Financial, housing, food, and healthcare insecurities and their independent and joint associations with depressive symptoms and stress in a U.S. cohort of adults with and without HIV

Financial, housing, food, and healthcare insecurities are prevalent forms of material-need insecurity (MNI) in the U.S. that often co-occur, with significant consequences for health. We investigated how these MNIs overlap and relate jointly and independently to mental health among people with and without HIV enrolled in the MACS/WIHS Combined Cohort Study (MWCCS). Confirmatory bifactor analyses were used to examine how much unique variability remained in subfactors for financial, housing, food, and healthcare insecurities after accounting for common, underlying material hardship, described herein as overall MNI severity (n = 2433). Structural equation models tested how overall and specific MNI severity relate independently to depressive symptoms, as measured by the Center for Epidemiologic Studies Depression scale, and perceived stress, as measured by the Perceived Stress Scale, adjusting for income and other socioeconomic covariates. Most of the variance in financial (76.2%), housing (88.7%), food (55.7%), and healthcare insecurity (64.4%) was explained by overall MNI severity, which was strongly related to depressive symptoms (standardized β: 0.508, SE: 0.028, p < 0.001) and perceived stress (standardized β: 0.538, SE: 0.026, p < 0.001). Independently of overall MNI severity and each other, the specific subfactors had additive associations with depressive symptoms and stress. In summary, financial, housing, food, and healthcare insecurities were strongly interrelated, and both their overlapping and distinct characteristics related independently and additively to depressive symptoms and perceived stress. These findings highlight the value of moving beyond studying MNIs in isolation to examining the health consequences of co-occurring MNIs and developing interventions and policies that improve multiple forms of MNIs simultaneously.