Community-dwelling older adults who are low-income and disabled weathering financial challenges

Abstract

Despite interventions aiming to improve outcomes among older adults experiencing financial challenges, the challenges and strategies employed to handle them are poorly understood. This study examined the experiences of financial challenges among low-income adults aged ≥65 years. Eleven semi-structured interviews were analyzed using thematic analyses. An overarching theme was “I guess it balances”, capturing attempts to maintain hope and proactively address challenges despite stress, uncertainty and limitations. Balancing was demonstrated within four domains, including cognitive bandwidth (“think a lot” versus “I don’t dwell on that”), emotional experience (“depressing” versus “be thankful”), learned resilience (“that was a shock” versus “there’s always a way”), and meeting daily needs (“we learned to do without” versus “take a dollar and stretch it”). Participants described being weathered by challenges and using predominately high-effort coping strategies to weather the challenges. These findings call for strengthening the safety net for older adults facing financial challenges.

Introduction

Financial challenges are common for U.S. older adults; approximately one-third report financial strain,¹ defined as difficulty making ends meet,² and 60% experience a financial shock each year, such as a large unanticipated expense or loss of income.³ However, older adults with incomes near the poverty threshold or who are disabled or Black disproportionately experience financial challenges.^1,4 The stress experienced during a financial challenge may contribute to weathering, defined in the Weathering Hypothesis as earlier physiologic aging as a result of accumulated social adversity among groups who are vulnerable because of constraints related to being poor or disabled or experiencing discrimination due to race or disability.⁵

There is ample quantitative evidence linking financial challenges to earlier aging and poorer health outcomes. Financial strain is associated with greater risk for obesity, disability and malnutrition, poorer health, increased depressive symptoms, and earlier mortality.^6–14 Likewise, loss of income or wealth have been associated with higher blood pressure, cholesterol, blood sugar and C-reactive protein and higher risk of heart disease and mortality.^4,15–18 Despite the consistent associations found between financial challenges and earlier aging-related health outcomes, the mechanisms remain underexplored. This knowledge is important to aid in the development of programs and policies to improve financial security and well-being for low-income older adults. Qualitative research may generate hypotheses about specific underlying mechanisms, but the experiences of financial challenges have not been explored qualitatively.

This study examines the experience of financial challenges based on concepts from the Weathering Hypothesis⁵ in two ways among older adults who are financially vulnerable because they are both low income and disabled. First, the theory describes the process of weathering,⁵ which is consistent with empirical evidence of higher allostatic load scores and earlier aging-related chronic diseases among groups who experience more social adversity based on race, income, gender and disability status.^19–21 Secondly, based on the Weathering Hypothesis, individuals facing social adversity are believed to use predominately high-effort coping strategies to weather adversity.^19,20 However, there is a gap in exploring the experience of financial challenges, which is one type of social adversity, among older adults. Therefore, this qualitative descriptive study investigates financial challenges by exploring how low-income disabled older adults 1) are weathered by financial challenges, and 2) weather financial challenges.

Research Design

Sample

Participants were recruited from individuals who participated in the CAPABLE studies. The CAPABLE studies recruited 543 low income (<200% federal poverty limit) community-dwelling and home-owning adults aged ≥65 years in Baltimore with at least some difficulty performing Activities of Daily Living (ADL’s) to participate in one of two trials between 2012 and 2016 using multiple non-random methods including mailings and community outreach and described in detail elsewhere.^22,23 The studies aimed to reduce disability among low-income older adults by addressing personal and home environmental factors. Of the 543 participants, 361 agreed to be contacted again for research purposes and this group formed the sampling frame for the current study. Twelve individuals out of 28 attempted were successfully contacted by the first author by phone to ascertain interest in the current study. All were eligible based on involvement in managing their household finances and not cognitively impaired based on a modified Short Portable Mental Status Questionnaire score ≥6²⁴ and 11 consented to participate in the current study. Once data saturation was achieved,²⁵recruitment was closed except that purposive sampling²⁶ was used to recruit two male participants. This study was approved by the Johns Hopkins Medicine IRB.

Study design and data collection

In this qualitative study, survey data were collected to understand participant characteristics and identify areas of inquiry based on domains assessed in the survey.^27,28 Interviews were conducted in the participants’ homes by the first author, who is a nurse and a researcher. After obtaining informed consent, participants completed the survey to collect data on age, gender, race/ethnicity, and factors related to financial challenges,^4,9 including employment status, annual household income, household size, financial strain, food insecurity, financial shocks, and chronic conditions. Participants were classified as having household food insecurity if they ever worry food would run out, lack money for food and/or couldn’t afford balanced meals of the past year.²⁹ As in prior work,³⁰ financial strain was measured by asking about difficulty paying bills and how much money was typically left over at the end of each month and scores ranged from zero to five. Based on a prior survey,³ financial shocks were measured by asking about an unexpected reduction in income, hospitalization, divorce or death of partner, major vehicle or appliance repair/replacement, or other unexpected household expense in the past year. Participants were also asked whether they had any of 18 different health conditions.

Then, in-depth semi-structured interviews were conducted using an interview guide developed by the first author (Table 1). Participants were asked to describe their experiences with financial strain and financial shock, describe their strategies for addressing and coping with these financial challenges and describe how the challenge(s) affected him/her. Participant survey responses were used to generate prompts to supplement and tailor the topic guide questions based on participant experiences. For example, participants who mentioned financial challenges related to housing in their survey were asked to describe those specific scenarios during the interview. Interviews lasted between 30 and 90 minutes. Interviews were audio-recorded and later transcribed verbatim. Field notes were documented during the study visit to provide additional contextual details.

Table 1.

Semi-structured interview guide with questions and prompts

Interview guide prompts

1) Can you describe how you generally manage your finances from one month to the next?

2) What challenges have you encountered in making ends meet from one month to the next?

a. How have you addressed those challenges?

3) Can you think of a time in the past few years when you’ve either struggled to make ends meet or you had to do something out of the ordinary to make ends meet?

a. Can you describe the situation?

b. Can you tell me how you handled it?

c. How did this experience affect you?

4) How well can you anticipate your financial needs from one month to the next?

5) What are some of the challenges you’ve encountered in trying to anticipate or budget your financial needs from one month to the next?

a. How have you addressed those challenges?

6) Can you think of a scenario in the last few months in which you had an unanticipated expense or loss of expected income?

a. Can you tell me about the situation?

b. How did you handle that situation?

c. How did this experience affect you?

7) If your financial situation worsened tomorrow, what kind of financial resources could you use to help you make ends meet?

a. Of those, which resource(s) would you prefer to use? Why would you prefer it/them?

8) Some people stretch money or try to be thrifty to make ends meet. Can you describe a situation in which you’ve cut back on spending in a time of need?

a. How did you feel about that experience?

b. How did this experience affect you?

9) Some people ask for help from friends or family, enroll in public benefits, such as food stamps, or ask for other support to help make ends meet. Can you describe a situation in which you’ve gotten financial support in a time of need?

a. How did you feel about that experience?

b. How did this experience affect you?

10) Some people increase their income by working, selling belongings or finding other sources of income. Can you describe a situation in which you’ve increased your income in a time of need?

a. How did you feel about that experience?

b. How did this experience affect you?

Analyses

Interviews were analyzed using thematic framework analysis³¹ due to its rigor, transparency, and credibility within a qualitative descriptive design.^27,28 The first and second author independently identified coded raw transcript data line by line to identify 43 codes, which were then grouped into themes. Then, they met to discuss initial themes and verify consistency in the analytical approach. Both coders then returned to the data and independently created a thematic framework pertaining to the effects of financial challenges and the ways that participants responded to financial challenges. The coders then met again to discuss findings and develop a single thematic framework. The final analyses viewed findings within the context of the Weathering Hypothesis. The final framework depicts an overarching theme captured across four domains which each include two sub-themes. Themes related to the Weathering Hypothesis were validated by (1) evaluating whether participants consistently reported both being weathered by financial challenges and weathering financial challenges, (2) contrasting responses for participants with more pronounced financial challenges to responses from participants with relatively less pronounced financial challenges and (3) reviewing findings with JLT, who is also a nurse and a researcher and has extensive experience conducting qualitative studies with the target population for this study as well as other older adults from underrepresented racial/ethnic minority groups. Analyses were supported by f4analyze software.³²

Results

As shown in Table 2, the people included in the sample were predominately Black female, and lived alone with incomes <$30,000. Most participants (>50%) had experienced at least one financial shock in the past year and reported some financial strain, although only 36% reported food insecurity. Participants reported several types of commonly encountered financial challenges including persistent difficulties making ends meet, loss of income due to disability, large unexpected expenses, and debt. Importantly, although participants were not asked about their early life, many commented that earlier experiences with adversity increased their knowledge, skills or confidence and sometimes shaped their identity, such as one participant who described himself as a survivor because he recovered from a devastating motorcycle accident as a teenager.

Table 2.

Selected characteristics of participants, recruited from a sampling pool of older adults living with low income and disabilities (n=11)

Variable		Sample characteristics
Age (%)	< 75 years	4 (36%)
	75 + years	7 (63%)
Gender (%)	Female	9 (82)
	Male	2 (18)
Race (%)	Black	9 (82)
	White	2 (18)
Income (%)	<$15,000	4 (36%)
	$15,000–$29,999	4 (36%)
	$>30,000	3 (27%)
Number in household (%)	1	8 (73)
	2	3 (27)
Median number of chronic diseases (Range)		4 (2, 5)
Food insecure (%)	No	7 (64)
	Yes	4 (36)
Median number of recent financial shocks (Range)		1 (0, 4)
Median financial strain score (Range)		2 (1, 4)

Consistent with the phenomena of weathering, participants reported that financial challenges worsened physical and mental health outcomes, including depressive symptoms, headaches, high blood pressure, sleep disturbance and well-being, making them feel ‘inadequate’, ‘worthless’ or ‘scared’. Notably, participants consistently used negative terms to describe their financially challenging experiences, including ‘frustrating’, ‘depressing’, ‘frightening’, ‘overwhelming’ and ‘terrifying’. However, participants also consistently describe strategies they employed to handle financial challenges. These findings provided context for the overarching theme of “I guess it balances”. This theme was exemplified within four domains of daily life relevant to financial challenges, including cognitive bandwidth, emotional experience, learned resilience, and meeting daily needs (see Table 3). Within each domain, a pair of sub-themes capture the ‘balancing’ act required to weather financial challenges while also being weathered by them.

Table 3.

Coding tree with case exemplars for the overarching theme and sub-themes demonstrating how low-income disabled older adults experience financial challenges and are affected by financial challenges, based on concepts of the Weathering Hypothesis

Participant characteristics	Exemplar quotes
	Overarching theme of balancing: “I guess it balances”
Multiple recent financial challenges; income <$10,000	“I realize my limitations. And before, I guess I thought I was invincible or −I don’t know what I thought I was. But I know now that I am limited in a lot of things but I also know that there are still a lot of things that I’m able to do. So I guess it balances, and I hope that keeps balancing all the time.”
Financial strain, living with husband on <$30,000	“all I can say is it’s rough. It’s really rough, but you just have to learn to live with you’ve got. You learn to live with it. You really can if you don’t mess up…. We just make it work. That’s all I can say. I really didn ‘t even realize that it was really that. We did it. You get used to it and it’s just a daily.”
Financial strain, food insecurity, income <$15,000	“I’m pretty much a spiritual person so I rely on God for all my needs. And believe it or not, I will run out on theday before I get my benefits. And it’s been happening like that just about since I’ve been in this house.”

	Sub-themes: Being weathered	Sub-themes: Weathering financial challenges
1. Cognitive Bandwidth
	“Think a lot”	“Idon’t dwell on that”
Only $4 in the bank after household repairs	“But right now, I have to just concentrate on paying those bills, because it’s heavy.”	“I don’t worry. Whatever will be, will be. Because if I worry, it will not – nothing will happen. I talk to God”
Forced to retire because of health	“Like I said it affects me a lot but you’d be thinking what you should’ve did but you didn’t do.”	“But I tell you, you know you take 1 day at a time. That’s all I can do ”
2. Emotional Experience
	“Depressing”	“be thankful”
Multiple household and medical expenses; income <$10,000	“It’s been frustrating. It’s been depressing. At times, it almost felt overwhelming…	…I’ve been to the point where I’ve had $5.00. But I had $5.00. I had food. I had a roof over my head. I had heat. You know, I had light. So I was very thankful for that.”
Living on <$15,000 with severe food insecurity and financial strain	“It makes me feel I guess – well I used to feel inadequate when I couldn’t meet my own needs…”	“…I think about all the people who are going through more than I could ever go through…I am just thankful just to be able to put one foot in front of the other.”
3. Learned Resilience
	“that was a shock”	“there’s always a way”
Lost a substantial amount of expected income after retirement	“… that was a shock. It really was. That went through me to my niece and I think that’s one of the few times that I had really, really bad depression…”	…And then I said okay, this too shall pass. You will pull up your big girl panties and you will figure this out…after I got over the initial anger and the initial pity party, then I was much better. I was able to really focus on what needed to be done.”
Needed to pay for costly car repairs and her partner became disabled	“Well, for a little while my pressure started going up and my doctor doubled my blood pressure meds ….	… You’d be surprised at – I know I was – at how you can get help if you just reach out. I just told them look, I cant’ do this. Well, maybe we can do this, that and the other for you. I’m like okay, thank you.”
4. Meeting Daily Needs
	“we learned to do without”	“cut back” / “take a dollar and stretch it”
Childhood poverty	“When I said we had nothing, we had nothing…. there was nothing extra anywhere. And we learned to do without.”	“I have already cut back … Now I’m just maintaining. …I don’t deny myself the basics. I just don’t bother with the extraneous stuff.”
Living on <$15,000 with severe food insecurity and financial strain	“Well, I dont’ depend on being warm; I just depend on not having the pipes freeze… So I’ve gone without a heat bill, now… That’s the way to bust it, so you dont’ have to be put out of your house.”	“Well, what you do is accept that…whatever all the rest of the people are doing, you just, it’ not open to you. …you know it’s your way of life, and – I dont’ even go to church, because I cant’ afford to go to church.”
Was a single mother with four children	“Well, baby, all I can tell you is every day is a struggle. … I worked my whole life, but there were years when you worked all that time and you really werent’ making anything.”	“You learn to take a dollar and stretch it to do the same things as two. When my kids were growing up, oh, god, I shopped a lot in the Goodwills, but they went to school looking as good as anybody.”

“I guess it balances”

The overarching concept of balancing captures the experience of living with the stress, uncertainty and limitations placed on them by the financial challenges and their attempt to maintain optimism and proactively handle their financial situations. Participant quotes in Table 3 reflect the uncertainty they expressed about their financial situations (i.e. “I guess”, “I didn’t even realize” and “believe it or not”) and the precariousness of their situation (i.e. “hope that keeps balancing” and “don’t mess up” and running out of money on the day before benefits). Although every participant described a strategy for managing day-to-day finances, many also reflected on the difficulties of managing their finances despite challenges, exemplified by one participant with multiple recent challenges who said “I don’t really know how [we managed] to tell you the truth”.

Participants were asked about governmental, non-profit and family systems that are commonly believed to provide support, including public benefit programs, family networks and churches. Importantly, participants reported that systems sometimes helped them handle financial challenges, but also noted that systems sometimes worsened their situation. As examples, the city had provided free major home repairs (i.e. a new furnace or repaired roof) for at least two participants but one participant thought the city was responsible for de-valuing homes in her community by disinvestment in the area. Some participants relied on family or churches, but others described situations in which they were the ones providing financial support to their families or churches. Relationships with families, churches and agencies were complex. As examples, many participants expressed fear of losing their independence or making loved ones worry if they asked family members to help. With regard to church, some reported receiving financial assistance from a church but others said they stopped attending church because they couldn’t afford to tithe. Finally, many participants avoided applying for public benefits because of cumbersome enrollment barriers, as one participant stated: “they give you a hard time. …I’d probably just walk out without the help that I need.” Overall, systems were not viewed as universally supportive.

Instead of relying on systems, participants consistently described using self-reliant strategies and coping mechanisms to handle financial challenges, even if challenges were persistent or intense. For example, instead of asking for help, participants described cutting back on basic necessities and strategies such as “take a dollar and stretch it”. This type of disclosure highlighted the mental and emotional weathering that came from the effort of balancing the challenges. One participant who had both food insecurity and financial strain said “I think a lot about how I’m gonna make it”.

Domain 1: Cognitive Bandwidth – balancing ‘think a lot’ with ‘don’t dwell’

Relevant to the domain of cognitive bandwidth, the sub-theme “think a lot” reflects the mental effort needed to juggle competing demands and cover basic needs (Table 3). Many participants commented on the vigilance required to handle household finances. Participants were asked to describe how they handled routine monthly finances, and each provided detailed routinized strategies used to keep track of Social Security payment dates, bill due dates and bank account balances. Some tracked due dates and amounts in a notebook or spreadsheet, while others relied on automatic Social Security deposit and automatic withdrawal for routine expenses. Many mentioned late charges for bills and emphasized the need to “make sure that it’s done on time ”.

Despite the vigilance and effort required to handle their financial situation, many participants consciously tried to not worry, as reflected in the sub-theme “I don’t dwell on that” (Table 3). Some participants suggested having a routine and personal system helped them to worry less. For example, one participant stacked up and set aside bills so he wouldn’t think about them again until payment was due.

Domain 2: Emotional experience – balancing ‘depressing’ versus’ ‘be thankful’

The sub-theme “depressing” captures the stress of living with financial challenges (Table 3). Many participants reported that one financial challenge often led to another and the severity and persistency of accumulated challenges affected a person’s well-being. Participants described the situation as ‘overwhelming’ and reported poor mental health outcomes. Importantly, some strategies for addressing financial challenges in the short-term actually added to their longer-term financial challenges. For example, several participants reported needing to use credit cards for an urgent financial need and described the effort required afterward to eliminate credit card debt, reflected by the following participant comment: “I said no, I’m not getting myself back in that blanket no more.”

In the face of large scale and often-repeated financial blows, participants tried to “be thankful” (Table 3). Many participants said they tried to focus on the resources and abilities they did have rather than focus on their financial needs. Many participants had either experienced more severe financial challenges in the past or had experienced other types of early life adversity and said that these experiences taught them to be thankful. For example, one participant lost a parent at a young age and stated: “My whole life has somewhat been defined by that, in that I know that tomorrow isn’t guaranteed, and we need to be thankful if we have today.”

Domain 3: Learned resilience – balancing ‘scared to death’ versus ‘there’s always a way’

The sub-theme “that was a shock” captures the uncertainty and fear many participants expressed about their precarious situation during a financial challenge (Table 3). For example, one participant described feeling “scared to death” when facing an unexpectedly large water bill due to a glitch in the city’s billing. Most participants said that they had to retire because of health declines. The health declines often led to disability and many said that they not only lost income, but also became more financially vulnerable and were less prepared to handle unexpected large expenses. For example, a participant who had recently faced unexpected large medical and home repair expenses said:

 “I didn’t worry too much … when I was working. We did have a little savings account. I could work overtime a couple of days and that would take care of that and [my husband] could do something. And – but since we’ve gotten older and not able to work and [we] can’t save anything either.”

The sub-theme “there’s always a way” captures how participants tried to maintain hope and optimism despite their fear and uncertainty and proactively handle their financial challenges (Table 3). Some participants described a reliance on God, making comments such as “God always provides” while others described a confidence that they could handle the situation. With regard to getting help, there was not a collective experience; for example, one participant had been pleasantly surprised that she could “get help if you just reach out” whereas another said that paying a large dental bill had “kind of set [him] back” and he “didn’t even think about [asking them to arrange payments]”.

Domain 4: Meeting Daily Needs – balancing ‘we learned to do without’ versus ‘take a dollar and stretch it’

Finally, participants described a balancing act related to daily necessities. Several participants discussed re-prioritizing their needs, which sometimes included re-classifying basic needs as non-necessities (Table 3). Most participants considered housing, food, medications, water and electricity to be necessities, but many said they no longer bought clothing and some skipped church to avoid paying tithes or social activities to avoid paying bus tickets. In one case, a participant had sacrificed heating to reduce spending. Notably, several participants described scenarios in which they relied on food stored at home rather than buying food at the end of the month, but did not respond as food insecure on the questionnaire, suggesting that they did not consider themselves to have run out of food.

The sub-theme “cut back” / “take a dollar and stretch it” conceptualizes the way in which almost all participants had strategies for being thrifty (Table 3). For example, one participant lost a part-time job that had provided her with critical income and described her response by saying: “I realized that okay, you’ve gotta make some different choices. You don’t have it. Okay, yes, you were able to save most of it but it’s gone. You’re gonna have to be very thrifty with it.” Other participants described learning strategies from past financial challenges and how these strategies had become daily habits, not just something they did while facing an unusual financial challenge. Another participant commented that she was used to “being broke” and “making the best out of whatever it is I happen to run across”. Many strategies were specific to food purchases, including buying discounted foods and timing food shopping to avoid first-of-the month high prices after food stamps are distributed. Approaches such as compromising basic necessities and using thrifty habits demonstrated the ways that participants maintained independence amid financial constraints. As one participant succinctly stated:

“It just comes naturally to me at this stage. I’m so – I’ve been doing it all my life. For one thing, that’s allowed me a certain kind of freedom that a lot of other people don’t have because my life is not tied to my possessions.”

Discussion

This study explored financially challenging experiences among a predominately Black sample of older adults living with low-income and disabilities. These findings contribute to the literature by showing that individuals weather financial challenges using mostly self-reliant strategies, including compromising basic necessities, and high-effort coping strategies, such as thinking a lot and actively trying to be thankful and find a way to address the problem. Notably, although many systems such as government agencies, public benefit programs, family networks and churches are believed to provide a social safety net, participants of this study who had experienced financial challenges did not necessarily believe these systems to always be helpful. In fact, some expressed surprise or lack of knowledge about getting help to address financial challenges. Finally, although older adults have numerous strategies for weathering financial challenges, they nonetheless also reported experiencing adverse health consequences. Overall, these findings suggest that older adults facing financial challenges are actively addressing their financial challenges but are doing so without a reliable safety net and are vulnerable to being overwhelmed by the challenge.

These findings are consistent with the Weathering Hypothesis⁵ and inform our understanding of the weathering process. The high-effort coping strategies used to weather financial challenges in this study are conceptually similar to John Henryism, which is defined as a tendency to use high-effort coping strategies to handle the socioeconomic disadvantage and discrimination experienced by many African Americans³³ and is associated with poorer cardiovascular health among low income African Americans.³⁴ There are at least three potential reasons why older adults use high-effort coping strategies to weather financial challenges. First, in this study and another study among individuals experiencing mortgage strain (i.e. difficulty paying the mortgage),³⁵ participants reported a lack of system-level supports suggesting a weak social safety net. The lack of system-level supports may force individuals to fend for themselves, spending time, effort and energy to handle the financial challenge(s). Secondly, findings from other qualitative studies among low-income groups have shown that stigma³⁶ and weariness after repeated financial challenges³⁷ are also barriers to asking for help with financial challenges and these factors may influence whether an individual uses more high-effort coping strategies. Finally, since participants reported that lessons learned from experiencing one type of social adversity translated into their approach to different types of social adversity and since most participants were African American, they may have learned high-effort coping strategies, including John Henryism,³³ from their own earlier life experiences or from their families. Regardless of the causes for using high-effort coping, findings from this study and prior studies linking John Henryism to poor health outcomes^34,38 together suggest that weathering a financial challenge may help an individual address their momentary situation, but may take a toll on their well-being and health.

These findings build on prior studies linking financial challenges to earlier aging-related health outcomes (reviewed earlier) by suggesting potential mechanisms of action. Findings from this study show that low-income older adults with disabilities temporarily forego basic necessities such as food and medications when funds run low and this may contribute to earlier aging. Similarly, other studies have found that low-income adults typically reduce household spending on food and medical expenses^39–42 and have reduced caloric intake and fewer servings of fruits⁴³ at the end of the month when funds tend to run low. Foregoing food and medical care may adversely affect health; one study found that low-income adults have a 27% higher rate of hypoglycemia admissions in the last vs. first week of the month.⁴⁴ Consistent with other findings^45–47, findings from this study suggest that financial challenges trigger stress-response mechanisms. This study builds on prior work by also showing that low-income older adults likely employ high-effort coping strategies to address financial challenges. Since high-effort coping has been associated with poor health outcomes,^33,34,38 this may be a pathway by which financial challenges accelerate the aging process.

These findings among older adults can be compared to those from similar studies in younger populations. Findings from this study about prioritizing necessities, thinking about budgeting and being thrifty were also found in another qualitative study that examined strategies used by young and middle-aged men with disabilities reliant on social benefits.⁴⁸ However, some strategies used by younger adults in other studies were not recommended by older adults in this study, including borrowing from family or using credit cards or payday loans⁴⁹ or relying on subsidies or community programs.⁴⁸ This finding is important because individuals who are older⁵⁰ and have disabilities⁵¹ are more likely to experience financial strain. Therefore, older adults with disabilities not only are more likely to experience financial challenges than younger individuals, but may also have fewer appropriate resources to address the challenge(s).

Importantly, some participants who did not report food insecurity still describe running out of money for food. Together with results about being “thrifty”, these findings suggest that older adults may have grown accustomed to making daily compromises, and may reframe food insecurity as thriftiness. These findings are consistent with other qualitative studies that have shown that low-income households compromise dietary quality even if categorized as food secure^52,53 and are often forced to choose between food, housing and medical needs.^54–56 This is important because food insecurity tends to co-occur with financial challenges.^57–59 Together, these findings suggest that low-income older adults may face trade-off decisions and compromise basic needs and call for refinement of food insecurity measures to screen vulnerable older adults.

Social desirability may have biased participant responses because financial challenges are socially stigmatizing. Also, this cross-sectional study could not validate findings related to the how the weathering process occurs over time and explore the evolution of adaptive responses over the life span. This study was strengthened by its conceptual grounding in the empirically tested Weathering Hypothesis.

Study findings have implications for future research. More research using a life course perspective is needed, both to better understand how early life experiences shape experiences of social adversity later in life and to understand how the process of weathering unfolds over the lifespan. Also, findings related to food insecurity in this study suggest that measurement work is needed to develop a more sensitive measure of food insecurity and a more exhaustive measure that accounts for trade-off decisions and the co-occurrence of food insecurity, financial strain and cost-related medication non-adherence. Research is also needed to develop and test strategies to improve access to supportive systems such as public benefits programs and increase the usefulness of those programs.

Together with results from other relevant studies reviewed earlier, these results have implications for policy. First, these findings highlight the need to reduce financial strain for low-income older adults with disabilities. Financial challenges are modifiable. As examples, there is evidence that implementation of the Affordable Care Act and Medicare Part D were associated with reductions in financial strain⁶⁰ and cost-related medication non-adherence,⁶¹ respectively and participation in the Supplemental Nutrition Assistance Program (SNAP) is associated with reduced food insecurity,⁶² less health care spending,^63–65 and less cost-related medication non-adherence.⁶⁶

Second, these findings suggest that system-level policies and programs that are intended to support economic well-being are not desirable for some of the most vulnerable in the population - older adults living with low-income and disability. Interventions are needed to develop and evaluate policies and programs that are better suited to the needs, preferences and constraints faced by low-income disabled older adults. Systems should be strengthened to increase benefits for those in need and streamlined to reduce barriers and improve timeliness of access for those with urgent financial needs. Furthermore, these findings show that systems may harm, as well as help. Policy makers should consider not only the health impact of policies,⁶⁷ but also consider the impact of policy change on social determinants of health, such as the risk of increasing financial challenges for low-income populations. Findings also suggest that low-income older adults with disabilities should be more proactively targeted for food support, such as SNAP and Meals on Wheels because they may not seek out resources even if they need them.

Conclusion

In conclusion, this study highlights the wealth of strategies that low-income older adults with disabilities have for weathering financial challenges. However, these findings also show how financial challenges influence earlier aging as previously theorized in the Weathering Hypothesis through stress, lack of basic necessities and high-effort coping. These findings suggest that greater efforts should be made to bolster supportive systems in an effort to attenuate earlier aging among low-income older adults facing financial challenges.

Highlights.

• Older adults who are low-income and disabled often face financial challenges

• Thematic analysis of semi-structured interviews examined this experience

• A key theme was ‘I guess it balances’, capturing effortful coping despite stress

• Balancing related to cognition, emotion, learned resilience and meeting needs

• Findings call for strengthening the social safety net for financial challenges