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.

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.

Deficit Attention Disorder: Partisanship, Issue Importance and Concern About Government Overspending

Political action and electoral behavior often stem from a conviction that an issue is important. Yet despite a growing literature on partisan bias, it remains unclear whether partisan attachment also affects the perceived importance of various issues. We propose a theory of partisan-motivated issue attention (PMIA), wherein citizens satisfy partisan instincts by shifting the perceived importance of an issue. We apply our theory to an issue involving a fundamental tool of the federal government-the power to deficit-spend-and test the hypothesis that partisans' concern about government overspending significantly changes depending on which party presides over deficit-spending. Leveraging pre-registered experimental and observational studies, we find strong support for this hypothesis among both Republicans and Democrats. Lastly, using text analytical methods, we also find evidence of PMIA in televised partisan media. Our study thus demonstrates that putative concern about deficit-spending contains a sizable partisan component and, more broadly, uncovers an additional means by which partisan bias guides citizens' attitude formation on policy-relevant issues in the United States.

SUPPLEMENTARY INFORMATION

The online version contains supplementary material available at 10.1007/s11109-022-09783-5.

In sickness and in debt: The COVID-19 impact on sovereign credit risk

The COVID-19 pandemic provides a unique setting in which to evaluate the importance of a country's fiscal capacity in explaining the relation between economic growth shocks and sovereign default risk. For a sample of 30 developed countries, we find a positive and significant sensitivity of sovereign default risk to the intensity of the virus's spread for fiscally constrained governments. Supporting the fiscal channel, we confirm the results for Eurozone countries and U.S. states, for which monetary policy can be held constant. Our analysis suggests that financial markets penalize sovereigns with low fiscal space, impairing their resilience to external shocks.

Benchmarking in Academic Physical Therapy: A Multicenter Trial Using the PT-GQ Survey

OBJECTIVE

Academic physical therapy has no universal metrics by which educational programs can measure outcomes, limiting their ability to benchmark to their own historical performance, to peer institutions, or to other health care professions. The PT-Graduation Questionnaire (GQ) survey, adapted from the Association of American Medical Colleges' GQ, addresses this gap by offering both inter-professional insight and fine-scale assessment of physical therapist education. This study reports the first wave of findings from an ongoing multi-site trial of the PT-GQ among diverse academic physical therapy programs, including (1) benchmarks for academic physical therapy, and (2) a comparison of the physical therapist student experience to medical education benchmarks.

METHODS

Thirty-four doctor of physical therapy (DPT) programs (13.2% nationwide sample) administered the online survey to DPT graduates during the 2019 to 2020 academic year. PT-GQ and Association of American Medical Colleges data were contrasted via Welch's unequal-variance t test and Hedges g (effect size).

RESULTS

A total of 1025 respondents participated in the study (response rate: 63.9%). The average survey duration was 31.8 minutes. Overall educational satisfaction was comparable with medicine, and respondents identified areas of curricular strength (eg, anatomy) and weakness (eg, pharmacology). DPT respondents provided higher ratings of faculty professionalism than medicine, lower rates of student mistreatment, and a lesser impact of within-program diversity on their training. One-third of respondents were less than "satisfied" with student mental health services. DPT respondents reported significantly higher exhaustion but lower disengagement than medical students, along with lower tolerance for ambiguity. Of DPT respondents who reported educational debt, one-third reported debt exceeding $150,000, the threshold above which the DPT degree loses economic power.

CONCLUSIONS

These academic benchmarks, using the PT-GQ, provided insight into physical therapist education and identified differences between physical therapist and medical student perceptions.

IMPACT

This ongoing trial will establish a comprehensive set of benchmarks to better understand academic physical therapy outcomes.

Financial Considerations II: Loans, Debt Management, Saving, and Investing

The financial considerations of becoming a physician are often not fully understood or appreciated until after residency and fellowship training. Once training is complete, physicians face a combination of increased financial rewards mixed with significant, and seemingly overwhelming, financial responsibilities, often with limited financial knowledge or understanding. Appropriately managing debt obligations, living expenses, saving for retirement, children's education, and establishing financial safety nets through savings, investments, and insurance are critical. This article is a starting point to provide the new physician with an introduction into some of those financial considerations, to both encourage further learning and promote successful financial decisions.

Landfall After the Perfect Storm: Cohort Differences in the Relationship Between Debt and Risk of Heart Attack

Analyses of the Health and Retirement Study (HRS) between 1992 and 2014 compare the relationship between different levels and forms of debt and heart attack risk trajectories across four cohorts. Although all cohorts experienced growing household debt, including the increase of both secured and unsecured debt, they nevertheless encountered different economic opportunity structures and crises at sensitive times in their life courses, with implications for heart attack risk trajectories. Results from frailty hazards models reveal that unsecured debt is associated with increased risk of heart attack across all cohorts. Higher levels of housing debt, however, predict higher rates of heart attack among only the earlier cohorts. Heart attack risk trajectories for Baby Boomers with high levels of housing debt are lower than those of same-aged peers with no housing debt. Thus, the relationship between debt and heart attack varies by level and form of debt across cohorts but distinguishes Baby Boomer cohorts based on their diverse exposures to volatile housing market conditions over the sensitive household formation period of the life course.

Financial Toxicity in Breast Reconstruction: A National Survey of Women Who have Undergone Breast Reconstruction After Mastectomy

BACKGROUND

Despite awareness regarding financial toxicity in breast cancer care, little is known about the financial strain associated with breast reconstruction. This study aims to describe financial toxicity and identify factors independently associated with financial toxicity for women pursuing post-mastectomy breast reconstruction.

METHODS

A 33-item electronic survey was distributed to members of the Love Research Army. Women over 18 years of age and at least 1 year after post-mastectomy breast reconstruction were invited to participate. The primary outcome of interest was self-reported financial toxicity due to breast reconstruction, while secondary outcomes of interest were patient-reported out-of-pocket expenses and impact of financial toxicity on surgical decision making.

RESULTS

In total, 922 women were included (mean age 58.6 years, standard deviation 10.3 years); 216 women (23.8%) reported financial toxicity from reconstruction. These women had significantly greater out-of-pocket medical expenses. When compared with women who did not experience financial toxicity, those who did were more likely to have debt due to reconstruction (50.9% vs. 3.2%, p < 0.001). Younger age, lower annual household income, greater out-of-pocket expenses, and a postoperative major complication were independently associated with an increased risk for financial toxicity. If faced with the same decision, women experiencing financial toxicity were more likely to decide against reconstruction (p < 0.001) compared with women not experiencing financial toxicity.

CONCLUSIONS

Nearly one in four women experienced financial toxicity from breast reconstruction. Women who reported higher levels of financial toxicity were more likely to change their decisions about surgery. Identified factors predictive of financial toxicity could guide preoperative discussions to inform decision making that mitigates undesired financial decline.

Trajectories of unsecured debt and health at midlife

BACKGROUND

Unsecured debt - debt not tied to an asset - is a financial stressor that undermines health, but prior research has not investigated relationships between group-based trajectories of unsecured debt and pain and disability at midlife.

METHODS

US respondents of the National Longitudinal Study of Youth-1979 cohort reported unsecured debt and income between ages 28-40. We used these measures to identify group-based trajectories of unsecured debt and unsecured debt-to-income ratio. We then used trajectory membership to predict three pain and disability-related health outcomes at age 50, adjusting for lagged health and other covariates.

RESULTS

Group-based trajectory models divided the sample of 7850 respondents into 6 unsecured debt trajectories and 5 unsecured debt-to-income trajectories. In fully adjusted unsecured debt models, compared to people with constant low debt, those who paid down debt over time, carried constant debt, experienced debt cycling, or accumulated debt later in life were more likely to report pain interference with activities or joint pain or stiffness at age 50 (pain interference ORs ranging from 1.33 to 1.76; joint pain or stiffness ORs ranging from 1.27 to 1.45). In fully adjusted unsecured debt-to-income models, compared to those with constant low debt, those with constant high debt or accumulating debt later in life were more likely to report pain interference or joint pain or stiffness (pain interference ORs ranging from 1.30 to 1.91; joint pain or stiffness ORs ranging from 1.19 to 1.33).

CONCLUSION

The amount, timing, and duration of unsecured debt accumulation and repayment have important health implications and may exacerbate midlife health inequalities.

Divorce, health, and socioeconomic status: An agenda for psychological science

This brief review article discusses marital dissolution and health with a focus on two specific themes. First, we introduce and discuss the search for plausible causal pathways that link the end of marriage to distal health outcomes. Second, we suggest that the socioeconomic status disruptions that follow divorce represent a plausible causal pathway and emphasize the need for more psychological science in this area of study. Although there is substantial literature that demonstrates that divorced adults, especially divorced women, experience significant financial disruptions, the research in this area remains broad and largely the province of family sociology and demography. Research is needed to better understand adults' psychological and behavioral responses to changes in their financial situation after the end of marriage.

Debt and financial market contagion

We empirically investigate why financial crises spread from one country to another. For our analysis, we develop a new multiple-channel test of financial market contagion and construct indices of crisis severity in equity markets in order to examine how the transmission of shocks across countries can be related to direct linkages between countries or to common characteristics. Based on network analysis with our proposed multiple-channel test for crises between 2007 and 2021, we find that the Great Recession is the most pervasive across countries, followed by the European sovereign debt crisis and the recent COVID pandemic, with the subprime mortgage crisis being the least pervasive. Our main finding is that similar public, private and external debt characteristics are particularly helpful in explaining the transmission of financial shocks during crises. Fiscal deficits appear more important than current account deficits, while stage of economic development matters more than regional linkages, but none of these indicators is as important as debt.

A Snapshot of Current US Medical School Off-Ramp Programs-a Way to Leave Medical School with Another Degree

Although most students finish medical school, those who do not frequently have no obvious programmatic alternatives. In recent years, a growing number of medical schools have been developing "off-ramp" programs to help such learners. We surveyed 12 medical schools with off-ramp programs to understand their characteristics and challenges. Differences existed between programs but most were deemed helpful to the students and institutions they served. Advantages included the opportunity to acknowledge the students' hard work, increase career opportunities, and reduce debt. Understanding and promoting such programs will assist students for whom medical school does not represent the optimal career path.

Disaster, Debt, and 'Underdevelopment': The Cunning of Colonial-Capitalism in the Caribbean

This article provides a critical overview of the structural forces exacerbating risk related to disasters in the Caribbean. It focuses on the historical antecedents and socio-environmental consequences of extreme weather events across the region via an anti-colonial analysis of Hurricanes Irma and Maria in 2017 and Dorian in 2019. The authors contend that the logics, practices and debts of colonial-capitalist development, neoliberal exploitation and post-independence corruption continue to reduce resilience and threaten public health in the region. They also detail the role that political economy and social geography play in the face of disasters. They end by proposing that future critiques of and solutions to vulnerability, disaster, and catastrophe in the Caribbean be more attentive to the historical trajectories of imperialism, debt and ‘underdevelopment’.

Internationalization and the capital structure of firms in emerging markets: Evidence from Latin America before and after the financial crisis

This study examines the impact of internationalization on the capital structure of firms in emerging markets before and after the financial crisis of 2008, with evidence from five countries in Latin America (Argentina, Brazil, Chile, Mexico, and Peru). We find that before the financial crisis, Latin American MNCs are characterized by lower debt levels than purely domestic firms. However, after the financial crisis, we find that the MNCs are characterized by higher debt levels. This finding suggests that after the financial crisis, the Latin American MNCs (like many firms) may be taking advantage of their access to low interest rates in the global capital markets.

COVID-19 Pandemic Recession and Recovery

This review draws pragmatic lessons for developing countries to address COVID-19-induced recessions and to sustain a developmental recovery. These recessions are unique, caused initially by supply disruptions, largely due to government-imposed ‘stay-in-shelter lockdowns’. These have interacted with falling incomes and demand, declining exports (and imports), collapsing commodity prices, shrinking travel and tourism, decreasing remittances and foreign exchange shortages. Highlighting implications for employment, wellbeing and development, it argues that governments need to design comprehensive relief measures and recovery policies to address short-term problems. These should prevent cash-flow predicaments from becoming full-blown solvency crises. Instead of returning to the status quo ante, developing countries’ capacities and capabilities need to be enhanced to address long-term sustainable development challenges. Multilateral financial institutions should intermediate with financial sources at low cost to supplement the International Monetary Fund’s Special Drawing Rights to lower borrowing costs for relief and recovery.

COVID-19 and the case for global development

COVID-19 accentuates the case for a global, rather than an international, development paradigm. The novel disease is a prime example of a development challenge for all countries, through the failure of public health as a global public good. The COVID-19 pandemic has highlighted the falsity of any assumption that the global North has all the expertise and solutions to tackle global challenges, and has further highlighted the need for multi-directional learning and transformation in all countries towards a more sustainable and equitable world. We illustrate our argument for a global development paradigm by examining the implications of the COVID-19 pandemic across four themes or 'vignettes': global value chains, digitalisation, debt, and climate change. We conclude that development studies must adapt to a very different context from when the field emerged in the mid-20th century.

The Covid-19 economic crisis: dangerously unique

The Covid-19 crisis is unique in several respects. This devastating recession does not have an economic origin, will dance largely to the tune of non-economic factors, and is truly global. The policy response has been equally unique, in terms of speed, size and scope, eliciting an unprecedented concerted effort combining monetary, fiscal and prudential policies. This has contained the fallout. At the time of writing, financial markets have rebounded to the point of looking exuberant, but it all feels more like a truce than a peace treaty. The crisis is transitioning from the liquidity to the solvency phase in a context of limited and shrinking room for policy manoeuvre. All this raises difficult near- and longer-term challenges. Rebuilding policy buffers in all policy areas is likely to be the policy challenge of the decade ahead.

Exploring sustainable scenarios in debt-based social-ecological systems: The case for palm oil production in Indonesia

A debt-based economy requires the accumulation of more and more debt to finance economic growth, while future economic growth is needed to repay the debt, and so the cycle continues. Despite global debt reaching unprecedented levels, little research has been done to understand the impacts of debt dynamics on environmental sustainability. Here, we explore the environmental impacts of the debt-growth cycle in Indonesia, the world's largest debt-based producer of palm oil. Our empirical Agent-Based Model analyses the future effects (2018-2050) of power (im)balance scenarios between debt-driven economic forces (i.e. banks, firms), and conservation forces, on two ecosystem services (food production, climate regulation) and biodiversity. The model shows the trade-offs and synergies among these indicators for Business As Usual as compared to alternative scenarios. Results show that debt-driven economic forces can partially support environmental conservation, provided the state's role in protecting the environment is reinforced. Our analysis provides a lesson for developing countries that are highly dependent on debt-based production systems: sustainable development pathways can be achievable in the short and medium terms; however, reaching long-term sustainability requires reduced dependency on external financial powers, as well as further government intervention to protect the environment from the rough edges of the market economy.

The passing of western civilization

Modern western civilization reached a pinnacle in the last half of the 20^th century, spending over 200 years evolving and spreading throughout the world. A robust social contract, technological advancement and pervasive economic success in the context of democracy and capitalism propelled the project. Unfortunately, two underlying pillars of past success developed intensifying negative consequences, hastening socioeconomic decline: insatiable collective wants and global population growth. The rise and decline of civilizations in history is well documented, yet oddly ignored in today's dialogue. Contemporary civilization is assumed to be immune from forces that shaped cycles of past civilizations-that our age is somehow an exception. For the first time in human history planetary systems that seemed invisible until recently are sending us the message that our civilization is not exceptional, that there are finite limits to the thrust of humanity's present trajectory. Viable solutions curbing the effects of habitat destruction, diminishing biodiversity and climate change along with rising inequality, debt, conflict and refugee flows are known but unimplementable. The current essay examines underlying causes of socioeconomic deterioration and entrapment, suggesting a comprehensive collective intelligence enterprise be launched to prepare for the global transition facing humanity.

Debt, Incarceration, and Re-entry: a Scoping Review

People involved with the criminal justice system in the United States are disproportionately low-income and indebted. The experience of incarceration intensifies financial hardship, including through worsening debt. Little is known about how people who are incarcerated and their families are impacted by debt and how it affects their reentry experience. We conducted a scoping review to identify what is known about the debt burden on those who have been incarcerated and their families and how this impacts their lives. We searched 14 data bases from 1990 to 2019 for all original research addressing financial debt held by those incarcerated in the United States, and screened articles for relevance and extracted data from pertinent studies. These 31 studies selected for inclusion showed that this population is heavily burdened by debt that was accumulated in three general categories: debt directly from criminal justice involvement such as LFOs, preexisting debt that compounded during incarceration, and debts accrued during reentry for everyday survival. Debt was generally shown to have a negative effect on financial well-being, reentry, family structure, and mental health. Debts from LFOs and child support is very common among the justice-involved population and are largely unpayable. Other forms of debt likely to burden this population remain largely understudied. Extensive reform is necessary to lessen the burden of debt on the criminal justice population in order to improve reentry outcomes and quality of life.

National prospective cohort study describing how financial stresses are associated with attrition from surgical residency

BACKGROUND

Attrition from general surgery residency is high with a national rate of 20%. We evaluated potential associations between financial considerations and attrition.

METHODS

National prospective cohort study of categorical general surgery trainees.

RESULTS

Of the 1048 interns who started training in 2007, 681 (65%) had complete survey and follow-up data. In logistic regression, those with higher starting attending salary expectations (>$300K) were more likely to leave training (OR 2.9, 95% CI 1.2-6.9). Women with a partner who earned more (>$50K/year) were more likely to leave training (OR 4.1, 95% CI 1.6-10.5). In a subgroup of interns undecided about their future practice setting (academic, community, private practice, industry), those with less debt (≤$100K) were more likely to leave training (OR 2.4, 95% CI 1.1-5.2).

CONCLUSIONS

Several financial matters were associated with attrition. Addressing these financial concerns may help decrease attrition in surgical training and improve surgical training.

Feasibility of Brief Screening for At-Risk Gambling in Consumer Credit Counseling

Gambling disorder and problem gambling often lead to major suffering in the form of mental health problems, interpersonal conflict, and financial crises. One potential setting for detecting at-risk gambling is credit counseling as gambling problems may manifest themselves in the form of financial distress and bankruptcy. Research studies have not considered those seeking credit counseling as individuals at risk for gambling problems even though gambling may contribute to financial distress. Therefore, the current study sought to quantify the prevalence of at-risk gambling in credit counseling compared with national estimates, to compare at-risk gamblers in this population to lower risk individuals, and to assess the feasibility of gambling screening in these settings. Using a mixed methods approach, the current study found that almost 20% of callers to a national agency reported gambling behavior, and among those who gambled, they reported higher rates of problems related to gambling than the broader U.S. population, thus supporting the idea that screening in credit counseling may help identify those at risk. Low risk gamblers were slightly younger than non-gamblers, but no other differences in sociodemographic and financial status variables were found based on gambling risk status. Results from focus groups and individual interviews suggest that credit counselors and program administrators see the benefit to brief screening within their intake and counseling processes. Our findings suggest that gambling screening is feasible in consumer credit counseling and may be acceptable to staff and administrators at these agencies.

Cost-related medication nonadherence among over-indebted individuals enrolled in statutory health insurance in Germany: a cross-sectional population study

Background

Millions of citizens in high-income countries face over-indebtedness that implies being unable to cover payment obligations with available income and assets on an ongoing basis. Studies have shown an association between over-indebtedness and health outcomes, independent of standard socioeconomic status measures. Patterns of cost-related medication nonadherence (CRN) among over-indebted individuals are yet unclear. The aim of this study was to examine the frequency of nonadherence to prescribed medications due to cost, and to identify risk factors for CRN among over-indebted individuals in Germany.

Methods

In 2017, we conducted a cross-sectional survey among over-indebted individuals recruited in 70 debt advice agencies in North Rhine-Westphalia, Germany. Data on CRN in the last 12 months (i.e. not filling prescriptions, skipping or decreasing doses of prescribed medication due to financial problems) were collected by a survey using a self-administered written questionnaire that was returned by 699 individuals with a response rate of 50.2%. Prevalence of CRN was assessed using descriptive statistics. Multiple logistic regression analysis was performed to examine risk factors of CRN, including participants enrolled in statutory health insurance with complete data (n = 521).

Results

The prevalence of CRN was 33.6%. The chronically ill had significantly greater odds of cost-related medication nonadherence (aOR 1.96; 95% CI 1.27–3.03) than individuals without a chronic illness. CRN was more likely to occur in individuals who had discussed financial problems with their general practitioner (aOR 1.58; 95% CI 1.01–2.47). There was no association between CRN and other sociodemographic factors or socioeconomic status.

Conclusions

Medication nonadherence due to financial pressures is common among over-indebted citizens enrolled in statutory health insurance in Germany. Stakeholders in social policy, research and health care need to address over-indebtedness to develop strategies to safeguard access to relevant medications, especially among those with high morbidity.

Trial registration

Arzneimittelkonsum, insbesondere Selbstmedikation bei überschuldeten Bürgerinnen und Bürgern in Nordrhein-Westfalen (ArSemü), (engl. ‘Medication use, particularly self-medication among over-indebted citizens in North Rhine-Westphalia’), German Clinical Trials Register: DRKS00013100. Date of registration: 23.10.2017. Date of enrolment of the first participant: 18.07.2017, retrospectively registered.

Financial stress and mental health among higher education students in the UK up to 2018: rapid review of evidence

Introduction

In the United Kingdom and many other countries, debt accrued during higher education has increased substantially in recent decades. The prevalence of common mental health problems has also increased alongside these changes. However, it is as yet unclear whether there is an association between financial stress and mental health among higher education students.

Methods

We conducted a rapid review of the peer-reviewed scientific literature. Eligible studies were English-language publications testing the association between any indicator of financial stress and mental health among higher education students in the UK. Papers were located through a systematic search of PsychINFO, PubMed and Embase up to November 2018.

Results

The search strategy yielded 1272 studies—9 met the inclusion criteria. A further two were identified through hand-searching. The median sample size was 408. Only three of seven studies found an association between higher debt and worse mental health. There was a consistent cross-sectional relationship between worse mental health and both experience of financial difficulties (seven of seven studies) and debt worry/financial concern (four of five studies), though longitudinal evidence was mixed and limited to six studies.

Conclusion

Among higher education students in the UK, there is little evidence that the amount of debt is associated with mental health. However, more subjective measures of increased financial stress were more consistently associated with worse mental health outcomes. Nevertheless, the identified evidence was judged to be weak; further research is required to examine whether links between financial stress and mental health outcomes are robust and causal in nature.

Over-indebtedness and its association with sleep and sleep medication use

BACKGROUND

Over-indebtedness is currently rising in high-income countries. Millions of citizens are confronted with the persistent situation when household income and assets are insufficient to cover payment obligations and living expenses. Previous research shows that over-indebtedness increases the risk of various adverse health effects. However, its association with sleep problems has not yet been examined. The objective of this study was to investigate the association between over-indebtedness and sleep problems and sleep medication use.

METHODS

A cross-sectional study on over-indebtedness (OID survey) was conducted in 70 debt advisory centres in Germany in 2017 that included 699 over-indebted respondents. The survey data were combined with the nationally representative German Health Interview and Examination Survey for Adults (DEGS1; n = 7987). We limited analyses to participants with complete data on all sleep variables (OID: n = 538, DEGS1: n = 7447). Descriptive analyses and logistic regression analyses were used to examine the association between over-indebtedness and difficulty initiating and maintaining sleep, and sleep medication use.

RESULTS

A higher prevalence of sleep problems and sleep medication use was observed among over-indebted individuals compared to the general population. After adjustment for socio-economic and health factors (age, sex, education, marital status, employment status, subjective health status and mental illness), over-indebtedness significantly increased the risk of difficulties with sleep onset (adjusted odds ratio (aOR) 1.79, 95%-confidence interval (CI) 1.45-2.21), sleep maintenance (aOR 1.45, 95%-CI 1.17-1.80) and sleep medication use (aOR 3.94, 95%-CI 2.96-5.24).

CONCLUSIONS

Evidence suggests a strong association between over-indebtedness and poor sleep and sleep medication use independent of conventional socioeconomic measures. Considering over-indebtedness in both research and health care practice will help to advance the understanding of sleep disparities, and facilitate interventions for those at risk.

TRIAL REGISTRATION

German Clinical Trials Register: DRKS00013100 (OID survey, ArSemü); Date of registration: 23.10.2017; Date of enrolment of the first participant: 18.07.2017, retrospectively registered.

Racial and Ethnic Variation in the Relationship Between Student Loan Debt and the Transition to First Birth

The present study employs discrete-time hazard regression models to investigate the relationship between student loan debt and the probability of transitioning to either marital or nonmarital first childbirth using the 1997 National Longitudinal Survey of Youth (NLSY97). Accounting for nonrandom selection into student loans using propensity scores, our study reveals that the effect of student loan debt on the transition to motherhood differs among white, black, and Hispanic women. Hispanic women holding student loans experience significant declines in the probability of transitioning to both marital and nonmarital motherhood, whereas black women with student loans are significantly more likely to transition to any first childbirth. Indebted white women experience only a decrease in the probability of a marital first birth. The results from this study suggest that student loans will likely play a key role in shaping future demographic patterns and behaviors.

Death or Debt? National Estimates of Financial Toxicity in Persons with Newly-Diagnosed Cancer

PURPOSE

The purpose of this study was to evaluate the impact of cancer upon a patient's net worth and debt in the US.

METHODS

This longitudinal study used the Health and Retirement Study from 1998-2014. Persons ≥50years with newly-diagnosed malignancies were included, excluding minor skin cancers. Multivariable generalized linear models assessed changes in net worth and debt (consumer, mortgage, home equity) at 2 and 4 years after diagnosis (year₊₂, year₊₄), controlling for demographic and clinically-related variables, cancer-specific attributes, economic factors, and mortality. A 2-year period before cancer diagnosis served as a historical control.

RESULTS

Across 9.5 million estimated new diagnoses of cancer from 2000-2012, individuals averaged 68.6±9.4 years with slight majorities being married (54.7%), not retired (51.1%), and Medicare beneficiaries (56.6%). At year₊₂, 42.4% depleted their entire life's assets, with higher adjusted odds associated with worsening cancer, requirement of continued treatment, demographic and socioeconomic factors (ie, female, Medicaid, uninsured, retired, increasing age, income, and household size), and clinical characteristics (ie, current smoker, worse self-reported health, hypertension, diabetes, lung disease) (P<.05); average losses were $92,098. At year₊₄, financial insolvency extended to 38.2%, with several consistent socioeconomic, cancer-related, and clinical characteristics remaining significant predictors of complete asset depletion.

CONCLUSIONS

This nationally-representative investigation of an initially-estimated 9.5 million newly-diagnosed persons with cancer who were ≥50 years of age found a substantial proportion incurring financial toxicity. As large financial burdens have been found to adversely affect access to care and outcomes among cancer patients, the active development of approaches to mitigate these effects among already vulnerable groups remains of key importance.

Problem gambling and psychological distress: a cross-national perspective on the mediating effect of consumer debt and debt problems among emerging adults

Background

Severe economic difficulties are common among younger generations who currently have an easy access to consumer credit and payday loans in many Western countries. These accessible yet expensive short-term loans may lead to more severe financial difficulties, including default and debt enforcement, both which are defined as debt problems within this study. This study hypothesized that consumer debt and debt problems mediate the relationship between problematic gambling and psychological distress. Excessive gambling can be funded with consumer debt, which in turn leads to the accumulation of financial stressors and, eventually, psychological distress.

Methods

Three studies were conducted to examine the hypotheses. Study 1 used a demographically balanced sample of Finnish participants aged 18 to 25 years (n = 985, 50.76% female). Study 2 used a sample collected from Finnish discussion forums and social networking sites, with participants ranging from 18 to 29 years of age (n = 205, 54.63% female). Study 3 used a demographically balanced sample of American youths aged 18 to 25 years (n = 883, 50.17% female). Analyses were based on generalized structural equation models examining the role of problem gambling, consumer debt, and debt problems (i.e., default and debt enforcement) on psychological distress. Additional mediation analysis was run with treating both instant loans and debt problems as mediators.

Results

All three studies showed that problem gambling was associated with consumer debt, which was further associated with debt problems. Both consumer debt (studies 1 and 2) and debt problems (study 3) were associated with psychological distress. Problem gambling was also directly associated with psychological distress in studies 1 and 3, but not in study 2. In Finland, consumer debt mediated the relationship between problem gambling and psychological distress (studies 1 and 2), while study 3 underlined the mediating role of debt problems in the USA, where consumer debt itself was not positively associated with psychological distress.

Conclusions

The results of the three studies indicate that problem gambling-related psychological distress is partly explained by consumer debt. Consumer credit and payday loans may provide resources for gamblers that enable them to keep up with the habit. This may eventually lead to debt problems and psychological distress. Cross-national differences exist, but in both Nordic and American models, similar mechanisms prevail. The results imply that limiting consumer debt among emerging adults could cushion the financial and psychological costs of problem gambling.