with contemporary heart failure (HF) risk among White and Black individuals is not well established. METHODS: We aimed to evaluate the association of redlining with the risk of HF among White and Black Medicare beneficiaries. Zip code-level redlining was determined by the proportion of historically redlined areas using the Mapping Inequality Project within each zip code. The association between higher zip code redlining proportion (quartile 4 versus quartiles 1-3) and HF risk were assessed separately among White and Black Medicare beneficiaries using generalized linear mixed models adjusted for potential confounders, including measures of the zip code-level Social Deprivation Index. RESULTS: A total of 2 388 955 Medicare beneficiaries (Black n=801 452; White n=1 587 503; mean age, 71 years; men, 44.6%) were included. Among Black beneficiaries, living in zip codes with higher redlining proportion (quartile 4 versus quartiles 1-3) was associated with increased risk of HF after adjusting for age, sex, and comorbidities (risk ratio, 1.08 [95% CI, 1.04-1.12]; P<0.001). This association remained significant after further adjustment for area-level Social Deprivation Index (risk ratio, 1.04 [95% CI, 1.002-1.08]; P=0.04). A significant interaction was observed between redlining proportion and Social Deprivation Index (Pinteraction<0.01) such that higher redlining proportion was significantly associated with HF risk only among socioeconomically distressed regions (above the median Social Deprivation Index). Among White beneficiaries, redlining was associated with a lower risk of HF after adjustment for age, sex, and comorbidities (risk ratio, 0.94 [95% CI, 0.89-0.99]; P=0.02). CONCLUSIONS: Historical redlining is associated with an increased risk of HF among Black patients. Contemporary zip code-level social determinants of health modify the relationship between redlining and HF risk, with the strongest relationship between redlining and HF observed in the most socioeconomically disadvantaged communities.