Financial Health of People Living With Dementia and Their Informal Care Partners: Protocol for a Mixed Methods Study

BACKGROUND

There is a growing body of academic literature focusing on the significant financial burdens placed on people living with cancer, but little evidence exists on the impact of rising costs of care in other vulnerable populations. This financial strain, also known as financial toxicity, can impact behavioral, psychosocial, and material domains of life for people diagnosed with chronic conditions and their care partners. New evidence suggests that populations experiencing health disparities, including those with dementia, face limited access to health care, employment discrimination, income inequality, higher burdens of disease, and exacerbating financial toxicity.

OBJECTIVE

The three study aims are to (1) adapt a survey to capture financial toxicity in people living with dementia and their care partners; (2) characterize the degree and magnitude of different components of financial toxicity in this population; and (3) empower the voice of this population through imagery and critical reflection on their perceptions and experiences relating to financial toxicity.

METHODS

This study uses a mixed methods approach to comprehensively characterize financial toxicity among people living with dementia and their care partners. To address aim 1, we will adapt elements from previously validated and reliable instruments, including the Comprehensive Score for Financial Toxicity and Patient-Reported Outcomes Measurement Information System, to develop a financial toxicity survey specific to dyads of people living with dementia and their care partners. A total of 100 dyads will complete the survey, and data will be analyzed using descriptive statistics and regression models to address aim 2. Aim 3 will be addressed using the process of "photovoice," which is a qualitative, participatory research method that combines photography, verbal narratives, and critical reflection by groups of individuals to capture aspects of their environment and experiences with a certain topic. Quantitative results and qualitative findings will be integrated using a validated, joint display table mixed methods approach called the pillar integration process.

RESULTS

This study is ongoing, with quantitative findings and qualitative results anticipated by December 2023. Integrated findings will enhance the understanding of financial toxicity in individuals living with dementia and their care partners by providing a comprehensive baseline assessment.

CONCLUSIONS

As one of the first studies on financial toxicity related to dementia care, findings from our mixed methods approach will support the development of new strategies for improving the costs of care. While this work focuses on those living with dementia, this protocol could be replicated for people living with other diseases and serve as a blueprint for future research efforts in this space.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

DERR1-10.2196/47255.

Economic strain and quality of life among families with emerging adult children: The contributions of family rituals and family problem-solving communication

Young people and their families around the world are especially vulnerable to macroeconomic hard times. This study sought to provide a more comprehensive view on how families with emerging adult children can successfully overcome economic distress. Specifically, we examined the links between economic strain-that is, the subjective perceptions of one's current and future financial situation-family ritual meaning, family problem-solving communication, and quality of life, as reported by emerging adults and their parents. Data were collected from 1017 individuals nested in 334 families living in Portugal in 2016/2017. Results from multilevel modeling provided evidence for a negative impact of economic strain on family members' quality of life (β = -0.30, p < 0.001); and for the role of family ritual meaning (β = 0.01, p = 0.022), but not family problem-solving communication, as a buffer against the negative effect of economic strain on quality of life. Findings also suggested that the subjective evaluations that family members formulated about their financial situations played a greater role than objective economic conditions (e.g., income) in establishing a deeper understanding on the impact of economic demands on individuals and families' lives in today's complex financial world. This study provides a significant contribution to family economic stress research, advancing family ritual meaning as a key family dynamic contributing to positive adaptation to economic distress. The implications of these findings for clinical interventions include the potential benefits of symbolic forms of family communication in the work carried out with economically stressed family members.

Food Security in the Time of COVID-19 for a Marshallese Community

Using an individual and family ecological systems model, we explored food security among a Marshallese cohort in Northwest Arkansas during the COVID-19 pandemic. We hypothesized that Marshallese households were experiencing high rates of food insecurity due to socioeconomic and systemic risk factors. Seventy-one Marshallese adults shared socioeconomic information about their household via an online survey. Descriptive results indicate that 91% of respondents report food insecurity. In terms of systemic barriers, almost half of Marshallese respondents do not have health insurance. Additionally, while most respondents report feeling calm, peaceful, and energetic, paradoxically, 81% report feeling depressed and downhearted at least some of the time. Logistic regression findings suggest that food insecurity is significantly related to education levels and household economic strain. These results are analogous with national findings, whereby non-native households are more likely to experience higher levels of food insecurity, lower rates of education, and higher economic strain than native households. As a collective community, the Marshallese could benefit from culturally responsive individual and family systems approaches for improving educational, social, financial, and health opportunities through workforce development, household income and asset development, and food security initiatives. Additional implications for policy, practice, and research are provided.

Economic Pressure and Intention to Complete Colorectal Cancer Screening: A Cross-Sectional Analysis Among U.S. Men

Although men's lives can be saved by colorectal cancer (CRC) screening, its utilization remains below national averages among men from low-income households. However, income has not been consistently linked to men's CRC screening intent. This study tested the hypothesis that men who perceive more economic pressure would have lower CRC screening intent. Cross-sectional data were collected via an online survey in February 2022. Men (aged 45-75 years) living in the U.S. (N = 499) reported their CRC screening intent (outcome) and their perception of their economic circumstances (predictors). Adjusted binary and ordinal logistic analyses were conducted. All analyses were conducted in March 2022. Men who perceived greater difficulty paying bills or affording the type of clothing or medical care they needed (i.e., economic strain) were less likely to have CRC screening intent (OR = 0.67, 95% CI: 0.49, 0.93). This association was no longer significant when prior screening behavior was accounted for (OR = 0.75, 95% CI: 0.52, 1.10). Contrary to our hypothesis, men who reported more financial cutbacks were more likely to report wanting to be screened for CRC within the next year (OR = 1.06, 95% CI: 1.01, 1.11). This is one of the first studies to demonstrate that men's perceptions of their economic circumstances play a role in their intent to complete early-detection screening for CRC. Future research should consider men's perceptions of their economic situation in addition to their annual income when aiming to close the gap between intent and CRC screening uptake.

Economic strain, parental education and psychotic experiences among college students in the United States: Findings from the Healthy Minds Study 2020

AIM

Socioeconomic status (SES) is linked to psychosis, and much can be learned by examining how various indicators of SES-specifically economic strain and intergenerational transfer of resources-are related to sub-threshold psychotic experiences among college students.

METHODS

Using data from the Healthy Minds Survey (September 2020-December 2020), we used multivariable logistic regression models to examine the associations between five SES indicators and 12-month psychotic experiences, adjusting for age, gender and race/ethnicity. We also examined the count of predictors and psychotic experiences.

RESULTS

Each indicator of economic strain was associated with greater odds of psychotic experiences. In particular, increasing levels of financial stress (current, childhood and pandemic-related) were associated with greater odds of psychotic experiences in a dose-response fashion. Food insecurity was associated with double the odds of psychotic experiences. In terms of intergenerational transfer of resources, having either one or no parents who attended college was associated with significantly greater odds of having psychotic experiences, when compared with having both parents who attended college. Examining all predictors in the same model, only childhood and current financial stress and food insecurity were significantly associated with psychotic experiences. The count of predictors was significantly associated with greater odds of having psychotic experiences in a dose-dependent fashion.

CONCLUSIONS

Among college students, economic strain and intergenerational transfer of resources were associated with recent psychotic experiences, highlighting the importance of economic interventions targeting young adults to influence risk for psychosis.

Head start parents' vocational preparedness indirectly predicts preschoolers' physical and relational aggression

Severe poverty has profound impacts on child outcomes, yet much of the research on poverty fails to consider the psychological experiences of poverty, frames low-socioeconomic status families as a monolith, and until recently, has not considered the utility of behavior within the poverty context. This short-term (4 months) longitudinal study was designed to consider children's aggression as predicted by their inhibitory control (IC) and parents' experiences of poverty-related strain in an urban Head Start sample. At Time 1, parents reported on their family's economic situation (income, family size), education, vocational preparedness, and completed a measure of psychological economic strain; children (N = 90; Mage = 52.78 months) completed two IC tasks (Day/Night Stroop; Whisper). Four months later, parents completed the Preschool Proactive and Reactive Aggression survey, used to assess children's physical and relational aggression. Mediation analyses supported that physical and relational aggression were both fully mediated from parents' vocational preparedness, though through different mechanisms. Physical aggression was mediated by parents' psychological economic strain. Relational aggression was mediated through children's IC. Findings support the proposal that aggression should be viewed within context and that typical assumptions about developmental patterns of physical aggression may not hold for all children.

Bills, babies, and (language) barriers: Associations among economic strain, parenting, and primary language during the newborn period

OBJECTIVE

The goal of this study was to examine associations among economic strain, parenting self-efficacy, parenting satisfaction, and parent primary language in a universally low-income sample of parents with newborns.

BACKGROUND

Previous research links increased economic strain to lower levels of parenting self-efficacy and parenting satisfaction among socioeconomically diverse parents with older children. Little research has examined whether primary language shapes the associations among economic strain, parenting self-efficacy, and parenting satisfaction.

METHOD

Parents (n = 194, M _age = 30.91) completed self-report surveys measuring economic strain, parenting self-efficacy, and parenting satisfaction. Parents' ethnic self-identification and primary language were used to stratify parents into three groups: Latinx Spanish speakers, Latinx English speakers, and non-Latinx English speakers.

RESULTS

Regression analyses revealed that economic strain was negatively associated with both parenting self-efficacy and parenting satisfaction. Further, the negative association between economic strain and parenting self-efficacy was stronger for Latinx Spanish speakers.

CONCLUSION

Economic strain may negatively influence parenting self-efficacy and parenting satisfaction during the newborn period. Parents whose primary language is Spanish may be disproportionately affected by economic strain.

IMPLICATIONS

Parents of newborns may benefit from increased economic supports in linguistically responsive pediatric care and social service settings.

Links between marital and parent-child relationship in African American families: A dyadic approach

Grounded in a family systems perspective, we used a dyadic approach to examine longitudinal associations between parents' marital relationship qualities (marital conflict and marital satisfaction) and parent-child warmth and conflict in a sample of 180 African American families with adolescent-age children. We also tested whether these associations varied as a function of family economic strain, parents' depressive symptoms, and parent and youth gender. Results from longitudinal, Actor-Partner Interdependence Models (APIMs) showed significant actor and partner effects for associations between marital satisfaction and parent-child relationships reflecting both spillover and compensation processes. With respect to compensation, on occasions when fathers experienced lower marital satisfaction than usual (i.e., compared to their own cross time average), youth reported more relationship warmth with mothers than usual. Spillover effects were moderated, such that, on occasions when parents experienced more marital satisfaction than usual, adolescents reported more warmth, but only on occasions when parents also experienced lower economic strain than usual. Neither parents' depressive symptoms nor youth gender moderated associations between marriage and parent-child relationships. Results highlight interconnections between marital and parent-child relationships within African American families, the importance of assessing experiences of multiple family members, and the role of family contextual factors for family systems processes in this sociocultural group. (PsycInfo Database Record (c) 2021 APA, all rights reserved).

Economic Strain Deteriorates While Education Fails to Protect Black Older Adults Against Depressive Symptoms, Pain, Self-rated Health, Chronic Disease, and Sick Days

Background

A large body of empirical evidence on Minorities' Diminished Returns (MDRs) suggests that educational attainment shows smaller health effects for Blacks compared to Whites. At the same time, economic strain may operate as a risk factor for a wide range of undesired mental and physical health outcomes in Black communities.

Aim

The current study investigated the combined effects of education and economic strain on the following five health outcomes in Black older adults in underserved areas of South Los Angeles: depressive symptoms, number of chronic diseases, pain intensity, self-rated health, and sick days.

Methods

This cross-sectional study included 619 Black older adults residing in South Los Angeles. Data on demographic factors (age and gender), socioeconomic characteristics, economic strain, health insurance, living arrangement, marital status, health behaviors, depressive symptoms, pain intensity, number of chronic diseases, sick days, and self-rated health were collected. Five linear regressions were used to analyze the data.

Results

Although high education was associated with less economic strain, it was the economic strain, not educational attainment, which was universally associated with depressive symptoms, pain intensity, self-rated health, chronic diseases, and sick days, independent of covariates. Similar patterns emerged for all health outcomes suggesting that the risk associated with economic strain and lack of health gain due to educational attainment are both robust and independent of type of health outcome.

Conclusion

In economically constrained urban environments, economic strain is a more salient social determinant of health of Black older adults than educational attainment. While education loses some of its protective effects, economic strain deteriorates health of Black population across domains. There is a need for bold economic and social policies that increase access of Black communities to cash at times of emergency. There is also a need to improve the education quality in the Black communities.

Multilevel Influences on Depressive Symptoms among Men in Bangladesh

Depression is a worldwide problem, and is especially prevalent in lower-income countries with insufficient resources and widespread poverty, such as Bangladesh. Yet multilevel determinants of depressive symptoms in men have not been studied in this context. We leverage a novel dataset from men in Bangladesh to determine the community- and individual-level influences of masculine dominance strain and financial strain on the frequency of married men's depressive symptoms in Bangladesh. Data were collected between January and June, 2011, as part of the UN Multi-Country Study of Men and Violence, conducted by The International Centre for Diarrhoeal Disease Research, Bangladesh (icddr,b). Masculine dominance strain at both levels was related to the frequency of depressive symptoms. Financial strain only at the individual level was related to the frequency of depressive symptoms. We conclude that community-level economic interventions may not directly influence individual-level depression; however, addressing customary conceptions of masculinity at the community and individual level and addressing individual-level financial strain are promising joint strategies to improve married men's mental health in Bangladesh and similar settings.

Economic strain and support in couple: The mediating role of positive emotions

This study examined positive emotions as mediating mechanisms in the association between economic strain and spouses' supportive behaviour. Data were collected from 295 married couples living in Romania. Results from the Actor-Partner Mediator Model indicated that economic strain had a negative indirect effect on spouses' supportive dyadic coping due to its negative association with partners' positive emotions (joy, contentment, and pride). For both partners, positive emotions decreased when they experienced economic strain, which in turn reduced supportive dyadic coping in couples. These findings have theoretical implications in explaining the association of economic strain with partners' positive emotions and behaviours and also clinical implications for practitioners working with couples experiencing economic strain.

Stress and marital adjustment in families of children with cancer

OBJECTIVE

Pediatric cancer is highly stressful for parents. The current prospective study examines the impact of several stressors (financial strain, life threat, treatment intensity, treatment-related events, and negative life events) on the trajectory of marital adjustment across the first year following diagnosis. We examined whether average level of stressors across the year was related to (1) levels of marital adjustment at the end of the first year of treatment and () the rate of change in marital adjustment.

METHOD

One hundred and thirty families of children newly diagnosed with cancer (M age = 6.33 years, SD = 3.61) participated. Primary caregivers provided 12 monthly reports on marital adjustment and stressors.

RESULTS

Multilevel models indicated that although marital adjustment was stable across the first year on average, random effect estimates suggested that this was the result of differing trajectories between families (eg, some increasing and others decreasing). Five individual stress constructs and a cumulative stress composite were then used to predict this variability. Higher average economic strain was related to consistently poorer marital adjustment across time. Higher average frequency of treatment-related events and negative life events were associated with decreasing adjustment over time and lower adjustment at the end of the first year of treatment. Perception of life threat and treatment intensity were not associated with final levels or trajectory of adjustment. Finally, higher cumulative stress was associated with consistently poorer marital adjustment across time.

CONCLUSION

Implications for identification of at-risk families are discussed, and importance of delivering tailored interventions for this population.

Financial distress and depressive symptoms among African American women: identifying financial priorities and needs and why it matters for mental health

Prior research found that financial hardship or distress is one of the most important underlying factors for depression/depressive symptoms, yet factors that contribute to financial distress remain unexplored or unaddressed. Given this, the goals of the present study were (1) to examine the relationship between perceived financial distress and depressive symptoms, and (2) to identify financial priorities and needs that may contribute to financial distress. Surveys from 111 African American women, ages 18-44, who reside in Allegheny County, PA, were used to gather demographic information and measures of depressive symptoms and financial distress/financial well-being. Correlation and regression analyses revealed that perceived financial distress was significantly associated with levels of depressive symptoms. To assess financial priorities and needs, responses to two open-ended questions were analyzed and coded for common themes: "Imagine you won a $10,000 prize in a local lottery. What would you do with this money?" and "What kinds of programs or other help would be beneficial to you during times of financial difficulties?" The highest five priorities identified by the participants were paying bills and debt, saving, purchasing a home or making home repairs, and/or helping others. The participant's perceived needs during times of financial difficulty included tangible assistance and/or financial education. The findings from this study can be used to create new and/or enhance existing programs, services, and/or interventions that focus on the identified financial priorities and needs. Collaborative efforts among professionals in different disciplines are also needed, as ways to manage and alleviate financial distress should be considered and discussed when addressing the mental health of African American women.