Healthy People 2030 identified economic stability as one of five key domains of the social determinants of health.¹ Key factors associated with economic stability include reduced employment opportunities, food insecurity, housing instability, and poverty.² As with all domains of the social determinants of health, economic instability can negatively affect an individual’s ability to achieve optimal health via diverse mechanisms (e.g., chronic stress, poor nutrition, lack of secure housing, and less access to health care).³ For people with chronic obstructive pulmonary disease (COPD), factors related to economic instability or their potential consequences can further influence a person’s ability to treat and manage their condition.⁴ For example, economic instabilities can directly influence treatment as adults may need to choose between paying for food or housing versus medical care and indirectly as related stress can influence behavioral choices, treatment adherence, and biological mechanisms that can increase risks of exacerbations.^5–8 COPD, like other chronic conditions, can also contribute to economic instability given the disease’s influence on health, disability, and costs.^9–11

Different factors related to economic instability have been examined among persons with COPD. Studies have identified higher rates of poverty using income-based measures among persons with COPD, and economic instabilities related to employment, including work impairments, reductions in employment, and early retirement have been associated with COPD status.^12–16 In addition, housing and food insecurity, two indicators of economic instability, have been positively associated with several chronic conditions, including COPD.^{17, 18} To our knowledge, no studies have examined the association between COPD and a general measure of financial insecurity in a population-based study. Concerns related to overall financial security were identified by a multinational working-age cohort of adults with COPD, including concerns about future earning capacity and difficulty meeting financial commitments.¹³ These concerns may not be completely captured by measures previously examined (e.g., measures of food or housing insecurity or income-based measures of poverty). A subjective measure of financial insecurity can capture the broader concept of the adequacy of household finances (e.g., income, savings, assets) to cover expenses.

Concerns related to economic instability can lead to increased stress levels among persons with COPD. Other factors, including difficulty overcoming pain or discomfort of symptoms, disruptions caused by exacerbations and emergency visits or hospitalizations, limited access to treatments for relieving symptoms, toll of caregiving on relationships, and social isolation and loneliness resulting from activity and functional limitations and changes to leisure pursuits, can contribute to increased stress levels.^19–22 Stress can negatively influence physical and mental health through multiple pathways, including negative behavioral, cognitive, physiologic, and neurologic changes.⁷ To our knowledge, no studies have examined the association between COPD and a general measure of stress in a population-based study, nor have studies examined the influence of economic instability on the association between COPD and stress.

COPD is a complicated disease and factors related to economic instability and stress can contribute to its incidence, management, and subsequent impairments in function and quality of life. The purpose of our study was to examine the association between self-reported doctor-diagnosed COPD status and prevalence of multiple indicators of economic instability, including financial, housing, and food insecurity, as well as an indicator of stress. We also examined the association between COPD and indicators of economic instability after adjusting for demographic covariates, existence of any chronic disease and depression, and employment, as well as between COPD and stress before and after adjusting for indicators of economic instability. Our modeling process adds adjustments using a stepwise approach. Presenting models in this way allows for a deeper understanding of the influence different adjustments have on the associations. While our cross-sectional study cannot determine causality, improving the understanding of the challenges adults with COPD may be experiencing related to economic instability and stress, as well as understanding the influence other important factors have on this association, can help to inform programs, practices and policies related to COPD prevention, treatment, and management.

The BRFSS is a state-based, random-digit-dialed telephone survey of the civilian, noninstitutionalized US adult population aged ≥18 years and is conducted by state health departments in collaboration with CDC.²³ The survey consists of core sections asked among all states and optional modules that states elect to use. In 2017, 16 states included the “Social Determinants of Health (SDOH)” as an optional module (Colorado, Florida, Georgia, Iowa, Maryland, Massachusetts, Minnesota, Mississippi, New Hampshire, Ohio, Oklahoma, Pennsylvania, Utah, West Virginia, Wisconsin, Wyoming). Response rates among states including this module ranged from 32.8% (Massachusetts) to 64.1% (Wyoming).²³

Respondents were classified as having COPD if they answered “yes” to: “Have you ever been told by a doctor, nurse, or other health professional that you have chronic obstructive pulmonary disease or COPD, emphysema, or chronic bronchitis?”

As a measure of financial insecurity, respondents’ financial status at the end of the month was assessed with the question, “In general, how do your finances usually work out at the end of the month?” with response options: “end up with some money left over,” “have just enough money to make ends meet,” or “not have enough money to make ends meet.” Related to housing insecurity, respondents were asked (yes or no), “During the last 12 months, was there a time when you were not able to pay your mortgage, rent or utility bills?” Related to food insecurity, respondents identified separately whether each of the two statements were “often true,” “sometimes true,” or “never true” in the last 12 months: “The food that I bought just didn’t last, and I didn’t have money to get more” and “I couldn’t afford to eat balanced meals.” We also created a separate dichotomous variable that categorized individuals as affirmative if they identified often or sometimes true to either statement related to food insecurity.

To measure frequency of feelings of stress, respondents were first provided a definition “Stress means a situation in which a person feels tense, restless, nervous, or anxious, or is unable to sleep at night because his/her mind is troubled all the time” and were then asked to report how often, in the last 30 days, they felt this kind of stress: “none of the time,” “a little of the time,” “some of the time,” “most of the time,” or “all of the time.” For our analysis, “most of the time” and “all of the time” responses were combined.

Covariates included four demographic characteristics (i.e., sex, age group, race/ethnicity, and education), an any chronic disease indicator, depression, and employment (as categorized in Table 1). Among the 127,790 adults with this module on their questionnaire, 127,122 had information on COPD status. Of those adults, 101,461 had information on the four measures of economic instability, the measure of general stress, and all covariates.

In these 16 states in 2017, the prevalence of reported COPD was 7.0% (95% CI: 6.8%, 7.3%). Compared to adults without COPD, adults with COPD were more likely to be female, aged 55 years and older, and White non-Hispanic. Those with COPD were also more likely to have lower education levels, report any chronic disease or depression, and to be retired, unemployed, or unable to work (Table 1).

Indicators of economic instability (i.e., financial, housing, and food insecurity) as well as more frequent feelings of stress were more prevalent in adults with COPD than those without. Associations were attenuated, but remained significant after adjusting for demographic characteristics, presence of comorbidities, and employment. When stress was the outcome, adjusting models further for indicators of economic instability did attenuate differences, although COPD status remained significantly associated with the highest frequency category. Findings suggest programs to address COPD management could benefit from addressing issues related to economic instability and feelings of stress to further improve the health of persons with COPD.

About 21% of adults with COPD reported not having enough money at the end of the month compared to 8% among those without COPD. Previous studies have mostly focused on financial measures related to the loss of employment associated with COPD, and our findings are similar to these existing studies that demonstrated people with COPD reported they stopped working due to their COPD.^12–15 However, our study demonstrated that while employment status explained some of the association between COPD status and financial insecurity, the association remained even after adjusting for employment. We also adjusted models for the presence of other chronic diseases and depression. There is a detrimental interrelationship between comorbidities and COPD^{24, 25} that can impact economic instability and stress. Our cross-sectional data do not allow us to parse out the independent influence comorbidities have on these association versus those influences that may be on pathway by which COPD and these measures are associated. However, our findings do highlight the importance of considering comorbidities when designing intervention strategies to address economic instability, given the higher prevalence of comorbidities in adults with COPD, as well as their significant role in the associations examined. Findings suggest multiple strategies may be applicable to address financial insecurity among persons with COPD, including those that address challenges with employment as well as other factors related to financial insecurity that may be more prominent among adults with COPD, such as high medical and treatment costs; high prevalence of additional comorbidities, including depression; impact of lost household wages for informal family caregivers; and navigating complex insurance and disability benefit processes. In addition, our findings suggest a need for COPD disease management options to be tailored for adults facing challenges related to financial insecurity. For example, including considerations related to cost of treatment regiments when developing an individualized management plan²⁶ may be especially important for adults with COPD who are more likely to experience financial insecurity.

Similar to our study, other population-based studies have demonstrated significant associations of COPD status with indicators of housing and food insecurity.^{17, 18} For example, Charkhchi et al.,¹⁸ similarly analyzed BRFSS data (2015 data from 11 states and one territory); however, their prevalence estimates were higher than ours (51% of adults with COPD were classified as experiencing housing insecurity and 44% with food insecurity).¹⁸ However, that study used different measures of housing insecurity (defined as they usually, always, or sometimes in the past month were worried about having enough money to pay rent/mortgage) and food insecurity (defined as they usually, always, or sometimes in the past month were worried about having enough money to buy nutritious meals) that may explain some of the difference in estimates. There are multiple ways to measure these indicators and the measure selected can greatly influence estimates.^{27, 28} Regardless of the measure used, studies have consistently identified persons with COPD as an important priority group for strategies addressing these social determinants of health.

Over 1 in 4 adults with COPD reported feelings of stress most or all the time, while this prevalence was 1 in 8 among adults without COPD. Findings highlight the importance of including coping strategies within COPD management programs, including self-management, to address the higher levels of stress that those with COPD may be more likely to experience. Examples of topics to cover may include relaxation techniques, communicating effectively with family, friends, and health professionals, and techniques to deal with problems such as frustration, fatigue, pain, and isolation.²⁹ Findings demonstrated adjusting for economic instability attenuated the unfavorable association between COPD and higher levels of stress (i.e., were explanatory factors); therefore, incorporating strategies to help address issues of economic instability may help to reduce feelings of stress in persons with COPD. Future studies may also aim to examine the role unhealthy behaviors and behavior change may play in moderating or mediating the role between COPD and stress.

International and U.S. national committees and initiatives have provided guidance on approaches to address social determinants of health, including economic instability.^{30, 31} In addition, several reviews and scientific statements have focused on the importance of social determinants of health in patients with chronic conditions, such as cardiovascular disease, heart failure, diabetes, and cancer.^32–35 Assessment of the social determinants of health has been identified as an important first step to addressing these issues in the clinical setting.³¹ Similarly, the Global Strategy for the Diagnosis, Management, and Prevention of Chronic Obstructive Lung Disease recommends a detailed medical history of any patient who is known, or suspected, to have COPD should include an assessment of the impact of disease on patient’s life, including limitation of activity, missed work and economic impact, and feelings of depression and anxiety.²⁶

Financial, housing, and food insecurity, as well as more frequent feelings of stress, were more prevalent in adults with COPD than without. Findings highlight the importance of tailoring disease management plans to address the increased levels of economic instability and feelings of stress that persons with COPD may be more likely to experience. In addition, including strategies to specifically address economic instability and reduce stress may be especially important for COPD management programs.