Beyond income: financial hardship as a pathway from socioeconomic disadvantage to depression among middle and older cancer survivors

Abstract

BACKGROUND: Depression disproportionately affects older cancer survivors with fewer socioeconomic resources, yet the mechanisms underlying this disparity remain under-explored. Guided by Fundamental Cause Theory, this study examined whether financial hardship mediates the relationship between socioeconomic status (SES) indicators, education, income, and wealth, and depressive symptoms among older cancer survivors in the United States. METHODS: Data were drawn from the Health and Retirement Study (2012-2018). The analytic sample comprised 1,520 cancer survivors aged 50 and older. A seven-item latent financial hardship variable was developed. Structural equation modeling with weighted least squares estimation was employed under a complex survey design to test direct and indirect effects of SES indicators on subsequent depressive symptoms through financial hardship, controlling for demographic, health, and cancer-related characteristics. RESULTS: The measurement model demonstrated excellent fit (CFI = .997; TLI = .995; RMSEA = .031). In the structural model, income and wealth were fully mediated by financial hardship in their associations with depression, while education exhibited partial mediation with both direct and indirect pathways. Younger age at cancer diagnosis and more recent diagnoses were significantly associated with greater financial hardship. Financial hardship was a significant predictor of subsequent de-pressive symptoms (β = 0.213, p < .001), and the model explained 36.2% of the variance in depression. CONCLUSIONS AND IMPLICATIONS: Financial hardship operates as a critical intermediary mechanism linking socioeconomic disadvantage to depression among older cancer survivors, suggesting that interventions targeting financial hardship may help reduce mental health disparities in this population. IMPLICATIONS FOR CANCER SURVIVORS: These findings indicate that the emotional toll of socioeconomic disadvantage operates largely through the concrete experience of financial hardship, such as difficulty affording necessities, medical costs, and other material demands. Because financial hardship is more immediately modifiable than underlying socioeconomic position, it offers a practical point of intervention. Routine screening for financial hardship in survivorship care, coupled with referral to financial navigation, benefits counseling, and cost-of-care support services, may help identify survivors at elevated risk of depression who might otherwise go unrecognized. Our findings further suggest that survivors relying on Medicare without supplemental coverage may warrant particular attention, as gaps in coverage can expose them to financial strain that income alone does not capture. Addressing material hardship may thus represent a concrete avenue for reducing socioeconomic disparities in mental health among older survivors.