Medical students in distress: a mixed methods approach to understanding the impact of debt on well-being

BACKGROUND

Nearly three in four U.S. medical students graduate with debt in six-figure dollar amounts which impairs students emotionally and academically and impacts their career choices and lives long after graduation. Schools have yet to develop systems-level solutions to address the impact of debt on students' well-being. The objectives of this study were to identify students at highest risk for debt-related stress, define the impact on medical students' well-being, and to identify opportunities for intervention.

METHODS

This was a mixed methods, cross-sectional study that used quantitative survey analysis and human-centered design (HCD). We performed a secondary analysis on a national multi-institutional survey on medical student wellbeing, including univariate and multivariate logistic regression, a comparison of logistic regression models with interaction terms, and analysis of free text responses. We also conducted semi-structured interviews with a sample of medical student respondents and non-student stakeholders to develop insights and design opportunities.

RESULTS

Independent risk factors for high debt-related stress included pre-clinical year (OR 1.75), underrepresented minority (OR 1.40), debt $20-100 K (OR 4.85), debt >$100K (OR 13.22), private school (OR 1.45), West Coast region (OR 1.57), and consideration of a leave of absence for wellbeing (OR 1.48). Mental health resource utilization (p = 0.968) and counselors (p = 0.640) were not protective factors against debt-related stress. HCD analysis produced 6 key insights providing additional context to the quantitative findings, and associated opportunities for intervention.

CONCLUSIONS

We used an innovative combination of quantitative survey analysis and in-depth HCD exploration to develop a multi-dimensional understanding of debt-related stress among medical students. This approach allowed us to identify significant risk factors impacting medical students experiencing debt-related stress, while providing context through stakeholder voices to identify opportunities for system-level solutions.

Why companies have low debt? An empirical evidence in Korea

The aim of this study is to examine the reasons why companies have been borrowing less, which has become increasingly popular recently. The study uses the method developed by Agrawal and Nagarajan (1990) [13] to select unlevered and levered companies for comparison to identify the causes of low leverage. The results of empirical analysis indicate that first, companies with low debt levels are relatively profitable, have high internal reserves, and possess future growth opportunities. Second, unlevered companies exhibit higher economic value compared to levered companies. Debt does not improve company value through low cost of capital or higher cash flow via tax shield. Third, family ownership tends to prefer low debt levels. Finally, unlevered companies have higher cash holding compared to levered companies, and this trend is maintained over long period of time. The preference for higher cash among unlevered companies has a historical basis. The companies are maintaining low debt levels for future growth opportunities and their management preference for high level of cash has remained consistent over time.

Racial Disparities in Cognitive Health Among Older Americans: The Role of Debt-Asset Profiles During Preretirement Age

OBJECTIVES

Low-cost debt can potentially enhance wealth and indirectly benefit health, yet Black Americans disproportionately lack this type of debt, which may constrain their ability to accumulate wealth throughout their lives and across generations. Our objectives are to develop a novel debt-asset measure, use it to quantify the Black-White differential in debt-asset profiles, and estimate its contribution to the racial gap in cognition.

METHODS

Using the Health and Retirement Study (1998-2020), we grouped individuals based on debt and asset information during the preretirement period of ages 55-61, including the absence of debt and the relative amount of debt compared to assets. Linear mixed models were used to examine the extent to which cognition in later life (ages 62-80) differs across these debt-asset profiles and its role in explaining the racial disparity in cognition.

RESULTS

Compared with Whites, Blacks were more likely to fall into categories characterized by high debt-to-asset ratio (DAR) or limited asset ownership. Low-asset nonborrowers displayed the poorest cognition, followed closely by high-DAR borrowers. The Black-White differential in debt-asset profiles contributed to the racial gap in cognition.

DISCUSSION

There were 2 unfavorable debt-asset profiles: high debt relative to assets and little or no debt due to a lack of assets, which was more prevalent among Blacks than Whites. We discuss how institutional and structural racism shapes Black-White disparities in debt-asset profiles, such as limited access to borrowing opportunities, thereby contributing to health inequalities, including cognition.

The development of racial wealth gaps in early adulthood

While much research has documented stark racial gaps in total net worth, few studies have examined the development of racial gaps across different types of assets using longitudinal data. Drawing on data from the National Longitudinal Survey of Youth (1997), we study the emergence of Black-White and Hispanic-White wealth gaps across different types of assets and debt among a recent cohort of young adults. We find that the gaps in net worth, financial assets, home equity, and debt all increase over time. The racial gaps in financial assets widen at a rate that exceeds the corresponding gaps in other components of net worth. Indeed, a decomposition analysis reveals that financial assets contribute more than home equity to exacerbating net worth disparities. Our findings underscore the unique role that financial assets play in expanding racial wealth gaps in young adulthood.

Social Determinants of Health: As Seen in a Courtroom

To provide effective care physicians must attend, not just to medical issues, but also to the social determinants of health - racial factors, food insecurity, housing instability, transportation barriers and beyond. Social determinants also include a largely underrecognized dimension: legal vulnerabilities such as rental evictions and debt adjudications. Yet rarely do medical trainees have an opportunity to witness legal vulnerabilities, firsthand.

Debt Inequity Among Clients of a Community Mental Health Center

Debt is an overlooked social determinant of health that reinforces systems of discrimination. This study examined the impact of debt among individuals with serious mental illness. Individuals with serious mental illness who identified as Black, Indigenous, or other people of color carried a disproportionate amount of debt, often from attempting to meet basic needs. Increased levels of debt were associated with symptoms of depression. Addressing debt inequity is essential to both financial justice and mental health recovery.

Financial debt, worry about debt and mental health in Japan

BACKGROUND

Financial debt has been linked to poorer mental health. However, most research has been undertaken in western countries. This study examined the association between financial debt, worry about debt, and mental health in Japan, where there has been little specific focus on debt and its effects on mental health.

METHODS

Data were analyzed from 3717 respondents collected in an online survey in 2023. Information on financial debt and worry about debt was collected with single-item questions. The Patient Health Questionnaire (PHQ-9) and Generalized Anxiety Disorder-7 (GAD-7) scale were used to respectively collect information on depression and anxiety symptoms, while a single-item measure was used to obtain information on a recent history of suicidal ideation. Logistic regression was used to assess associations.

RESULTS

Both financial debt (17.7%) and worry about debt (14.8%) were prevalent in the study sample. In fully adjusted analyses, compared to those with no debt and worry about debt, individuals who were worried about debt but had no debt, or who had debts and were worried about debt had significantly higher odds for suicidal ideation and depressive symptoms. In contrast, having debt but not being worried about debt was not associated with any of the mental health outcomes.

CONCLUSION

The results of this study suggest that worrying about debt is strongly associated with poorer mental health among Japanese adults. Interventions to address debt and its associated worries may be important for improving public mental health in Japan.

Economic costs of family caregiving for persons with advanced stage cancer: a longitudinal cohort study

PURPOSE

To form a multifaceted picture of family caregiver economic costs in advanced cancer.

METHODS

A multi-site cohort study collected prospective longitudinal data from caregivers of patients with advanced solid tumor cancers. Caregiver survey and out-of-pocket (OOP) receipt data were collected biweekly in-person for up to 24 weeks. Economic cost measures attributed to caregiving were as follows: amount of OOP costs, debt accrual, perceived economic situation, and working for pay. Descriptive analysis illustrates economic outcomes over time. Generalized linear mixed effects models asses the association of objective burden and economic outcomes, controlling for subjective burden and other factors. Objective burden is number of activities and instrumental activities of daily living (ADL/IADL) tasks, all caregiving tasks, and amount of time spent caregiving over 24 h.

RESULTS

One hundred ninety-eight caregivers, 41% identifying as Black, were followed for a mean period of 16 weeks. Median 2-week out-of-pocket costs were $111. One-third of caregivers incurred debt to care for the patient and 24% reported being in an adverse economic situation. Whereas 49.5% reported working at study visit 1, 28.6% of caregivers at the last study visit reported working. In adjusted analysis, a higher number of caregiving tasks overall and ADL/IADL tasks specifically were associated with lower out-of-pocket expenses, a lower likelihood of working, and a higher likelihood of incurring debt and reporting an adverse economic situation.

CONCLUSIONS

Most caregivers of cancer patients with advanced stage disease experienced direct and indirect economic costs.

IMPLICATIONS FOR CANCER SURVIVORS

Results support the need to find solutions to lessen economic costs for caregivers of persons with advanced cancer.

Healthcare educational debt in the united states: unequal economic impact within interprofessional team members

BACKGROUND

Advancing healthcare access and quality for underserved populations requires a diverse, culturally competent interprofessional workforce. However, high educational debt may influence career choice of healthcare professionals. In the United States, health professions lack insight into the maximum educational debt that can be supported by current entry-level salaries. The purpose of this interprofessional economic analysis was to examine whether average educational debt for US healthcare graduates is supportable by entry-level salaries. Additionally, the study explored whether trainees from minoritized backgrounds graduate with more educational debt than their peers in physical therapy.

METHODS

The study modeled maximum educational debt service ratios for 12 healthcare professions and 6 physician specialties, incorporating profession-specific estimates of entry-level salary, salary growth, national average debt, and 4 loan repayment scenarios offered by the US Department of Education Office of Student Financial Aid. Net present value (NPV) provided an estimate for lifetime "economic power" for the modeled careers. The study used a unique data source available from a single profession (physical therapy, N = 4,954) to examine whether educational debt thresholds based on the repayment model varied between minoritized groups and non-minoritized peers.

RESULTS

High salary physician specialties (e.g. obstetrics/gynecology, surgery) and professions without graduate debt (e.g. registered nurse) met debt ratio targets under any repayment plan. Professions with strong salary growth and moderate debt (e.g. physician assistant) required extended repayment plans but had high career NPV. Careers with low salary growth and high debt relative to salary (e.g. physical therapy) had career NPV at the lowest range of modeled professions. 29% of physical therapy students graduated with more debt than could be supported by entry-level salaries. Physical therapy students from minoritized groups graduated with 10-30% more debt than their non-minoritized peers.

CONCLUSIONS

Graduates from most healthcare professions required extended repayment plans (higher interest) to meet debt ratio benchmarks. For several healthcare professions, low debt relative to salary protected career NPV. Students from minoritized groups incurred higher debt than their peers in physical therapy.

Religious affiliation and debt among U.S. households

Religion has been shown to have both a direct and indirect role in shaping personal values, especially pertaining to money and wealth accumulation. Existing research establishes a strong relationship between religious affiliation and wealth attainment. However, previous scholarship has largely ignored the link between religious affiliation and debt, an important yet overlooked indicator of total net worth. To address this gap, we utilize data from the 2017 wave of the Panel Study of Income Dynamics (PSID) and examine how religious affiliation is associated with two forms of household debt: credit card and mortgage debt. Findings from a series of logistic regression models indicate that Black Protestants have the lowest rates of both credit card and mortgage debt and Hispanic/Latinx Catholics have comparably low rates of credit card debt relative to Conservative Protestants. KHB decomposition analyses reveal that race/ethnicity explain some of the relationship between a Black Protestant or Hispanic/Latinx Catholic religious affiliation and household debt. While our study is the first to document the link between religious affiliation and debt profiles of Americans, we would encourage future research to explore how other elements of religiosity-long acknowledged by sociologists to affect wealth and social status-influence different types of debt accumulation in nuanced and meaningful ways.

Medical student intentions to practice internal medicine in underserved areas associated with debt, identity and extracurricular participation

BACKGROUND

Currently, Internal Medicine (IM) physicians do not reflect the ethno-racial diversity of the US population. Moreover, there is a shortage of IM physicians in Medically Underserved Areas (MUAs) in the US. The purpose of this study was to determine factors that influence medical students' intent to practice IM in MUAs. We hypothesized students with intentions to pursue a career in IM and work in MUAs were more likely than their peers to identify as underrepresented in medicine (URiM), report greater student debt loads, and report medical school experiences in cultural competencies.

METHODS

We analyzed de-identified data of 67,050 graduating allopathic medical students who completed the Association of American Medical Colleges' (AAMC) Medical School annual Graduation Questionnaire (GQ) between 2012-2017 by multivariate logistic regression models, examining intent to practice IM in MUAs based on respondent characteristics.

RESULTS

Of 8,363 students indicating an intent to pursue IM, 1,969 (23.54%) students also expressed an intent to practice in MUAs. Students awarded scholarships, (aOR: 1.23, [1.03-1.46]), with debt greater than $300,000 (aOR: 1.54, [1.21-1.95], and self-identified non-Hispanic Black/African American (aOR: 3.79 [2.95-4.87]) or Hispanic (aOR: 2.53, [2.05-3.11]) students were more likely than non-Hispanic White students to indicate intent to practice in MUAs. This pattern also existed for students who participated in a community-based research project (aOR: 1.55, [1.19-2.01]), had experiences related to health disparities (aOR: 2.13, [1.44-3.15]), or had experiences related to global health (aOR: 1.75, [1.34-2.28]).

CONCLUSIONS

We identified experiences and characteristics that associate with intention to practice IM in MUAs, which can aid future curricular redesign by medical schools to expand and deepen comprehension of health disparities, access to community-based research, and global health experiences. Loan forgiveness programs and other initiatives to increase recruitment and retention of future physicians should also be developed.

Black/white differences in the relationship between debt and risk of heart attack across cohorts

Background

Numerous studies show that increasing levels of education, income, assets, and occupational status are linked to greater improvements in White adults' health than Black adults'. Research has yet to determine, however, whether there are racial differences in the relationship between health and debt and whether this relationship varies across cohorts.

Methods

Using data from the 1992-2018 Health and Retirement Study, we use survival analyses to examine the link between debt and heart attack risk among the Prewar Cohort, born 1931-1941, and Baby Boomers, born 1948-1959.

Results

Higher unsecured debt is associated with increased heart attack risk for Black adults, especially among Baby Boomers and during economic recessions. Higher mortgage debt is associated with lower risk of heart attack for White but not Black Baby Boomers. The relationship between debt and heart attack risk remains after controlling for health behaviors, depressive symptoms, and other economic resources that are concentrated among respondents with high levels of debt.

Conclusion

Debt is predictive of heart attack risk, but the direction and strength of the relationship varies by type of debt, debtors' racial identity, and economic context.

Cost burden among the CF population in the United States: A focus on debt, food insecurity, housing and health services

BACKGROUND

Advancements in the cystic fibrosis (CF) field have resulted in longer lifespans for individuals with CF. This has led to more responsibility for complex care regimens, frequent health care, and prescription medication utilization that are costly and may not be fully covered by health insurance. There are outstanding questions about unmet medical needs among the U.S. population with CF and how the financial burden of CF is associated with debt, housing instability, and food insecurity.

METHODS

Researchers developed the CF Health Insurance Survey (CF HIS) to survey a convenience sample of people living with CF in the U.S. The sample was weighted to reflect the parameters of the 2019 Cystic Fibrosis Foundation Patient Registry Annual Data Report, and chi-square tests and multiple logistic regression models were conducted.

RESULTS

A total of 1,856 CF patients in the U.S. were included in the study. Of these, 64% faced a financial burden: 55% of respondents faced debt issues, 26% housing issues, and 33% food insecurity issues. A third reported at least one unmet medical need: 24% faced unmet prescription needs, 12% delayed or shortened a hospitalization, and 10% delayed or skipped a care center visit as a result of the cost of care.

CONCLUSIONS

People with CF in the U.S. experience high financial burden, which is associated with unmet medical needs. Income is the biggest risk factor for financial burden for people with CF, with people dually covered by Medicare and Medicaid particularly at risk.

The Case for Needed Financial Literacy Curriculum During Resident Education

OBJECTIVE

Personal physician finance is an overlooked source of stress that negatively impacts resident wellbeing with formal financial education often left out of medical training. This study attempts to (1) evaluate the perceptions of financial literacy, (2) determine the level of financial education incorporated across residency programs, and (3) evaluate the resources that residents utilize to obtain information about managing their personal finances.

DESIGN

A systematic literature search of articles published between January 2012 to January 2022, in the MEDLINE, EMBASE, and Cochrane databases was performed during February 2022]. The combination of search terms included: (financial literacy OR debt) AND (residency OR graduate medical education). The primary outcome measures included the perception of financial literacy during residency and the type of financial education incorporated during residency. Secondary outcomes included resources utilized to obtain financial education.

PARTICIPANTS

Twenty-three studies evaluating a total of 5146 residents were included in this systematic review.

RESULTS

The 42% to 79% of residents responded in surveys that they had "below average" understanding of finance, investing, and savings and that they felt unprepared to handle future financial decisions. 79% to 95% of respondents agreed that personal finance should be taught during residency training. The included studies also demonstrate that residents seek education through personal research, through a family member, or through attending outside financial planning seminars or courses.

CONCLUSION

This study demonstrates that the majority of residents feel underprepared when making financial decisions and that formal financial education should be incorporated during their residency training. Educating residents can help mitigate financial stress which can improve physician well-being, reduce attrition, and result in better patient care.

LEVEL OF EVIDENCE

IV.

Loss-of-learning and the post-Covid recovery in low-income countries

We analyze the medium-term macroeconomic impact of the Covid-19 pandemic and associated lock-down measures on low-income countries. We focus on the impact of the degradation of health and human capital caused by the pandemic and its aftermath, exploring the trade-offs between rebuilding human capital and the recovery of livelihoods and macroeconomic sustainability. A dynamic general equilibrium model is calibrated to reflect the structural characteristics of vulnerable low-income countries and to replicate key dimensions of the Covid-19 shock. We show that absent significant and sustained external financing, the persistence of loss-of-learning effects on labor productivity is likely to make the post-Covid recovery more attenuated and more expensive than many contemporary analysis suggests.

Informal creditors and sovereign debt restructuring

A conventional view of sovereign debt restructuring suggests that costly sovereign debt restructuring is required to lower the interest rate charged on it. In the presence of a negative external shock, under certain conditions, we show that (a) debt restructuring leads to interim social welfare gains and ex ante efficiency gains, (b) participation by citizens will lead to efficient debt restructuring. Using our results, we discuss provide a normative case for the proposed UNCTAD Roadmap.

Exploring the Relationship between Debt and Health after Incarceration: a Survey Study

Financial debt and incarceration are both independently associated with poor health, but there is limited research on the association between debt and health for those leaving incarceration. This exploratory study surveyed 75 people with a chronic health condition and recent incarceration to examine debt burden, financial well-being, and possible associations with self-reported health. Eighty-four percent of participants owed at least one debt, with non-legal debt being more common than legal debt. High financial stress was associated with poor self-reported health and the number of debts owed. Owing specific forms of debt was associated with poor health or high financial stress. Non-legal financial debt is common after incarceration, and related stress is associated with poor self-reported health. Future research is needed in larger populations in different geographical areas to further investigate the relationship and the impact debt may have on post-release poor health outcomes. Policy initiatives to address debt in the post-release population may improve health.

Adult life-course trajectories of psychological distress and economic outcomes in midlife during the COVID-19 pandemic: evidence from the 1958 and 1970 British birth cohorts

PURPOSE

Financial adversity in times of economic recession have been shown to have an unequal effect on individuals with prior mental health problems. This study investigated the relationship between mental health groupings across the adult life-course and change in financial situation and employment status during the COVID-19 pandemic, as well as the use of financial measures to mitigate the economic shock.

METHODS

Using two nationally representative British birth cohorts, the National Child Development Study (1958) n = 17,415 and 1970 British Cohort Study n = 17,198, we identified 5 different life-course trajectories of psychological distress from adolescence to midlife which were similar but not identical across the two cohorts. We explored their relation to changes in financial and employment circumstances at different stages during the pandemic from May 2020 to March 2021, applying multinomial logistic regression and controlling for numerous early life covariates, including family socio-economic status (SES). In addition, we ran modified Poisson models with robust standard errors to identify whether different mental health trajectories were supported by government and used other methods to mitigate their financial situation.

RESULTS

We found that the financial circumstances of pre-pandemic trajectories of psychological distress with differential onset, severity, and chronicity across the life-course were exacerbated by the COVID-19 economic shock. The 'stable-high' (persistent severe symptoms) and 'adult-onset' (symptoms developing in 30s, but later decreasing) groups were vulnerable to job loss. Compared to pre-pandemic trajectory groupings with no, minor, or psychological distress symptoms in early adulthood, the 'stable-high', 'midlife-onset' (symptoms developing in midlife), and 'adult-onset' trajectory groups were more likely to seek support from the UK governments economic response package. However, trajectories with pre-pandemic psychological distress were also at greater risk of reducing consumption, dis-saving, relying on increased financial help from family and friends, and also taking payment holidays (agreements with lenders to pause mortgage, credit card or loan payments for a set period) and borrowing.

CONCLUSION

This work highlights different trajectories of pre-pandemic psychological distress, compared to groups with no symptoms were more vulnerable to pandemic-related economic shock and job loss. By adopting unsustainable mitigating measures (borrowing and payment holidays) to support their financial circumstances during COVID-19, these mental health trajectories are at even more risk of lasting adverse impacts and future economic difficulties.

Student loans, physical and mental health, and health care use and delay in college

Objective: Determine relationships between college students' student loan presence and self-rated physical and mental health, major medical problems, mental health conditions, physical, dental, and mental health care visits and delays, and medication use and reductions. Participants: A total of 3,248 undergraduates at two regional public U.S. universities, surveyed Spring 2017. Methods: OLS and Logistic regression. Results: Loan presence was related to significantly worse self-rated physical and mental health and more major medical problems, but not to mental health conditions, or physical or mental health medication use. Respondents with loans were less likely to visit the dentist and more likely to report delaying medical, dental, and mental health care, and reducing medication use to save money. Conclusions: Results provide evidence of health and health care use divides among college students by loan presence.

Growing debt burden in low- and middle-income countries during COVID-19 may constrain health financing

Debt burdens are growing steadily in Low- and Middle-Income Countries (LMICs), compounded by the COVID-19 economic recession, threatening to crowd out essential health spending. In 2019, 54 LMICs spent more on servicing their debt to foreign creditors than on financing their health services. While development loans may have positive effects on population health, the ensuing debt servicing requirements may have detrimental effects on health through constrained fiscal space for government health spending. However, the existing evidence is inadequate for an understanding of whether, and if so how and under what circumstances, debt may constrain government health spending. We call for more research on the impacts of debt on health financing and call on creditors and borrowers to carefully consider the potential impacts of lending on borrower countries' ability to finance their health services.

Putting climate-induced migration in context: the case of Honduran migration to the USA

Over the past decade, unauthorized migration from Honduras to the USA has become a topic of pressing international concern and a major factor in the political and humanitarian crisis at the southern border of the USA that has been unfolding since 2014. Untangling the causes of recent Honduran migration requires attending to economic change, political instability, the impact of violence and crime, rapidly changing gender roles, among many other forces that shape migration patterns. Recently, scholars and policy-makers have analyzed the impact of drought in the so-called Dry Corridor of Central America as a major source of migration, particularly among coffee producers who have been hard hit by unprecedented heat and lack of rain in parts of Honduras. Drawing on ethnographic studies of Honduran coffee farmers, this paper will discuss how and if climatic factors can be isolated from other factors to explain recent Honduran migration behavior, in order to move towards a holistic explanation of climate-driven migration.

Fiscal adjustment in a panel of countries 1870-2016

The financial crisis from 2007 and, even more so, the Covid-19 pandemic caused large increases in public sector deficits and debts in many countries and prompted concern about fiscal adjustment. This paper examines fiscal adjustment to debt and deficits for a panel of 17 countries over 1870-2016 using the Jordà-Schularick-Taylor Macrohistory Database. This long span panel is informative since it contains many examples of large fiscal shocks similar to those recently experienced. The results from reduced-form models suggest that large deficits or surpluses tend to prompt stabilising feedbacks, mainly through changes in revenue, and there is greater pressure to adjust on countries running a deficit versus those running a surplus. However, the debt-GDP ratio prompts much less stabilising feedback by expenditure or revenue.

Recovery and Resilience in the Canal Community: Economic Impacts and Solutions During the COVID-19 Pandemic

BACKGROUND

Public health pandemics, such as COVID-19, not only impact the physical health and wellbeing of communities but also often have far-reaching effects on their social, psychological, environmental, and economic welfare. The coronavirus pandemic has highlighted the significant inequities experienced among those who are Black, Indigenous, and People of Color (BIPOC), especially in the areas of housing instability, unemployment, and debt accrual. This study investigates the socioeconomic impacts of COVID-19 on residents of the Canal neighborhood ("The Canal"), a low-income Latinx community in Marin County, California. This study also uplifts mitigation strategies already underway to facilitate post-pandemic recovery efforts.

METHODS

This study utilized a mixed-methods, community participatory approach in which community leaders from a local nonprofit, Canal Alliance, administered a survey assessing the impact of COVID-19 on Canal residents. Additionally, community stakeholders including nonprofits, small businesses, and public officials were interviewed, and their field notes were analyzed through exploratory open coding.

RESULTS

On a macro level, the data showed that Canal residents were severely impacted by COVID-19 in the form of massive job loss (61.2% of respondents were unemployed or underemployed) as well as financial stress related to eviction, housing instability, and debt accrual (78.8% of respondents struggled to cover rent and often had to borrow money from friends and family).

CONCLUSIONS

In spite of the severe socioeconomic impacts of COVID-19 on The Canal, there is a significant opportunity for recovery and growth because of an overwhelming investment by residents, community-based organizations, and public officials to support those who have been financially impacted by the pandemic. Some key areas of policy focus include expansion of affordable housing, pandemic-resistant workforce development, and restructuring of social services to increase accessibility. This report will explore recommendations related to strategic funding of community-based programs as well as short-term and long-term solutions for economic recovery.

Qualitative modelling of social determinants of health using group model building: the case of debt, poverty, and health

Background

Social determinants of health (SDoH) are known to have a large impact on health outcomes, but their effects are difficult to make visible. They are part of complex systems of variables largely indirect effects on multiple levels, constituting so-called wicked problems. This study describes a participatory approach using group model building (GMB) with stakeholders, in order to develop a qualitative causal model of the health effects of SDoH, taking poverty and debt in the Dutch city of Utrecht as a case study.

Methods

With GMB we utilised the perspective of stakeholders who are directly involved in policy and practice regarding poverty, debt, and/or health. This was done using system dynamic modelling, in three interactive sessions lasting three hours each. In these sessions, they constructed a model, resulting in a system of variables with causal relationships and feedback loops. Subsequently, the results of these GMB sessions were compared to scientific literature and reviewed by a panel of researchers with extensive experience in relevant scientific fields.

Results

The resulting model contains 71 causal relationships between 39 variables, 29 of which are present in feedback loops. The variables of participation in society, stress, shame, social contacts and use of services/provisions appear to hold prominent roles in the model’s mechanisms. Most of the relationships in the model are supported by scientific literature. The researchers reviewing the model in the scientific meeting agreed that the vast majority of relationships would concur with scientific knowledge, but that the model constructed by the stakeholders consists mostly of individual-level factors, while important conditions usually relate to systemic variables.

Conclusions

Building a model with GMB helps grasp the complex situation of a wicked problem, for which it is unlikely that its interrelationships result in a fully intuitive understanding with linear mechanisms. Using this approach, effects of SDoH can be made visible and the body of evidence expanded. Importantly, it elicits stakeholders’ perspectives on a complex reality and offers a non-arbitrary way of formulating the model structure. This qualitative model is also well suited to serve as conceptual input for a quantitative model, which can be used to test and estimate the relationships.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12939-022-01676-7.

The gender gap in access to finance: Evidence from the COVID-19 pandemic

Using gender as a theoretical framework, we analyse the dynamics of debt and equity financing during the COVID-19 pandemic for a cross-country sample of 8,921 private firms. We provide evidence of a slight gender bias in debt financing, with creditors favouring female entrepreneurs when dealing with cash flow problems during the COVID-19 pandemic. We find no evidence of gender bias in equity financing. The results are robust after controlling for a larger number of firm-specific characteristics and selection bias. We challenge the assumption of "gender-based discrimination" in the debt market, speculating that in the context of high uncertainty, prototypical forms of femininity may be advantageous as financial institutions seek to hedge their risk by favouring more conservative borrowers.