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

Socioeconomic status, loneliness, and depression among older adults: a cross-sectional study in Spain

BACKGROUND

The association between socioeconomic status and depression is weaker in older adults than in younger populations. Loneliness may play a significant role in this relationship, explaining (at least partially) the attenuation of the social gradient in depression. The current study examined the relationship between socioeconomic status and depression and whether the association was affected by loneliness.

METHODS

A cross-sectional design involving dwelling and nursing homes residents was used. A total of 887 Spanish residents aged over 64 years took part in the study. Measures of Depression (GDS-5 Scale), Loneliness (De Jong-Gierveld Loneliness Scale), Socioeconomic Status (Education and Economic Hardship), and sociodemographic parameters were used. The study employed bivariate association tests (chi-square and Pearson's r) and logistic regression analyses.

RESULTS

The percentage of participants at risk of suffering depression was significantly higher among those who had not completed primary education (45.5%) and significantly lower among those with university qualifications (16.4%) (X2 = 40.25;p <.001), and respondents who could not make ends meet in financial terms faced a higher risk of depression (X2 = 23.62;p <.001). In terms of the respondents who experienced loneliness, 57.5% were at risk of depression, compared to 19% of those who did not report loneliness (X2 = 120.04;p <.001). The logistic regression analyses showed that having university qualifications meant a 47% reduction in the risk of depression. This risk was 86% higher among respondents experiencing financial difficulties. However, when scores for the loneliness measure were incorporated, the coefficients relating to education and economic hardships ceased to be significant or were significantly reduced.

CONCLUSION

Loneliness can contribute to explaining the role played by socioeconomic inequalities in depression among older adults.

Associations between a Novel Measure of Census Tract-Level Credit Insecurity and Frequent Mental Distress in US Urban Areas, 2020

Access to and utilization of consumer credit remains an understudied social determinant of health. We examined associations between a novel, small-area, multidimensional credit insecurity index (CII), and the prevalence of self-reported frequent mental distress across US cities in 2020. The census tract-level CII was developed by the Federal Reserve Bank of New York using Census population information and a nationally representative sample of anonymized Equifax credit report data. The CII was calculated for tracts in 766 cities displayed on the City Health Dashboard at the time of analysis, predominantly representing cities with over 50,000 residents. The CII combined data on tract-level participation in the formal credit economy with information on the percent of individuals without revolving credit, percent with high credit utilization, and percent with deep subprime credit scores. Tracts were classified as credit-assured, credit-likely, mid-tier, at-risk, or credit-insecure. We used linear regression to examine associations between the CII and a modeled tract-level measure of frequent mental distress, obtained from the CDC PLACES project. Regression models were adjusted for neighborhood economic and demographic characteristics. We examined effect modification by US region by including two-way interaction terms in regression models. In adjusted models, credit-insecure tracts had a modestly higher prevalence of frequent mental distress (prevalence difference = 0.38 percentage points; 95% CI = 0.32, 0.44), compared to credit-assured tracts. Associations were most pronounced in the Midwest. Local factors impacting credit access and utilization are often modifiable. The CII, a novel indicator of community financial well-being, may be an independent predictor of neighborhood health in US cities and could illuminate policy targets to improve access to desirable credit products and downstream health outcomes.

Health insurance coverage and poverty status of postpartum women in the United States in 2019: an ACS-PUMS population-based cross-sectional study

BACKGROUND

A quarter of United States (US) postpartum women still report unmet health care needs and health care unaffordability. We aimed to study associations between receipt of health insurance coverage and poverty status/receipt of government financial support and determine coverage gaps overall and by social factors among US postpartum women in poverty.

METHODS

This study design is a cross-sectional study using secondary data. We included women who gave birth within the last 12 months from 2019 American Community Survey Public Use Microdata Sample. Poverty was defined as having an income-to-poverty ratio of less than 100%. We explored Medicaid/government medical assistance gaps among women in poverty. To examine the associations between Medicaid/government medical assistance (exposures) and poverty/government financial support (outcomes), we used age-, race-, and multivariable-adjusted logistic regression models. We also evaluated the associations of state, race, citizenship status, or language other than English spoken at home (exposures) with receipt of Medicaid/government medical assistance (outcomes) among women in poverty through multivariable-adjusted logistic regression.

RESULTS

It was notable that 35.6% of US postpartum women in poverty did not have Medicaid/government medical assistance and only a small proportion received public assistance income (9.8%)/supplementary security income (3.1%). Women with Medicaid/government medical assistance, compared with those without the coverage, had statistically significantly higher odds of poverty [adjusted odds ratio (aOR): 3.15, 95% confidence interval (95% CI): 2.85-3.48], having public assistance income (aOR: 24.52 [95% CI: 17.31-34.73]), or having supplementary security income (aOR: 4.22 [95% CI: 2.81-6.36]). Also, among postpartum women in poverty, women in states that had not expanded Medicaid, those of Asian or other race, non-US citizens, and those speaking another language had statistically significantly higher odds of not receiving Medicaid/government medical assistance [aORs (95% CIs): 2.93 (2.55-3.37); 1.30 (1.04-1.63); 3.65 (3.05-4.38); and 2.08 (1.86-2.32), respectively].

CONCLUSIONS

Our results showed that the receipt of Medicaid/government medical assistance is significantly associated with poverty and having government financial support. However, postpartum women in poverty still had Medicaid/government medical assistance gaps, especially those who lived in states that had not expanded Medicaid, those of Asian or other races, non-US citizens, and other language speakers.

Financial Strain and Psychological Distress Among Middle-Aged and Older Adults: A Moderated Mediation Model

This study investigates the association between financial strain and psychological distress among middle-aged and older adults, exploring how this association is mediated by sleep problems and moderated by marital status. A subsample of 12,095 adults aged 50 and older was selected from the 2018 National Health Interview Survey. Results showed that financial strain was associated with higher psychological distress, and sleep problems partially mediated this association. Marital status moderated the association between sleep problems and psychological distress, and between financial strain and psychological distress, but not between financial strain and sleep problems. These findings partially support the stress-buffering role of marriage. The study offers valuable insights into the complex relationship between financial strain, sleep problems, marital status, and psychological distress among middle-aged and older adults in the United States, highlighting the need for interventions targeting financial stressors and sleep problems, especially for unmarried individuals, to improve mental health outcomes in this population.

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.

How does debt shape health outcomes for older Americans?

The deleterious effects that debt can have on health outcomes are well documented, yet comprehensive studies of the debt-health link for older adults remain limited even as their indebtedness has increased dramatically in recent decades. Additionally, the literature cannot explain the causal pathway linking poor health with debt. Using data from the Health and Retirement Study (1998-2016), we examine a range of physical and mental health measures and assess how they may be shaped by the amount and type of debt held by older adults. To address the likely endogeneity of debt and health, we employ marginal structural models, developed specifically as an identification strategy in the presence of possible endogeneity, alongside population-averaged models that allow us to compare outcomes for populations with and without debt without relying on unverifiable assumptions regarding the underlying population distribution as is the case with random- and fixed-effects models. Findings indicate that carrying any debt has a negative effect on a range of health outcomes for older adults, including objective and subjective physical and mental health. In addition, the more debt older adults carry, the more detrimental it is for their health. Finally, the type of debt matters: while secured debt has a limited, if any, negative impact on health outcomes, unsecured debt has a substantial negative impact on health. Policymakers should design policies that promote the prudent use of debt and discourage carrying large debt burdens, especially unsecured debt, into retirement as this would promote better health outcomes for older Americans.

Cumulative Pandemic Stressors, Psychosocial Resources, and Psychological Distress: Toward a More Comprehensive Test of a Pandemic Stress Process

Although the mental health consequences of individual COVID-19 stressors (e.g., bereavement, job loss, or financial strain) have been well-documented, little is known about the cumulative toll of multiple pandemic stressors. Using national data from the Crime, Health, and Politics Survey (May–June 2021), we test whether the accumulation of pandemic stressors is associated with greater psychological distress. We also consider whether this association is moderated by psychosocial resources (i.e., mastery, self-esteem, and social support). Our findings suggest that individuals who report three or more pandemic stressors tend to exhibit greater psychological distress than those who report fewer pandemic stressors or no pandemic stressors. While mastery offsets the impact of pandemic stressors at higher levels of stress exposure (i.e., two or more COVID-19 stressors), social support and self-esteem played a stress-buffering role to a point, but became ineffective at the highest levels of pandemic stress. The current study provides new insights into the pandemic stress process by conceptualizing and operationalizing the cumulative impact of COVID-19 stressors. We also confirm the continued significance of traditional coping resources in the context of novel pandemic stressors.

Socioeconomic Background and Self-Reported Sleep Quality in Older Adults during the COVID-19 Pandemic: An Analysis of the English Longitudinal Study of Ageing (ELSA)

The COVID-19 pandemic negatively impacted sleep quality. However, research regarding older adults' sleep quality during the pandemic has been limited. This study examined the association between socioeconomic background (SEB) and older adults' sleep quality during the COVID-19 pandemic. Data on 7040 adults aged ≥50 were acquired from a COVID-19 sub-study of the English Longitudinal Study of Ageing (ELSA). SEB was operationalized using educational attainment, previous financial situation, and concern about the future financial situation. Sociodemographic, mental health, physical health, and health behavior variables were included as covariates. Chi-squared tests and binary logistic regression were used to examine associations between SEB and sleep quality. Lower educational attainment and greater financial hardship and concerns were associated with poor sleep quality. The relationship between educational attainment and sleep quality was explained by the financial variables, while the relationship between previous financial difficulties and sleep quality was explained by physical health and health behavior variables. Greater financial concerns about the future, poor mental health, and poor physical health were independent risk factors for poor sleep quality in older adults during the pandemic. Healthcare professionals and service providers should consider these issues when supporting older patients with sleep problems and in promoting health and wellness.

Financial hardship and change in emotional well-being before to during COVID-19 pandemic among middle-aged and older Americans: Moderating effects of internal coping resources

OBJECTIVE

The purpose of this study was to investigate associations between financial hardship and change in emotional well-being-positive and negative affect-before to during the COVID-19 pandemic among middle-aged and older Americans and to examine the extent to which associations were moderated by internal coping resources-dispositional mastery and optimism.

METHOD

Data derived from the Leave-Behind Questionnaire in the 2016 and 2020 waves of the Health and Retirement Study, a nationally representative longitudinal survey of U.S. adults aged 51 and older (N = 1312). We estimated multivariate ordinary least squares regression models with interaction terms to evaluate prospectively the benefits of mastery and optimism as internal coping resources for middle-aged and older adults.

RESULTS

Dispositional mastery moderated the effects of financial hardship on changes in negative and positive affect, respectively, before to during the COVID-19 pandemic; however, optimism did not significantly moderate the effects of financial hardship on change in negative and positive affect before to during the COVID-19 pandemic.

CONCLUSIONS

Our findings have implications for interventions aimed at improving middle-aged and older adults' emotional well-being by promoting internal coping resources. Specifically, interventions should focus on financial hardship and mastery for vulnerable middle-aged and older adults in the context of public health crises.

Racial differences in Financial Hardship and depressive symptoms among older adults

BACKGROUND

The purpose of this study was to examine the association between three specific indicators of financial hardship (difficulty paying bills, food insecurity, reduced medication use due to cost) and depressive symptoms by race.

METHODS

This was a cross sectional study using the Health and Retirement Study to analyze the data by conducting a logistic regression (N = 3014).

RESULTS

When stratified by race, White participants who were food insecure had nearly a 3.0 higher odds of high depressive symptoms (95% CI: 1.59-5.51) and African Americans who took less medication due to cost had a 5.1 higher odds of reporting higher depressive symptoms (95% CI: 2.30-11.2) compared to those who did not report these hardships.

CONCLUSIONS

This research highlights the important role expanded socioeconomic measures such as hardship play in the lives of older adult populations. It further elucidates the differences in the specific measures of hardship that impact older adults by race.

Perceived manageability of debt and mental health during the COVID-19 pandemic: A UK population analysis

Objectives

This study examined the association between perceived manageability of debt and risk of depression, anxiety, and mental health help-seeking among a nationally representative sample of adults living in the United Kingdom (UK).

Methods

Data was derived from the COVID-19 Psychological Research Consortium (C19PRC) Study Wave 6 (August/September 2021) which examined the psychological, social, and economic effects of the COVID-19 pandemic on the UK adult population. Bivariate and logistic regression analyses were conducted to determine the association between different levels of perceived debt manageability (i.e., “easily manageable”, “some problems”, “quite serious problems”, “very serious problems”, “cannot manage at all”) and mental health related outcomes.

Results

Almost a quarter of the sample (24%, n = 494) reported debt management problems, and debt manageability associated with higher levels of anxiety, depression, and mental health help-seeking. After adjusting for demographic variables (e.g. income, receipt of benefits), logistic regression analysis demonstrated a dose-response association between increasing levels of debt manageability problems and mental health outcomes. Specifically, adjusted odds ratios for anxiety ranged from 2.28 (‘some problems’) to 11.18 (‘very serious problems’), for depression ranged from 2.80 (‘some problems’) to 16.21 (‘cannot manage at all’), and for mental health help-seeking ranged from 1.69 (‘some problems’) to 3.18 (‘quite serious problems’, ‘very serious problems’).

Conclusion

This study highlights that debt manageability problems represent a robust predictor of depression, anxiety, and mental-health help seeking.

Financial hardship and mental health conditions in people with underlying health conditions during the COVID-19 pandemic in Bangladesh

Background

Financial hardship is a major concern for patients who are suffering from long-term underlying health conditions. It is likely that emergencies such as the COVID-19 pandemic would impose increased financial distress and lead to the development or exacerbation of mental health conditions.

Objective

The present study aimed to explore the relationship between financial hardship and mental health conditions (loneliness, anxiety, and depression) among patients with underlying health conditions in Bangladesh.

Methods

An e-survey based cross-sectional study was conducted among purposively selected 971 patients (50.1% male; mean age = 42.29 [SD = 15.86]) with underlying health conditions between November 2020 and January 2021. Depression, anxiety, and loneliness were measured using the Patient Health Questionnaire (PHQ-9), Generalized Anxiety Disorder (GAD-7), and UCLA loneliness scale, respectively. Multiple logistic regression analyses were performed to determine any associations between financial hardship and mental health conditions (loneliness, anxiety, and depression).

Results

46.2% of participants reported experiencing financial difficulties, and a number of respondents (12.3%) had lost their jobs during the COVID-19 pandemic. The prevalence of anxiety, depression and loneliness were 35.2%, 38.9%, and 47.68%, respectively. In the multiple logistic regression analysis, age, gender, occupation, marital status, monthly income, self-reported health status and financial hardship were significantly associated with mental health conditions.

Conclusions

Mental health problems were prevalent among people with underlying health conditions and were also associated with financial difficulties. The findings suggest that care facilities should be strengthened by including psychosocial support components delivered with lower costs, particularly for patients with underlying health conditions.

Prediction of Future Health Care Utilization Through Note-extracted Psychosocial Factors

BACKGROUND

Persons with multimorbidity (≥2 chronic conditions) face an increased risk of poor health outcomes, especially as they age. Psychosocial factors such as social isolation, chronic stress, housing insecurity, and financial insecurity have been shown to exacerbate these outcomes, but are not routinely assessed during the clinical encounter. Our objective was to extract these concepts from chart notes using natural language processing and predict their impact on health care utilization for patients with multimorbidity.

METHODS

A cohort study to predict the 1-year likelihood of hospitalizations and emergency department visits for patients 65+ with multimorbidity with and without psychosocial factors. Psychosocial factors were extracted from narrative notes; all other covariates were extracted from electronic health record data from a large academic medical center using validated algorithms and concept sets. Logistic regression was performed to predict the likelihood of hospitalization and emergency department visit in the next year.

RESULTS

In all, 76,479 patients were eligible; the majority were White (89%), 54% were female, with mean age 73. Those with psychosocial factors were older, had higher baseline utilization, and more chronic illnesses. The 4 psychosocial factors all independently predicted future utilization (odds ratio=1.27-2.77, C -statistic=0.63). Accounting for demographics, specific conditions, and previous utilization, 3 of 4 of the extracted factors remained predictive (odds ratio=1.13-1.86) for future utilization. Compared with models with no psychosocial factors, they had improved discrimination. Individual predictions were mixed, with social isolation predicting depression and morbidity; stress predicting atherosclerotic cardiovascular disease onset; and housing insecurity predicting substance use disorder morbidity.

DISCUSSION

Psychosocial factors are known to have adverse health impacts, but are rarely measured; using natural language processing, we extracted factors that identified a higher risk segment of older adults with multimorbidity. Combining these extraction techniques with other measures of social determinants may help catalyze population health efforts to address psychosocial factors to mitigate their health impacts.

Community optimized management for better eating after hospital sTay among geriatric patients of poor socio-economic status - The COMEAT study

INTRODUCTION

In patients suffering from disease-related and socioeconomic malnutrition and being discharged from hospital, continuity of care is challenging. Lack of adequate nutrition may lead to increase in morbidity and mortality. The aim of this study was to overcome the handicap of limited nutrition access in this category of patients and to study its consequences on clinical outcome.

METHODS

Hospitalized patients screened to be at risk of malnutrition were approached and if diagnosed as suffering from malnutrition and from limited financial resources, they were randomized to receive a delivered daily dinner tray for 6 months and an assistance during the meal by a philanthropic association, or to regular food. At entry to the study, patients were assessed by indirect calorimetry, bioimpedance, Hospital Anxiety and Depression Scale (HADS), Functional independence measure (FIM) and SF 36 quality of life questionnaire. The latest questionnaires were reproduced after 3 and 6 months. Survival was followed at 6 months. The student t-test, the paired t-test, ANOVA were used. 180 days survival curves were expressed using the Kaplan-Meier method.

RESULTS

631 patients were screened and 60 patients were randomized. There was no difference between groups. Survival at 6 months was improved significantly in the intervention group (87%) compared to the control group (65%, p<005). HADS did significantly improve at 3 months and other parameters (FIM, SF 36) were not changed significantly.

CONCLUSIONS

In hospitalized patients at nutritional risk, lunch home delivery, supported by a physical company after hospital discharge was associated with significantly lower mortality rates and improved depression and anxiety scores in elderly patients suffering from socioeconomic related malnutrition.

The filial piety paradox: Receiving social support from children can be negatively associated with quality of life

RATIONALE

Despite strong norms of filial obligation in Asian countries, little is known about whether child-provided support promotes older adults' well-being.

OBJECTIVE

This study sought to examine whether and how the source (e.g., child/non-child providers) and the form (e.g., financial, instrumental) of received social support are associated with older adults' quality of life.

METHODS

Data are from two waves of a longitudinal survey of older adults in Singapore (N = 2887). Two-wave mediation analyses were conducted to determine associations of the source and form of received social support with quality of life, and the extent to which personal mastery mediated these associations.

RESULTS

We find that, although receiving financial assistance from more children promotes older men's quality of life, older women's quality of life is eroded when receiving housework help from more children. These relationships are partially mediated through increase (for men) or decline (for women) in personal mastery.

CONCLUSIONS

The findings suggest that both the form and source of help provided to older adults matter. Receiving social support from children may not always benefit older adults - more attention is needed on how best to support older adults while giving them sufficient control to maintain a high quality of life.

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

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

The Relationship Between Financial Worries and Psychological Distress Among U.S. Adults

This study examines the association between financial worries and psychological distress among US adults and tests its moderating effects by gender, marital status, employment status, education, and income levels. Data were derived from the cross-sectional 2018 National Health Interview Survey (NHIS) of the adult population. The hierarchical regression analysis revealed that higher financial worries were significantly associated with higher psychological distress. Additionally, the association between financial worries and psychological distress was more pronounced among the unmarried, the unemployed, lower-income households, and renters than their counterparts. The findings suggest that accessible financial counseling programs and public health intervention programs are needed to mitigate financial worries and its negative influences on overall psychological health, with greater attention devoted to vulnerable populations.

The role of consumer and mortgage debt for financial stress

OBJECTIVES

Financial debt held by older adults in the U.S. has grown over the past two decades. This study examines the extent to which credit cards, other consumer debts, and mortgage debt increase financial stress. Outcome measures of financial stress include the material domain ("bill-paying difficulty") and psychological domain ("ongoing financial strain").

METHOD

We analyzed adults age 62 and older in the 2004 to 2016 waves of the Health and Retirement Study using random-effects logit regressions.

RESULTS

Unsecured consumer debt is associated with more financial stress per dollar than mortgage debt. A detailed assessment of mortgage debt finds that greater levels of both first and secondary mortgages are associated with greater bill-paying difficulty and greater ongoing financial strain. An increase in new mortgage debt obtained after age 62 is associated with an increase in bill-paying difficulty, but is not significantly associated with ongoing financial strain. In contrast, a reduction in mortgage debt since age 62 is associated with lower bill-paying difficulty and lower levels of ongoing financial strain.

CONCLUSION

The relationship between consumer debt, mortgages, and financial stress is nuanced, and depends on both the type and timing of the debt.

Financial Hardship Among Pregnant and Postpartum Women in the United States, 2013 to 2018

Importance

Financial hardship affects health care access and health outcomes among peripartum women.

Objective

To evaluate the prevalence of financial hardship among peripartum women over time and by insurance type and income.

Design, Setting, and Participants

This cross-sectional study included peripartum women, defined as women aged 18 to 45 years who reported being currently pregnant or pregnant in the past 12 months, who participated in the National Health Interview Survey from 2013 to 2018. Data were analyzed from January to May 2021.

Exposures

Current pregnancy or recent pregnancy as well as insurance type and income.

Main Outcomes and Measures

Three measures of financial hardship within the last year were evaluated: (1) unmet health care need due to cost (unmet need for medical care or delayed or deferred medical care due to cost); (2) health care unaffordability (worry about paying for potential medical bills or existing medical debt); and (3) general financial stress (worry about subsistence spending [eg, monthly bills, housing]).

Results

The study cohort included 3509 peripartum women, weighted to represent 1 050 789 women (2018: an estimated 36 045 of 184 018 [19.6%] Hispanic, 39 017 [21.2%] Black, and 97 366 [52.9%] White), with a mean (SD) age of 29 (6) years. Overall, from 2013 to 2018, 24.2% (95% CI, 22.6%-26.0%) of peripartum women reported unmet health care need, 60.0% (95% CI, 58.0%-61.9%) reported health care unaffordability, and 54.0% (95% CI, 51.5%-56.5%) reported general financial stress. The prevalence of financial hardship outcomes did not substantially change between 2013 and 2018 (unmet health care need in 2013: 27.9% [95% CI, 24.4%-31.7%]; in 2018: 23.7% [95% CI, 19.5%-28.6%]; health care unaffordability in 2013: 65.7% [95% CI, 61.1%-70.0%]; in 2018: 58.8% [95% CI, 53.4%-64.0%]; general financial stress in 2013: 60.6% [95% CI, 55.2%-65.8%]; in 2018: 53.8% [95% CI, 47.8%-59.8%]). Women with private insurance had lower odds of unmet need (adjusted odds ratio [aOR], 0.67; 95% CI, 0.52-0.87) but higher odds of health care unaffordability (aOR, 1.88; 95% CI, 1.49-2.36) compared with women with public insurance. Peripartum women with household incomes less than 400% of the federal poverty level had higher odds of unmet need (aOR, 1.50; 95% CI, 1.08-2.08) and unaffordable care (aOR, 1.98; 95% CI, 1.54-2.55) compared with those with household incomes 400% or more of federal poverty level.

Conclusions and Relevance

These findings suggest that financial hardship among peripartum women in the United States was common from 2013 to 2018, including 24% of pregnant and postpartum women reporting unmet health care need and 60% reporting health care unaffordability. Women with private insurance and those living on lower incomes were more likely to experience unaffordable health care than women with pubic insurance and those with higher incomes, respectively. Targeted policy interventions are needed to improve health care affordability and promote overall economic security among peripartum women.

Measuring More Than Exposure: Does Stress Appraisal Matter for Black-White Differences in Anxiety and Depressive Symptoms Among Older Adults?

BACKGROUND AND OBJECTIVES

Prior research and theory suggest that exposure to objectively stressful events contributes to mental health disparities. Yet, blacks report higher cumulative stress exposure than whites but lower levels of common psychiatric disorders. In order to understand why blacks bear disproportionate stress exposure but similar or better mental health relative to whites, we need to consider race differences in not only stress exposure, but also stress appraisal-how upsetting stress exposures are perceived to be.

RESEARCH DESIGN AND METHODS

We examine whether race differences in the number of reported chronic stressors across 5 domains (health, financial, residential, relationship, and caregiving) and their appraised stressfulness explain black-white differences in anxiety and depressive symptoms. Data come from 6019 adults aged older than 52 from the 2006 Health and Retirement Study.

RESULTS

Older blacks in this sample experience greater exposure to chronic stressors but appraise stressors as less upsetting relative to whites. In fully adjusted models, stress exposure is related to higher levels of anxiety and depressive symptoms, and perceiving stress as upsetting is associated with higher symptomology for whites and blacks. We also find that blacks report greater anxiety symptoms but fewer depressive symptoms with more stress exposure relative to whites. Stress appraisal partially explains race differences in the association between stress exposure and anxiety symptoms and fully explains race differences in the association between exposure and depressive symptoms.

DISCUSSION AND IMPLICATIONS

The relationship between race, chronic stress exposure, and mental health is mediated by stress appraisal. Stress appraisal provides insight on important pathways contributing to black-white mental health disparities in older adulthood.