Mortgage delinquency and changes in access to health resources and depressive symptoms in a nationally representative cohort of Americans older than 50 years

Does Subsidized Housing Prevent Health Decline and 2-Year Mortality Among Low-Income Older Renters?

BACKGROUND AND OBJECTIVES

A growing number of older adults in the United States need subsidized housing, but only 36% of eligible households receive assistance. The purpose of this study is to examine if older renters living in subsidized housing are less likely to experience health decline and mortality over 2 years compared to low-income older renters who are likely eligible, but do not receive assistance.

RESEARCH DESIGN AND METHODS

Baseline data include 671 subsidized and unsubsidized low-income older renters from the 2015 National Health and Aging Trends Study. Outcomes of interest include self-rated health decline, developing a new activity limitation, or 2-year mortality between 2015 and 2017. Weighted stepwise logistic regression models test (a) if subsidized older renters were less likely to experience health decline or 2-year mortality compared to unsubsidized older renters, and (b) if housing quality and neighborhood factors mediate the association between subsidized housing and health decline/mortality.

RESULTS

Subsidized older renters were less likely to develop a new activity limitation compared to unsubsidized older renters, but there was not a statistically significant difference in experiencing self-rated health decline or 2-year mortality by subsidized housing status. Housing quality and neighborhood factors did not significantly mediate this association.

DISCUSSION AND IMPLICATIONS

The results provide some support that improving access to subsidized housing for low-income older renters may have additional health benefits, even in the short term. To inform program improvements and maximize potential health benefits, more research is needed to understand the specific health-promoting features of subsidized housing.

Housing debt and depressive symptoms: evidence from the China family panel studies

BACKGROUND

There is limited evidence on the association between housing debt and depressive symptoms in China. This study aimed to examine the impact of housing debt on depressive symptoms and explore the heterogeneous impacts arising from two sources of housing debt and two types of housing demands.

METHODS

Using data from the 2016 and 2018 China Family Panel Studies (CFPS), this study included 25,232 Chinese individuals. Depressive symptoms were assessed using the eight-item Center for Epidemiological Studies Depression Scale (CES-D8). Housing debt was measured by dummy variables, indicating whether an individual had housing debt, and continuous variables, which were the logarithm of the total amount of housing debt. The two-way fixed effects model was used to examine the relationship.

RESULTS

Housing debt had a significant positive impact on depressive symptoms in China. Individuals with housing debt had a 0.176-point higher depressive symptom score than those without housing debt. A 10% increase in the total amount of housing debt led to a 0.16-point increase in depressive symptoms. Non-bank housing loans significantly increased the level of depressive symptoms with a larger coefficient (coef = 0.289), while the impact of bank housing loans was small and not statistically significant. In terms of the types of housing demands, a positive impact was observed only among individuals who had only one property meeting their housing consumption demands.

CONCLUSIONS

This study found a significant positive impact of housing debt on depressive symptoms, primarily driven by non-bank housing loans. Furthermore, housing debt increased the depressive symptoms among individuals with consumption demands, while those with investment demands did not show a significant impact. Government interventions should prioritize easing formal financial constraints and providing support for individuals with housing consumption demands.

Negative Wealth Shock and Cognitive Decline and Dementia in Middle-Aged and Older US Adults

Importance

As a financial hardship, negative wealth shock has been implicated in some adverse health outcomes. However, associations between negative wealth shock and cognitive decline and dementia have not been examined.

Objective

To investigate whether negative wealth shock was associated with cognitive decline and incident dementia among middle-aged and older US adults.

Design, Setting, and Participants

The Health and Retirement Study (HRS) is a prospective cohort study conducted biennially among US adults older than 50 years. Data from the HRS from calendar years 1996 to 2020 were analyzed from July 1 to 31, 2023. The final sample included 8082 participants with complete data of interest.

Exposures

Wealth status was quantified with questionnaires. Negative wealth shock was defined as a loss of 75% or more in total wealth over a 2-year period. Asset poverty was defined as zero or less total net wealth.

Main Outcomes and Measures

Cognitive function was assessed with the modified Telephone Interview for Cognitive Status (TICS-m). Dementia status was determined with TICS-m scores and proxy assessment.

Results

Among 8082 participants included (mean [SD] age, 63.7 [5.7] years; 4179 women [51.7%] and 3903 men [48.3%]; 1111 Black [13.7%], 6689 White [82.7%], and 282 other [3.5%]), 1441 developed incident dementia over a median follow-up time of 14 (IQR, 7-20) years. Compared with participants who had positive wealth without shock, those with negative wealth shock had accelerated cognitive decline (β coefficient, -0.014 [95% CI, -0.027 to -0.001]; P = .03) and increased risks of dementia (hazard ratio [HR], 1.27 [95% CI, 1.11-1.46]; P < .001). Higher dementia risks were also found in participants with asset poverty at baseline (HR, 1.61 [95% CI, 1.30-2.00]; P < .001). Associations were found in White participants (HR, 1.34 [95% CI, 1.14-1.58]; P < .001) and participants younger than 65 years (HR, 1.38 [95% CI, 1.13-1.68]; P = .001) but not in other races and ethnicities or those 65 years or older.

Conclusions and Relevance

In this cohort study, negative wealth shock was associated with accelerated cognitive decline and elevated risks of dementia among middle-aged and older US adults, with modifications by age and ethnicity. These findings should be confirmed by further prospective and interventional studies.

Disparities in property insurance relief among socially vulnerable Texas communities after Winter Storm Uri

Property insurance is an important tool for resiliency from the accelerating impacts of climate-intensified extreme weather events. However, disparities in property insurance payouts may reduce their potential protective effects. The objective of this study was to quantify disparities in insurance payouts by Texas' insurers after the 2021 Winter Storm Uri, and to understand if any socioeconomic factors were associated with higher rates of declined relief. We extracted data from the Texas Department of Insurance on rates of denied insurance claims by zip code and county at 1 month and 13 months into the recovery period. We then linked these data to community-level socioeconomic information. Finally, we produced separate linear regressions for each predictor and covariate. Across both time points, communities with a higher proportion of Hispanic people, primary Spanish speakers, people who did not graduate high school, and people living below the federal poverty line were significantly more likely to experience denied claims. Communities with higher social vulnerability scores also experienced more denied claims. While financial security is a critical social determinant of health, findings suggest that insurers may be engaging in structurally discriminatory practices and failing to provide relief for people from socially vulnerable communities in the wake of climate-intensified events.

In the wake of a crisis: Caught between housing and healthcare

Objective

To measure the association between housing insecurity and foregone medication due to cost among Medicare beneficiaries aged 65+ during the Recession.

Methods

Data came from Medicare beneficiaries aged 65+ years from the 2006-2012 waves of the Health and Retirement Study (HRS). Two-wave housing insecurity changes are evaluated as follows: (i) No insecurity, (ii) Persistent insecurity, (iii) Onset insecurity, and (iv) Onset security. We implemented a series of four weighted longitudinal General Estimating Equation (GEE) models, two minimally adjusted and two fully adjusted models, to estimate the probability of foregone medications due to cost between 2008 and 2012.

Results

Our study sample was restricted to non-proxy interviews of non-institutionalized Medicare beneficiaries aged 65+ in the 2006 wave (n = 9936) and their follow up visits (n = 8753; in 2008; n = 7464 in 2010; and n = 6594 in 2012). Results from our fully adjusted model indicated that the odds of foregone medication was 64% higher among individuals experiencing Onset insecurity versus No insecurity in 2008, and also generally larger for individuals experiencing Onset Insecurity versus Persistent Insecurity. Odds of foregone medication was also larger among females, minority versus non-Hispanic white adults, those reporting a chronic condition, those with higher medical expenditures, and those living in the South versus Northeast.

Conclusion

This study drew from nationally representative data to elucidate the disparate health and financial impacts of a crisis on Medicare beneficiaries who, despite health insurance coverage, displayed variability in foregone medication patterns. Our findings suggest that the onset of housing insecurity is most closely linked with unexpected acute economic shocks leading households with little time to adapt and forcing trade-offs in their prescription and other needs purchases. Both housing and healthcare policy implications exist from these findings including expansion of low-income housing units and rent relief post-recession as well as wider prescription drug coverage for Medicare adults.

Systemic Financial Risk Arising from Residential Flood Losses

Direct damage from flooding at residential properties has typically been categorized as insured, with liabilities accruing to insurers, or uninsured, with costs accruing to property owners. However, residential flooding can also expose lenders and local governments to financial risk, though the distribution of this risk is not well understood. Flood losses are not limited to direct damages, but also include indirect effects such as decreases in property values, which can be substantial, though are rarely well quantified. The combination of direct damage and property value decrease influences rates of mortgage default and property abandonment in the wake of a flood, creating financial risk. In this research, property-level data on sales, mortgages, and insurance claims are used in combination with machine learning techniques and geostatistical methods to provide estimates of flood losses that are then utilized to evaluate the risk of default and abandonment in eastern North Carolina following Hurricane Florence (2018). Within the study area, Hurricane Florence generated $366M in observed insured damages and an estimated $1.77B in combined uninsured damages and property value decreases. Property owners, lenders, and local governments were exposed to an additional $562M in potential losses due to increased rates of default and abandonment. Areas with lower pre-flood property values were exposed to greater risk than areas with higher valued properties. Results suggest more highly resolved estimates of a flooding event's systemic financial risk may be useful in developing improved flood resilience strategies.

Exploring the role of discretionary income as a social determinant of health

OBJECTIVE

The object of this study is to explore the impact of discretionary income on the overall well-being of Americans.

DATA SOURCE

The data source used for this study was 2017 Behavioral Risk Factor Surveillance System data comprising 12 states that used the Social Determinants of Health (SDOH) module.

STUDY DESIGN

Multivariable logistic regression models were used to analyze the relationship between discretionary income and self-reported health status after adjusting for common SDOH measures, sociodemographic factors, chronic conditions, and perspectives and experiences of respondents regarding specific aspects of their health. Average marginal effects (AME) were reported.

DATA COLLECTION/EXTRACTION METHODS

Not applicable.

PRINCIPAL FINDINGS

At all income levels, those with discretionary income at the end of the month were 6-7 percentage points more likely to report better than average health than those with none, controlling for other factors (AME: 0.07, 95% CI: 0.02-0.12).

CONCLUSION

Our study suggests that discretionary income has a role to play in overall health and well-being that goes beyond that of disposable income and may be an important resource for diverse communities.

Descriptive phenomenology study of the reasons for the low uptake of free health service package among type II diabetic patients

BACKGROUND

Although several diabetes management and control programs are introduced in Iran, rate of using such cares in patients with Type II Diabetic in Ahvaz is low and they show no tendency for receiving free diabetes service package. The aim of this study was to identify reasons behind low uptake of free health service package among T2DM patients in Ahvaz, Iran.

METHODS

This descriptive phenomenology study based on semi-structured guided interviews of patients with Type II Diabetic in Ahvaz, was carried out in the year 2021. Through purposeful sampling, 495 patients with diabetics who not received health services package more than 6 months were interviewed until the data saturation. The gathered data were analyzed through conventional content analysis.

RESULTS

Reasons were categorized into three themes which include 13 subthemes and 57 codes. Themes included individual, accessibility, and structural factors. Besides, subthemes were lack of awareness, poor health literacy, adverse patients experience, difficulties to use services, verbal miscommunication cultural barriers, low trust, geographic barriers, time barriers, financial difficulties, lack of human resources, poor service delivery, and organizational factors were as barriers to participation.

CONCLUSION

Regarding individual level, there is a need for further training of diabetic patients. Besides, for accessibility and structural factors Iranian healthcare system needs a comprehensive integrated care for the management of diabetes, this underlines the collaboration for improving patients' uptake of free health service package.

The risk of eviction and the mental health outcomes among the US adults

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Perceived risk of eviction among people living with rent arrears is associated with elevated mental health problems.

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Prevalence of depression, anxiety, and pyschotropic medication use is higher in the at-risk of eviction group compared to the non-risk group.

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Addressing the housing crisis is crucial in decreasing the mental health burden among people living in rented residences.

Although past studies establish a link between residential instability and poor mental health, studies investigating the association between perceived risk of eviction and mental health with nationally representative data are largely lacking. This study examines the association between self-reported risk of eviction and anxiety, depression, and prescription medication use for mental or emotional health reasons. This is a retrospective observational study using the repeated-cross sectional data (n = 14548; unweighted) using the US Census Bureau’s Household Pulse Survey from July 2021 to March 2022. Survey respondents aged 18 years and above who lived in rented residences and were not caught up with the rent payments at the time of the survey were included in the analysis. The descriptive summary shows a higher prevalence of depression (59.33 % vs 37.01 %), anxiety (67.01 % vs 43.28 %), and prescription medication use (26.57 % vs 23.68 %) among the respondents who are likely to face eviction in the next two months compared to the reference group not at the risk of eviction. When adjusted for demographic characteristics, family context, and socioeconomic setting, the odds of depression, anxiety, and prescription medication use in the at-risk eviction group were significantly higher than in the reference group. Specifically, odds ratios (ORs) [95 % CI] for depression, anxiety, and prescription medication use are 2.366 [2.364, 2.369], 2.650 [2.648, 2.653], and 1.172 [1.171, 1.174], respectively. These results suggest that the perceived risk of eviction is associated with elevated mental health problems. Addressing the housing crisis may help decrease the mental health burden among rented households.

Mental health and life-course shocks in a low-income country: Evidence from Malawi

Economic insecurity has been widely hypothesized to be an important determinant of mental health, but this relationship has not been well-documented in low-income countries. Using data from the Mature Adults Cohort of the Malawi Longitudinal Study of Families and Health (MLSFH-MAC), we investigate the association of negative economic shocks with mental health outcomes such as depression and anxiety among adults aged 45+ years living in a low-income country. Using fixed effects estimates that control for time-invariant unobserved individual heterogeneity, we find that increased economic instability caused by events such as death of a family member, yield loss, or income loss is positively associated with worse mental health outcomes as measured by the PHQ-9 and GAD-7 instruments. Our results suggest that costly economic events are a key component to worsening mental health in settings characterized by pervasive poverty and underscore the importance of mental health as a public health and development target.

The Role of Microfinance in China's Rural Public Health: Evidence from the Anti-Poverty Microcredit Program

This study presents nonlinear evidence of the effects of a microcredit program implemented in poverty-stricken villages in China on rural public health using multivariate-ordered Probit and IV-ordered Probit models. The results, which were based on a unique set of data gathered from two rounds of official tracking statistics obtained through investigation (2015 and 2018) at a household level, suggest that rural residents' health levels and health insurance demands are related to the formal credit amount that they receive from the microcredit program. Further, the amount of debt that remains to be paid is a negative mediator and the poverty reduction degree is a positive mediator for the health impact of credit. After dividing the sample into subgroups according to income, credit rating and social network, the results show heterogeneity: the health outcomes of groups with a low income, a high credit rating and a strong social network are more significantly improved by loans. The estimations are still robust after using network and village clan numbers as instrumental variables to address endogeneity. Although most of the existing literature demonstrates that credit and indebtedness have negative impacts on health, our results supplement previous findings of the positive causality between access to formal credit and rural public health by showing that the former can exert positive effects by relaxing individuals' external constraints and increasing health spending.

A Legal Mapping Analysis and Model Bylaw of Massachusetts Municipal Accessory Dwelling Units

Adapting the built-environment to include an accessory-dwelling unit (ADU) is one alternative housing solution for community-dwelling older adults (CDOA) to age-in-place and avoid institutionalization. ADUs are one form of the built-environment in which the field of public health law can intervene to accommodate population aging. Under Massachusetts law MGL c. 40A, the state gives authority to municipalities to adopt zoning bylaws to regulate the use of land, buildings, and structures. A legal mapping content analysis was employed to quantify Massachusetts municipalities' (N=351) ADU zoning ordinances using the ADU Friendliness Score instrument and to describe the characteristics of ADU availability across the state. Results are organized into four ordinal categories of POOR (score 0-24; 24%), FAIR (score 25-49; 8.5%), GOOD (score 50-74; 53%), and EXCELLENT (score 75-100%; 13.5%). An age-and-disability specific model ADU bylaw is reported as an outcome of this research.

Financial stress and depression in adults: A systematic review

Financial stress has been proposed as an economic determinant of depression. However, there is little systematic analysis of different dimensions of financial stress and their association with depression. This paper reports a systematic review of 40 observational studies quantifying the relationship between various measures of financial stress and depression outcomes in adults. Most of the reviewed studies show that financial stress is positively associated with depression. A positive association between financial stress and depression is found in both high-income and low-and middle-income countries, but is generally stronger among populations with low income or wealth. In addition to the "social causation" pathway, other pathways such as "psychological stress" and "social selection" can also explain the effects of financial stress on depression. More longitudinal research would be useful to investigate the causal relationship and mechanisms linking different dimensions of financial stress and depression. Furthermore, exploration of effects in subgroups could help target interventions to break the cycle of financial stress and depression.

Housing and Child Health in South Africa: The Value of Longitudinal Research

Research investigating the link between housing and health often produces mixed results. It does not always prove that good housing improves health. The results suggest a complex set of factors play a role, and the findings are sometimes contradictory. Two ways of addressing these concerns are longitudinal research, where the relationship between housing and health is measured in the short and medium terms, and a focus on children. We use the children’s housing and health data from the five waves of the National Income and Distribution Survey (NIDS) survey in South Africa, 2008 to 2017. We investigate the effect that continued living in informal housing over the five waves has had on these children’s health. Our results show a statistically significant relationship between prolonged residence in poor housing and poor health outcomes for some health indicators. The results call for a closer understanding of health issues in housing policy in South Africa.

Housing Cost Burden and Health Decline Among Low- and Moderate-Income Older Renters

OBJECTIVE

To examine the association between housing cost burden and health decline among low- and moderate-income older renters in the U.S.

METHODS

Baseline data include low- and moderate-income community-dwelling older renters (N = 1,064) from the nationally representative 2015 National Health and Aging Trends Study. Housing cost burden (HCB) was defined as the percentage of monthly income spent on rent, categorized as "no HCB" (<30%), "moderate HCB" (30-49%), and "severe HCB" (≥50%). We used weighted logistic regression models to estimate whether HCB status in 2015 and change in HCB between 2015 and 2017 were associated with self-rated health decline and developing a new limitation related to activities of daily living (ADL) or instrumental activities of daily living (IADL) between 2015 and 2017.

RESULTS

Older renters with severe HCB in 2015 were the most likely to develop a new ADL/IADL limitation (63.4%) over time (p < .05). The association between HCB status in 2015 and self-rated health decline was not statistically significant, but older renters with persistent HCB had 1.64 times greater odds of self-rated health decline (p < .05) and 2.01 times greater odds of developing a new ADL/IADL limitation (p < .01), compared to older renters with no HCB at baseline and follow-up.

DISCUSSION

Even in the short term, HCB contributes to health decline in later life. Efforts to promote equity and healthy aging in the community must consider how to best address housing affordability among the growing population of older renters.

The Effects of Housing Cost Burden and Housing Tenure on Moves to a Nursing Home Among Low- and Moderate-Income Older Adults

BACKGROUND AND OBJECTIVES

In the United States, a growing number of older adults struggle to find affordable housing that can adapt to their changing needs. Research suggests that access to affordable housing is a significant barrier to reducing unnecessary nursing home admissions. This is the first empirical study we know of to examine whether housing cost burden (HCB) is associated with moves to nursing homes among older adults.

RESEARCH DESIGN AND METHODS

Data include low- and moderate-income community-dwelling older adults (N = 3,403) from the nationally representative 2015 National Health and Aging Trends Study. HCB (≥30% of income spent on mortgage/rent) and housing tenure (owner/renter) are combined to create a 4-category housing typology. Multinomial logistic regression models test (a) if renters with HCB are most likely (compared with other housing types) to move to a nursing home over 3 years (2015-2018) and (b) if housing type interacts with health and functioning to predict moves to a nursing home.

RESULTS

Across all models, renters with HCB had the greatest likelihood of moving to a nursing home. Moreover, self-rated health, physical capacity, and mental health were weaker predictors of nursing home moves for renters with HCB.

DISCUSSION AND IMPLICATIONS

Results suggest that older renters with HCB are most likely to experience unnecessary nursing home placement. The growing population of older renters experiencing HCB may not only signal a housing crisis, but may also challenge national efforts to shift long-term care away from nursing homes and toward community-based alternatives.

The health impacts of eviction: Evidence from the national longitudinal study of adolescent to adult health

Eviction represents an urgent social and economic issue in the United States, with nearly two million evictions occurring annually in the U.S. Still, the population health impacts of evictions, as well as the pathways linking eviction to health, are not well documented or understood, particularly among young adults. Using nationally-representative, longitudinal data from the National Longitudinal Study of Adolescent to Adult Health (1994-2008) (n = 9029), the present study uses a combination of analytic methods-including prospective lagged dependent variable regression models, inverse probabilities of treatment weighting, longitudinal first difference models, causal mediation techniques-to comprehensively assess whether and how evictions relate to depressive risk and self-rated health across early adulthood, paying particular attention to the stress-related pathways linking eviction and health. Results provide robust evidence of positive longitudinal associations between eviction and depressive risk, in particular. In the prospective regression models, young adults who experienced recent eviction had more depressive symptoms and worse self-rated health than those who were not evicted, net a host of background characteristics. Using treatment weighting techniques, results showed that young adults who experienced eviction had more depressive symptoms than those who were not evicted (5.921 vs. 4.998 depressive symptoms, p = 0.003). Perceived social stress mediated nearly 18 percent of the associations between eviction and the depressive symptoms (p < 0.001). In the first difference models, young people who experienced eviction between survey waves experienced greater increases in depressive symptoms over time compared to those who were not evicted, net of changes in other indicators of socioeconomic status and residential instability. Taken together, our results suggest that the recent surges in evictions in the U.S. serve as a potent threat to population health during the emerging adult period, with especially devastating consequences for low-income individuals and communities of color.

Economy-Sensitive Conditions: Are Some Pediatric Hospitalizations Triggered By Economic Recessions?

The impact of economic recessions on child health is complex and varied. Here we examine associations between county-level unemployment and pediatric hospitalizations in fourteen states every third year from 2002 to 2014. After adjusting for state-specific effects of unemployment across all counties and years, we found that increased unemployment was associated with increased pediatric hospitalizations for four potentially economy-sensitive conditions, such that a 1 percent increase in unemployment was associated with a 5 percent increase in hospitalizations for substance abuse, a 4 percent increase for diabetes mellitus, and a 2 percent increase both for children with medical complexity and for poisoning and burns. Mean pediatric all-cause hospitalizations increased by 2 percent for every 1 percent increase in unemployment (or 54,177 excess hospitalizations in 2011 compared with 2005). Hospitalizations for mental health, despite the increased severity of these conditions during recessions, were not associated with unemployment. Further research is needed to examine potential federal, state, and local policies that may mitigate the influence of unemployment on child health and pediatric hospitalizations.

Association between over-indebtedness and antidepressant use: A cross-sectional analysis

Background

Burden of disease caused by depression and its association with socioeconomic status is well documented. However, research on over-indebtedness is scarce although millions of European citizens in all socioeconomic positions are over-indebted. Prior studies suggested that over-indebtedness is associated with poor physical and mental health.

Aims

Investigate the association between over-indebtedness and antidepressant use in Germany.

Method

A cross-sectional survey among debt advice agencies’ clients was conducted in North Rhine-Westphalia, Germany, in 2017 (OID). Data were merged with the first wave of the German Health Interview and Examination Survey for Adults (DEGS1). Descriptive statistics and logistic regression analysis were used to examine antidepressant use in the previous 7 days (OID: n = 699; DEGS1: n = 7115).

Results

Prevalence of antidepressant use was higher in the over-indebted (12.3%) than the general population (5.0%). The over-indebted were significantly more likely to use antidepressants than the general population even after controlling for other socioeconomic, demographic and health factors (adjusted odds ratio 1.83; 95% confidence interval 1.35–2.48).

Conclusions

Stakeholders in health care, debt counselling, research and social policy should consider the link between over-indebtedness and mental illness to advance the understanding of health inequalities and to help those who have mental health and debt problems.

Looking homeward with the life course: Early origins of adult dwelling satisfaction?

The long-term influence of childhood economic and social exposures on adult health and well-being is well-known. Most childhood circumstances transpire in or near the home, yet research has largely neglected how early exposures shape people's experience of their residential context in adulthood. To help address this gap, we use retrospective longitudinal data from the Midlife Development in the United States (MIDUS) study. Drawing on a life course framework, we test the potential mediating roles of adult social, economic, and mental health processes. Results suggest that childhood parental warmth and maltreatment have an enduring influence on people's satisfaction with their adult home, while there is little indication that childhood economic conditions shape adult dwelling satisfaction. Analyses of average controlled direct effects suggest that the effects of childhood parental warmth are mediated slightly by adult socioeconomic attainment and psychological adjustment but especially by supportive family relationships during adulthood. This pattern is consistent with an attachment-based interpretation of the importance of childhood conditions for adult relationships as well as home satisfaction. Taken together, our results suggest that parent-child bonds cast a long shadow over how people experience their residential context decades later, through a diffuse, multifaceted set of intervening pathways.

Do financial hardship and social support mediate the effect of unaffordable housing on mental health?

PURPOSE

Unaffordable housing has a negative impact on mental health; however, little is known about the causal pathways through which it transmits this effect. We examine the role of financial hardship and social support as mediators of this relationship.

METHODS

We identified households where housing costs changed from affordable to unaffordable across two waves of the Household, Income and Labour Dynamics in Australia (HILDA) Survey (2014-2015). The sequential causal mediation analysis was used to decompose the total effect of unaffordable housing on mental health into the portion attributable to financial hardship and social support [natural indirect effect (NIE)] and the portion not occurring through measured pathways [natural direct effect (NDE)]. Mental health was measured using the Mental Health Inventory (MHI) and Kessler psychological distress (KPD) scale. Baseline covariates included age, sex, household income, financial hardship, social support, marital status and employment status. Bootstrapping with 1000 replications was used to calculate 95% confidence intervals (CIs). Multiple imputations using chained equations were applied to account for missing data.

RESULTS

Unaffordable housing led to a change in mean mental health score on the MHI scale (- 1.3, 95% CI: - 2.1, - 0.6) and KPDS scale (0.9, 95% CI: 0.4, 1.4). Financial hardship accounted for 54% of the total effect on MHI scale and 53% on KPD scale. Collectively, financial hardship and social support explained 68% of the total effect on MHI scale and 67% on KPD scale, respectively.

CONCLUSIONS

In conclusion, the negative mental health effect of unaffordable housing is largely mediated through increased financial hardship.

Patient-physician communication about financial problems: A cross-sectional study among over-indebted individuals

Background

About every tenth household across Europe is unable to meet payment obligations and living expenses on an ongoing basis and is thus considered over-indebted. Previous research suggests that over-indebtedness reflects a potential cause and consequence of psychosomatic health problems and limited access to care. However, it is unclear whether those affected discuss their financial problems with general practitioners. Therefore, this study examined patient-physician communication about financial problems in general practice among over-indebted individuals.

Methods

We conducted a cross-sectional survey among clients of 70 debt advice agencies in North Rhine-Westphalia, Germany, in 2017. We assessed the prevalence of patient-physician communication about financial problems and its association with patient characteristics using descriptive statistics and logistic regression analysis. Of 699 individuals who returned the questionnaire (response rate:50.2%), we included 598 respondents enrolled in statutory health insurance with complete outcome data in the analyses.

Results

Conversations about financial problems with general practitioners were reported by 22.6% (n = 135) of respondents. Individuals with a high educational level were less likely to report such conversations than those with medium educational level (aOR 0.11; 95%CI 0.01–0.83) after adjustment for other sociodemographic characteristics, health status and measures of financial distress. Those without a migrant background(aOR 2.09; 95%CI 1.32–3.32), the chronically ill(aOR 1.90; 95%CI 1.16–3.13) and individuals who reported high financial distress(aOR 2.15; 95%CI 1.22–3.78) and cutting on necessities to pay for medications(aOR 1.86; 95%CI 1.12–3.09) were more likely to discuss financial problems than their counterparts.

Conclusions

Few over-indebted individuals discussed financial problems with their general practitioner. Patients’ health status, coping strategies and perception of financial distress might contribute to variations in disclosure of financial problems. Thus, enhancing communication and screening by routine assessment of financial problems in clinical practice can help to identify vulnerable patients and promote access to health care and social services and well-being for all.

Homeownership status and risk of food insecurity: examining the role of housing debt, housing expenditure and housing asset using a cross-sectional population-based survey of Canadian households

BACKGROUND

Household food insecurity is a potent marker of material deprivation with adverse health consequences. Studies have repeatedly found a strong, independent relationship between owning a home and lower vulnerability to food insecurity in Canada and elsewhere, but the reasons for this relationship are poorly understood. We aimed to examine the influence of housing asset, housing debt and housing expenditure on the relationship between homeownership status and food insecurity in Canada.

METHODS

Cross-sectional data on food insecurity, housing tenure and expenditures, home value, income and sociodemographic characteristics were derived from the 2010 Survey of Household Spending, a population-based survey. Multivariable logistic regression models were conducted to estimate odds ratios of food insecurity among households of all incomes (n = 10,815) and those with lower incomes (n = 5547).

RESULTS

Food insecurity prevalence was highest among market renters (28.5%), followed by homeowners with a mortgage (11.6%) and mortgage-free homeowners (4.3%). Homeowners with a mortgage (OR: 0.51, 95% CI: 0.39-0.68) and those without a mortgage (OR: 0.23, 95% CI: 0.16-0.35) had substantially lower adjusted odds of food insecurity than market renters, and accounting for the burden of housing cost had minimal impact on the association. Mortgage-free homeowners had lower adjusted odds ratios of food insecurity compared to homeowners with a mortgage, but differences in the burden of housing cost fully accounted for the association. When stratifying homeowners based on presence of mortgage and housing asset level, the adjusted odds ratios of food insecurity for market renters were not significant when compared to mortgage holders with low housing asset. Mortgage-free owners with higher housing asset were least vulnerable to food insecurity (adjusted OR: 0.18, 95% CI: 0.11-0.27).

CONCLUSIONS

Substantial disparities in food insecurity exist between households with different homeownership status and housing asset level. Housing policies that support homeownership while ensuring affordable mortgages may be important to mitigate food insecurity, but policy actions are required to address renters' high vulnerability to food insecurity.

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

In developed countries, millions of households are over-indebted, and the number continues to rise. Studies have found an increased risk of adverse health effects among individuals that cannot cover payment obligations with available assets persistently. However, little is known about the role of over-indebtedness in pain. This study examined the association between over-indebtedness and pain and pain medication use. A cross-sectional study conducted among over-indebted individuals in 70 debt advisory centres in Germany (OID-survey; n = 699) was linked to the nationally representative German Health Interview and Examination Survey for Adults (DEGS1; n = 7987). Descriptive statistics and logistic regression analyses were used to examine the association between over-indebtedness and pain and pain medication use among participants with valid data on both outcome variables (n = 7560). Pain was experienced by over-indebted individuals more frequently (71.3%) compared to the general population (59.6%) whereas the prevalence of pain medication use was similar in both samples (DEGS1 12.6% vs. OID-survey 13.1%). Over-indebtedness significantly increased the odds of pain (aOR 1.30; 95%-CI 1.07-1.59) after adjusting for socioeconomic, demographic and health factors. The over-indebted were significantly less likely to use pain medication compared to the general population after adjustment (aOR 0.76; 95%-CI 0.58-0.99). Taking over-indebtedness into account as risk factor for pain and restricted pain medication use in research and clinical practice will help to advance the understanding of pain disparities, develop suitable interventions for preventive action and promote accessible pain management among those at risk.

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.

Housing as a determinant of health equity: A conceptual model

Housing is a major pathway through which health disparities emerge and are sustained over time. However, no existing unified conceptual model has comprehensively elucidated the relationship between housing and health equity with attention to the full range of harmful exposures, their cumulative burden and their historical production. We synthesized literature from a diverse array of disciplines to explore the varied aspects of the relationship between housing and health and developed an original conceptual model highlighting these complexities. This holistic conceptual model of the impact of housing on health disparities illustrates how structural inequalities shape unequal distribution of access to health-promoting housing factors, which span four pillars: 1) cost (housing affordability); 2) conditions (housing quality); 3) consistency (residential stability); and 4) context (neighborhood opportunity). We further demonstrate that these four pillars can lead to cumulative burden by interacting with one another and with other structurally-rooted inequalities to produce and reify health disparities. We conclude by offering a comprehensive vision for healthy housing that situates housing's impact on health through a historical and social justice lens, which can help to better design policies and interventions that use housing to promote health equity.

Housing Disadvantage and Poor Mental Health: A Systematic Review

CONTEXT

This study reviews collective evidence on the longitudinal impact of housing disadvantage (based on tenure, precarity, and physical characteristics) on mental health. It is focused on temporally ordered studies where exposures preceded outcomes, a key criterion to establishing causal evidence.

EVIDENCE ACQUISITION

A systematic review of evidence on housing disadvantage and mental health was performed. The literature search used six electronic databases including MEDLINE (PubMed and Ovid platform), Embase, PsycINFO, Web of Science, SciELO, and Sociological Abstracts. Population-based longitudinal studies where exposure to housing disadvantage (excluding exposure to homelessness) preceded mental health were included. Methodologic quality of selected studies was examined using the Newcastle-Ottawa Quality Assessment Scale. Because of definitional and methodologic heterogeneity among studies, narrative synthesis rather than meta-analysis was used to summarize research findings.

EVIDENCE SYNTHESIS

Of the 1,804 unique titles identified in the literature search, 12 met the selection criteria for inclusion in the systematic review. Housing disadvantage was measured by overcrowding, mortgage delinquency, housing mobility, housing tenure, subjective perceptions of inadequate housing, eviction, and physical housing conditions. Mental health was measured as depression, psychological impairment, anxiety, allostatic load, mental strain, and psychological health. Study sample sizes ranged from 205 to 16,234 people, and the follow-up period ranged from within 1 year to 34 years. Each study indicated a positive association between housing disadvantage and mental health for at least one housing disadvantage measure and mental health outcome.

CONCLUSIONS

This systematic review confirms that prior exposure to housing disadvantage may impact mental health later in life.

Relationship between area mortgage foreclosures, homeownership, and cardiovascular disease risk factors: The Hispanic Community Health Study/Study of Latinos

Background

The risk of mortgage foreclosure disproportionately burdens Hispanic/Latino populations perpetuating racial disparities in health. In this study, we examined the relationship between area-level mortgage foreclosure risk, homeownership, and the prevalence of cardiovascular disease risk factors among participants of the Hispanic Community Health Study/Study of Latinos (HCHS/SOL).

Methods

HCHS/SOL participants were age 18–74 years when recruited from four U.S. metropolitan areas. Mortgage foreclosure risk was obtained from the U.S. Department of Housing and Urban Development. Homeownership, sociodemographic factors, and cardiovascular disease risk factors were measured at baseline interview between 2008 and 2011. There were 13,856 individuals contributing to the analysis (median age 39 years old, 53% female).

Results

Renters in high foreclosure risk areas had a higher prevalence of hypertension and hypercholesterolemia but no association with smoking status compared to renters in low foreclosure risk areas. Renters were more likely to smoke cigarettes than homeowners.

Conclusion

Among US Hispanic/Latinos in urban cities, area foreclosure and homeownership have implications for risk of cardiovascular disease.

Household debt and depressive symptoms among older adults in three continental European countries

In this comparative study focusing on the population aged 50 and over in three European countries, we investigate the association between household debt and depressive symptoms, and possible country differences in this association, using data from Waves 1, 2, 4, 5 and 6 of the Surveys of Health, Ageing and Retirement in Europe (SHARE) for Belgium, France and Germany. Multi-level regression models with random intercepts for individuals were used to analyse the association between household debt status and number of depressive symptoms (EURO-D score). Country differences in the household debt–depression nexus were tested using country interaction models. After controlling for other measures of socio-economic position and physical health, low or substantial financial debt was associated with a higher number of depressive symptoms in all countries. Housing debt was strongly linked to depressive symptoms for women while the association was weaker for men. The only country difference was that for both sexes substantial financial debt (more than €5,000) was strongly associated with depressive symptoms in Belgium and Germany, but the association was weak or non-significant in France. Associations between financial debt and depression were also evident in analyses of within-individual changes in depressive symptoms for a longitudinal sub-group, and in analyses using a dichotomised, rather than a continuous, measure of depression. The findings indicate that measures of household indebtedness should be taken into consideration in investigations of social inequalities in depression and suggest a need for mental health services targeted at indebted older people.

Short-term lending: Payday loans as risk factors for anxiety, inflammation and poor health

While research now consistently links consumer financial debt with adverse emotional health outcomes, specific forms of debt and their impact on measures of physical health are underexplored. This gap in knowledge is significant because different forms of loans and debt may have different experiential qualities. In this paper, we focus on a type of unsecured debt - short-term/payday loan borrowing – that has risen dramatically in recent decades in the United States and is characterized by predatory, discriminatory, and poorly regulated lending practices. Using data from a study of debt and health among adults in Boston, MA (n=286), we test whether short-term borrowing is associated with a range of emotional and physical health indicators. We find that short-term loans are associated with higher body mass index, waist circumference, C-reactive protein levels, and self-reported symptoms of physical health, sexual health, and anxiety, after controlling for several socio-demographic covariates. We discuss these findings within the contexts of regulatory shortcomings, psychosocial stress, and racial and economic credit disparities. We suggest that within the broader context of financial debt and health, short-term loans should be considered a specific risk to population health.

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Short-term loans (STL) are associated with multiple indicators of poor health

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Prior research has explored general debt as a health determinant

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Specific types of debt, like STL, are understudied

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STL’s predatory lending practices raise concerns for population health

Negative wealth shock and short-term changes in depressive symptoms and medication adherence among late middle-aged adults

BACKGROUND

Experiencing a negative wealth shock in late middle age may cause high levels of stress and induce reductions in health-related consumption.

METHODS

We used data on late middle age individuals (51-64 years) from the longitudinal US-based Health and Retirement Study (N=19 281) to examine the relationship between negative wealth shock and short-term outcomes that serve as markers of the pathways from wealth shock to health: elevated depressive symptoms, as a marker of the stress pathway and cost-related medication non-adherence (CRN), as a marker of the consumption pathway. Negative wealth shock was considered to be a loss of total net worth of 75% or more.

RESULTS

Using a nested cross-over approach-a within-person design among exposed individuals only that adjusts by design for all time-invariant individual characteristics-we found that negative wealth shock was significantly associated with increased odds of elevated depressive symptoms (OR=1.50, CI 1.10 to 2.05), but was not significantly associated with higher odds of CRN (OR=1.18, CI 0.76 to 1.82), even after further adjustment for time-varying sociodemographic and health covariates.

CONCLUSIONS

Negative wealth shock during late middle age confers an increased risk of elevated depressive symptoms, but does not change levels of CRN. Personal and policy factors that may buffer the mental health risks of negative wealth shock, such as social support and social welfare policy, should be considered.

Exposure to Neighborhood Foreclosures and Changes in Cardiometabolic Health: Results From MESA

Home foreclosures can precipitate declines in health among the individuals who lost their homes. Whether home foreclosures can "spillover" to affect the health of other neighborhood residents is largely unknown. Using longitudinal data from the Multi-Ethnic Study of Atherosclerosis that were linked to foreclosure data from 2005 to 2012, we assessed whether greater exposure to neighborhood foreclosures was associated with temporal changes in 3 objectively measured cardiometabolic risk factors: body mass index, systolic blood pressure, and fasting glucose level. We used fixed-effects models to estimate mean changes in cardiometabolic risk factors associated with changes in neighborhood foreclosures over time. In models in which we controlled for time-varying income, working status, medication use, neighborhood poverty, neighborhood unemployment, and interactions of age, sex, race, and state foreclosure laws with time, a standard-deviation increase in neighborhood foreclosures (1.9 foreclosures per quarter mile) was associated with increases in fasting glucose (mean = 0.22 mg/dL, 95% confidence interval: -0.05, 0.50) and decreases in blood pressure (mean = -0.27 mm Hg, 95% confidence interval: -0.49, -0.04). Changes in neighborhood foreclosure rates were not associated with changes in body mass index. Overall, greater exposure to neighborhood foreclosures had mixed associations with cardiometabolic risk factors over time. Given the millions of mortgages still in default, further research clarifying the potential health effects of neighborhood foreclosures is needed.

Impact of Marital Status on Tumor Stage at Diagnosis and on Survival in Male Breast Cancer

The effect of marital status (MS) on survival varies according to cancer type and gender. There has been no report on the impact of MS on survival in male breast cancer (MBC). This study aims to determine the influence of MS on tumor stage at diagnosis and survival in MBC. Men with MBC ≥18 years of age in the SEER database from 1990 to 2011 were included in the study. MS was classified as married and unmarried (including single, divorced, separated, widowed). Kaplan–Meier method was used to estimate the 5-year cancer-specific survival. Multivariate regression analyses were done to determine the effect of MS on presence of Stage IV disease at diagnosis and on cancer-specific mortality. The study included 3,761 men; 2,647 (70.4%) were married. Unmarried men were more often diagnosed with Stage IV MBC compared with married (10.7% vs. 5.5%, p < .001). Unmarried men (compared with married) were significantly less likely to undergo surgery (92.4% vs. 96.7%, p < .001). Overall unmarried males with Stages II, III, and IV MBC have significantly worse 5-year cancer-specific survival compared with married. On multivariate analysis, being unmarried was associated with increased hazard of death (HR = 1.43, p < .001) and increased likelihood of Stage IV disease at diagnosis (OR = 1.96, p < .001). Unmarried males with breast cancer are at greater risk for Stage IV disease at diagnosis and poorer outcomes compared with married males.

Medication affordability gains following Medicare Part D are eroding among elderly with multiple chronic conditions

Elderly Americans, especially those with multiple chronic conditions, face difficulties paying for prescriptions, which results in worse adherence to and discontinuation of therapy, called cost-related medication nonadherence. Medicare Part D, implemented in January 2006, was supposed to address issues of affordability for prescriptions. We investigated whether the gains in medication affordability attributable to Part D persisted during the six years that followed its implementation. Overall, we found continued incremental improvements in medication affordability in the period 2007-09 that eroded during the period 2009-11. Among elderly beneficiaries with four or more chronic conditions, we observed an increase in the prevalence of cost-related nonadherence from 14.4 percent in 2009 to 17.0 percent in 2011, reversing previous downward trends. Similarly, the prevalence among the sickest elderly of forgoing basic needs to purchase medicines decreased from 8.7 percent in 2007 to 6.8 percent in 2009 but rose to 10.2 percent in 2011. Our findings highlight the need for targeted policy efforts to alleviate the persistent burden of drug treatment costs on this vulnerable population.

Losing Ground: Racial Disparities in Medical Debt and Home Foreclosure in the Deep South

Medical debt is a persistent problem in the United States. This study examined the role of medical debt in relation to home foreclosure in a Deep South county with high rates of poverty, health disparities, and a racial gap in homeownership. Statistical analysis and geographic information systems mapping of municipal court records for 890 foreclosees indicated disproportionately high rates of medical debt among African Americans who lived in racially distinct neighborhoods. Both nonmedical and medical debt judgments were more numerous among African Americans than among whites; foreclosees in both groups had a higher medical debt burden compared with nonforeclosees. These results help to explain medical debt as a driver of foreclosure and racial disparities in homeownership.

The health effects of the foreclosure crisis and unaffordable housing: A systematic review and explanation of evidence

The foreclosure crisis was detrimental to the financial well-being of many households, yet the non-economic consequences are still poorly understood. This systematic review aims to understand the direct and spillover effect of foreclosures on several health-related outcomes by synthesizing evidence from 40 studies. First, this study identifies research gaps using a schema to organize studies by line of inquiry, health-related outcome, and measure of homeowner financial distress. In order to provide context for the findings, four pathways - stress, effect-budgeting, frustration-aggression, and trust - evoked in the literature are described to explain the relationship between foreclosures and health. The research suggests that experiencing a foreclosure and living near foreclosures are associated with poor psychological and behavioral morbidities, namely anxiety and violent behavior, and declining health utilization. Evidence is sparse on suicide, substance abuse, somatic morbidities, and mortality. Future research is needed to fill the gaps and explicitly test the mechanisms proposed.

EPA guidance on mental health and economic crises in Europe

This European Psychiatric Association (EPA) guidance paper is a result of the Working Group on Mental Health Consequences of Economic Crises of the EPA Council of National Psychiatric Associations. Its purpose is to identify the impact on mental health in Europe of the economic downturn and the measures that may be taken to respond to it. We performed a review of the existing literature that yields 350 articles on which our conclusions and recommendations are based. Evidence-based tables and recommendations were developed through an expert consensus process. Literature dealing with the consequences of economic turmoil on the health and health behaviours of the population is heterogeneous, and the results are not completely unequivocal. However, there is a broad consensus about the deleterious consequences of economic crises on mental health, particularly on psychological well-being, depression, anxiety disorders, insomnia, alcohol abuse, and suicidal behaviour. Unemployment, indebtedness, precarious working conditions, inequalities, lack of social connectedness, and housing instability emerge as main risk factors. Men at working age could be particularly at risk, together with previous low SES or stigmatized populations. Generalized austerity measures and poor developed welfare systems trend to increase the harmful effects of economic crises on mental health. Although many articles suggest limitations of existing research and provide suggestions for future research, there is relatively little discussion of policy approaches to address the negative impact of economic crises on mental health. The few studies that addressed policy questions suggested that the development of social protection programs such as active labour programs, social support systems, protection for housing instability, and better access to mental health care, particularly at primary care level, is strongly needed.

Over-indebtedness and chronic disease: a linked register-based study of Finnish men and women during 1995-2010

OBJECTIVES

More knowledge of the associations between over-indebtedness and health is needed. This study is the first longitudinal register-based study analysing long-term health consequences of severe over-indebtedness.

METHODS

Adult Finnish persons, identified in 2010 as having been over-indebted for at least 15 years, were compared with matched controls (total N = 48,778). The analyses utilized register data on socio-demographic and health-related factors. Incidence of chronic disease during 1995-2010 was measured with entitlements to special reimbursement for medicines for treatment of severe and chronic diseases. Incidence of all diseases was examined, as well as incidence of hypertension, diabetes, bronchial asthma and COPD, coronary heart disease, and psychoses. Multivariate analyses were conducted with the Cox proportional hazards method.

RESULTS

Severe over-indebtedness was associated with increased incidence of any chronic disease, and most notably with increased risk of psychoses and diabetes. The associations were stronger among women than among men.

CONCLUSIONS

Over-indebtedness is associated with harmful health conditions. Policy makers should consider taking steps to prevent over-indebtedness and to increase the awareness of social and health service professionals of the problems associated with over-indebtedness.

Hardships of the Great Recession and health: Understanding varieties of vulnerability

The Great Recession of 2007-2009 is regarded as the most severe economic downturn since World War II. This study examined relationships between reported recession hardships and physical health in a national survey of American adults (N = 1275). Furthermore, education and psychological resources (perceived control, purpose in life, and conscientiousness) were tested as moderators of the health impacts of the recession. A greater number of hardships predicted poorer health, especially among the less educated. Psychological resources interacted with education and hardships to predict health outcomes. Although typically viewed as protective factors, such resources became vulnerabilities among educationally disadvantaged adults experiencing greater recession hardships.

Medical Causes and Consequences of Home Foreclosures

The objective of this study was to elucidate the medical causes and consequences of foreclosure. We surveyed 90 households undergoing foreclosure in 2013–2014 in Maricopa County, Arizona on two occasions approximately five months apart. At baseline, median monthly household income was $3,000, and median mortgage payment $1,350. Only 10% of respondents lacked health insurance when surveyed, although 28% had experienced a gap in coverage within the past two years. Fifty-seven percent identified a medical debt or another medical cause of their foreclosure, and 54% had taken on new debt to pay medical bills; 10% had mortgaged their home for this reason. Although 57% of respondents had a chronic condition requiring ongoing care, more than half reported delaying or skipping a needed medical visit. At follow-up, one-third of respondents had been unable to afford food, and 3 respondents reported becoming homeless; 46% said foreclosure had worsened their health; and 63% had already incurred new medical debts. Medical debt and medical problems frequently contribute to foreclosure, even among insured families. Foreclosure compromises access to care and basic necessities like food and shelter, and worsens self-reported health.

Flu and Finances: Influenza Outbreaks and Loan Defaults in US Cities, 2004-2012

OBJECTIVES

We examined the association between influenza outbreaks in 83 metropolitan areas and credit card and mortgage defaults, as measured in quarterly zip code-level credit data over the period of 2004 to 2012.

METHODS

We used ordinary least squares, fixed effects, and 2-stage least squares instrumental variables regression strategies to examine the relationship between influenza-related Google searches and 30-, 60-, and 90-day credit card and mortgage delinquency rates.

RESULTS

We found that a proxy for influenza outbreaks is associated with a small but statistically significant increase in credit card and mortgage default rates, net of other factors. These effects are largest for 90-day defaults, suggesting that influenza outbreaks have a disproportionate impact on vulnerable borrowers who are already behind on their payments.

CONCLUSIONS

Overall, it appears there is a relationship between exogenous health shocks (such as influenza) and credit default. The results suggest that consumer finances could benefit from policies that aim to reduce the financial shocks of illness, particularly for vulnerable borrowers.

Increase in suicides associated with home eviction and foreclosure during the US housing crisis: findings from 16 National Violent Death Reporting System States, 2005-2010

OBJECTIVES

We aimed to determine the frequency, characteristics, and precipitating circumstances of eviction- and foreclosure-related suicides during the US housing crisis, which resulted in historically high foreclosures and increased evictions beginning in 2006.

METHODS

We examined all eviction- and foreclosure-related suicides in the years 2005 to 2010 in 16 states in the National Violent Death Reporting System, a surveillance system for all violent deaths within participating states that abstracts information across multiple investigative sources (e.g., law enforcement, coroners, medical examiners).

RESULTS

We identified 929 eviction- or foreclosure-related suicides. Eviction- and foreclosure-related suicides doubled from 2005 to 2010 (n=88 in 2005; n=176 in 2010), mostly because of foreclosure-related suicides, which increased 253% from 2005 (n=30) to 2010 (n=106). Most suicides occurred before the actual housing loss (79%), and 37% of decedents experienced acute eviction or foreclosure crises within 2 weeks of the suicide.

CONCLUSIONS

Housing loss is a significant crisis that can precipitate suicide. Prevention strategies include support for those projected to lose homes, intervention before move-out date, training financial professionals to recognize warning signs, and strengthening population-wide suicide prevention measures during economic crises.

Home foreclosure, health, and mental health: a systematic review of individual, aggregate, and contextual associations

BACKGROUND

The U.S. foreclosure crisis intensified markedly during the Great Recession of 2007-09, and currently an estimated five percent of U.S. residential properties are more than 90 days past due or in the process of foreclosure. Yet there has been no systematic assessment of the effects of foreclosure on health and mental health.

METHODS AND FINDINGS

I applied systematic search terms to PubMed and PsycINFO to identify quantitative or qualitative studies about the relationship between home foreclosure and health or mental health. After screening the titles and abstracts of 930 publications and reviewing the full text of 76 articles, dissertations, and other reports, I identified 42 publications representing 35 unique studies about foreclosure, health, and mental health. The majority of studies (32 [91%]) concluded that foreclosure had adverse effects on health or mental health, while three studies yielded null or mixed findings. Only two studies examined the extent to which foreclosure may have disproportionate impacts on ethnic or racial minority populations.

CONCLUSIONS

Home foreclosure adversely affects health and mental health through channels operating at multiple levels: at the individual level, the stress of personally experiencing foreclosure was associated with worsened mental health and adverse health behaviors, which were in turn linked to poorer health status; at the community level, increasing degradation of the neighborhood environment had indirect, cross-level adverse effects on health and mental health. Early intervention may be able to prevent acute economic shocks from eventually developing into the chronic stress of foreclosure, with all of the attendant benefits this implies for health and mental health status. Programs designed to encourage early return of foreclosed properties back into productive use may have similar health and mental health benefits.

"When you're in a crisis like that, you don't want people to know": mortgage strain, stigma, and mental health

OBJECTIVES

We analyzed experiences of stigmatization, concealment, and isolation among African American homeowners who were experiencing mortgage strain.

METHODS

We conducted semistructured interviews between March 2012 and May 2013 with 28 African American homeowners in a northeastern US city who were experiencing mortgage strain. We coded all of the transcripts and reviewed data for codes relating to stigma, sharing information, social support, social isolation, and the meaning of homeownership.

RESULTS

Our data showed that mortgage strain can be a concealable stigma. Participants internalized this stigma, expressing shame about their mortgage situation. Additionally, some participants anticipated that others would view them as less worthy given their mortgage trouble. In an effort to avoid stigmatization, many concealed their mortgage trouble, which often led to isolation. This stigmatization, concealment, and isolation seemed to contribute to participants' depression, anxiety, and emotional distress.

CONCLUSIONS

Stigma may exacerbate stress associated with mortgage strain and contribute to poor mental health, particularly among upwardly mobile African Americans who have overcome significant structural barriers to home ownership. Reducing stigma associated with mortgage strain may help to reduce the health consequences of this stressful life event.

Is there a Link Between Foreclosure and Health?

We investigate the relationship between foreclosures and hospital visits using data on all foreclosures and all hospital and emergency room visits from four states that were among the hardest hit by the foreclosure crisis. We find that living in a neighborhood with a spike in foreclosures is associated with significant increases in urgent unscheduled visits, including increases in visits for preventable conditions. The estimated relationships cannot be accounted for by increasing unemployment, declines in housing prices, migration, or by people switching from out-patient providers to hospitals.

Getting sick and falling behind: health and the risk of mortgage default and home foreclosure

BACKGROUND

An emerging literature shows that mortgage strain can lead to poor health outcomes, but less work has focused on whether and how health shocks influence mortgage distress. We examine the link between changes in health status and default/foreclosure risk among older middle-aged adults.

METHOD

We used National Longitudinal Study of Youth 1979 data and multivariate logistic regression models to examine the relationship between changes in health limitations and chronic conditions across survey waves and risk of mortgage default and foreclosure.

RESULTS

We found that changes in health limitations and chronic conditions increased the risk of default and foreclosure between 2007 and 2010. These associations were partially mediated by changes in family income and loss of health insurance.

CONCLUSIONS

From a policy perspective, the strong link between the onset of illness and foreclosure suggests a need to re-examine the safety-nets that are available to individuals who become ill or disabled.