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.

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.

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.

Predictors of Financial Toxicity Among United States Prostate Cancer Survivors: Results From a National Survey.

INTRODUCTION: Despite increasing attention to financial toxicity associated with prostate cancer, national rates of subjective and objective financial toxicity have not been well characterized, and it remains unknown which prostate cancer survivors are at highest risk for undue financial burden. METHODS: Men with a history of prostate cancer were identified from the Medical Expenditure Panel Survey. The proportion of men reporting catastrophic health care expenditures (out-of-pocket spending >10% of income) and other measures of financial toxicity were assessed. Multivariable logistic regression was used to identify independent predictors of financial toxicity. RESULTS: Of a weighted estimate of 2,349,532 men with a history of prostate cancer, 13.5% reported catastrophic health care expenditures, 16% reported subjective worry about ability to pay medical bills, and 15% reported work changes due to their cancer diagnosis. Significant predictors of catastrophic expenditures included private insurance (OR 4.62, 95% CI 1.29-16.49) and medical comorbidities (OR 1.38, 95% CI 1.05-1.82), while high income was protective (>400% vs <100% federal poverty level, OR 0.06, 95% CI 0.02-0.19). Each year of older age was associated with decreased odds of subjective worry about medical bills. Only 12% of men reported their doctor discussed the costs of care in detail. CONCLUSIONS: Nearly 1 in 7 prostate cancer survivors experience catastrophic health care expenditures, and a larger proportion report subjective manifestations of financial toxicity. Many men report their physicians did not address the financial side effects of treatment. These results highlight the patient characteristics associated with this important side effect of prostate cancer care.

Financial hardship, sleep disturbances, and their relationship among men and women in the United States during the COVID-19 pandemic.

OBJECTIVE: In the United States (US), the health and financial consequences of COVID-19 have disproportionately impacted women and minoritized racial-ethnic groups. Yet, few US studies have investigated financial hardship during the COVID-19 pandemic and sleep health disparities. Our objective was to investigate associations between financial hardship and sleep disturbances during the COVID-19 pandemic by gender and race and ethnicity in the United States. METHODS: We used the nationally representative COVID-19's Unequal Racial Burden cross-sectional survey data collected among 5339 men and women from 12/2020 to 2/2021. Participants reported financial hardship (eg, debt, employment/work loss) since the pandemic began and completed the Patient-Reported Outcomes Management Information System Short Form 4a for sleep disturbances. Prevalence ratios (PRs) and 95% confidence intervals were estimated using adjusted, weighted Poisson regression with robust variance. RESULTS: Most (71%) participants reported financial hardship. Prevalence of moderate to severe sleep disturbances was 20% overall, higher among women (23%), and highest among American Indian/Alaska Native (29%) and multiracial adults (28%). Associations between financial hardship and moderate to severe sleep disturbances (PR = 1.52 [95% confidence interval: 1.18, 1.94]) did not differ by gender but varied by race and ethnicity: associations were strongest among Black/African American (PR = 3.52 [1.99,6.23]) adults. CONCLUSIONS: Both financial hardship and sleep disturbances were prevalent, and their relationships were strongest among certain minoritized racial-ethnic groups, particularly Black/African American adults. Interventions that alleviate financial insecurity may reduce sleep health disparities.

The Economic Burden of Racial, Ethnic, and Educational Health Inequities in the US.

Importance: Health inequities exist for racial and ethnic minorities and persons with lower educational attainment due to differential exposure to economic, social, structural, and environmental health risks and limited access to health care. Objective: To estimate the economic burden of health inequities for racial and ethnic minority populations (American Indian and Alaska Native, Asian, Black, Latino, and Native Hawaiian and Other Pacific Islander) and adults 25 years and older with less than a 4-year college degree in the US. Outcomes include the sum of excess medical care expenditures, lost labor market productivity, and the value of excess premature death (younger than 78 years) by race and ethnicity and the highest level of educational attainment compared with health equity goals. Evidence Review: Analysis of 2016-2019 data from the Medical Expenditure Panel Survey (MEPS) and state-level Behavioral Risk Factor Surveillance System (BRFSS) and 2016-2018 mortality data from the National Vital Statistics System and 2018 IPUMS American Community Survey. There were 87 855 survey respondents to MEPS, 1 792 023 survey respondents to the BRFSS, and 8 416 203 death records from the National Vital Statistics System. Findings: In 2018, the estimated economic burden of racial and ethnic health inequities was $421 billion (using MEPS) or $451 billion (using BRFSS data) and the estimated burden of education-related health inequities was $940 billion (using MEPS) or $978 billion (using BRFSS). Most of the economic burden was attributable to the poor health of the Black population; however, the burden attributable to American Indian or Alaska Native and Native Hawaiian or Other Pacific Islander populations was disproportionately greater than their share of the population. Most of the education-related economic burden was incurred by adults with a high school diploma or General Educational Development equivalency credential. However, adults with less than a high school diploma accounted for a disproportionate share of the burden. Although they make up only 9% of the population, they bore 26% of the costs. Conclusions and Relevance: The economic burden of racial and ethnic and educational health inequities is unacceptably high. Federal, state, and local policy makers should continue to invest resources to develop research, policies, and practices to eliminate health inequities in the US.

COVID-19-Related Employment Disruptions and Increased Financial Burden Among Survivors of Adolescent and Young Adult Cancer.

Background: Financial burden is a major concern for survivors of adolescent and young adult (AYA) cancers. We identified if employment disruptions during the COVID-19 pandemic affected AYA survivors' financial burden. Methods: AYAs who were enrolled in a cancer patient navigation program were e-mailed a survey in fall 2020. Survey items included sociodemographics, employment disruption, and two measures of financial burden: COmprehensive Score for Financial Toxicity (COST) and material and behavioral financial hardship items (for any reason, COVID-19 induced, cancer induced). Financial burden outcomes were dichotomized at the median (COST = 21; financial hardship = 3). The association of employment disruptions and sociodemographics with financial burden was assessed using multivariable logistic regression models. Results: Reduced hours/job loss was reported by 24.0% of 341 participants. Survivors with a high school education or less (odds ratio [OR]: 2.70; 95% confidence interval [CI]: 1.21-6.03) or who had decreased hours or job loss (OR: 3.97; 95% CI: 2.01-7.84) had greater odds for high financial toxicity. Reduced hours/job loss was the only factor associated with high material and behavioral financial hardship for both any reason (OR: 2.75; 95% CI: 1.41-5.33) and owing to COVID-19 (OR: 4.98; 95% CI: 2.28-10.92). Cancer treatment since March 2020 was associated with cancer-induced high material and behavioral financial hardship (OR: 3.31; 95% CI: 1.96-5.58). Conclusion: Employment disruptions owing to the COVID-19 pandemic, lower education levels, and cancer treatment were associated with high financial burden among AYA cancer survivors. Our findings suggest the need for multilevel interventions to identify and address financial burden among vulnerable cancer survivors.

Race-Ethnic Differences in the Effects of COVID-19 on the Work, Stress, and Financial Outcomes of Older Adults.

OBJECTIVES: This study investigates race-ethnic differences among older non-Hispanic Black, non-Hispanic White, and Hispanic adults' financial, employment, and stress consequences of COVID-19. METHODS: We use data from the Health and Retirement Study, including the 2020 COVID-panel, to evaluate a sample of 2,929 adults using a combination of bivariate tests, OLS regression analysis, and moderation tests. RESULTS: Hispanic and non-Hispanic Black older adults experienced more financial hardships, higher levels of COVID-19 stress, and higher rates of job loss associated with COVID-19 relative to their Non-Hispanic White counterparts. Non-Hispanic Black and Hispanic adults reported significantly higher levels of COVID-19 resilience resources, yet, these resources were not protective of the consequences of COVID-19. DISCUSSION: Understanding how the experiences of managing and coping with COVID-19 stressors differ by race-ethnicity can better inform intervention design and support services.

Financial toxicity and mental well-being of the oral cancer survivors residing in a developing country in the era of COVID 19 pandemic - A cross-sectional study.

OBJECTIVES: The primary outcome measures evaluated the financial toxicity and mental well-being of the oral cancer survivors. METHODS: A cross-sectional study of oral cancer survivors who were disease-free for more than 6 months after treatment and visited the hospital for a routine follow-up is included in the study. Mental well-being and financial toxicity were evaluated using the Depression, Anxiety, and Stress Scale - 21 (DASS 21) and Comprehensive Score for financial Toxicity (COST- Functional Assessment of Chronic Illness Therapy) questionnaires. A literature review was done to compare the results with financial toxicity and mental health in cancer patients from the pre-pandemic era. RESULTS: A total of 79 oral cancer survivors were included in the study, predominantly males (M: F = 10:1). The age ranged from 26 to 75 years (The median age is 49). The full-time employment dropped from 83.5% in the pre-treatment period to 21.5% post-treatment. Depression was observed in 58.2% and anxiety in 72.2%. Unemployed survivors were observed to have more depression (OR = 1.3, 95% confidence interval (CI) = 0.3-5.4, p = 0.6), anxiety (OR = 3.5, 95% CI = 0.3-21.2, p = 0.1) and stress (OR = 1.6, 95% CI = 0.3-6.6, p = 0.5) than rest of the cohort. On univariate analysis, unemployed survivors (M = 11.8 ± 3.8, p = 0.01) had significantly poorer financial toxicity scores. Survivors with depression (M = 16.4 ± 7.1, p = 0.06) and stress (M = 14.4 ± 6.8, p = 0.002) had poor financial toxicity scores. On multifactorial analysis of variance, current employment (p = 0.04) and treatment modality (p = 0.05) were significant factors impacting the financial toxicity. CONCLUSION: There is a trend towards increased incidence of depression, anxiety, and stress among oral cancer survivors compared to the literature from the pre-COVID era. There is significant financial toxicity among either unemployed or part-time workers. This calls for urgent public/government intervention to prevent the long-term impact of financial toxicity on survival and quality of life.

Financial toxicity in prostate cancer survivors: A national cross-sectional assessment of subjective financial burden.

BACKGROUND: In prostate cancer (CaP) survivorship, subjective financial burden (SFB), an aspect of financial toxicity, has not been studied using a national sample. Our goal was to explore and identify factors associated with patient-reported SFB in CaP survivors. MATERIALS AND METHODS: We conducted a retrospective, cross-sectional study of 264 adult individuals with a history of CaP that completed the AHRQ - Medical Expenditures Panel Survey - Household Component and Cancer Self-Administered Questionnaire Supplement in 2016 or 2017. Primary outcomes were the presence of cancer-related SFB and the severity of this burden. Multivariable ordinal logistic regression and logistic regression models were used to identify factors associated with the severity of SFB and different domains of burden. RESULTS: Most participants were non-Hispanic white, had 3 or more comorbidities and had a median age of 72 years. 62.1% of survivors indicated SFB associated with their CaP care and long-term effects. 49.2% of CaP survivors indicated coping SFB, 27.7% psychological, and 29.2% material. Older (OR: 0.95, 95%CI 0.92-0.98) was associated with less SFB. Low-income level (OR: 2.1, 95%CI 1.01-4.36) was associated with higher SFB. Hispanic survivors (OR: 2.8 95%CI 1.1-7.4) indicated more psychologic SFB. Presence of a caregiver was noted as a predictor of material (OR 2.6, 95%CI 1.45-4.49) and psychological (OR: 2.2, 95%CI 1.13-3.91) SFB. CONCLUSIONS: Many CaP survivors experience SFB and associated factors differ in domain of financial burden. This provides evidence and groundwork for understanding financial burden and improving the quality of counseling and care for this population.

Mental Health Status during COVID-19 Pandemic and its Relationship with Economic Hardship and Financial Threat among Rural Population in Sarawak, Malaysia.

Background During the COVID-19 pandemic, job and income loss, social isolation may aggravate mental health, particularly among the most vulnerable groups. Objective To assess the current mental health situation among the rural population in Samarahan district and determine the relationship between economic hardships, financial threats, and mental health status. Method This study was a cross-sectional study conducted among the 530 households in the Samarahan district. A multistage cluster sampling technique was used to select the participants in this study. Data were collected by face-to-face interview using a structured questionnaire. The mental health status was assessed by using a validated and translated DASS-21 scale. Data analysis was done by SPSS version 27.0. A p-value of ≤ .05 was considered statistically significant. Result Analysis showed that two-thirds of the respondents (66.6%) had no mental health problem. Meanwhile, 22.4% had anxiety, 1% had depression, and 0.19% had stress. Anxiety and depression accounted for 5.8% and stress and anxiety 1.3%. However, 2.64% had stress, anxiety, and depression. In bivariate analysis, age, monthly income, type of job, economic hardship, and expenditure difference appeared to be significant predictors of mental health problems (p < .05). Conclusion Depression, anxiety, and stress pose a significant threat to the rural population's health. Therefore, public health practitioners and policymakers need to address this to minimise the pandemic's impact on mental health and provide psychological support, particularly among the most affected group.

Health insurance and financial hardship in cancer survivors during the COVID-19 pandemic.

Uninsured or underinsured individuals with cancer are likely to experience financial hardship, including forgoing healthcare or non-healthcare needs such as food, housing, or utilities. This study evaluates the association between health insurance coverage and financial hardship among cancer survivors during the COVID-19 pandemic. This cross-sectional analysis used Patient Advocate Foundation (PAF) survey data from May to July 2020. Cancer survivors who previously received case management or financial aid from PAF self-reported challenges paying for healthcare and non-healthcare needs during the COVID-19 pandemic. Associations between insurance coverage and payment challenges were estimated using Poisson regression with robust standard errors, which allowed for estimation of adjusted relative risks (aRR). Of 1,437 respondents, 74% had annual household incomes <$48,000. Most respondents were enrolled in Medicare (48%), 22% in employer-sponsored insurance, 13% in Medicaid, 6% in an Affordable Care Act (ACA) plan, and 3% were uninsured. Approximately 31% of respondents reported trouble paying for healthcare during the COVID-19 pandemic. Respondents who were uninsured (aRR 2.58, 95% confidence interval [CI] 1.83-3.64), enrolled in an ACA plan (aRR 1.86, 95% CI 1.28-2.72), employer-sponsored insurance (aRR 1.70, 95% CI 1.23-2.34), or Medicare (aRR 1.49, 95% CI 1.09-2.03) had higher risk of trouble paying for healthcare compared to Medicaid enrollees. Challenges paying for non-healthcare needs were reported by 57% of respondents, with 40% reporting trouble paying for food, 31% housing, 28% transportation, and 20% internet. In adjusted models, Medicare and employer-sponsored insurance enrollees were less likely to have difficulties paying for non-healthcare needs compared to Medicaid beneficiaries. Despite 97% of our cancer survivor sample being insured, 31% and 57% reported trouble paying for healthcare and non-healthcare needs during the COVID-19 pandemic, respectively. Greater attention to both medical and non-medical financial burden is needed given the economic pressures of the COVID-19 pandemic.

Measures of Financial Hardship From Health Care Expenses Among Families With a Member With Atherosclerotic Cardiovascular Disease in the US.

Importance: Patients with atherosclerotic cardiovascular disease (ASCVD) face substantial financial burden from health care costs as assessed by many disparate measures. However, evaluation of the concordance of existing measures and the prevalence of financial burden based on these measures is lacking. Objective: To compare subjectively reported and objectively measured financial burden from health care in families of patients with ASCVD. Design Setting and Participants: This cross-sectional study used data from the Medical Expenditure Panel Survey, a nationally representative survey of individuals and families in the US, and included all families with 1 or more members with ASCVD from 2014 to 2018. Analyses were conducted from October 2021 to April 2022. Main Outcomes and Measures: Using accepted definitions, objective financial hardship represented annual out-of-pocket medical expenses exceeding 20% of annual postsubsistence income, and subjective financial hardship represented self-reported problems paying medical bills or paying them over time. Prevalence of financial hardship was identified based on individual definitions and their concordance was assessed. Factors associated with each type of financial hardship were examined using risk-adjusted survey logistic regression. Multivariable logistic regression was used to model the odds of subjective financial hardship vs objective financial hardship across subgroups. The association between measures of financial hardship and self-reported deferral of care was also assessed. Results: Among 10 975 families of patients with ASCVD, representing 22.5 million families nationally (mean [SD] age of index individual, 66 [24] years; estimated 54% men]), 37% experienced either objective or subjective financial hardship. This group included 11% (95% CI, 10%-11%) with objective financial hardship, 21% (95% CI, 20%-22%) with subjective financial hardship, and 5% (95% CI, 5%-6%) with both objective and subjective financial hardship. Mean age was 70 (95% CI, 68-71) years vs 61 (95% CI, 60-62) years for index patients in families reporting objective financial hardship only vs subjective financial hardship only, with no difference in sex (50% [95% CI, 46%-54%] of men vs 49% [95% CI, 47%-52%] of women). In risk-adjusted analyses, among families of patients with ASCVD, patient age of 65 years or older was associated with lower odds of subjective financial hardship than objective financial hardship (odds ratio [OR], 0.39; 95% CI, 0.20-0.76), whereas higher income (OR, 6.08; 95% CI, 3.93-9.42 for an income of >100%-200% of the federal poverty level [FPL] vs ≤100% of the FPL and OR, 20.46; 95% CI, 11.45-36.56 for >200% of FPL vs ≤100% of FPL), public insurance (OR, 6.60; 95% CI, 4.20-10.37), and being uninsured (OR, 5.36; 95% CI, 2.61-10.98) were associated with higher odds of subjective financial hardship than objective financial hardship. Subjective financial hardship alone was associated with significantly higher adjusted odds of self-reporting deferred or forgone care compared with objective financial hardship alone (OR, 2.69; 95% CI, 1.79-4.06). Conclusions and Relevance: In this cross-sectional study of US adults, 2 in 5 families of patients with ASCVD experienced health care-related financial hardship, but a focus on objective or subjective measures alone would have captured only half the burden and not identified those deferring health care. The findings suggest that a comprehensive framework that evaluates both objective and subjective measures is essential to monitor financial consequences of health care.

Testing positive, losing a loved one, and financial hardship: Real-world impacts of COVID-19 on US college student distress.

BACKGROUND: The COVID-19 pandemic has taken a particularly heavy toll on U.S. college students. In addition to facing academic-related stress and social pressures, these individuals are now increasingly susceptible to experiences such as contracting the virus, losing loved ones to COVID-19, or facing financial hardship due to the pandemic. The effects of such personal, pandemic-related experiences on young adult mental health - and the inherent racial disparities within these outcomes - remain largely understudied. METHODS: We analyzed 65,568 undergraduate students from the Spring 2021 American College Health Association-National College Health Assessment (ACHA-NCHA). RESULTS: The rates of the aforementioned COVID-19-related stressors were unevenly distributed across racial groups. A logistic regression analysis to identify predictors of moderate and serious psychological distress revealed that participants who had experienced the death of a loved one had 1.14 times greater odds of developing psychological distress (p < 0.0001). Those who experienced financial hardship had an odds ratio of 1.78 (p < 0.0001). Surprisingly, testing positive for COVID-19 was associated with an odds ratio of 0.82 of psychological distress (p < 0.0001). LIMITATIONS: Self-reported measures are susceptible to recall bias and misinterpretation. Exposure and outcome variables were measured simultaneously in this cross-sectional study which limits inference on causality. CONCLUSIONS: Financial burdens and bereavement are especially impactful stressors among college students during the pandemic, whereas contracting COVID-19 seemingly exhibits less impact on distress levels. When addressing student wellbeing, institutions should consider prioritizing the implementation of resources to support individuals affected by pandemic-related financial and familial losses.

Associations between local COVID-19 case rates, pandemic-related financial stress and parent and child functioning.

The COVID-19 global crisis led to unprecedented disruption of family routines and heightened family stress. This study examines the effects of local COVID-19 case rates and pandemic-related financial stress on family processes (e.g., caregiving behavior) and school-aged children's outcomes. The project was launched shortly after stay-at-home orders began in the U.S. Data were collected online using Amazon's Mechanical Turk (MTurk), which allowed for nationwide recruitment. Using four waves of data (N = 308), with initial data collected between 4/20/20 and 5/6/20 and 2-3 weeks between each wave, this study examined the influence of local rates of COVID-19 infection on pandemic-related financial stress and the association of these constructs on maternal psychological distress and negative parenting. We also examined the potential cascade linking COVID-19 case rates and pandemic-related financial stress with child behavior problems via maternal psychological distress and negative parenting behavior, while controlling for prior child behavior problems. In line with hypotheses, higher Wave 1 (W1) pandemic-related financial stress was significantly associated with higher Wave 2 (W2) maternal psychological distress, which was significantly associated with higher Wave 3 (W3) negative parenting, which, in turn, was significantly associated with higher Wave 4 (W4) child behavior problems. In addition, the indirect effect of W1 pandemic-related financial stress on W3 negative parenting through W2 maternal psychological distress was significant. Higher W1 local COVID-19 case rates were significantly related to higher W3 negative parenting. Results suggest local COVID-19 case rates and pandemic-related financial stressors are associated with poorer child and family functioning. Implications for policy and practice are discussed. (PsycInfo Database Record (c) 2022 APA, all rights reserved).