# The role of hopelessness in mediating the relationship between income loss and delaying and foregoing healthcare: Evidence from repeated cross-sectional waves of the Household Pulse Survey

## TL;DR

This study shows that losing income during the pandemic increases feelings of hopelessness, which in turn leads people to delay or avoid healthcare.

## Contribution

The study identifies hopelessness as a key mediator linking income loss to healthcare avoidance during the pandemic.

## Key findings

- Income loss significantly increases hopelessness (OR=1.68).
- Hopelessness is strongly linked to delaying or foregoing healthcare (OR=4.18).
- Hopelessness mediates about 30% of the effect of income loss on healthcare access.

## Abstract

Research has documented direct negative impacts of crises, such as COVID-19, on people’s mental health. However, evidence is limited about how these events impact decision-making through direct influences on choices, or by indirectly changing decision-making through mental health effects. Research on avoidance behaviors suggests that affective states influence decisions to access healthcare and receive diagnoses. While there is significant evidence that hopelessness related to a potential health threat impacts decisions to learn about that threat, affective responses to crises may also cause spillovers to decision-making in other domains. In this study, we examine linkages between exposure to a stressor (COVID-19-related income loss), feelings of hopelessness, and foregoing or delaying healthcare across multiple cross-sections of the US Census’s Household Pulse Survey, featuring 2.76 million survey responses collected between April 23, 2020, and July 5, 2021. After removing observations with missing data for dependent variables, the final sample size is just under 2.3 million responses. We conduct ordered logistic regressions of the relationship of income loss with hopelessness levels, and logistic regression of the relationship of income loss and hopelessness levels on health care access. We additionally report versions of the regressions with demographic variables and time and state fixed effects to control for important factors related to those variables. We conduct a mediation analysis to estimate the pathway of income loss acting through hopelessness. The analyses find that experienced income loss predicts significantly higher levels of hopelessness (odds ratio (OR)=1.68 (95%CI = 1.67, 1.69)). Both hopelessness and income loss are, in turn, associated with healthcare access—an increased likelihood of foregoing and/or delaying needed medical care (e.g., hopelessness nearly every day (OR=4.18, 95%CI = 4.13, 4.23), experienced income loss OR=1.25, 95%CI = 1.24, 1.26)). A mediation analysis confirms that hopelessness significantly and consistently mediates approximately 30% of the relationship of COVID-19 income loss to foregoing/delaying healthcare.