A rapid review of initiatives to address financial strain and wellbeing in high-income contexts July 2023, Volume 33, Issue 2

Introduction

Financial circumstances have a direct impact on health outcomes in adults and children.^1-3 Financial strain, more specifically, is associated with poor physical and mental health^1-3 and work absenteeism.⁴ Financial strain describes the stress of worrying about an imbalance between income and expenditures.⁵ In contrast, financial wellbeing indicates an absence of financial strain where a person has financial security now and in the foreseeable future.⁶ Financial strain is conceptually similar to financial distress, stress, economic strain, financial health, and financial wellbeing. It differs, however, from poverty, indebtedness, employment status, and income, which categorise people’s financial status based on quantifiable measures of their financial circumstances.⁵ Financial strain has an impact on health independent of these measures.^7,8 It can lead to the deterioration of self-esteem and social relationships.^5,9

The link between financial strain and health is an emerging area of research and practice in public health.^5,10,11 As a result, there is a lack of evidence focused on initiatives addressing the structural and systemic factors underpinning financial strain.¹² Instead, individual-level behavioural interventions predominate.¹² The coronavirus 2019 disease (COVID-19) pandemic highlighted the way in which structural factors (e.g. pandemic policy-making) can determine health, social, and economic outcomes..¹³ Governments and organisations acted – to varying degrees – to stem the growing inequities and support people’s health and overall wellbeing, economic and otherwise, during the pandemic.¹⁴ Although many jurisdictions have now shifted to a ‘living with COVID’ period, there remains an urgent need for initiatives to address ongoing financial strain, which disproportionately impacts systemically excluded groups.¹⁵

This review was part of a larger project that created a practice-oriented framework¹⁶ and a guidebook of strategies and indicators¹⁷ to promote financial wellbeing, informed by a public health perspective.¹⁶ To ground the development of the framework and guidebook to promote financial wellbeing, we conducted a rapid review to identify and describe initiatives targeting personal and household financial strain and wellbeing in high income economies.¹⁸ We applied an equity lens¹⁹ to understand factors related to equitable impact and identify literature gaps.

Methods

We have published the methods for the broader project elsewhere.^16,17 For this study, we followed rapid review methods²⁰ and applied an equity lens²¹ to conduct an inductive narrative synthesis²² of the literature. We took a systematic approach to the search strategy using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines²³ and conducted separate searches for peer-reviewed and practice-based literature. We conceptualised financial strain as a present, subjective aspect of financial wellbeing, where the presence of financial strain indicated a lack of financial wellbeing.⁶ The term ‘initiative’ is used to describe different actions taken to promote financial wellbeing, and is herein used to describe such actions. However, various terms were used in our search strategy to identify relevant papers (See Supplementary Tables 1 and 2, available from: doi.org/10.6084/m9.figshare.23120978).

Peer-reviewed literature search strategy

We conducted a search of the following databases for studies published between 2015 and August 2020: MEDLINE, PsycINFO, and Web of Science (Social Science Citation Index) using a two-concept search: i) financial strain and/or financial well-being; AND ii) initiative. We added the following limits to the search: English-language and full-text available. A research librarian designed and ran the searches on 13 August 2020. Details and results are provided in Supplementary Table 1 (available from doi.org/10.6084/m9.figshare.23120978).

Practice-based literature search strategy

We conducted a search for practice-based sources using two databases (ProQuest and Informit) and filtered the search results by source type (e.g., reports, other articles). We adapted the search terms and limitations used in the peer-reviewed strategy to create a set of search strings (See Supplementary Table 2, available from doi.org/10.6084/m9.figshare.23120978) that we input into Google Advanced search. We executed the searches using the ‘private’ browser setting and reviewed the first 200 hits. The search was limited to sources published in or after 2015. We took an iterative approach to the search and continued until new searches were not retrieving many new, potentially relevant sources.

Inclusion and exclusion criteria

We applied the following inclusion criteria to all sources: i) evaluated an initiative targeting financial strain or financial wellbeing; ii) high-income context¹⁸; iii) published after 2015; and iv) English. We excluded sources if i) they were reviews, study protocols, commentaries, editorials, books, or theses; ii) they did not describe the results of an initiative, including empirical research on a process or outcome evaluation of an initiative using qualitative, quantitative, or mixed-methods, or had a companion source with information about an evaluated initiative; iii) the primary focus of the initiative was not financial strain and/or financial wellbeing as defined for this study; or iv)  they did not have the potential to contribute meaningfully to answering the research question.

Study selection

We uploaded the retrieved peer-reviewed sources to EPPI-Reviewer software (Version 4) for title/abstract and full-text screening. Using the inclusion and exclusion criteria, two independent reviewers conducted title and abstract screening, any discrepancies were discussed, and a consensus was reached. We followed the same process for full-text article screening. Three reviewers piloted the screening process to assess reliability before we proceeded. We discussed discrepancies among at least two independent reviewers to reach a consensus. To ensure the diversity of the sources and alignment with the research purpose, we prioritised sources for final inclusion that reported on initiatives in: Canada, Australia, and non-US developed economies; in rural locations; targeting Indigenous peoples, Native Americans, and/or Aboriginal peoples; and, representing a diversity of settings, levels, types, and targets.

For the practice-based sources, a single reviewer conducted the primary screening against the inclusion and exclusion criteria based on the title and/or link and text available on the search engine home site. For this reason, we undertook the search and primary screening simultaneously for practice-based sources. We reviewed the first 200 hits retrieved through each search and recorded full-text sources in an Excel sheet. A single reviewer screened all full texts of practice-based sources, and a 10% sample was reviewed by an additional reviewer.

Quality & relevance appraisal

We used the Mixed Methods Appraisal Tool (MMAT)²⁴ to describe the quality of peer-reviewed sources that reported on empirical research. None of the peer-reviewed sources were excluded based on the response to the MMAT screening questions.

Data extraction & synthesis

We created a detailed data extraction tool using EPPI-Reviewer to capture the initiative level, type, design, and context (e.g. setting, environment). We extracted data related to health equity using the principles defined by the Public Health Agency of Canada tool to develop equity-sensitive initiatives.^19. We included: equity objectives, social determinants of health (SDoH), and equity target (i.e. whether the initiative was universal, targeted, or proportionate in its delivery)¹⁹, and if the targeted population included systemically excluded groups such as racialised and/or Indigenous peoples, women, and recently arrived immigrants The ‘effectiveness’ of initiatives was not explicitly analysed. Rather, where outcomes of initiatives were reported in studies, these were captured and included in the synthesis. Results of an in-depth critical realist analysis of included papers are reported elsewhere.²⁵

Results

A total of 4385 peer-reviewed sources were included in primary screening, with title screening n= 3516) and abstract screening (n = 261) completed in separate steps. For practice-based sources only the first 200 hits of each search string were included (see Supplementary Table 2 for practice-based search strategy, available from doi.org/10.6084/m9.figshare.23120978), leaving a total of 394 practice-based sources that were included in primary screening, whereby titles and abstracts were screened in the same step. After primary screening was complete a total of 182 sources remained which were included in the full text review (peer-reviewed n = 87; practice-based n = 95). Once full texts were reviewed against our selection criteria, and relevance to our research question, a further 107 sources were excluded, leaving 75 sources (peer-reviewed n = 39, practice-based n = 36) in the final extraction.  We outline the process and reasons for exclusion in Figure 1. A brief description and summary of characteristics for all included sources are provided in Supplementary Tables 3 (academic sources) and 4 (practice-based sources, available from doi.org/10.6084/m9.figshare.23120978). References for all papers included in the review process are listed in Supplementary Table 5 (available from doi.org/10.6084/m9.figshare.23120978). Most sources used a quantitative approach, including non-randomised (n = 23), randomised controlled trial (n= 4), descriptive (n = 4), and natural experiment (n = 1) designs; followed by mixed-methods (n = 27) and qualitative (n = 16) designs. The study design was unclear for four practice-based sources due to the lack of methods descriptions.^{S2,S60,S63,S67}

Figure 1.     PRISMA flow chart of included sources (click figure to enlarge)

PB = practice-based sources; PR = peer-reviewed sources

Most sources were from Australia (n= 25), the US (n = 24), and Canada (n = 10), followed by the UK (n = 6) and the EU-27 (i.e., all European Union countries together) (n = 2). The remaining sources (n = 10) were located in the following countries: Switzerland, Denmark, Spain, Austria, Sweden and New Zealand. Where identified, initiatives were largely undertaken in urban (n = 34) compared to rural (n = 11) environments. We classified the initiatives by setting, which included society (i.e. policy or government) (n = 33), community (e.g., local, neighbourhood) (n = 27), school (n = 3), healthcare (n = 3), and workplace (n = 1). The setting for six initiatives was unclear, and two took place in multiple settings.

Figure 2 shows the characteristics of source initiatives and their target populations in relation to the equity principles previously defined.^19,21 In many sources, the initiatives targeted multiple areas or foci. In terms of equity orientation¹⁹, we found that the source initiatives were mainly targeted (i.e. focused on distinct populations) (n = 27), followed by universal (i.e. focused on everyone) (n = 11), and studies combining universal and targeted initiatives (n = 10). Initiatives were largely balanced between downstream (i.e., focused on behaviour change) (n = 32) and upstream (i.e., focused on changing socioeconomic environments) (n = 32 actions; with the majority (n = 56) focused on systemically excluded populations. Systemically excluded populations broadly included people with low or no income, including people facing unemployment (n = 29), and more specifically: people experiencing or at risk of homelessness (n = 9); Indigenous peoples (n = 5); older people (n = 5); single mothers (n = 3); people experiencing disability (n = 3); caregivers (n = 3); refugees and immigrants (documented and undocumented) (n = 3); and children and youth in or leaving out-of-home care (i.e., transitioning out of care) (n= 2).

Figure 2.     Characteristics of source interventions and target groups for interventions

2a)    Target population for included studies (N = 75) (click figure to enlarge)

2b) Target area for included studies (N = 156^a) (click figure to enlarge)

^a  Some of the 75 included studies targeted multiple areas and are represented in more than one category.

2c)    Intervention setting for included studies (N = 75) (click figure to enlarge)

Figure 2c) Intervention setting for included studies (N = 75)

2d)    Intervention level for included studies (N = 75) (click figure to enlarge)

Intervention impacts on financial wellbeing

Financial literacy initiatives (n = 41) were the most prominent target area (Figure 2), and these targeted individual behaviour change. The reported effectiveness of financial behaviour change initiatives was limited, particularly where they were not paired with wrap-around services addressing structural inequity related to, for example, housing, education and unemployment. Key areas that determined the reported effectiveness of financial literacy initiatives included awareness of and access to financial knowledge, as well as advice on how to manage credit and debt^{S4,S7,S14,S26,S60,S62,S72}; resilience and confidence building^{S4,S7,S11,S12,S14,S74}, self-identified need for financial assistance^{S12,S14,S26,S62}, and, self-perception of financial progress, future, and goals.^{S4,S7,S12,S15,S16,S60,S62,S72} In the US, a person’s debt/credit score also impacted financial decision making, which had a subsequent consequence on the reported effectiveness of individualised programs.^{S16,S60,S68,S69}

Initiatives targeting personal/family finances (n = 39) were also prominent and included cash benefits, welfare payments, and income management. Strong social welfare benefits, including universal and targeted types of social equity policies that covered or extended beyond basic needs and had minimal contingencies and barriers to access, positively impacted financial wellbeing. This was particularly so among systemically excluded groups^S24, non-citizen and racialised immigrants^S75, and older women.^S37 Conditions that constrained the accessibility and reported the effectiveness of social welfare benefits included: the rising pension age^S2; work for welfare programs^{S5,S21,S23,S24,S30}; mandatory attendance at job seeking meetings and complex administrative requirements^{S6,S10,S25,S59}; citizenship and immigration status-related restrictions^S75; tax-exemption-based benefits prioritising two-parent families.^S13 Other factors reported to have impacted the effectiveness of these benefits were: breadwinner-based family and labour policies that incentivised traditional gender roles and women’s dependence (e.g., household taxation, preferential training/employment for men)^S37; and eligibility requirements that did not consider complex social locations including Indigenous peoples^S5,S59; asylum seekers^S1,S57; people who experience homelessness^S57; undocumented immigrants^S75; caregivers^S27,S20; and mothers^S32,S37,S21, including single mothers.^S13,S25

All but one of the initiatives^S43 that targeted employment (n = 18) incorporated other components. In most cases, employment was paired with initiatives to address personal/family finances (including the provision of social welfare).^{S4,S5,S10,S18,S21,S22,S43,S45,S46,S54,S66,S73} However, some initiatives providing financial literacy^{S9,S21,S46,S33,S4,S10,S11,S35,S53}, education, social support^{S21,S22,S10,S11,S63}, housing^{S22,S4,S11,S10,S63}, healthcare^S4,S18,S22, and caregiving^S4,S45, also included an employment component. In the US, providing standalone financial coaching services among unemployed people was reported ineffective unless paired with employment support.^S68 Coupling social welfare benefits with employment conditions and outcomes created barriers to promoting financial wellbeing. In the US, a conditional cash transfer initiative with strict employment conditions that occurred during the 2007–2009 recession^S18 and a homeownership program (Housing Plus)^S51 created barriers leading to participant disengagement and dropout. Two examples from Australia that coupled social welfare (cash benefits) with employment outcomes among remote Indigenous peoples^S5, and single mothers^S25, increased impoverishment, stress, and anxiety among recipients.

We noted that housing (n = 13) and education (n = 12) initiatives were less prominent than employment and individual/household finance initiatives (Figure 2), despite being associated with improvements in financial wellbeing, particularly when part of a holistic or wrap-around approach. Housing initiatives included assistance in securing housing for homeless people^S56, interest-free loans^S33 or bursary payments^S11,S63to cover rent and housing expenses, subsidised housing^S10,S42,S22, shared homeownership^S65, and a US-based wrap-around home ownership support program known as Housing Plus^S51 (i.e., low mortgage rates, escrow savings, matched down payment savings, education, financial inclusion).^S51 In general, longer-term housing initiatives were more impactful than short-term programs to promote housing security and financial wellbeing.^S10,S22,S42Initiatives that improved access to education also positively impacted financial wellbeing. These included: a bursary program for young Australian caregivers that allowed participants to study and work towards sustainable employment^S27; a wrap-around service linking people leaving out-of-home care with free community college courses^S63; and an early life education initiative that promoted cumulative socioeconomic advantage.^S50 A financial coaching initiative that also provided literacy and numeracy training contributed small increases (12%) in job placement rates, hourly wages, and net monthly income.^S35

A limited number of sources we reviewed included a component supporting access to healthcare (n = 8). In the US, a study reporting extended access to Medicaid via the Patient Protection and Affordable Care Act (known as.”Obamacare”) had a beneficial impact on healthcare-related financial strain and economic uncertainty of people at up to 199% above the Federal poverty line, demonstrating its positive equity impact.^S41 A US policy providing comprehensive caregiver support to the partners of injured veterans, including access to physical and mental healthcare, positively impacted financial strain.^S55 However, strict eligibility criteria hampered participation in the program. Two Australian initiatives that included a component facilitating access to healthcare for at-risk youth^S10 and recent immigrants and refugees^S57 reported positive impacts on physical and financial wellbeing.

Identified literature included initiatives targeting social support (e.g., connecting people with social services) (n = 8) as part of multifaceted initiatives.^{S19,S21,S48,S10,S11,S56,S63} All but two^S19,S21of these focused on housing initiatives to improve financial wellbeing^{S22,S48,S10,S11,S56,S63}among people with little to no income^S21, those experiencing or at risk of homelessness^{S19,S22,S11,S56}, and/or involved people living in out-of-home care.^S10,S63

Discussion

This rapid review aimed to identify and describe peer-reviewed and practice-based literature that evaluated community-led and government initiatives targeting financial wellbeing and financial strain in high-income economies. We also assessed the initiatives through an equity lens. The review showed that initiatives seeking to improve financial wellbeing were largely focused on financial capability – including financial skills, knowledge, and attitudes – and targeted individual behaviour change. This aligns with previous research conducted in the area.^12,26 However, evidence from the included sources highlighted the limitations of these initiatives when not coupled with other components addressing structural inequity with regard to having a long-term positive impact on financial wellbeing or financial strain. A systematic review²⁷ examining the equity impact of various interventions reported that ‘downstream’ behaviour change initiatives did not reduce health and social inequities and might even exacerbate them. Despite evidence demonstrating that complex system-focused solutions can potentially reduce inequities more sustainably than individual behavioural initiatives²⁸, the latter remains socially and politically attractive because it places the responsibility for change on the individual rather than the government, systems or society. The review showed that initiatives that applied holistic and flexible approaches, including structural approaches – such as addressing housing factors – were reported to be effective in enhancing the accessibility of services and benefits and providing longer-term pathways toward sustained financial wellbeing. Holistic initiatives often included wrap-around support and/or bundled multiple services into one program (e.g. food, clothing)^S10, ‘living skills’ development^S4,S11, or education pathways.^S22

In this review, we identified several equity-relevant^19,21gaps in the literature. Specifically, evaluations of initiatives targeting financial wellbeing rarely assessed outcomes related to equity-relevant social locations and/or SDoH, including age, ability, and race. This is unsurprising, given that many countries do not collect robust data to enable disaggregation by disability²⁹ or race/ethnicity.³⁰ Issues surrounding data disaggregation and equity became markedly apparent at the onset of the COVID-19 pandemic, where a lack of visibility and representation heightened risk and impacted health and economic response planning.^30,31 Many sources assessed outcomes related to education level and/or sex. To ensure equitable approaches to policy and planning now and in the future, we suggest that data on outcomes and impacts of interventions be disaggregated by age, ability, and race, in addition to gender identities and education.

Overall, we found that initiatives accounting for diverse cultural values were received positively^S26,S71,S66, and were in some instances reported to be effective in reducing short-term financial strain.^S71 Yet few initiatives were tailored to racially minoritised populations – specifically Black, Hispanic, or Indigenous peoples^S5,S18,S32– despite the over-representation of these groups among people experiencing financial strain. In addition, COVID-19 has exacerbated health³² and economic³³ risks among these groups. We found that initiatives targeting financial behaviour change had a relative over-representation of participants who were racialised primarily Black and Hispanic, with these groups comprising up to 70% of initiative participants^{S16,S68,S39,S61,S69,S70}, yet they failed to tailor initiatives to the complex sociocultural needs of these groups. Moreover, there were no Canadian initiatives identified that were created for Indigenous peoples, even though approximately one-quarter of urban Indigenous peoples in Canada live in poverty.³⁴

Our review identified a lack of community-led and participatory-based initiatives. Previous reviews in health and policy have reported that collaboration and participatory approaches support cultural appropriateness, enhance recruitment, build capacity, minimise health inequities, and lead to community-level action to improve wellbeing.³⁵ To adequately promote financial wellbeing in a way that is culturally responsive, relevant, and effective³⁶, more robust literature is required on the specific needs and approaches to initiatives that account for complex and intersecting social locations among systemically excluded populations, as well as initiatives undertaking participatory approaches.

We found few initiatives that focused on rural populations. Living in rural communities can compound social, economic, and health inequities, including people having access to fewer employment opportunities and healthcare. One of the reviewed sources^S5 highlighted the negative impact of pairing employment outcomes with social welfare benefits in rural Indigenous Australian communities experiencing chronic job shortages and unemployment. Socioeconomic disadvantage experienced by people who live rurally is also associated with poorer health outcomes in high-income contexts, including increased mortality. This is often attributed to decreased access to health and social services.^37,38 Based on the results of our review, we suggest an increased focus on the financial wellbeing of rural communities. This should include careful consideration of structural factors such as the availability of employment opportunities and accessibility of resources and services.

Evaluating initiatives and programs is crucial to understand effectiveness, refining their delivery, and incorporating an evidence-informed approach. A source from the practice-based literature that evaluated a government-based welfare-to-work initiative for single mothers reported the negative impact of pairing employment outcomes with cash benefits.^S25 This highlights the importance of evaluation and publication of the results. Nevertheless, several sources we reviewed did not undertake evaluation due to reported funding restrictions^S10,S63,S56, emphasising the need to incorporate evaluation into the initial program design.

Very few sources we reviewed evaluated the impact of policies and programs that were introduced to improve financial wellbeing and reduce financial strain in response to COVID-19. This was due to the timing of our investigation, which took place in the first year of the pandemic. Understanding the impact of these policies and practices will strengthen the evidence base for initiatives related to pandemics like COVID-19. It will also add to the literature on initiatives to promote financial wellbeing, which will be required to inform policy and programs now as many jurisdictions focus on ‘recovery’.

Limitations

To remain within the scope of a rapid review, we limited included studies by date and country. These restrictions may have introduced bias into the sources and excluded potentially relevant initiatives elsewhere. Our analysis was based on author-reported outcomes, and we did not conduct an independent review of initiative effectiveness due to the heterogeneity of studies included in the review. We acknowledge that financial strain is a prevalent and pressing issue in low- and middle-income countries that requires targeted attention. Our selection criteria was based on capturing sources that were most relevant to our research question, and captured a diversity of populations and initiatives while remaining within the scope of the rapid review. Using this purposive sampling approach may have influenced the transferability of the results.

Conclusion

We found that holistic initiatives were aligned with positive financial wellbeing and financial strain outcomes, as reported in the reviewed studies. Before targeting financial skills development, holistic initiatives ensured people’s basic needs, such as housing, food, and clothing, were met while considering SDoH, such as job opportunities. Downstream behaviour change initiatives that were not paired with wrap-around components targeting people’s basic needs were severely limited in effectiveness, as reported by reviewed studies, particularly among groups experiencing multiple forms of inequity that intersect (e.g. age, ability, and race).

We noted significant gaps in the literature related to equity. Limited initiatives included in the reviewed sources were specifically targeted and tailored for systemically excluded groups that are over-represented among people experiencing financial strain, such as racialised communities, Indigenous peoples and rural dwellers. We also identified a lack of robust evaluative data reporting the long-term impact of financial strain and financial wellbeing initiatives. More research using an equity-focused public health lens is required to understand what works for whom, how, and under what conditions to ensure an equitable approach to policy and practice to address financial wellbeing. Strong welfare and labour policies remain key to curbing increasing inequity in the present context of ‘living with COVID-19’ and its enduring physical (e.g. long-COVID) and socioeconomic effects within groups already experiencing disadvantage.³⁹

Acknowledgements

This work was funded by the Canadian Institutes for Health Research (#172694).

We acknowledge Krystyna Kongats, Kayla Atkey, Lisa Allen Scott, Stephanie Montesanti, Jane Springett, Elaine Hyshka, Roman Pabayo, and Laura Nieuwendyk for their contributions to the research project encompassing this review. We wish to acknowledge Meghan Sebastianski (PhD) and Diana Keto-Lambert (MLIS) from the Alberta Strategy for Patient-Oriented Research (AbSPOR) SUPPORT Unit Knowledge Translation Platform for their assistance in designing and conducting the searches for the academic literature and providing guidance on the practice-based search.

Peer review and provenance

Externally peer reviewed, not commissioned.

Copyright:

© 2023 Yashadhana et al. This work is licensed under a Creative Commons Attribution-NonCommercial-ShareAlike 4.0 International Licence, which allows others to redistribute, adapt and share this work non-commercially provided they attribute the work and any adapted version of it is distributed under the same Creative Commons licence terms.