Social inequalities, debt, and health in the United States.

BACKGROUND: Household financial debt has more than tripled since the 1980s in the United States. The experience of indebtedness is socially structured and there is mounting evidence that debt is linked to decrements in health. However, it is unclear whether debt contributes to social disparities in health. OBJECTIVE: We examined whether household debt, measured by debt in excess of income and wealth, mediated education-based social inequalities in health, including cardiovascular risk factors (hypertension) and chronic conditions (diabetes, coronary heart disease, and psychiatric problems). METHOD: We used longitudinal data from a sample of over 10,500 adults aged 18 years and older surveyed biennially between 1999 and 2015 as part of the Panel Study of Income Dynamics (PSID). We estimated the total effect of education on our health outcomes. To assess mediation by levels of household debt, we then estimated the controlled direct effect of education through pathways not mediated by levels of household debt, after accounting for lagged time-varying confounders and loss to follow-up using marginal structural models. RESULTS: Compared to respondents with at least a high school education, respondents with less than a high school education reported higher household debts in excess of income and wealth; they also reported a higher incidence of hypertension [risk ratio (RR) = 1.25, 95%CI = 1.13, 1.39), coronary heart disease (RR = 1.42, 95%CI: 1.25, 1.62), diabetes (RR = 1.50, 95%CI: 1.34, 1.68), and psychiatric problems (RR = 1.39, 95%CI: 1.24, 1.56). Compared to the total effects, the controlled direct effects of education on health were attenuated, particularly for death or first onset of hypertension and coronary heart disease, after fixing levels of household debt-to-income and debt-to-wealth. CONCLUSION: Our results provide early evidence that household debt in excess of wealth partly mediates education-based inequalities in hypertension and coronary heart disease in the United States, with less consistent evidence for other chronic conditions.

Debt-Related Financial Hardship and Health.

Recent research shows personal financial debt is an important socioeconomic determinant of health, but the mechanisms through which it operates are not well understood. This article uses data from a mixed-methods study to explore how changes in spending and behavior that result from debt have salient health consequences in a cross-sectional sample of Boston area adults (n = 286). Findings show that a large majority of respondents had skipped medical care, housing payments, or consumer purchases at least once because of their debt. Controlling for multiple sociodemographic characteristics, each of these measures of debt-related behavior change was associated with worse self-rated health, and higher depressive symptoms, anxiety, and perceived stress. In models including all three measures, skipped medical care was associated with worse health across all outcomes, while skipped consumer purchases were associated with higher perceived stress and depression. These findings suggest that altered spending and care-seeking behaviors are potential pathways through which financial debt can negatively affect health and suggest areas in need of additional research.

"Like you failed at life": Debt, health and neoliberal subjectivity.

The need to more explicitly incorporate political economy and neoliberalism into research on social inequalities in health has been acknowledged across disciplines. This paper explores neoliberalism as it relates to consumer financial debt and internalized feelings of personal responsibility and failure for adults in Boston, Massachusetts. Using data from a mixed-methods study (n = 286), findings show that endorsing a neoliberalized view of personal debt as failure is associated with significantly worse health across a range of measures, including blood pressure, adiposity, self-reported physical and emotional symptoms, depression, anxiety, and perceived stress, even when controlling for several socio-demographic confounders. Results are discussed within the context of both neoliberal economic policies that funnel consumers into chronic debt and neoliberal sociocultural ideologies that promote self-judgments of indebtedness as personal failure. Findings highlight the importance of neoliberalism as an important contemporary social determinant of health and suggest new directions for research to explore.

Short-term lending: Payday loans as risk factors for anxiety, inflammation and poor health.

While research now consistently links consumer financial debt with adverse emotional health outcomes, specific forms of debt and their impact on measures of physical health are underexplored. This gap in knowledge is significant because different forms of loans and debt may have different experiential qualities. In this paper, we focus on a type of unsecured debt - short-term/payday loan borrowing - that has risen dramatically in recent decades in the United States and is characterized by predatory, discriminatory, and poorly regulated lending practices. Using data from a study of debt and health among adults in Boston, MA (n=286), we test whether short-term borrowing is associated with a range of emotional and physical health indicators. We find that short-term loans are associated with higher body mass index, waist circumference, C-reactive protein levels, and self-reported symptoms of physical health, sexual health, and anxiety, after controlling for several socio-demographic covariates. We discuss these findings within the contexts of regulatory shortcomings, psychosocial stress, and racial and economic credit disparities. We suggest that within the broader context of financial debt and health, short-term loans should be considered a specific risk to population health.

Embodied Neoliberalism: Epidemiology and the Lived Experience of Consumer Debt.

A growing set of epidemiological data links personal financial debt to negative mental and physical health outcomes. These findings point to debt as a potentially significant socioeconomic determinant of population health, especially given rising rates of household and consumer debt in industrialized nations. However, the political and economic contexts in which rising consumer debt is embedded and the ways in which it is experienced in everyday life are underexplored in this epidemiological literature. This gap leaves open questions about how best to situate and understand debt as a health determinant with both psychosocial and neo-material attributes. In this article, we discuss findings from a qualitative study of personal debt experience in Boston, Massachusetts. Participants' debt narratives highlight the powerful feelings of shame, guilt, and personal responsibility that debt engenders. The findings point to the influence of neoliberal ideology in shaping emotional responses to debt and suggest that these responses may be important pathways through which debt affects health. We discuss our findings within the broader landscape of American neoliberal economic policy and its role in shaping trends of consumer debt burden.

The Health Equity Scholars Program: Innovation in the Leaky Pipeline.

Despite attempts to increase enrollment of under-represented minorities (URMs: primarily Black/African American, Hispanic/Latino, and Native American students) in health professional programs, limited progress has been made. Compelling reasons to rectify this situation include equity for URMs, better prepared health professionals when programs are diverse, better quality and access to health care for UMR populations, and the need for diverse talent to tackle difficult questions in health science and health care delivery. However, many students who initiate traditional "pipeline" programs designed to link URMs to professional schools in health professions and the sciences, do not complete them. In addition, program requirements often restrict entry to highly qualified students while not expanding opportunities for promising, but potentially less well-prepared candidates. The current study describes innovations in an undergraduate pipeline program, the Health Equity Scholars Program (HESP) designed to address barriers URMs experience in more traditional programs, and provides evaluative outcomes and qualitative feedback from participants. A primary outcome was timely college graduation. Eighty percent (80%) of participants, both transfer students and first time students, so far achieved this outcome, with 91% on track, compared to the campus average of 42% for all first time students and 58-67% for transfers. Grade point averages also improved (p = 0.056) after program participation. Graduates (94%) were working in health care/human services positions and three were in health-related graduate programs. Creating a more flexible program that admits a broader range of URMs has potential to expand the numbers of URM students interested and prepared to make a contribution to health equity research and clinical care.

Associations between macrolevel economic factors and weight distributions in low- and middle-income countries: a multilevel analysis of 200,000 adults in 40 countries.

OBJECTIVES: We examined associations between macrolevel economic factors hypothesized to drive changes in distributions of weight and body mass index (BMI) in a representative sample of 200,796 men and women from 40 low- and middle-income countries. METHODS: We used meta-regressions to describe ecological associations between macrolevel factors and mean BMIs across countries. Multilevel regression was used to assess the relation between macrolevel economic characteristics and individual odds of underweight and overweight relative to normal weight. RESULTS: In multilevel analyses adjusting for individual-level characteristics, a 1-standard-deviation increase in trade liberalization was associated with 13% (95% confidence interval [CI] = 0.76, 0.99), 17% (95% CI = 0.71, 0.96), 13% (95% CI = 0.76, 1.00), and 14% (95% CI = 0.75, 0.99) lower odds of underweight relative to normal weight among rural men, rural women, urban men, and urban women, respectively. Economic development was consistently associated with higher odds of overweight relative to normal weight. Among rural men, a 1-standard-deviation increase in foreign direct investment was associated with 17% (95% CI = 1.02, 1.35) higher odds of overweight relative to normal weight. CONCLUSIONS: Macrolevel economic factors may be implicated in global shifts in epidemiological patterns of weight.

The high price of debt: household financial debt and its impact on mental and physical health.

Household financial debt in America has risen dramatically in recent years. While there is evidence that debt is associated with adverse psychological health, its relationship with other health outcomes is relatively unknown. We investigate the associations of multiple indices of financial debt with psychological and general health outcomes among 8400 young adult respondents from the National Longitudinal Study of Adolescent Health (Add Health). Our findings show that reporting high financial debt relative to available assets is associated with higher perceived stress and depression, worse self-reported general health, and higher diastolic blood pressure. These associations remain significant when controlling for prior socioeconomic status, psychological and physical health, and other demographic factors. The results suggest that debt is an important socioeconomic determinant of health that should be explored further in social epidemiology research.

Symbolic capital, consumption, and health inequality.

Research on economic inequalities in health has been largely polarized between psychosocial and neomaterial approaches. Examination of symbolic capital--the material display of social status and how it is structurally constrained--is an underutilized way of exploring economic disparities in health and may help to resolve the existing theoretical polarization. In contemporary society, what people do with money and how they consume and display symbols of wealth may be as important as income itself. After tracing the historical rise of consumption in capitalist society and its interrelationship with economic inequality, I discuss evidence for the role of symbolic capital in health inequalities and suggest directions for future research.

Planning responds to gender violence: evidence from Spain, Mexico and the United States.

Urban planning has been largely ineffective in addressing urban violence and particularly slow in responding to gender violence. This paper explores the public and private divide, structural inequalities, and issues of ethnicity and citizenship, in terms of their planning implications for gender violence. Drawing on evidence from Spain, Mexico and the United States, it examines how economic and social planning and gender violence intertwine. The three case studies demonstrate that the challenge is not only to break constructed structural inequalities and divisions between public and private spheres, but also to promote changes in the working models of institutions and organisations.

"If your shoes are raggedy you get talked about": symbolic and material dimensions of adolescent social status and health.

This paper examines the interaction of symbolic and material dimensions of social status for African American adolescents and its relationship with blood pressure. Mixed ethnographic methods were used to develop cultural models of social status for urban African American teens in a predominantly African American lower-income community west of Chicago. Resting blood pressure and covariate data were collected, as well as standardized measures of perceived stress and social standing. Findings show that, adjusting for covariates, adolescents' consumption of symbolic status goods is significantly associated with their blood pressure, dependent upon parental economic resources. The political economy of status consumption, the underlying contexts of racial and economic inequality, and the implications of these findings for health disparities are discussed.

Epigenetics and the embodiment of race: developmental origins of US racial disparities in cardiovascular health.

The relative contribution of genetic and environmental influences to the US black-white disparity in cardiovascular disease (CVD) is hotly debated within the public health, anthropology, and medical communities. In this article, we review evidence for developmental and epigenetic pathways linking early life environments with CVD, and critically evaluate their possible role in the origins of these racial health disparities. African Americans not only suffer from a disproportionate burden of CVD relative to whites, but also have higher rates of the perinatal health disparities now known to be the antecedents of these conditions. There is extensive evidence for a social origin to prematurity and low birth weight in African Americans, reflecting pathways such as the effects of discrimination on maternal stress physiology. In light of the inverse relationship between birth weight and adult CVD, there is now a strong rationale to consider developmental and epigenetic mechanisms as links between early life environmental factors like maternal stress during pregnancy and adult race-based health disparities in diseases like hypertension, diabetes, stroke, and coronary heart disease. The model outlined here builds upon social constructivist perspectives to highlight an important set of mechanisms by which social influences can become embodied, having durable and even transgenerational influences on the most pressing US health disparities. We conclude that environmentally responsive phenotypic plasticity, in combination with the better-studied acute and chronic effects of social-environmental exposures, provides a more parsimonious explanation than genetics for the persistence of CVD disparities between members of socially imposed racial categories.

Race, ethnicity, and racism in medical anthropology, 1977-2002.

Researchers across the health sciences are engaged in a vigorous debate over the role that the concepts of "race" and "ethnicity" play in health research and clinical practice. Here we contribute to that debate by examining how the concepts of race, ethnicity, and racism are used in medical-anthropological research. We present a content analysis of Medical Anthropology and Medical Anthropology Quarterly, based on a systematic random sample of empirical research articles (n = 283) published in these journals from 1977 to 2002. We identify both differences and similarities in the use of race, ethnicity, and racism concepts in medical anthropology and neighboring disciplines, and we offer recommendations for ways that medical anthropologists can contribute to the broader debate over racial and ethnic inequalities in health.

Relationships between skin color, income, and blood pressure among African Americans in the CARDIA Study.

OBJECTIVES: We explored how income and skin color interact to influence the blood pressure of African American adults enrolled in the longitudinal Coronary Artery Risk Development in Young Adults (CARDIA) Study. METHODS: Data were derived from 1893 African American CARDIA year-15 participants who had undergone skin reflectance assessments at year 7. We adjusted for age, gender, body mass index, smoking status, and use of antihypertensive medication to examine whether year-15 self-reported family incomes, in interaction with skin reflectance, predicted blood pressure levels. RESULTS: Mean systolic and diastolic blood pressure levels were 117.1 (+/-16.07) and 76.9 (+/-12.5) mm Hg, respectively. After adjustment, the interaction between skin reflectance and income was significantly associated with systolic blood pressure (P< .01). Among lighter-skinned African Americans, systolic pressure decreased as income increased (b= -1.15, P<.001); among those with darker skin, systolic blood pressure increased with increasing income (b=0.10, P=.75). CONCLUSIONS: The protective gradient of income on systolic blood pressure seen among African Americans with lighter skin is not observed to the same degree among those with darker skin. Psychosocial stressors, including racial discrimination, may play a role in this relationship.