Health insurance and financial hardship in cancer survivors during the COVID-19 pandemic.

Uninsured or underinsured individuals with cancer are likely to experience financial hardship, including forgoing healthcare or non-healthcare needs such as food, housing, or utilities. This study evaluates the association between health insurance coverage and financial hardship among cancer survivors during the COVID-19 pandemic. This cross-sectional analysis used Patient Advocate Foundation (PAF) survey data from May to July 2020. Cancer survivors who previously received case management or financial aid from PAF self-reported challenges paying for healthcare and non-healthcare needs during the COVID-19 pandemic. Associations between insurance coverage and payment challenges were estimated using Poisson regression with robust standard errors, which allowed for estimation of adjusted relative risks (aRR). Of 1,437 respondents, 74% had annual household incomes <$48,000. Most respondents were enrolled in Medicare (48%), 22% in employer-sponsored insurance, 13% in Medicaid, 6% in an Affordable Care Act (ACA) plan, and 3% were uninsured. Approximately 31% of respondents reported trouble paying for healthcare during the COVID-19 pandemic. Respondents who were uninsured (aRR 2.58, 95% confidence interval [CI] 1.83-3.64), enrolled in an ACA plan (aRR 1.86, 95% CI 1.28-2.72), employer-sponsored insurance (aRR 1.70, 95% CI 1.23-2.34), or Medicare (aRR 1.49, 95% CI 1.09-2.03) had higher risk of trouble paying for healthcare compared to Medicaid enrollees. Challenges paying for non-healthcare needs were reported by 57% of respondents, with 40% reporting trouble paying for food, 31% housing, 28% transportation, and 20% internet. In adjusted models, Medicare and employer-sponsored insurance enrollees were less likely to have difficulties paying for non-healthcare needs compared to Medicaid beneficiaries. Despite 97% of our cancer survivor sample being insured, 31% and 57% reported trouble paying for healthcare and non-healthcare needs during the COVID-19 pandemic, respectively. Greater attention to both medical and non-medical financial burden is needed given the economic pressures of the COVID-19 pandemic.

Financial stress during COVID-19: implications for parenting behaviour and child well-being.

BACKGROUND: Family financial stress and parenting behaviours are each associated with child behaviours. We sought to explore the association between parent financial stress and child socioemotional and behavioural difficulties during the COVID-19 pandemic and examine parenting behaviour, including overreactive and lax parenting approaches, as a potential mediator to this relationship. METHODS: Cross-sectional sample of parent and child data pairings in Ontario, Canada between April and November of 2020. Linear models were used to describe the relationships between financial worry, child Strengths and Difficulties Questionnaire (SDQ) total difficulties and parenting behaviours measured by the Parenting Scale 8-item (PS-8), which includes measures of both overreactive and lax parenting tendencies. Formal mediation testing was performed to assess the potential mediating role of parenting behaviour. RESULTS: 528 parent and child pairs were enrolled from largely European ancestry (78%), female (93%) and varied household income levels. Analysis revealed increased financial worry during the COVID-19 pandemic was significantly associated with increased child SDQ total difficulties scores (ß=0.23, SE=0.10, p=0.03). This relationship was mediated by reported parenting behaviour, independent of parent education, household income, parent age, parent sex, parent anxiety and child sex (total effect: ß=0.69, p=0.02, average causal mediation effects: ß=0.50, p=0.02, average direct effects: ß=0.19, p=0.08). CONCLUSION: Financial stress during the COVID-19 pandemic was associated with poorer child social and emotional well-being. Parenting behaviours measured by the PS-8 significantly mediated these effects. This work supports the importance of policies aimed to alleviate family financial stresses and highlights the potential impact such policies have on child well-being.

Testing positive, losing a loved one, and financial hardship: Real-world impacts of COVID-19 on US college student distress.

BACKGROUND: The COVID-19 pandemic has taken a particularly heavy toll on U.S. college students. In addition to facing academic-related stress and social pressures, these individuals are now increasingly susceptible to experiences such as contracting the virus, losing loved ones to COVID-19, or facing financial hardship due to the pandemic. The effects of such personal, pandemic-related experiences on young adult mental health - and the inherent racial disparities within these outcomes - remain largely understudied. METHODS: We analyzed 65,568 undergraduate students from the Spring 2021 American College Health Association-National College Health Assessment (ACHA-NCHA). RESULTS: The rates of the aforementioned COVID-19-related stressors were unevenly distributed across racial groups. A logistic regression analysis to identify predictors of moderate and serious psychological distress revealed that participants who had experienced the death of a loved one had 1.14 times greater odds of developing psychological distress (p < 0.0001). Those who experienced financial hardship had an odds ratio of 1.78 (p < 0.0001). Surprisingly, testing positive for COVID-19 was associated with an odds ratio of 0.82 of psychological distress (p < 0.0001). LIMITATIONS: Self-reported measures are susceptible to recall bias and misinterpretation. Exposure and outcome variables were measured simultaneously in this cross-sectional study which limits inference on causality. CONCLUSIONS: Financial burdens and bereavement are especially impactful stressors among college students during the pandemic, whereas contracting COVID-19 seemingly exhibits less impact on distress levels. When addressing student wellbeing, institutions should consider prioritizing the implementation of resources to support individuals affected by pandemic-related financial and familial losses.

Associations between local COVID-19 case rates, pandemic-related financial stress and parent and child functioning.

The COVID-19 global crisis led to unprecedented disruption of family routines and heightened family stress. This study examines the effects of local COVID-19 case rates and pandemic-related financial stress on family processes (e.g., caregiving behavior) and school-aged children's outcomes. The project was launched shortly after stay-at-home orders began in the U.S. Data were collected online using Amazon's Mechanical Turk (MTurk), which allowed for nationwide recruitment. Using four waves of data (N = 308), with initial data collected between 4/20/20 and 5/6/20 and 2-3 weeks between each wave, this study examined the influence of local rates of COVID-19 infection on pandemic-related financial stress and the association of these constructs on maternal psychological distress and negative parenting. We also examined the potential cascade linking COVID-19 case rates and pandemic-related financial stress with child behavior problems via maternal psychological distress and negative parenting behavior, while controlling for prior child behavior problems. In line with hypotheses, higher Wave 1 (W1) pandemic-related financial stress was significantly associated with higher Wave 2 (W2) maternal psychological distress, which was significantly associated with higher Wave 3 (W3) negative parenting, which, in turn, was significantly associated with higher Wave 4 (W4) child behavior problems. In addition, the indirect effect of W1 pandemic-related financial stress on W3 negative parenting through W2 maternal psychological distress was significant. Higher W1 local COVID-19 case rates were significantly related to higher W3 negative parenting. Results suggest local COVID-19 case rates and pandemic-related financial stressors are associated with poorer child and family functioning. Implications for policy and practice are discussed. (PsycInfo Database Record (c) 2022 APA, all rights reserved).

The effect of COVID-19 pandemic-related financial challenges on mental health and well-being among US older adults.

BACKGROUND: Despite profound financial challenges during the COVID-19 pandemic, there is a gap in estimating their effects on mental health and well-being among older adults. METHODS: The National Health and Aging Trends Study is an ongoing nationally representative cohort study of US older adults. Outcomes included mental health related to COVID-19 (scores averaged across eight items ranging from one to four), sleep quality during COVID-19, loneliness during COVID-19, having time to yourself during COVID-19, and hopefulness during COVID-19. Exposures included income decline during COVID-19 and financial difficulty due to COVID-19. Propensity score weighting produced covariate balance for demographic, socioeconomic, household, health, and well-being characteristics that preceded the pandemic to estimate the average treatment effect. Sampling weights accounted for study design and non-response. RESULTS: In weighted and adjusted analyses (n = 3257), both income decline during COVID-19 and financial difficulty due to COVID-19 were associated with poorer mental health related to COVID-19 (b = -0.159, p < 0.001 and b = -0.381, p < 0.001, respectively), poorer quality sleep (OR = 0.63, 95% CI: 0.46, 0.86 and OR = 0.42, 95% CI: 0.30, 0.58, respectively), more loneliness (OR = 1.53, 95% CI: 1.16, 2.02 and OR = 2.72, 95% CI: 1.96, 3.77, respectively), and less time to yourself (OR = 0.54, 95% CI: 0.40, 0.72 and OR = 0.37, 95% CI: 0.27, 0.51, respectively) during COVID-19. CONCLUSIONS: Pandemic-related financial challenges are associated with worse mental health and well-being regardless of pre-pandemic characteristics, suggesting that they are distinct social determinants of health for older adults. Timely intervention is needed to support older adults experiencing pandemic-related financial challenges.

The Mental Health of Employees with Job Loss and Income Loss during the COVID-19 Pandemic: The Mediating Role of Perceived Financial Stress.

The COVID-19 outbreak, which was followed by home confinement, is expected to have had profound negative impact on the mental health of people. Associated factors, such as losing jobs and income, can be expected to lead to an increased risk of suffering from psychopathological problems. Therefore, this study was aimed at researching the associations of job and income loss with mental health, as well as the possible mediating role of perceived financial stress during the COVID-19 outbreak. The sample included 2381 Spanish workers who were interviewed right after the first COVID-19 lockdown. Measures were taken for generalized anxiety disorder, panic attacks, depression, post-traumatic stress disorder, substance abuse, suicidal thoughts and behaviors, working conditions, sociodemographic variables, and perceived financial stress. Logistic regression models were calculated with psychological variables as outcomes, and with job loss and income loss as predictors. Mediation analyses were performed by adding the financial threat as a mediator. Nineteen point six percent and 33.9% of participants reported having lost their jobs and incomes due to the pandemic, respectively. Only income loss was related to a higher risk of suffering from depression and panic attacks. When adding financial stress as a mediator, the indirect effects of job and income loss on the mental health measures were found to be significant, therefore indicating mediation. These findings pinpoint the vulnerability of this population, and highlight the need for interventional and preventive programs targeting mental health in economic crisis scenarios, such as the current one. They also highlight the importance of implementing social and income policies during the COVID-19 pandemic to prevent mental health problems.

The impact of coronavirus disease 2019 on the quality of life and treatment disruption of patients with breast cancer in a multiethnic cohort.

BACKGROUND: As the coronavirus disease 2019 (COVID-19) pandemic continues to spread, it remains unclear how vulnerable populations with preexisting health conditions like cancer have been affected. METHODS: Between July and September of 2020, the authors conducted a cross-sectional study that surveyed 2661 patients with breast cancer who were registered in the Chicago Multiethnic Epidemiologic Breast Cancer Cohort and received 1300 responses (71.5% White patients and 22.4% Black patients). The survey measured the psychosocial well-being of participants before and during the COVID-19 pandemic and examined whether they experienced any type of financial challenges or treatment disruption. RESULTS: The results indicated that feelings of isolation increased significantly during the pandemic. Meanwhile, the overall median isolation/stress score was 1.2 on a scale from 0 (never) to 4 (always), which was not significantly different between White patients and Black patients. One-third of patients experienced some type of financial challenge during this time. Medicaid recipients, of whom almost 80% were Black, were more likely to experience financial challenges. In addition, approximately one-fourth of patients experienced difficulty getting treatment. CONCLUSIONS: This study indicates that the quality of life of patients with breast cancer and their scheduled treatments have been adversely affected during the COVID-19 pandemic. These findings suggest that more support should be provided by hospital centers and the medical research community to patients with cancer during this challenging pandemic. LAY SUMMARY: The authors surveyed patients with breast cancer in Chicago using a questionnaire to examine how their lives have been affected during the coronavirus disease 2019 (COVID-19) pandemic. The results indicate that the lives of patients with breast cancer and their scheduled treatments have been adversely affected during the pandemic. In addition, patients who were covered by Medicaid, most of whom were Black, were more likely to experience financial challenges. The findings suggest that hospital centers and the medical research community should reach out and provide more information to support patients with cancer during this challenging pandemic.

Financial toxicity, mental health, and gynecologic cancer treatment: The effect of the COVID-19 pandemic among low-income women in New York City.

BACKGROUND: New York City (NYC) emerged as an epicenter of the COVID-19 pandemic, and marginalized populations were affected at disproportionate rates. The authors sought to determine the impact of COVID-19 on cancer treatment, anxiety, and financial distress among low-income patients with gynecologic cancer during the peak of the NYC pandemic. METHODS: Medicaid-insured women who were receiving gynecologic oncology care at 2 affiliated centers were contacted by telephone interviews between March 15 and April 15, 2020. Demographics and clinical characteristics were obtained through self-report and retrospective chart review. Financial toxicity, anxiety, and cancer worry were assessed using modified, validated surveys. RESULTS: In total, 100 patients completed the telephone interview. The median age was 60 years (range, 19-86 years), and 71% had an annual income <$40,000. A change in employment status and early stage cancer (stage I and II) were associated with an increase in financial distress (P < .001 and P = .008, respectively). Early stage cancer and telehealth participation were significantly associated with increased worry about future finances (P = .017 and P = .04, respectively). Lower annual income (<$40,000) was associated with increased cancer worry and anxiety compared with higher annual income (>$40,000; P = .036 and P = .017, respectively). When controlling for telehealth participation, income, primary language, and residence in a high COVID-19 prevalence area, a delay in medical care resulted in a 4-fold increased rate of anxiety (P = .023, 95% CI, 1.278-14.50). Race was not significantly associated with increased financial distress, cancer worry, or anxiety. CONCLUSIONS: Low socioeconomic status was the most common risk factor for increased financial distress, cancer worry, and anxiety. Interventions aimed at improving access to timely oncology care should be implemented during this ongoing pandemic.

The Impact of the COVID-19 Pandemic on Self-Reported Outcomes in Patients With Adrenal Insufficiency.

CONTEXT: The COVID-19 pandemic has impacted healthcare environment. OBJECTIVE: To determine the impact of the pandemic on self-reported outcomes in patients with adrenal insufficiency (AI). DESIGN AND SETTING: Prospective longitudinal survey study at 2 tertiary centers. PARTICIPANTS: Patients with AI. INTERVENTION: Patient-centered questionnaire. MAIN OUTCOME MEASURES: Depression Anxiety Stress Scales-21, Short Form-36, and AI self-management. RESULTS: Of 342 patients, 157 (46%) had primary AI, 109 (32%) had secondary AI, and 76 (22%) had glucocorticoid-induced AI. When compared to prepandemic, daily glucocorticoid dose and number of adrenal crises did not change. However, patients reported a higher financial impact from AI (34% vs 23%, P = 0.006) and difficulty accessing medical care (31% vs 7%, P < 0.0001) during the pandemic. A third of patients reported difficulty managing AI during the pandemic. After adjusting for duration and subtypes of AI, younger patients [odds ratio (OR) 2.3, CI 95% 1.3-4.1], women (OR 3.7, CI 95% 1.9-7.1), poor healthcare access(OR 4.2, CI 95% 2.3-7.7), lack of good insurance support (OR 2.8, CI 95% 1.3-5.9), and those with a higher financial impact (OR 2.3, CI 95% 1.3-4.3) reported greater difficulties managing AI. Patients were more likely to report a higher anxiety score (≥8) if they found managing AI challenging during the pandemic (OR 3.0, CI 95% 1.3-6.9), and had lower Physical Component Summary (OR 4.9, CI 95% 2.2-11.0) and Mental Component Summary (OR 4.1, CI 95% 1.8-9.5) scores prior to the pandemic. CONCLUSIONS: A third of patients with AI reported difficulties with management of AI during the pandemic, particularly in younger patients, women, and those with poor healthcare access.

Racial and ethnic variations in caregiving-related physical, emotional, and financial strain during COVID-19 among those caring for adult cancer patients.

PURPOSE: Cancer caregiving is shown to be a burdensome experience in typical times. The purpose of this study was to describe cancer caregivers' emotional, physical, and financial strain during the COVID-19 pandemic and compared to preCOVID-19, and explore racial and ethnic variations in caregiver strain. METHODS: We conducted a cross-sectional online survey using Lucid, LLC, incorporating quotas for race, ethnicity, gender and age. Caregivers had to be adults living in the USA and currently providing unpaid care to an adult cancer patient (i.e., during COVID-19) and prior to the pandemic. We assessed the caregivers' emotional, physical, and financial strain and asked them to compare to preCOVID-19 caregiving. Analyses included descriptive and linear regression adjusting for sociodemographic and caregiving-related variables. RESULTS: A total of 285 caregivers met eligibility, and most were nonHispanic white (72.3%) and female (59.6%). Based on a scale of "1: Much lower" to "5: Much higher", the financial, physical and emotional strain/stress experienced by caregivers compared to preCOVID-19 was, on average, 3.52 (SD: 0.82; range: 1-5) for financial strain, 3.61 (SD: 0.86; range: 1-5) for physical strain, and 3.88 (SD: 0.89; range: 1-5) for emotional stress. NonHispanic black caregivers were significantly more likely than nonHispanic white caregivers to indicate that caregiving-related financial strain was higher than preCOVID-19. Moreover, Hispanic caregivers compared to nonHispanic white caregivers reported caregiving-related emotional stress was higher than preCOVID-19. CONCLUSION: These findings suggest a need to be attentive to racial and ethnic variations in emotional and financial strain and provide targeted support in clinical care and via public policy during a public health crisis.

COVID-19 and financial toxicity in patients with renal cell carcinoma.

PURPOSE: To ascertain renal cell carcinoma (RCC) financial toxicity on COVID-19 during the COVID-19 crisis as patients are struggling with therapeutic and financial implications. METHODS: An online survey was conducted from March 22 to March 25, 2020. It included baseline demographic, clinicopathologic, treatment-related information, anxiety levels related to COVID-19, questions related to financial concerns about COVID-19 as well as the validated 11-item COST measure. RESULTS: Five-hundred-and-thirty-nine patients (39%:58% male:female) from 14 countries responded. 23% of the patients did not feel in control of their financial situation but 8% reported being very satisfied with their finances. The median COST score was 21.5 (range 1-44). Metastatic patients who have not started systemic therapy had a COST score (19.8 range 2-41) versus patients on oral systemic therapy had a COST score (23.9 range 4-44). Patients in follow-up after surgery had a median COST score at 20.8 (range 1-40). A low COST scores correlated (p < 0.001) were female gender (r = 0.108), younger age (r = 0.210), urban living situation (r = 0.68), a lower educational level (r = 0.155), lower income (r = 0.165), higher anxiety about acquiring COVID-19 (r = 0.198), having metastatic disease (r = 0.073) and a higher distress score about cancer progression (r = 0.224). CONCLUSION: Our data highlight severe financial impact of COVID-19. Acknowledging financial hardship and thorough counseling of cancer patients should be part of the conversation during the pandemic. Treatment and surveillance of RCC patients might have to be adjusted to contemplate financial and medical needs.