Social Norms About Handling Financial Challenges 
in Relation to Health-Protective Capacity Among 
Low-Income Older Adults

Abstract

Background and Objectives

Despite evidence linking financial challenges to poor health among older adults, effective interventions are lacking. This study examined the experience of living with financial challenges, useful strategies to handle them, and social norms that may constrain options and decision-making.

Research Design and Methods

This two-staged qualitative study recruited low-income older adults from the United States Baltimore City area. First, semistructured individual interviews examined older adults’ experiences and strategies used to handle financial challenges. Then, vignette-based focus groups examined relevant social norms. Transcripts were coded, and hierarchical themes were described using thematic analysis.

Results

Two themes were generated. First, the social norms relevant to financial challenges share a common underlying assumption of personal responsibility. Second, social norms about personal responsibility are inconsistent with the experiences of older adults facing financial challenges, who typically lack control over their situation and face structural barriers to preventing and handling financial challenges. Differences between statements related to norms and personal responsibility were found across six subthemes, including how finances should be handled to prevent financial challenges, the causes of financial challenges, asking for help from community resources, navigating community resources, getting help from family, and cutting back to handle financial challenges.

Discussion and Implications

The disconnect between social norms and the reality of financial challenges among older adults may explain why so many older adults cut back to the point of foregoing necessities. There is an urgent need to strengthen the social safety net and remove normative barriers to services.

More than half of low-income older adults face financial challenges each year, including chronic financial strain or wealth loss (Alley & Kahn, 2012; Pool et al., 2018). Although financial challenges are associated with a higher risk of disability and earlier mortality (Szanton et al., 2010; Tucker-Seeley et al., 2009) and older adults report an effortful balancing act required to cope with financial challenges (Samuel et al., 2021), programs that are intended to buffer their impact are under-utilized. For example, the Supplemental Nutrition Assistance Program (SNAP) reduces food insecurity (Ratcliffe et al., 2011) but less than half of older adults eligible for SNAP participate in the program (Farson, 2014). A recent survey of middle-aged and older adults experiencing chronic financial strain found that they were more likely to make ends meet by cutting back on expenses (69%) or delaying medical care (52%) than receiving financial help from family or friends (30%) or enrolling in SNAP (14%; Persons, 2010). Together, these results suggest that older adults facing financial challenges may choose to forego basic necessities rather than seek help. This is problematic because cutting back on necessities may worsen health outcomes and increase health care costs (Chen et al., 2011). However, there is a gap in understanding why older adults handle financial challenges the ways that they do.

Qualitative studies show that working-age adults generally use multiple strategies to handle financial challenges, including compromising basic needs (Moffatt et al., 2016), utilizing social public benefits programs, using credit cards or payday loans, receiving support from family or friends, and juggling or negotiating payments to avoid service cutoffs (Bartfeld & Collins, 2017; Caplan, 2014; Edin & Lein, 1997; Heflin et al., 2011). However, findings may differ in older adults for at least two reasons. First, older adults are more likely to experience financial challenges than younger adults (Bierman, 2014), and accumulated challenges may deplete resources or support over time. Second, older adults are more likely to experience disability than younger adults and disability limits opportunities to earn income or obtain loans and may worsen chronic financial strain (Samuel et al., 2019). There is a need to understand the strategies that are already employed by low-income older adults to address financial challenges and the social norms that underlie their decision-making.

The strategies employed by older adults to handle financial challenges are likely partly driven by social norms, which are defined as “social attitudes of approval and disapproval, specifying what ought to be done and what ought not to be done” (Sunstein, 1996). Although financial decisions are typically made privately, individual preferences are likely influenced by social norms, which often dictate how the social safety net should be structured (Sunstein, 1996). Also, families facing financial challenges experience stigma and weariness (Inglis et al., 2019; Keene et al., 2015; Lens et al. 2018), which may discourage them from seeking help and encourage them to act in a way that is consistent with social norms, even if those actions are not in their best interest (Sunstein, 1996). In addition to influencing the acceptability of seeking help, social norms also influence the way structures are shaped in society, including the accessibility of community resources. For example, social norms influence policy decisions related to whether a community has a social safety net, whether older adults are eligible for resources, and whether bureaucratic processes are required to access resources. Social norms differ across cultures or societies and are revealed not only in stated norms, but also in the structures created by the society (Sunstein, 1996). For example, because racism is woven throughout the U.S. society, individuals who are Black face disproportionate structural barriers to community resources (Williams et al., 2019). The depth and breadth of race-based structural barriers reveal that discrimination has been normatively acceptable (Sunstein, 1996). Therefore, the structures of society can reveal underlying norms. However, there are gaps in understanding the social norms relevant to financial challenges for older adults and in exploring the real-life experiences of older adults facing financial challenges to evaluate the alignment of them with social norms.

The two purposes of this study were to (a) examine the strategies already employed to handle financial challenges by low-income older adults who were living in a city that is predominately Black and no longer able to earn income due to disability and (b) to explore the social norms relevant to financial challenges among low-income older adults. Such research could advance health equity by informing the development and strengthening of programs and policies that are acceptable, accessible, and useful to support older adults facing financial challenges.

Method

Design

Using a qualitative descriptive design, we explored financial challenges in a two-staged study of individual interviews followed by focus groups in 2017 and 2018 (Lambert & Loiselle, 2008). This approach was selected to examine both the experiences of living with financial challenges and the strategies used to address them in an in-depth fashion in one-on-one interviews and, separately, elicit social normative data related to financial challenges from a homogeneous group of individuals (e.g., low-income older adults who are predominately Black and disabled; Wilkinson, 1998). Data from both stages were triangulated for analysis. All participants provided written informed consent. This study received ethical approval from the local institution review board.

Sample

The study focused on low-income older adults who were no longer working, and participants were initially recruited from individuals who had completed one of the two CAPABLE trials. The CAPABLE studies recruited 543 low income (<200% federal poverty limit) community-dwelling adults aged ≥65 years in Baltimore with at least some difficulty performing activities of daily living between 2012 and 2016 (Szanton et al., 2016, 2019) and 361 of those individuals agreed to be contacted again for research purposes. Of those, 42 individuals were contacted by phone to ascertain interest in the current study and determine eligibility (12 for interviews and 30 for focus groups). Individuals were included if they reported involvement in managing their household finances and excluded if cognitively impaired, based on a modified Short Portable Mental Status Questionnaire score less than 6 (Pfeiffer, 1975). Eleven of 12 eligible individuals agreed to participate in interviews. A new sample was recruited for focus groups to protect the privacy of individuals who disclosed sensitive financial information in interviews. Because individuals with incomes ≥200% of the poverty limit and without a disability may have knowledge of financial challenges and to obtain a more diverse set of perspectives and experiences, the selection criteria and sampling were altered for the focus group phase. Specifically, focus group selection criteria were expanded to simply include any individual who selfidentified as a low-income older adult and snowball sampling supplemented the CAPABLE studies sampling frame to recruit nine of the 28 members of four focus groups. Twenty-eight out of 36 eligible individuals agreed to participate in focus groups. Due to the preponderance of women, purposive sampling was used to recruit men for both study stages.

Data Collection

Participants in both stages of the study completed a brief paper-based survey before participating in the interview/focus group to understand their background characteristics (Supplement 1 in Online Supplementary Material). Participants were asked to record their age, race/ethnicity, gender, and factors concerning financial challenges (Alley & Kahn, 2012; Pool et al., 2018), including household size, household income, employment status (working full-time, working part-time, retired, and/or disabled), home ownership, whether they had a checking/savings account or financial assets (Certificate[s] of Deposit, a pension or IRA, stocks/bonds, or real estate), financial strain, such as difficulty paying bills and having enough money each month (Lantz et al., 2005), food insecurity, such as running out of money for food and eating balanced meals (Bickel et al., 2000), financial shocks, including unexpected expenses or losses of income (Pew Charitable Trusts, 2015), and a count of chronic conditions.

Individual interviews

Audio-recorded, semistructured in-depth one-to-one interviews were conducted in participant homes by L. J. Samuel, who is a nurse and a researcher and are described elsewhere (Samuel et al., 2021). An interview guide provided question prompts such as “What challenges have you encountered in making ends meet from one month to the next?” (Supplement 2 in Online Supplementary Material). Topics included the types of financial challenges experienced by the household, the ways that they addressed the financial challenges, and the ways that the financial challenges affected them. Interviews lasted between 30 and 90 minutes. Interview questions were tailored to participant survey responses related to food insecurity, financial strain, and financial shocks. Interviews were transcribed verbatim. Field notes captured details such as tone, nonverbal communication, housing conditions, and the presence of other people, which were annotated onto transcripts to provide context and increase the accuracy of interpretation (Phillippi & Lauderdale, 2018).

Focus groups

Focus group participants were asked to respond to four vignettes (Supplement 3 in Online Supplementary Material). Each vignette described a financially challenging scenario for a low-income older adult who no longer works, which was intended to elicit normative responses from participants about potential reasons for the scenario and responses to it. Vignettes for this study were written based on Stage 1 findings to reflect the types of financial challenges commonly encountered by individual interview participants, such as income loss, costly home repairs, or struggling to pay for both medications and food. Vignettes are well-used in focus groups and offer three advantages for the proposed research. First, vignettes offer a standardized scenario so that individuals who have different financial characteristics all respond to the same financial situation (Finch, 1987). Second, vignettes protect participant privacy because participants are not expected to disclose sensitive financial information in a group setting. Third, vignettes can elicit social norms because the participants are distanced from the scenario―for example, they are asked about how another individual should respond rather than how they would respond (Finch, 1987). Focus groups were conducted by L. J. Samuel and lasted around 60 minutes. Focus groups were audio-recorded and transcribed verbatim. Two graduate students took field notes to capture crosstalk and nonverbal communication and noted responses that provoked signs of disagreement, agreement, and consensus within the group. Field notes were used to improve the accuracy of transcripts when crosstalk occurred and to annotate transcripts by adding nonverbal behaviors (Phillippi & Lauderdale, 2018).

Data Analyses

Thematic analysis was selected as the analytic approach for both the interview data and focus group data based on its flexible yet theoretically sensitive approach (Braun & Clarke, 2006, 2021). As per phase one of the six phases of thematic analysis, raw transcripts were read and reread independently by two researchers with qualitative training who noted initial “ideas” (Braun & Clarke, 2006) with regards to our research questions about (a) the individual experiences of financial challenges and (b) the shared social norms. In phase two, the two researchers generated codes, such as “I wanna be independent,” summarizing concerns about asking family for help, and “we’re still working,” summarizing the effort of navigating community resources. In the third phase, the researchers met with a senior qualitative researcher to develop themes by identifying codes with shared meaning or relationships. For example, several codes captured the utilization of different community resources. Although resources differed, identification of a central concept of asking for help led to the theme “asking for help from community resources.” Themes were developed separately for each data set. After the third phase was completed, data sets were triangulated to evaluate whether and how individual experiences were reflected in social norms (Lambert & Loiselle, 2008). For example, although many comments were made about getting help from family, perspectives differed depending on whether participants were discussing the way things should be based on norms or the way things were based on first- or second-person experiences. Participants highlighted reasons why they did not ask family for help themselves, but emphasized that families should help older adults. Then, in the fourth phase, detailed coding trees were constructed to trace themes back across codes and raw data to ensure that the conclusions and developing definitions were accurate and representative. For example, when contrasting findings were noted between norms and experience with regard to families, the original transcripts were reread to confirm that the conclusions remained accurate to the original meaning. Effort was taken to bracket potential biases as a way to “own the perspectives” (Braun & Clarke, 2021) of a research team lacking the intersectional personal experience of being a low-income Black older adult with a disability. When no new themes or explanations were found, themes were then given clear definitions and names. Thematic saturation of data were considered complete when the research team was unable to identify any new codes or themes pertaining to the research question (Walker, 2012). However, we acknowledge that further analysis with a new research question may yield additional insights from these data beyond the scope of the present study. Data analysis were managed using the qualitative software f4analyze (audiotranskription, 2019).

Results

Both the interview and focus group participants were predominately Black, female, living alone with incomes less than $20,000 and with few financial assets other than a checking/savings account (Table 1). Most interview participants were ≥75 years, and focus group participants were typically 65–74 years of age. Most participants were retired, had some financial strain, food insecurity, and chronic condition(s) and more than a quarter reported not working due to a disability.

Table 1.

Selected Characteristics of Low-Income Older Adult Focus Group and Individual Interview Participants

Variable	Categories	Focus group (n = 28)		Individual interview (n = 11)
		n (%)	Median (range)	n (%)	Median (range)
Age	60–64	4 (14)		0 (0)
	65–69	10 (36)		2 (18)
	70–74	8 (29)		2 (18)
	75–79	4 (14)		3 (27)
	≥80	2 (7)		4 (36)
Race	Black	24 (89)		9 (82)
	White	2 (7)		2 (18)
	Other	1 (4)		0 (0)
Sex	Female	27 (96)		9 (82)
	Male	1 (4)		2 (18)
Household size	1	20 (71)		8 (72)
	≥2	8 (29)		3 (27)
Income	<$10,000	3 (11)		1 (9)
	$10,000–14,999	6 (22)		3 (27)
	$15,000–19,999	8 (30)		1 (9)
	$20,000–29,999	5 (19)		3 (27)
	$≥30000	5 (19)		3 (27)
Employment statusa	Disabled	8 (29)		3 (27)
	Retired	22 (79)		9 (82)
	Working part-time	4 (14)		0 (0)
	Working full-time	0 (0)		0 (0)
Owns home	No	9 (32)		2 (18)
	Yes	19 (68)		9 (82)
Has checking/savings	No	4 (14)		0 (0)
	Yes	24 (86)		11 (100)
Financial assetsb	0	21 (75)		5 (45)
	1	7 (25)		5 (45)
	2	0 (0)		0 (0)
	3	0 (0)		0 (0)
	4	0 (0)		1 (9)
Financial strain score			2 (0, 4)		2 (1, 4)
Food insecurity score			2 (0, 6)		0 (0, 5)
Number of financial shocks			2.5 (0, 6)		1 (0, 4)
Number of chronic conditions			4 (0, 9)		4 (2, 5)

Notes: 

^aCategories are not mutually exclusive. So, counts may exceed sample sizes.

^bFinancial assets included Certificate(s) of Deposit, a pension or IRA, stocks/bonds, or real estate.

Two overarching themes were identified. First, the social norms related to financial challenges reveal assumptions about personal responsibility based on the social roles for older adults facing financial challenges, their families, and their communities. Second, social norms relevant to financial challenges are often inconsistent with the reality of living with financial challenges. Within the first theme, the shared assumption of personal responsibility was manifest in several ways in the findings. As an example, when presented with a vignette, participants typically first asked questions to evaluate whether the person in the story could earn money, such as asking about retirement status, age, and ability to work. Participants typically only suggested asking for help if they believed the person could not earn money. Regarding the second theme, participants’ real-life experiences reveal that individuals often lack personal control of their situation, suggesting that individuals are not responsible for financial challenges, and that they face structural barriers in accessing resources. Normative responses differed from real-life experiences for all but one of the following six subthemes: (a) how finances should be handled to prevent financial challenges, (b) the causes of financial challenges, (c) asking for help from community resources, (d) navigating community resources, (e) getting help from family, and (f) cutting back to handle financial challenges. Except for the subtheme of cutting back, participant responses about how things should be handled differed from responses about how challenges were actually handled, suggesting that the normative understanding of financial challenges differs from reality. A conceptual framework is proposed (Figure 1) synthesizing results across subthemes to show how the normative social roles of individuals, families, and community resources are not consistent with the reality of living with financial challenges.

Figure 1.

A proposed conceptual framework based on study findings related to financial challenges among older adults, contrasting social norms with real-life experiences. On the left, the framework summarizes the social roles for older adults facing financial challenges and their families as well as the role and structure of community resources based on the underlying social norm focused on personal responsibility. On the right, the social norm, roles, and structure are contrasted with the real-life experiences of older adults living with financial challenges, which suggest that sociopolitical factors bear responsibility for financial challenges.

Subtheme: How Finances Should be Handled to Prevent Financial Challenges

The theme of personal responsibility was revealed in several ways when discussing handling finances. Participants agreed that low-income older adults should live on a budget and reduce spending if needed so that basic necessities, including food, housing, and medications are covered with their Social Security check rather than other income sources. They also recommended anticipating financial challenges by saving (“never spend your last dime,” #25) or insuring household items, including kitchen appliances, the furnace, water heater, and pipes to avoid paying for expensive household repairs. Some even recommended applying for assistance programs before a problem arose (“you have to go in these programs ahead of time” #20). They also recommended avoiding financial risks, including debt, by making comments such as “don’t owe anybody” (#19) and “you don’t wanna borrow money” (#34).

Participants also generally agreed that low-income older adults regularly reprioritize money and juggle needs rather than sticking to a budget and may not be able to anticipate the specific resources they will need to face future challenges. Focus group participants enthusiastically endorsed the statement “Rob Peter to pay Paul” (#41), suggesting that money is fungible and financial needs are reprioritized frequently. They recommended the same resources for all scenarios, although the basic need varied from one vignette to another. Despite first asking detailed questions about the vignette character’s age, ability to work, housing situation, and presence of family, they often recommended that the person “[apply] for everything and see what happens” (#17). Interview participants described experiencing challenges in saving money. One participant (#10) who had raised her children and her sister’s children as a single mother commented, “I wish I had saved up some money [before retirement],” but had to quit her physically demanding health aide job due to health declines. Another participant planned to buy shoes using her credit card because she needed them but could not otherwise afford them. These experiences exemplified the challenges faced by low-income older adults in handling finances.

Subtheme: The Causes of Financial Challenges

Some focus group participants’ comments revealed an assumption that the character in the vignette faced financial challenges because they were irresponsible (Table 2). For example, when one focus group participant (#27) said, “you supposed to learn from mistakes,” several group members chimed in that the person in the vignette should reduce expenses and downsize. When asked to role play how she would give this advice to the person in the vignette, she responded by suggesting that the person must have squandered money at the casino, saying, “next month if you want to go down to [the casino] but you going in there with the part-time money,” (#27).

Table 2.

Participant Quotes Exemplifying the Discrepancies Between Social Norms and the Real-life Experiences of Financial Challenges

Social norms centered on personal responsibility	Reality revealing lack of personal control
Subtheme: How finances should be handled to prevent financial challenges
“It has to be on a budget, you know because anything can happen and it does, yes, yes.” (#19, focus group) “you have to go in these programs ahead of time, you know, and so you have to anticipate well, this might happen; my furnace is going to break before I die, you know, or this is going to happen and get on those waiting lists. ” (#20, focus group) “never spend your last dime” (#25, focus group) “don’t owe anybody” (#29, focus group)	“Rob Peter to pay Paul” (#41, focus group) “fill out for everything and see what happens.” (#17, focus group) “I wish I had saved up some money like―well I did at 1 time and then things happened but then I wish I could’ve continued working some. ” (#10, interview) “I know I need some shoes, and I can’t buy them, so I’m going to buy them with the credit card. So that’s where things are. ” (#5, interview)
Subtheme: The causes of financial challenges
“Aw, baby, you not living right. You got to cut it out and you got to stop. … You got to figure out how you gonna buy food and pay those bills with that Social Security check. And next month if you want to go down to [the casino] but you going in there with the part-time money.” (#27, focus group) “For a future, I would suggest that the rent would be one of the most important things to make sure you’re getting. ” (#21, focus group)	“Well, baby, all I can tell you is every day is a struggle … .it wasn’t because I was lazy. I worked my whole life, but there were years when you worked all that time and you really weren’t making anything.” (#1, interview) “when I was no longer able to work, he was already on disability. We lost our apartment and everything.” (#3, interview) “I just retired in July. I’m still working to bring my budget. I cut my income in half. My budget don’t wanna be cut in half. So I’m struggling a little bit. So I’m gonna have to start making phone calls.. because I’m not making ends meet. ” (#17, focus group)
Subtheme: Asking for help from community resources
“That’s all you do is ask. That’s right.” (#34) “And you go and you find out. And it’s … in other words, don’t close yourself in.” (#25, focus group) “I told a couple friends of mines about this center and everything. They would not go. [Murmuring in the group]. They would not use the information so I stopped giving the information.” (#32, focus group) “That’s right … You can go. Don’t complain to me no more. I don’t wanna hear it.” (#33, focus group) “go to the church or Social Service or go somewhere and don’t have too much pride.” (#22, focus group)	“Too many of us don’t wanna share, but God knows you gotta share it.” (#17, focus group) “It’s not easy … I mean when you’ve taken care of yourself for all your life, and your kids, and ex-husband, and you just don’t even want to ask for help, and it’s hard. It’s hard to ask for help.” (#21, focus group) “The people [at social services programs] are not very nice and they give you a hard time. I worked all my life and I’m an old lady. … And I don’t know if I would stand and let them do that to me. I’d probably just walk out without the help that I need. ” (#1, interview)
Subtheme: Navigating community resources
“You gotta do that homework.” (#34, focus group) “There’s no free lunch. You’ve got to work.” (#30, focus group) “You have to cry for it.” (#18, focus group) “So we don’t have any problem working for this. We’re still working. We’re retired but we’re working for ourselves.” (#21, focus group)	“So it’s not because they lazy or don’t want to do it. It’s just say, for instance, you 80 years old and something come up that you haven’t confronted and you been depending on somebody all those years but then you don’t have that resource no more. So you don’t know how to get on the phone and really communicate with somebody.” (#22, focus group) “resources for housing is a problem.” (#21, focus group) “[SNAP’s] definitely according to your income and most people, if you’re social security, you not going to get that much. You might get $16.00 a month. I’m going to tell you right there.” (#34, focus group)
Subtheme: Getting help from family
“If she has a problem like if she’s 70 years old, the whole family need to step up, of the system, or because aunts, uncles, everyone should step up and just give her a helping hand … . We gotta help our mothers.” (#16, focus group) “You’ve raised your kids and you―and you did for them. … I think they should come to mama’s aid―and help her.” (#19, focus group) “So, she has kids, maybe they can help her.  Usually family members for seniors sometimes will kind of pitch in a little bit.” (#41, focus group)	“I’d try all the other avenues before I called my family.” (#29, focus group) “Like that means giving up independence too, you know, a little bit.” (#20, focus group) “I try not to give them the what I call it the bad part. I’ll tell them afterwards and it’s mom, why didn’t you blah, blah, blah, blah?” (#8, interview)
Subtheme: Cutting back to handle financial challenges
“the main thing is prioritizing. You need a roof over your house, you need food in your stomach. That’s what you need most, everything. If the gas light gets turned off, the blanket’s warm. It could be that the water, if you have to have that roof and you have to have a bed. You can even―and I have gone without medical attention.” (#20, focus group) “what you do is accept that you’re not gonna go anywhere because you can’t afford gas, and [laughs] whatever all the rest of the people are doing, you just, it’s not open to you. … I don’t even go to church, because I can’t afford to go to church. I know you’re supposed to give ten percent, but I don’t have ten percent.” (#6, interview) “If you’ve gotta eat hot dogs for the rest of the month, pay your rent, you know, you’ve gotta keep the rent in front of your head. ” (#21, focus group) “ I’ve been to the point where what I had for food was what was all I had. I didn’t have any money to buy anything else until the next month … But I’ve been fortunate in that I haven’t had anything turned off. ” (#8, interview) “ Right now, I’m not cutting back on anything. I have already cut back on the going to the store and shopping and catching the sales. I’ve already done that. Now I’m just maintaining.” (#4, interview)	N/A

First-person accounts of financial challenges in individual interviews were vastly different from their normative understanding of them. Several participants described not “making anything” despite hard work. Many had faced significant losses of income or large expenses that were “a shock” (#8) to them and could not have been anticipated, such as household repairs, or medical/dental expenses. Although some participants in the focus group setting also reported experiencing financial challenges, they tended to readily express personal responsibility for handling the situation. For example, one participant (#21) who recently stopped working said, “I’m not making ends meet right now,” but also followed up this comment by saying, “I know I gotta do my homework and find these resources. I know that.”

Subtheme: Asking for Help From Community Resources

In focus groups, there was general consensus that there are ample community resources and older adults facing financial challenges should seek them out. Many participants were knowledgeable about a wealth of local resources, providing specific agencies, phone numbers, addresses, and opening times. Participants described resources as being readily available, saying, “all you do is ask” (#34), and several participants described being annoyed with people who do not use resources, making comments such as “You can go. Don’t complain to me no more. I don’t wanna hear it” (#33). Many focus group participants also commented that individuals should not “have too much pride” (#22) in asking for help, acknowledging stigma and potential threats to dignity.

When participants discussed their own experiences, they discussed challenges in asking for help. Participants generally discovered community resources by word of mouth, and some commented that this is a barrier because some people are “selfish” and “don’t wanna share” (#17) about useful resources. For example, some focus group participants were less engaged in the conversation than others and said that they were learning about resources themselves. In fact, when Participant #17 described a program providing free water heaters, Participant #15 raised her eyebrows, asking, “they’d get it for free?” and then said, “A similar incident happened to me, and I had to buy one. … I didn’t know nothing about it.” In individual interviews, participants revealed that they did not apply for resources that might have helped because they had “heard horror stories” of being treated poorly; one participant commented that she would “probably just walk out without the help that [she needed]” because the people are “not very nice” (#1).

Subtheme: Navigating Community Resources

Focus group participants expressed an expectation that individuals work hard to get help. There was consensus around the idea that “we’re still working” and participants described devoting a large amount of time, effort, and attention to handling financial challenges. Participants described filling out multiple forms and making many phone calls that typically each takes an hour or more. Despite the work, focus group participants did not complain, making comments such as “we worked all our lives. So we don’t have any problem working for this,” (#21). In addition, they described a mental and emotional toll required, especially when they had urgent needs like a broken furnace or a leaky roof, saying, “You have to cry for it” (#18).

In contrast, both focus group and interview participants also acknowledged that there are barriers to using resources. Focus group participants noted that older adults who had not handled their household finances may not be knowledgeable or skilled at navigating complex application processes when encountering financial challenges later in life, making comments such as “you really don’t know how to get on the phone and really communicate with somebody” (#22). Focus group participants also identified important gaps in the social safety net, especially a lack of resources for housing with comments such as “resources for housing is a problem” (#21). Also, although multiple resources were recommended, many had limitations. For example, many participants relied on food pantries, but did not believe SNAP was particularly useful because, as one participant said, “you not going to get that much,” (#34).

Subtheme: Getting Help From Family

Focus group participants generally agreed that families should financially support older adults experiencing financial challenges, although some of them noted that older adults may lack family members who have the financial resources to help face those challenges (Table 2). Notably, participants often asked about the presence of family members after presented with a vignette. Responses suggested that there is a moral imperative for families to help their older family members, including comments such as “We gotta help our mothers” (#16).

However, when talking in the first person, most participants in both focus group or individual interview settings agreed that they would not want to ask their family for support (Table 2). Some said they didn’t want to worry their families, saying, “I try not to give them the what I call the bad part” (#8). Others said that involving family members in their personal finances may mean compromises as an older adult: “that means giving up independence too” (Participant #20). Overall, participants in individual interviews did not want to include family members by either asking them for money or by asking them to help navigate access to resources.

Subtheme: Cutting Back to Handle Financial Challenges

Unlike other subthemes, the norms about cutting back were generally consistent with real-life experiences. Participants universally recommended that vignette characters cut back or eliminate spending to prioritize housing and food needs. Focus group participants had a consensus around the comment that “Your rent should be first” (#15). They explained that housing costs should be prioritized partly because housing resources are lacking and because homelessness is more permanent and stigmatizing than going without other necessities, evidenced by comments such as “Don’t nobody know you’re hungry unless you tell them, but everybody know when you outdoors” (#30).

Consistent with these norms, participants universally described using at least one and often multiple strategies to cut back on expenses, including going without food, health care, heat, or social gatherings (Table 2). Participants in both focus groups and interviews reported making trade-off decisions and foregoing necessities in order to “have that roof” (#20; Table 2). Notably, many interview participants had not planned to retire but had to stop working due to their health, and all participants in interviews and focus groups reported needing to cut back on spending after they stopped working. Some participants who stopped working years ago no longer considered their spending patterns to be “cutting back,” such as one woman who said, “Now I’m just maintaining” (#4), suggesting that they expected to continue this practice indefinitely.

Discussion

This study contributes to the literature by demonstrating that social norms related to handling financial resources are built on assumptions about personal responsibility, but these social norms typically are not consistent with the daily reality faced by older adults experiencing financial challenges. These findings highlight three potential reasons why older adults facing financial challenges may cut back on expenses or even go without necessities rather than seek help. First, there was a normative expectation that low-income older adults carefully budget their expenses, suggesting that cutting back is expected to be the first step in handling financial challenges. Second, participants described challenges and substantial effort required to access community resources. Based on our conceptualization of social norms (Sunstein, 1996), we believe that these structural barriers are a reflection of the underlying social norms in the United States. So, older adults facing financial challenges may prefer to cut back rather than deal with the hassle of applying for support. Finally, the finding that “cutting back” is the only subtheme of this study for which the social norm is consistent with the lived reality suggests that older adults may rely on this strategy more than they rely upon seeking help because this strategy is the only one that is both socially acceptable and practical for them to do. This has important health and safety implications as cutting back included compromising basic necessities, such as food, health care, or heat.

Importantly, the presence of social norms that are not consistent with the daily reality of living with financial challenges likely contributes to the stigma about asking for help. The findings from this study related to asking for help are notable because Maslow’s hierarchy of need suggests that individuals prioritize physiologic needs, such as food, over dignity, and independence (Maslow, 1943). However, our findings suggest that individuals do not necessarily prioritize physiologic needs over dignity and may even prioritize dignity over physiologic needs. New scholarship on the origins of Maslow’s theory in collective societies reinforces that actualization may be prioritized above physiologic needs (Blackstock, 2011). Based on our understanding of social norms and social identities (Sunstein, 1996), this may be due to pervasive and stigmatizing social norms related to financial challenges, which force older adults to make decisions based on protecting their social identity rather than protecting their health.

Implications

These results can inform the development and improvement of financial and community programs and policies for low-income older adults addressing financial challenges in several ways. First, theories of financial behaviors focus on individual-level factors, such as individual knowledge and attitudes (Gudmunson & Danes, 2011), and much of the empirical literature on financial decision-making has focused on financial literacy and cognitive factors (Agarwal & Mazumder, 2013; Frydman & Camerer, 2016). Although there is some evidence that financial challenges impair cognitive function (Mani et al., 2013) results from this study suggest that financial decision-making is constrained by structural barriers, social norms, and stigma associated with financial challenges. Greater attention should be paid to addressing structural factors and decreasing stigma for low-income older adults facing financial challenges.

These findings have several implications related to strengthening financial resources for low-income older adults facing financial challenges. At least three specific steps could be taken to make it easier and less stigmatizing to access resources. First, more effort could be taken to disseminate information about public benefits, entitlements, and tax credits that are intended to improve economic well-being for low-income older adults. In this study, not all eligible older adults knew about programs that may have helped them handle financial challenges. Second, cumbersome enrollment and renewal processes for many programs could be streamlined or eliminated. Participants in this study reported not using resources because the amount of effort required was not worth the benefit received, and lamented challenges in navigating access to supportive resources. Examples of streamlining include allowing joint applications and shared information for programs with similar eligibility criteria, such as SNAP and energy assistance. Such strategies have been shown to increase participation (Kauff et al., 2014). Importantly, simplifying the cumbersome application processes may also reduce the stigma induced by asking for help. These findings highlight that money is fungible in households and older adults typically apply for multiple programs, but the support received from most programs is not fungible. Joint applications and information sharing are likely important tools to assist older adults juggling multiple competing demands. Renewal processes could be eliminated for older adults reliant on fixed Social Security income because their eligibility does not change over time. This is important to ensure that older adults do not experience benefit gaps. Third, allowing more options for enrollment and renewal, such as online or phone applications, may facilitate access for older adults, especially if they no longer drive or have functional limitations.

Recent recommendations to incorporate screening for financial strain into clinical practice (Alley et al., 2016) may help reduce stigma. Clinician referral to case management may reduce the amount of effort required by individuals in need of help. This study found that older adults may struggle to navigate complex systems, suggesting that case management or other assistance may be essential to ensure that older adults get the support and services they need during a financially challenging situation. However, most U.S. clinical practices do not screen for social determinants of health, including financial strain (Fraze et al., 2019). Some clinicians fear causing unintended harm to patients by screening for social determinants of health if they are then unable to assist a patient in need (Garg et al., 2016) and findings from this study show that resources to address financial strain are not consistently accessible for individuals facing financial strain. One reason for these findings is, despite evidence of health benefits from income supplements such as SNAP, energy assistance, and supplemental security income (Taylor et al., 2016; Thornton et al., 2016), there are no clear standards for integrating the delivery of care for medical and social needs (Carey & Crammond, 2015; Garg et al., 2016). Further work is needed to develop and evaluate strategies to improve the integration and coordination of medical services with social services. The development and evaluation of these resources are particularly timely to respond to recommendations from the Centers for Medicare and Medicaid Services and other organizations to incorporate financial strain screening into clinical practice and provide clinicians with evidence-based strategies for addressing financial strain.

These findings also have important implications about the need to align resources with the needs of the population. For example, participants in this study described housing and food as essential, suggesting that eligibility restrictions and enrollment requirements may need to be more relaxed for food assistance and housing assistance than for other types of benefits to ensure basic needs are met. Participants consistently highlighted needing greater housing assistance. This is consistent with data elsewhere showing the rate of housing cost burden, classified based on paying more than 30% of income for housing, has increased over the past 20 years (Hess et al., 2020). This is important because the housing cost burden has predicted nursing home placement among older adults (Morales & Robert, 2020). Together, these studies show an urgent need for more affordable housing units in the United States.

Limitations and Strengths

This study may have been limited by social desirability bias related to sensitive topics such as financial challenges, although the use of vignettes in focus groups should have reduced response bias. These findings reveal social norms about personal responsibility specific to handling financial challenges among older adults in a United States city; future studies should explore how these norms differ in other countries and settings or with different groups of people. This study did not systematically survey participants about program participation; future studies should examine user experiences with supportive services to understand how these can be aligned with the needs of low-income older adults. This study was strengthened by the use of two data collection approaches (i.e., focus group and individual interviews), which allowed us to more thoroughly compare norms versus reality than we could have with just one data collection method.

Conclusions

The social norms relevant to older adults’ handling of financial challenges that were discussed in this study focused on personal responsibility and were typically inconsistent with real-life experiences of older adults for multiple subthemes, with the exception of norms related to cutting back on spending. This may explain why older adults facing financial challenges forego basic necessities rather than seek assistance, despite risks to their health and well-being. Urgent action is needed to strengthen social safety nets and prioritize housing and food support for older adults facing financial challenges.

Funding

This work was supported by the National Institute on Aging (K01AG054751 to L. J. Samuel) and the National Heart, Lung, and Blood Institute (F31 HL146080 to L. C. R. Lavigne).

Conflict of Interest

None declared.