Financial vulnerability and the impact of COVID-19 on American households

In May 2020, Westat, in partnership with Stanford University School of Medicine, conducted a nationally-representative household survey of American attitudes and behaviors regarding COVID-19. In this article, we examine what the Coronavirus Attitudes and Behaviors Survey tells us about the impact of COVID-19 on financial status and how this impact varies by demographic characteristics, the presence of health risk factors, and financial status (including employment factors). The survey reveals significant inequality in financial impact, as those who were most financially vulnerable prior to the pandemic found themselves under greater financial strain, while those who were more financially secure have experienced a neutral or even positive impact of the pandemic on household finances. These findings have important implications for public policy as policymakers seek to target aid to those who need it most.

What’s important to you? Socioeconomic inequalities in the perceived importance of health compared to other life domains

Background Pressing issues, like financial concerns, may outweigh the importance people attach to health. This study tested whether health, compared to other life domains, was considered more important by people in high versus low socioeconomic positions, with future focus and financial strain as potential explanatory factors. Methods A cross-sectional survey was conducted in 2019 among N=1,330 Dutch adults. Participants rated the importance of two health-related domains (not being ill, living a long life) and seven other life domains (e.g., work, family) on a five-point scale. A latent class analysis grouped participants in classes with similar patterns of importance ratings. Differences in class membership according to socioeconomic position (indicated by income and education) were examined using structural equation modelling, with future focus and financial strain as mediators. Results Three classes were identified, which were defined as: neutralists, who found all domains neutral or unimportant (3.5% of the sample); hedonists, who found most domains important except living a long life, work, and religion (36.2%); and maximalists, who found nearly all domains important, including both health domains (60.3%). Of the neutralists, 38% considered not being ill important, and 30% considered living a long life important. For hedonists, this was 92% and 39%, respectively, and for maximalists this was 99% and 87%, respectively. Compared to belonging to the maximalists class, a low income predicted belonging to the neutralists, and a higher educational level and unemployment predicted belonging to the hedonists. No mediation pathways via future focus or financial strain were found. Conclusions Lower income groups were less likely to consider not being ill important. Those without paid employment and those with a higher educational level were less likely to consider living a long life important. Neither future focus nor financial strain explained these inequalities. Future research should investigate socioeconomic differences in conceptualisations of health, and if inequalities in the perceived importance of health are associated with inequalities in health. To support individuals dealing with challenging circumstances in daily life, health-promoting interventions could align to the life domains perceived important to reach their target group and to prevent widening socioeconomic health inequalities.

A guaranteed immediate payout reduces impatience of financially constrained individuals

A large stream of literature found that individuals who experience financial strain are particularly concerned about their present needs—that is, they are more likely to choose smaller immediate payoffs over larger future payoffs. In contrast, some recent findings suggest that financially constrained individuals may be more concerned about future needs instead (e.g., they are relatively more likely to invest in long-lived durables than in short-lived experiences). We propose that the use of traditional intertemporal choice tasks has made prior studies overly sensitive to the myopia-inducing effects of financial constraint. These tasks typically offer a choice between receiving a smaller payoff in the present versus a larger payoff in the future. Across three studies, we observe that, as long as some immediate payout is guaranteed, financially constrained individuals are as likely as nonconstrained individuals to accept a delay for a larger payoff. These findings qualify prior demonstrations of the myopic effects of financial constraint and suggest that the traditionally used choice paradigm might not accurately capture time preferences, particularly for financially constrained individuals. Furthermore, they provide possible interventions for those interested in reducing the myopia of financially constrained individuals who are facing all now versus all later decisions.

Examining the Impact of Employment Status on Sleep Quality During the COVID-19 Pandemic in Two Low-Income Neighborhoods in Pittsburgh, PA

Study Objectives African Americans have faced disproportionate socioeconomic and health consequences associated with the COVID-19 pandemic. The current study examines employment and its association with sleep quality during the initial months of the pandemic in a low-income, predominantly African American adult sample. Methods In the early months of COVID-19 (March to May 2020), we administered a survey to an ongoing, longitudinal cohort of older adults to assess the impact of COVID-related changes in employment on self-reported sleep quality (N=460; 93.9% African American). Participants had prior sleep quality assessed in 2018 and a subset also had sleep quality assessed in 2013 and 2016. Primary analyses focused on the prevalence of poor sleep quality and changes in sleep quality between 2018 and 2020, according to employment status. Financial strain and prior income were assessed as moderators of the association between employment status and sleep quality. We plotted trend lines showing sleep quality from 2013 to 2020 in a subset (n=339) with all four waves of sleep data available. Results All participants experienced increases in poor sleep quality between 2018 and 2020, with no statistical differences between the employment groups. However, we found some evidence of moderation by financial strain and income. The trend analysis demonstrated increases in poor sleep quality primarily between 2018 and 2020. Conclusions Sleep quality worsened during the pandemic among low-income African American adults. Policies to support the financially vulnerable and marginalized populations could benefit sleep quality.

Student well-being during dedicated preparation for USMLE Step 1 and COMLEX Level 1 exams

Background Nearly all U.S. medical students engage in a 4–8 week period of intense preparation for their first-level licensure exams, termed a “dedicated preparation period” (DPP). It is widely assumed that student well-being is harmed during DPPs, but evidence is limited. This study characterized students’ physical, intellectual, emotional, and social well-being during DPPs. Methods This was a cross-sectional survey sent electronically to all second-year students at four U.S. medical schools after each school’s respective DPP for USMLE Step 1 or COMLEX Level 1 in 2019. Survey items assessed DPP characteristics, cost of resources, and perceived financial strain as predictors for 18 outcomes measured by items with Likert-type response options. Open-ended responses on DPPs’ influence underwent thematic analysis. Results A total of 314/750 (42%) students completed surveys. DPPs lasted a median of 7 weeks (IQR 6–8 weeks), and students spent 70 h/week (IQR 56–80 h/week) studying. A total of 62 (20%) reported experiencing a significant life event that impacted their ability to study during their DPPs. Most reported 2 outcomes improved: medical knowledge base (95%) and confidence in ability to care for patients (56%). Most reported 9 outcomes worsened, including overall quality of life (72%), feeling burned out (77%), and personal anxiety (81%). A total of 25% reported paying for preparation materials strained their finances. Greater perceived financial strain was associated with worsening 11 outcomes, with reported amount spent associated with worsening 2 outcomes. Themes from student descriptions of how DPPs for first-level exams influenced them included (1) opportunity for synthesis of medical knowledge, (2) exercise of endurance and self-discipline required for professional practice, (3) dissonance among exam preparation resource content, formal curriculum, and professional values, (4) isolation, deprivation, and anguish from competing for the highest possible score, and (5) effects on well-being after DPPs. Conclusions DPPs are currently experienced by many students as a period of personal and social deprivation, which may be worsened by perceived financial stress more than the amount of money they spend on preparation materials. DPPs should be considered as a target for reform as medical educators attempt to prevent student suffering and enhance their well-being.

The association between financial strain and volatility in daily relationship uncertainty: A dyadic investigation

Prior research suggests that financial strain negatively impacts relational outcomes and that fluctuations (i.e., volatility) in daily reports of relationship aspects may be detrimental for relational outcomes. Daily relational uncertainty may also be associated with financial stressors; however, little is known about the association between financial strain and levels of daily relational uncertainty, as well as the volatility in day-to-day relational uncertainty. The current study includes both members of 100 adult different-sex couples (relationship length M = 7.0 years, SD = 7.1) who completed 14 days of daily diaries. We examined whether greater baseline financial strain is associated with higher levels of daily relational uncertainty and greater day-to-day volatility in relational uncertainty among actors and partners. Individuals who reported greater financial strain also reported higher overall levels of daily relationship uncertainty, as well as greater volatility in daily relationship uncertainty. The association between actor financial strain and volatility in daily relationship uncertainty was moderated by gender and marital status, such that financial strain was only associated with greater volatility in daily relationship uncertainty for men (but not for women) and for unmarried (but not married) individuals. Evidence for partner effects were also found, where partners’ higher levels of financial strain was associated with less volatility in actors’ daily relational uncertainty; however, this relationship was moderated by income, gender, and marital status. Individuals with lower income levels (versus high income levels) reported less volatility in their daily relationship uncertainty when their partners reported higher financial strain. Males rather than women reported lower volatility in daily relational uncertainty when their partners reported greater financial strain. In addition, unmarried rather than married individuals reported greater volatility in daily relationship uncertainty when their partners reported higher financial strain. Implications for future research and practice are discussed.

Comparison of resident and intern salaries with the current living wage as a quantitative estimate of financial strain among postgraduate veterinary trainees

OBJECTIVE To compare resident and intern salaries with current regional living wages as a quantitative estimate of financial strain. SAMPLE 152 residency programs and 141 internship programs listed with the Veterinary Internship and Residency Matching Program for the 2021–2022 training year. PROCEDURES Data were collected for program annual salary and location. Regional living wage for each location was determined with the Massachusetts Institute of Technology Living Wage Calculator, and annual salary was compared with living wage to estimate income surplus before and after taxes. Results for programs in academia and private practice were compared. Spearman correlation was used to determine whether program annual salary was significantly associated with regional living wage. RESULTS Mean ± SD income surplus before taxes was $7,786 ± 9,426 for clinical residency programs, $16,672 ± 5,105 for laboratory animal programs, and $5,829 ± 8,119 for internships. Academic residencies and internships offered salaries significantly lower than those offered in private practice, and income surpluses before and after taxes were significantly lower for academic programs than for private practice programs. There were weak and moderate, respectively, correlations between program annual salary and regional living wage for residency (r = 0.369) and internship (r = 0.570) programs. CLINICAL RELEVANCE Postgraduate training prolongs financial instability, and annual salaries generally do not meet the minimum income standard of a living wage. Financial stress has implications for mental health and diversity, and these findings invite deeper consideration of current remuneration practices for veterinary residents and interns.

A Researcher–Practitioner Collaboration to Enable Replication of an Evidence-Based Financial Education and Coaching Program That Improves Health in Low-Income Single Mothers

Financial strain is a social determinant of health (SDOH). Although public financial education helps individuals improve financial well-being, specifics are lacking on how and why effective programs work, potentially limiting their successful replication in other practice settings. In this study, researchers and practitioners cocreated the core components and theory of change of a novel financial education and coaching program, which a randomized controlled trial found was effective in significantly improving participants’ financial and health-related behaviors. A Cocreating Knowledge Translation Framework within a case study design was used at a university-affiliated nonprofit in Omaha, Nebraska, from August to December 2020. Twelve practitioner and alumni participants were purposefully sampled. An administrative records review, semi-structured interviews (n =3), survey (n = 10), and facilitated backward mapping session (n = 5) were conducted. Transcripts were coded to identify themes. Thirty-one core components were identified within program principles, design, tools, activities, and expectations of participants and coaches. Ten theory of change outcomes described participants’ pathway to change. Interventions occurred at individual, relationship, and community levels from initial engagement, through behavioral changes, to improved health-related quality of life. Activities and indicators were mapped to each outcome. The program’s intersecting and reinforcing design was key to enabling participants’ outcomes. Its theory of change described how and why the model improved financial and health behaviors. Findings suggest that other SDOH-focused organizations may benefit from researcher–practitioner collaboration to investigate their interventions’ core components and theories of change. This may enable replication, promoting downstream health benefits in new community settings.