Financial health as a measurable social determinant of health.

OBJECTIVES: Financial health, understood as one's ability to manage expenses, prepare for and recover from financial shocks, have minimal debt, and ability to build wealth, underlies all facets of daily living such as securing food and paying for housing, yet there is inconsistency in measurement and definition of this critical concept. Most social determinants research and interventions focus on siloed solutions (housing, food, utilities) rather than on a root solution such as financial health. In light of the paucity of public health research on financial health, particularly among low-income populations, this study seeks to: 1) introduce the construct of financial health into the domain of public health as a useful root term that underlies other individual measures of economic hardship and 2) demonstrate through outcomes on financial, physical and mental health among low-income caregivers of young children that the construct of financial health belongs in the canon of social determinants of health.
MATERIALS AND METHODS: In order to extract features of financial health relevant to overall well-being, principal components analysis were used to assess survey data on banking and personal finances among caregivers of young children who participate in public assistance. Then, a series of logistic regressions were utilized to examine the relationship between components of financial health, depression and self-rated health.
RESULTS: Components aligned with other measures of financial health in the literature, and there were strong associations between financial health and health outcomes. PRACTICE IMPLICATIONS: Financial health can be conceived of and measured as a key social determinant of health.

Introduction

Exposure to prolonged economic hardship has detrimental impacts on individual health and well-being [1-8]. Despite the widespread acceptance of economic hardship as a social determinant of health, the way it has been measured is restricted to income in relation to the federal poverty line (FPL) or to issues related to housing insecurity, food insecurity, healthcare tradeoffs, and other measures related to tangible basic needs [2, 9–12]. Comprehensive solutions, such as efforts to improve financial capability (known as a combination of self-efficacy, skill, attitude, and knowledge needed to make financial decisions) [13], build assets to protect from financial shocks, and reduce income volatility are missing from public health research [14-17]. As well, interventions tend to be “siloed.” That is, they address access to safe and affordable housing, medical care, and food in distinct interventions without addressing financial health, or the longer-term and underlying issues of having enough money, income, or financial capability [3, 18, 19]. Financial health is a comprehensive assessment of finances that includes the ability to support meeting basic needs, which also encompasses opportunities to save and build wealth. Building on research on associations between income and physical health [8, 20, 21], this work demonstrates that financial health is an important, independent social determinant of health that can be defined, measured, and influenced to improve health and wellbeing.

Financial health in the literature

Although the concept of financial health (or financial well-being) has been discussed for several decades, most literature on the subject lies outside the public health domain, and definitions (if present) vary from source to source. Often, if a definition is provided, such as in gray literature, details on the measurement or operationalization of this concept are scarce, or the measurement is relating to a narrow aspect of a family’s financial situation such as income level or employment. Despite this, some recent studies have tied specific measures of financial health with health outcomes [6–8, 19, 21]. For example, several researchers found associations between financial distress or well-being and perceived health [22-24] and mental health outcomes [25]. Additionally, several studies have examined links between health and financial literacy [26], as well as financial stress and mental and physical health outcomes. However, the majority of these studies lie outside of public health journals, and definitions or measurements of ‘financial health’ [27-29], ‘financial well-being’ [25, 30, 31], ‘financial well-ness’ [32], or ‘financial fitness’ [33] are inconsistent across studies. This poses challenges, such that the domains where most of the financial health studies are located (i.e. consumer finance) often do not target interventions for lower-income populations or under/un-banked populations. Moreover, they do not create opportunities for interdisciplinary interventions aimed at improving physical and mental health.

Experiences of economic hardship such as housing and food insecurity are symptoms of a deeper hardship in financial health. Fig 1 depicts how the authors conceptualize how financial health is related to other forms of economic insecurity (housing insecurity, food insecurity, energy insecurity) such that it is a root cause of these other insecurities. Efforts to create meaningful opportunities to increase wealth in order to improve food security, housing security, and other economic hardships have been limited by the lack of consistent, validated measures and definitions of individual financial health [31, 34–37].

Fig 1

Financial Health underlies other economic social determinants.

For instance, Netemeyer et al. [38] identified two dimensions of financial “wellbeing” (characterizing the dynamic relationship between finances and well-being): behaviors like managing the day-to-day and planning, and perceptions such as “a state of being wherein you have control over day-to-day, month-to-month finances […] have the financial freedom to make the choices that allow one to enjoy life.” The Center for Financial Services Innovation (CFSI) established a definition and measure of financial health based on a mixed-methods study examining financial habits (cash flow, spending, income volatility, savings, investments, etc.) among moderate-income families [39], stating financial health consists of effective management of day-to-day financial decisions; resilience in facing “ups and downs”; and ability to seize opportunities for financial security and mobility” [40].

In light of the paucity of public health research on financial health, particularly among low-income populations, this study seeks to: 1) introduce a construct of financial health into the domain of public health defined by more than just individual measures of economic hardship, and 2) demonstrate via models on financial, physical and mental health among low-income caregivers of young children that the construct of financial health belongs in the canon of social determinants of health.

Methods

Study sample

The Building Wealth and Health Network (The Network) began as a randomized controlled trial in 2014 (N = 103), operating out of Drexel University in Philadelphia, PA. The Network continued as a single arm intervention study (Phase II; N = 373); a trauma-informed peer support financial empowerment program to address depression and economic hardship through building social capital and financial capability among caregivers of children aged 6 years or younger. All participants in The Network were referred to as “members” to reflect the peer format nature of the program to foster social capital, connection and belonging. Network members attended 16 Financial SELF Empowerment Group sessions on financial topics including building and fixing credit, reducing debt, and encouraging entrepreneurship, while also creating a culture of healing through peer support around issues of safety, emotional management, loss and letting go, and developing a sense future. Members received support in opening a savings account with a partner credit union. Members responded to surveys at baseline, and every three months for a year about economic securities, employment, finances, entrepreneurship, depression, and child health. All members provided written informed consent. Full methods and outcomes [41-44] of the Network can be found elsewhere [45]. The Drexel Institutional Review Board approved this study.

Economic hardship and financial measures

As mentioned above, the Center for Financial Services Innovation (CFSI) developed a definition and measure for financial health for consumer finance in 2016. The CFSI identifies four components of financial heath that mirror daily financial activities: spend, save, borrow and plan. Indicators include paying bills on time and in full (spend), having sufficient long-term savings (save), having a prime credit score (borrow) and planning ahead for expenses (plan). CSFI components draw from banking and finance industry standards (e.g.: having a debt-to-income ratio below 36%, or a particular credit score) [40]. Given its comprehensive scope, the parameterization of financial health was guided by the CFSI. Finance-related questions were selected from The Network’s survey that matched face validity with the CFSI’s categories of spend, save, borrow, and plan, as well as their suggested survey questions [40]. This analysis focused on ability to pay bills (spend), having checking and savings accounts (save), borrowing money (borrow), and financial planning behaviors (plan) (Table 1). Two spending questions (e.g. “Over the past month, would you say your family's spending on living expenses was less than its total income?”, “Over the last 2 months, have you paid a late fee on a loan or bill?”) are from the Financial Behavior, Knowledge and Self-Efficacy Scale [46], which assesses respondents’ financial behaviors, knowledge and feelings of efficacy around financial decision-making, while the other two spending questions (e.g. “In the last three months, has the utility company shut off your utilities for not paying bills?” “In the last 3 months were there any days that the home was not heated or cooled because you couldn't pay the bills?”) are taken from a validated energy insecurity screener, but used in this analysis as indicators for inability to pay bills [47]. These spending questions were chosen as they aligned with the CFSI’s spending indicators (pay bills on time and in full, and spend less than you earn) as well as their suggested survey questions [40]. Questions relating to savings and checking accounts (e.g. “Do you have a savings account” and “Do you have a checking account”) were chosen as they aligned with savings [40]. Borrowing questions (e.g. “Do you owe anyone money?” and “In the last three months I repaid the money I owed on time”) aligned with CFSI’s borrow components and come from previous work [48] and Danes [46], respectively. The financial planning questions (e.g. “Do you currently have at least one financial goal?”, “Do you currently have a personal budget, spending plan, or financial plan?”, “Do you currently have an automatic deposit or electronic transfer set up to put money away for a future use?”) are from the Financial Behavior, Knowledge and Self-Efficacy Scale [46]. These questions were chosen as they matched face validity with the CFSI “planning” questions [40]. Affirmative answers scored one point, negative answers scored zero (e.g.: for “Do you have a savings account?,” a yes was scored 1, a no was scored 0). Some questions were scored in reverse in order to align behaviors across categories (e.g.: for the borrow question, “Within the last 3 months, I paid the money I owed on time” a yes was scored 0, a no was scored 1).

Table 1

Mapping of CSFI indicators with the Building Wealth and Health Network’s (The Network) survey questions.

Domain	CSFI Indicators	The Network Survey Questions
Spend	Spend less than you earnPay bills on time and in full	- Over the past month, would you say your family's spending on living expenses was less than its total income? (Yes = 0, No = 1)- Over the last 2 months, have you paid a late fee on a loan or bill? (Yes = 0, No = 1)- In the last three months, has the utility company shut off your utilities for not paying bills? (Yes = 0, No = 1)- In the last 3 months were there any days that the home was not heated or cooled because you couldn't pay the bills? (Yes = 0, No = 1)
Save	Have sufficient living expenses in liquid savingsHave sufficient long-term savings or assets	- Do you have a savings account? (Yes = 0, No = 1)- Do you have a checking account? (Yes = 0, No = 1)
Borrow	Have a sustainable debt loadHave a prime credit score	-Within the last three months, I repaid the money I owed on time. (Yes = 0, No = 1)-Do you owe anyone money? (please include banks, friends, family, payday lenders, etc) (Yes = 0, No = 1)
Plan	Have appropriate insurancePlan ahead for expenses	-Do you currently have at least one financial goal? (Yes = 0, No = 1)-Do you currently have a personal budget, spending plan or financial plan? (Yes = 0, No = 1)-Do you currently have an automatic deposit or electronic transfer set up to put money away for a future use? (Yes = 0, No = 1)

Energy insecurity was assessed by a validated scale [47] asking respondents to answer whether in the last 3 months: the gas/electric company sent a letter threatening to shut off service whether energy service was not delivered, the home was not heated/cooled, and whether the cooking stove was used to heat the home because the family could not pay heating bills. Housing insecurity was assessed with a validated scale [9, 49, 50] that measures access to adequate and stable housing, where housing insecurity is indicated by affirmative response to at least two of the following: overcrowding (more than two people per bedroom) or multiple moves (two or more moves in the previous year). Household food insecurity (HFI) within the last 30 days was assessed using the validated 18-item Household Food Security Survey Module [51].

Health and depression measures

Self-rated physical health was assessed with a question adapted from The National Health and Nutrition Examination Survey [52], where health is self-rated as “excellent,” “good,” “fair,” or “poor,” then categorized into excellent/good and fair/poor. Self-reported depressive symptoms were assessed using the Center for Epidemiological Studies-Depression Revised 10 (CES-D- 10) [53], a ten-item screening tool validated to assess risk for clinical depression with good sensitivity, specificity and high internal consistency [53]. The CES-D-10 measures depressive symptoms over the previous week: 0 = rarely or none of the time (<1 day), 1 = some or a little of the time (1–2 days), 2 = occasionally or a moderate amount of the time (3–4 days), and 3 = most or all of the time (5–7 days). The range of the 10-item scale is 0 to 30 and the recommended cutoff score of ≥10 was used to indicate presence of depressive symptoms.

Statistical analysis

For this analysis, the full Phase II baseline sample (N = 373) consisting of participants recruited between 2015–2017 was used. Members that responded to the finance-related questions described above, economic hardship (food insecurity, energy insecurity and housing insecurity), as well as metrics on self-rated health and depressive symptoms, were included in the analysis. To aggregate over the range of the original 10 survey variables comprised of economic hardship and financial questions (discussed above, see Table 2), principal components analysis (PCA) was used to reduce the variables into a smaller number of “dimensions” [54]. This approach was utilized because it captures the most variance in the data as examining each variable individually may not be sufficient to differentiate financial health levels. Additionally, simply adding up the responses to each question assumes that all responses should be weighted equally when they may have differential impacts on financial health. To avoid collinearity due to the interrelated nature of energy security, housing security and food security, only questions relating to energy security were used for the PCA. Variables were considered meaningful if the absolute value of factor loadings were greater than 0.35 and components were only considered if their eigenvalues were >1.00 [55].

Table 2

Baseline characteristics of Building Wealth and Health Network members, the Network Phase II, 2015–2017 (N = 373).

Variable	N (%)
Demographics
Caregiver age (Mean, SD)	28.0 (11)
No. of children in household (Mean, SD)	2.08 (1.28)
Gender
Male	19 (5.1)
Female	354 (94.9)
Race/Ethnicity
Black	341 (91.4)
White	9 (2.4)
Hispanic	13 (3.5)
Other	10 (2.7)
Partner in home	79 (21.3)
Sexual Orientation
Heterosexual	318 (85.2)
Gay or lesbian	13 (3.5)
Bisexual	28 (7.6)
Education
Some high school	94 (25.3)
High school or GED	172 (46.1)
Some college	106 (28.3)
Recruitment Site
County Assistance Office	258
Community	115
Financial Measures
Checking Account	138 (36.9)
Savings Account	100 (26.7)
Currently Employed	65 (17.3)
Receive TANF	267 (77.0)
Receive SNAP	358 (96.8)
Receive WIC	203 (54.9)
Household food security
High	112 (30.2)
Marginal	63 (16.9)
Low	92 (24.8)
Very low	105 (28.3)
Housing Insecurity
Secure	143 (38.4)
Moderate	101 (27.1)
Severe	129 (34.7)
Energy Insecurity
Secure	240 (64.5)
Moderate	42 (11.3)
Severe	91 (24.4)
Health Measures
Self-rated health
Excellent, very good, good	223 (60.1)
Fair or poor	148 (39.9)
Depression Score (CES-D)*	209 (56.2)

*A score of >10 indicates depression.

To test associations between financial health components from the PCA and self-rated health and depression, separate multivariate logistic regressions were run modelling the odds of poor-fair vs. good-excellent self-rated physical health and depression (yes/no) with each of the financial health components, adjusting for marital status, age, race/ethnicity, education, employment and other established and related social determinants of health: food, housing and energy insecurity. Results were considered significant at α = 0.05. Tests were run in SAS 9.4 and R.

Results

Demographic information is provided in Table 2. Over 90 percent of respondents were Black/African American women and participating in some form of public assistance such as The Temporary Assistance for Needy Families (TANF) program or The Supplemental Nutrition Assistance Program (SNAP). Less than a third of respondents (26.7%) had a savings account at baseline and fewer than half (36.9%) had a checking account. Notably, more than half of the respondents were food insecure and over a third were severely housing insecure.

The four financial health components—“can’t pay bills” (spend), “having assets” (save), “owing money” (borrow), and “planning” (plan), identified from The Network survey using the CSFI framework are presented in Table 3. Their associated eigenvalues are 1.28 (spend), 1.97 (save), 1.36 (borrow), 1.25 (plan), accounting for 29%, 20%, 19%, and 18% of variance in the original data, respectively, or 86% of the variance in the original data combined. Individual survey items and their loading factor values are listed in Table 3. The higher the factor loading of a given financial item, the greater the contribution of that item to the component. The spend component was characterized by experiencing a utility shutoff (factor loading = 0.651) and having no heat in the home (factor loading = 0.598). The save component was characterized by having a checking account (factor loading = 0.411), savings account (factor loading = 0.424), and an automatic deposit set up (factor loading = 0.378). The borrow component was characterized by having paid a late fee on a bill (factor loading = 0.569) and owing money (factor loading = 0.568). The plan component contained at least one financial goal (factor loading = 0.667) and a personal budget (factor loading = 0.551). No survey items overlapped between components (Table 3).

Table 3

Principal components analysis (N = 373) from baseline surveys (Oct 2015 –June 2018).

		Four Components of Financial Health
Variable	Survey Question Text	Spend	Save	Borrow	Plan
Utility Shut-off	In the last 3 months, has PGW, PECO, or other company [shut off/oil company refused to deliver] the [gas/ electricity/ oil] for not paying bills?	0.651*	0.083	-0.191	-0.108
No Heat	In the last 3 months, were there any days that the home was not heated or cooled because you couldn’t pay the bills?	0.598*	-0.079	0.154	0.154
Checking	Do you have a checking account?	0.042	0.411*	-0.003	0.053
Savings	Do you have a savings account?	-0.02	0.424*	0.007	-0.087
Direct deposit	Do you currently have an automatic deposit or electronic transfer set up to put money away for a future use (such as savings)?	-0.01	0.378*	-0.021	0.037
Owe money	Do you owe anyone money (please include banks, friends, family, payday lenders, etc)?	0.004	-0.036	0.568*	-0.084
Late Fee	Over the last 2 months, have you paid a late fee on a loan or bill?	-0.066	0.022	0.569*	0.07
Financial Goal	Do you currently have at least one financial goal?	0.029	-0.039	0.118	0.667*
Budget	Do you currently have a personal budget, spending plan, or financial plan?	0.007	0.058	-0.174	0.551*
Spend >Save	Over the past month, would you say your family’s spending on living expenses was less than its total income?	-0.026	-0.02	0.021	-0.026

* Indicates variable with an absolute value factor loading greater than 0.35. Variables with factor loading >0.35 were included in final construction of financial health domains.

Table 4 shows results from the logistic regression models examining the association between having significant depressive symptoms with each of the aforementioned financial health components, as well as the association between fair/poor physical health and each of the financial health components. All displayed odds ratios are adjusted for demographic variables and food, housing and energy insecurity. A higher score in owing money (borrow) was associated with greater odds of depression (AOR = 2.16, 95% CI: 0.21–0.83) and fair/poor health (AOR = 1.83, 95% CI:1.05–3.20), whereas a higher score in financial planning (plan) was associated with lower odds of both depression and fair/poor health (AOR = 0.42, 95% CI:0.21–0.83 and AOR = 0.46, 95% CI:0.24–0.87). There were no significant associations found with either the spend or save domains. None of the covariates were themselves associated with either having significant depressive symptoms or fair/poor physical health (results not shown).

Table 4

Associations between physical and mental health outcomes and financial health domains (N = 373)*.

	Presence of Significant Depressive Symptomsa	Fair/Poor Physical Healthb
	AOR (95% CI)	AOR (95% CI)
Spend	1.08 (0.68–1.70)	1.04 (0.69–1.57)
Save	0.73 (0.39–1.36)	0.94 (0.52–1.71)
Borrow	2.16 (1.21–3.87)	1.83 (1.05–3.20)
Plan	0.42 (0.21–0.83)	0.46 (0.24–0.87)

* Results are presented as adjusted odds ratios (AOR) with 95% confidence intervals in parentheses. Bolded results are statistically significant (p<0.05).

a. AOR represents the odds of depression associated with a unit increase in scores for each financial health domain (spend, save, borrow, or plan), adjusting for included age, race/ethnicity, educational attainment, employment, marital status, food insecurity, energy insecurity and housing insecurity.

b. AOR represents the odds of fair/poor physical health (vs. good/excellent health) associated with a unit increase in scores for each financial health domain (spend, save, borrow, or plan), adjusting for included age, race/ethnicity, educational attainment, employment, marital status, food insecurity, energy insecurity and housing insecurity.

Internal validity

The financial health components demonstrated both discriminant and convergent validity when compared to individual measures of economic hardship (See Table 5). The save component was negatively correlated with household food insecurity (r = -0.124, p = 0.04) and positively correlated with wages (r = 0.423, p = 0.003). Conversely, the borrow component was positively correlated with food (r = 0.245, p<0.0001) and energy insecurity (r = 0.167, p = 0.007). The spend component was similarly correlated with energy insecurity (r = 0.311, p<0.0001). Financial health overall was negatively correlated with energy insecurity (r = -0.166, p = 0.007).

Table 5

Spearman correlations between financial health and other measures of economic hardship.

	SPEND	SAVE	BORROW	PLAN	Financial HealthOverall
	R (p-value)	R (p-value)	R (p-value)	R (p-value)	R (p-value)
Hourly Wage	.002 (0.99)	0.42 (.003)	-0.01 (0.96)	.21 (0.15)	0.04 (0.80)
Food Insecurity	0.01 (0.85)	-0.12 (0.04)	0.42 (< .0001)	-0.09 (0.14)	-0.06 (0.32)
Energy Insecurity	0.31 (< .0001)	-0.02 (0.81)	0.17 (0.007)	0.08 (0.19)	-0.17 (0.007)
Housing Insecurity	-0.04 (0.55)	-0.10 (0.11)	-0.04 (0.52)	-0.11 (0.06)	0.004 (0.94)

*Bolded values are significant at p<0.05.

Discussion

Findings demonstrated that financial health is distinct from other measures of economic security, such that behavior and planning indicate more of a family’s ability to be financially ‘healthy’ and have better physical and mental health outcomes than other individual measures of income poverty such as housing/food insecurity or income level. Results also show that domains of financial health can be defined and measured, and that they are associated with both physical and mental health. Components measured in The Network aligned closely and intuitively with a validated and established measure of financial health from the literature; these findings corroborate that there are four domains to financial health: spend, save, borrow and plan. Moreover, the borrow and plan components were associated with self-rated health and depressive symptoms, independent of food, housing, and energy security, providing further evidence that financial health may be a standalone social determinant of health.

With the PCA, questions aligned as expected, and closely mirrored indicators from CSFI. However, the question of “would you say your family’s spending on living expenses was less than its total income” closely aligned with a CFSI spending indicator but not with other questions within the PCA. Associations between the financial health measure and the domains of health were mostly as anticipated. Overall, two of the domains (borrow, and plan) were associated with both meeting the cut off for depression (CES-D score >10) and self-rated physical health. This association with poor physical health is consistent with other research [56, 57]. Additionally, results from the Spearman correlations provide evidence of construct validity, distinguishing this overall financial health construct as separate from other forms of economic hardship, including housing and food insecurity.

This study has some limitations. First, causal interpretations cannot be drawn as this study is observational. Second, this study relies on self-reported information for depression and health rather than a clinical diagnosis. However, both scales have shown reliability in multiple settings and study populations. Respondents also may have underreported on socially undesirable financial questions such as paying a late fee, though this is unlikely as members were enrolling into a financial self-empowerment program. Additionally, the financial questions, structured as yes/no, may not be sufficiently precise to characterize financial health. For example, simply answering yes to “have you paid a late fee on a bill or a loan?” does not distinguish between missing one bill, paying just one late fee, and being behind on multiple bills. Also, results of the PCA are influenced by variables that possess higher degrees of both variance and associated covariance. That is, variables with large variances have important structure, while those with lower variances represent noise, a strong and sometimes incorrect assumption especially in data derived from a homogenous sample. Lastly, while using a non-parametric method like PCA is advantageous in that the output is unique and independent of the user, the fact that PCA is “agnostic to the source of the data” is also a limitation as it does not take a-priori knowledge into account as do parametric methods [58].

Despite these limitations, this study is the first to connect components of financial health drawn from an industry-backed tool to salient public health outcomes. For example, Netemeyer, et al’s [38] work on financial well-being was published within a consumer research journal, yet they did not address how these perceptions are associated with specific health outcomes. Similarly, ProsperityNow, an organization devoted to advancing asset building, recently established a Financial Well-being Scale [59], yet the population which informed their scale were middle-to-high income.

While not generalizable to the general banking population, this study adds to the evidence base by using data derived from a historically underrepresented population: African-American caretakers participating in public assistance who would otherwise be missed in most conventional finance studies. Additionally, existing conceptualizations of financial health tend to focus on short-term risks and exposure to financial shocks, emphasizing savings and assets. However, most households with few or no assets are vulnerable to economic shocks [60], so considering assets alone is incomplete, and people with low incomes may rely on the alternative financial industry rather than bank accounts and partake in an informal economy where conventional forms of assets cannot be measured [45, 60, 61]. Moreover, financial studies typically rely on benchmarks unattainable for many low-income individuals, especially those that supplement income with public assistance supports such as TANF, SNAP, or the Special Supplemental Nutrition Program for Women, Infants, and Children (WIC). This study, as one of the first to assess financial health among low-income caregivers, provides a foundation for future research that can enable public health practitioners and researchers to further understand the relationship between financial health and physical health among caregivers of young children. Additionally, as social service providers can measure patient and client financial health, they can more appropriately provide resources and solutions to help low-income families improve their overall health. Providing early interventions to help caregivers of young children to improve financial health can benefit children with lifelong health and wellbeing.

Practice implications

The American Psychological Association considers financial stress to be one of the top stressors in America [62], with severe stresses considered an adversity akin to adverse childhood experiences (ACEs), which include abuse, neglect, and household dysfunction [63]. Financial stress and economic hardships have been linked with increased physical pain, lowered pain tolerance, and risk of coronary heart disease [64]. Despite this evidence, comprehensive efforts to consider financial health as a mode of fostering financial capability and asset building that: 1) protect from the very financial shocks that can lead to or exacerbate economic hardship; and 2) address the harmful effects of the disparities in income and wealth [65-67], are missing from the public health landscape [14-17].

In order to better understand financial health and its implications for public health, consistent definition and measurement are necessary. Integrating financial health into the overall understanding of health determinants will help guide more effective and far-reaching interventions by providing a framework for solutions that do not rely on isolated approaches to food, housing, energy or other economic insecurities, but rather can address all of these issues by seeking to improve financial health in its four domains of spend, save, borrow and plan. Moreover, to reduce health disparities and address root causes of poor health, the public health community should generate opportunities for families who are financially and socially marginalized to build their wealth. This work sets the foundation for future researchers to investigate and agree upon a consistent measure and definition of financial health, which may help to generate interventions that build people’s capacities to improve their financial situation and may help inform policies that can increase or eliminate asset limits, promoting savings, and ultimately promote wellbeing.

(SAS7BDAT)

Click here for additional data file.

14 Jan 2020

PONE-D-19-31725

Financial Health as a Measurable Social Determinant of Health

PLOS ONE

Dear Mrs. Weida,

Thank you for submitting your manuscript to PLOS ONE. After careful consideration, we feel that it has merit but does not fully meet PLOS ONE’s publication criteria as it currently stands. Therefore, we invite you to submit a revised version of the manuscript that addresses the points raised during the review process.

The paper has a great deal of promise, but it needs some revisions. First, there is a lack of supporting literature in the introduction. Please add more information about the history of finance as a component of overall health. If it is postulated to be an interdisciplinary perspective on health, this needs to be more clearly stated. The analyses should be more sophisticated given the robustness of the data. Please note the suggestions made by the reviewers (below).

We would appreciate receiving your revised manuscript by Feb 28 2020 11:59PM. When you are ready to submit your revision, log on to https://www.editorialmanager.com/pone/ and select the 'Submissions Needing Revision' folder to locate your manuscript file.

If you would like to make changes to your financial disclosure, please include your updated statement in your cover letter.

To enhance the reproducibility of your results, we recommend that if applicable you deposit your laboratory protocols in protocols.io, where a protocol can be assigned its own identifier (DOI) such that it can be cited independently in the future. For instructions see: http://journals.plos.org/plosone/s/submission-guidelines#loc-laboratory-protocols

Please include the following items when submitting your revised manuscript:

A rebuttal letter that responds to each point raised by the academic editor and reviewer(s). This letter should be uploaded as separate file and labeled 'Response to Reviewers'.

A marked-up copy of your manuscript that highlights changes made to the original version. This file should be uploaded as separate file and labeled 'Revised Manuscript with Track Changes'.

An unmarked version of your revised paper without tracked changes. This file should be uploaded as separate file and labeled 'Manuscript'.

Please note while forming your response, if your article is accepted, you may have the opportunity to make the peer review history publicly available. The record will include editor decision letters (with reviews) and your responses to reviewer comments. If eligible, we will contact you to opt in or out.

We look forward to receiving your revised manuscript.

Kind regards,

Heidi H Ewen

Academic Editor

PLOS ONE

Journal Requirements:

When submitting your revision, we need you to address these additional requirements.

1. Please ensure that your manuscript meets PLOS ONE's style requirements, including those for file naming. The PLOS ONE style templates can be found at

http://www.journals.plos.org/plosone/s/file?id=wjVg/PLOSOne_formatting_sample_main_body.pdf and http://www.journals.plos.org/plosone/s/file?id=ba62/PLOSOne_formatting_sample_title_authors_affiliations.pdf

2. Please ensure you have cited any additional publications that have arisen from the Building Wealth and Health Network Trial in the manuscript.

3. In your Data Availability statement, you have not specified where the minimal data set underlying the results described in your manuscript can be found. PLOS defines a study's minimal data set as the underlying data used to reach the conclusions drawn in the manuscript and any additional data required to replicate the reported study findings in their entirety. All PLOS journals require that the minimal data set be made fully available. For more information about our data policy, please see http://journals.plos.org/plosone/s/data-availability.

Upon re-submitting your revised manuscript, please upload your study’s minimal underlying data set as either Supporting Information files or to a stable, public repository and include the relevant URLs, DOIs, or accession numbers within your revised cover letter. For a list of acceptable repositories, please see http://journals.plos.org/plosone/s/data-availability#loc-recommended-repositories. Any potentially identifying patient information must be fully anonymized.

Important: If there are ethical or legal restrictions to sharing your data publicly, please explain these restrictions in detail. Please see our guidelines for more information on what we consider unacceptable restrictions to publicly sharing data: http://journals.plos.org/plosone/s/data-availability#loc-unacceptable-data-access-restrictions. Note that it is not acceptable for the authors to be the sole named individuals responsible for ensuring data access.

We will update your Data Availability statement to reflect the information you provide in your cover letter.

4. Please include a separate caption for each figure in your manuscript.

[Note: HTML markup is below. Please do not edit.]

Reviewers' comments:

Reviewer's Responses to Questions

Comments to the Author

1. Is the manuscript technically sound, and do the data support the conclusions?

The manuscript must describe a technically sound piece of scientific research with data that supports the conclusions. Experiments must have been conducted rigorously, with appropriate controls, replication, and sample sizes. The conclusions must be drawn appropriately based on the data presented.

Reviewer #1: Partly

Reviewer #2: Yes

**********

2. Has the statistical analysis been performed appropriately and rigorously?

Reviewer #1: No

Reviewer #2: No

**********

3. Have the authors made all data underlying the findings in their manuscript fully available?

The PLOS Data policy requires authors to make all data underlying the findings described in their manuscript fully available without restriction, with rare exception (please refer to the Data Availability Statement in the manuscript PDF file). The data should be provided as part of the manuscript or its supporting information, or deposited to a public repository. For example, in addition to summary statistics, the data points behind means, medians and variance measures should be available. If there are restrictions on publicly sharing data—e.g. participant privacy or use of data from a third party—those must be specified.

Reviewer #1: No

Reviewer #2: Yes

**********

4. Is the manuscript presented in an intelligible fashion and written in standard English?

PLOS ONE does not copyedit accepted manuscripts, so the language in submitted articles must be clear, correct, and unambiguous. Any typographical or grammatical errors should be corrected at revision, so please note any specific errors here.

Reviewer #1: Yes

Reviewer #2: Yes

**********

5. Review Comments to the Author

Please use the space provided to explain your answers to the questions above. You may also include additional comments for the author, including concerns about dual publication, research ethics, or publication ethics. (Please upload your review as an attachment if it exceeds 20,000 characters)

Reviewer #1: Reviewer’s Comments for “Financial Health as a Measurable Social Determinant of Health”

It was a pleasure to read this manuscript in that the topic of this study is timely important and worth to be explored beyond the discipline. Nevertheless, I would bring up some questions and concerns that may help the manuscript strengthened.

Title

1. This study is not to examine the relationship between “financial health” and “health” because financial health variables are not used as predictors or determinants of health. Thus, the title may mislead readers. The authors should conduct further analyses to use this title.

Abstract

2. “Objectives” does not get the gist. Is the purpose of this study to develop the new measurement of financial health? Or to suggest a root solution for improving financial health?

Keywords

3. Again, this study does not reflect the “social determinant of health.” Be careful to include it.

Introduction

4. I can see the concept, “financial capability” throughout the manuscript. What is the difference between financial health and financial capability? They sound similar.

5. P3 Line 69: class � does it mean social class?

Methods

Parent Study and Study Sample

6. Please provide a bit more explanation about the Building Wealth and Health Network program. Readers have less information on what this program is (e.g., what organization develops the program, where or in what area/region it is run, how many people have participated in this program).

7. It would be better to use the term “participants” instead of “members” of the program.

8. As authors are stating about the “study sample,” elucidate the total sample used in this study.

9. P5 Line 103: <6yrs � please spell out and write in a full sentence.

Economic Hardship and Financial Measures

10. There is an unmatched question:

� P6 Line135: In the last three months I repaid the money I owned on time

� Table 1. (Borrow x The Network Survey Questions): Within the last six months, I repaid the money I owned on time

11. Please say more about how you code variables that align with the four categories. What answers are considered as affirmative or negative? Which variables were reversely coded? Does a higher/lower score in each category (i.e., spend, save, borrow, plan) represent a higher level of financial health?

12. Where does the Financial Behavior, Knowledge, and Self-Efficacy Scale come from? This a new term/concept that you need to explain.

Statistical Analysis

13. P8 Line 158: Are economic hardship, food insecurity, energy insecurity, and housing insecurity all different concepts?

14. P8 Line 169: Why do authors use .35 as the cutoff value for factor loadings? If there is a reference, please cite it.

15. The sample size of this study is 373, which may fulfill the normality assumption. Please add more explanation of why authors used a nonparametric test (i.e., Mann-Whitney U Test) instead of t-test.

16. P8 Line 161: Specify which energy security question is included (or excluded) in the analysis.

Result

17. Table 2: How household food security, Hosing insecurity, and Energy insecurity are measured? If they are indicating the questions used in Table 1, you need to specify which one is which.

18. Table 3: Please complete the table. What do the first and second columns stand for?

19. It would be better to use the term “participants” instead of “members” of the program.

20. Table 4: Mann-Whitney U Test is used to compare the mean value differences between two independent groups. Thus, you cannot use the term “Association.”

Internal Validity

21. Please add tables for this part of the result. Also, authors need to provide more explanation about food insecurity, energy insecurity, and wages. Are food insecurity and energy insecurity subordinate to economic hardship? How are they measured?

22. P13 Line 224-225: what are “other distinct constructs of economic hardship”? How can you say financial health is distinct from other distinct constructs of economic hardship? Is it tested?

23. Where are the results for the Spearman rank test?

Discussion

24. Again, Mann-Whitney U Test is not testing the association between two variables. Thus, you cannot say “the associations between our financial health measure and the domains of health were as we anticipated.” If you’d like to see the association or relationship between those variables, additional statistical tests are required (e.g., regression).

25. The section explaining Figure 1 is missing.

26. Overall, check verb tenses. Some are used in present tenses, and some are used in past tenses.

Reviewer #2: PLOUS-D-19-31725

Paper Review

This paper was well written and nicely conceptualized. I must say, however, that I was surprised a bit by the framing of the paper. The notion of financial health is really not a new concept. Financial health has its origins in the 1970s and 1980s. What has happened, unfortunately, is that health researchers, in general, have not gone back deeply enough when conducting literature reviews to find this early work. Much of the early work was published as family resource management, consumer economics, family economics, or under the broader categorization of family and consumer sciences. Beginning in 1990, the work on financial health transitioned to the field of financial counseling and planning. This paper references a few papers from the Journal of Financial Counseling and Planning; it is this type of journal where much of the early work was being published. The leading researchers in the field include O’Neill, Kim, and Xiao; however, their work is seldom published in health journals, which explains why health researchers often assume that there is a paucity of research in the area. Here is an example of the type of work that exists, but which is rarely cited in health journals:

• Small steps to health and wealth™: Program update and research insights B O'Neill, K Ensle - The Forum for Family and Consumer Issues, 2014 - theforumjournal.org

• Propensity to plan: A key to health and wealth

B O'Neill, JJ Xiao, K Ensle - Journal of Financial Planning, 2016 - search.proquest.com

• Financially distressed consumers: Their financial practices, financial well-being, and health

B O'Neill, B Sorhaindo, JJ Xiao… - Journal of Financial …, 2005 - papers.ssrn.com

• Changes in health, negative financial events, and financial distress/financial well-being for debt management program clients

B O'Neill, A Prawitz, B Sorhaindo, J Kim… - Journal of Financial …, 2006 - papers.ssrn.com

• The small steps to health and wealth™ challenge: An online tool to motivate consumers to make positive behavior changes

B O'Neill, K Ensle - Proceedings of the Eastern Family Economics …, 2010 - fermascholar.org

• Family health and financial literacy–forging the connection

B Braun, J Kim, EA Anderson - Journal of Family and Consumer …, 2009 - sph.umd.edu

Anyway, this is just a summary of my initial reactions.

Comments:

I would like more information on the measure used in the study. The questions seem very similar to scaling items developed by Garman and his students Joo and Kim (e.g., InCharge Financial Distress/Financial Well-Being Scale: Development, Administration, and Score Interpretation).

As far as I know, this was one of the first dissertations on the topic of financial stressors, which is essentially what is being measured in the “new” scale: https://vtechworks.lib.vt.edu/handle/10919/30519 It is possible that the CFSI measure was developed totally independently of other work related to financial stress and financial stressors, but that seems somewhat unlikely given that any google scholar search would bring up some important past research. It is possible that had a literature review been added to the current paper, much of my concern/questioning would be addressed.

A few questions/issues:

1. Is there a reason the paper is missing a review of literature? (The answer may be that it is not common for this journal to publish reviews of literature as an element of an accepted paper.)

2. On p. 12, was the spend>save question included in any of the domains? The factor loadings are very small across the domains. If it was not included, why is it shown? If it was included, why?

3. Given the sample size, and the demographic data available, why was the choice made to use a non-parametric bivariate test rather than a multivariate model? The literature shows that several demographic variables are typically associated with health and wealth outcomes. It seems like the Mann-Whitney U test would be the first stage level of analysis followed by a MANOVA or even a series of regressions.

I do like how the authors have concluded that integrating financial health into a broader definition of health is important. It may take more papers like this to help shift the health research to this acknowledgement. I like the paper; my general conclusion is that this seems very brief given the topic; also, I do think a more robust series of tests would help the paper quite a bit.

**********

6. PLOS authors have the option to publish the peer review history of their article (what does this mean?). If published, this will include your full peer review and any attached files.

If you choose “no”, your identity will remain anonymous but your review may still be made public.

Do you want your identity to be public for this peer review? For information about this choice, including consent withdrawal, please see our Privacy Policy.

Reviewer #1: No

Reviewer #2: No

[NOTE: If reviewer comments were submitted as an attachment file, they will be attached to this email and accessible via the submission site. Please log into your account, locate the manuscript record, and check for the action link "View Attachments". If this link does not appear, there are no attachment files to be viewed.]

While revising your submission, please upload your figure files to the Preflight Analysis and Conversion Engine (PACE) digital diagnostic tool, https://pacev2.apexcovantage.com/. PACE helps ensure that figures meet PLOS requirements. To use PACE, you must first register as a user. Registration is free. Then, login and navigate to the UPLOAD tab, where you will find detailed instructions on how to use the tool. If you encounter any issues or have any questions when using PACE, please email us at figures@plos.org. Please note that Supporting Information files do not need this step.

24 Mar 2020

Thank you for the great suggestions and edits to strengthen our manuscript. For a clearer point by point response, please see our attached document "Response to Reviewers".

General Comments:

The paper has a great deal of promise, but it needs some revisions. First, there is a lack of supporting literature in the introduction. Please add more information about the history of finance as a component of overall health. If it is postulated to be an interdisciplinary perspective on health, this needs to be more clearly stated. The analyses should be more sophisticated given the robustness of the data. Please note the suggestions made by the reviewers (below).

Thank you for this feedback. We have improved the introduction and added more background literature Please see lines 65-118.

Please ensure that your manuscript meets PLOS ONE's style requirements, including those for file naming.

Thank you for catching this, we have now adhered to PLOS ONE’s file naming requirements.

Please ensure you have cited any additional publications that have arisen from the Building Wealth and Health Network Trial in the manuscript.

Thank you for this reminder. We have added this into the text, please see line 135.

In your Data Availability statement, you have not specified where the minimal data set underlying the results described in your manuscript can be found. PLOS defines a study's minimal data set as the underlying data used to reach the conclusions drawn in the manuscript and any additional data required to replicate the reported study findings in their entirety. All PLOS journals require that the minimal data set be made fully available

We have included a minimal de identified dataset as a Supporting Information file.

Please include a separate caption for each figure in your manuscript.

We have ensured that our figure has a separate caption within the text.

Reviewer 1: It was a pleasure to read this manuscript in that the topic of this study is timely important and worth to be explored beyond the discipline. Nevertheless, I would bring up some questions and concerns that may help the manuscript strengthened.

Title

1. This study is not to examine the relationship between “financial health” and “health” because financial health variables are not used as predictors or determinants of health. Thus, the title may mislead readers. The authors should conduct further analyses to use this title.

Thank you for this comment. We have conducted logistic regressions with financial health domains as predictors of our health outcomes to better reflect the title and objectives of the paper.

Abstract

2. “Objectives” does not get the gist. Is the purpose of this study to develop the new measurement of financial health? Or to suggest a root solution for improving financial health?

Thank you for this point. We updated our objectives to better reflect the purpose of the paper.

Keywords

3. Again, this study does not reflect the “social determinant of health.” Be careful to include it.

Thank you for this catch. We have updated our analyses to reflect the use of this term more appropriately.

Introduction

4. I can see the concept, “financial capability” throughout the manuscript. What is the difference between financial health and financial capability? They sound similar.

Thank you for the opportunity to clarify. Financial capability relates more to an individual’s knowledge and skills to make money-related decisions whereas we are claiming that financial health is a more holistic approach to a family’s financial situation. We have included this definition for financial capability to the introduction to help clarify.

5. P3 Line 69: class � does it mean social class?

The term class is out of place and has been removed.

Methods

Parent Study and Study Sample

6. Please provide a bit more explanation about the Building Wealth and Health Network program. Readers have less information on what this program is (e.g., what organization develops the program, where or in what area/region it is run, how many people have participated in this program).

Thank you for pointing out this oversight. We have added in text to reflect the number of participants from the pilot (N=103) as well as the Phase II (N=373), and that the study takes place in Philadelphia, PA out of Drexel University.

7. It would be better to use the term “participants” instead of “members” of the program

Thank you for this opportunity to clarify why we use the term “members” over “participants”. All participants in The Network are referred to as “members” to reflect the peer format nature of the program to foster social capital, connection and belonging. We have added these citations to the text (please see line 126)

8. As authors are stating about the “study sample,” elucidate the total sample used in this study.

We have specified that the sample was taken from all participants recruited for Phase II at baseline (lines 196-197).

9. P5 Line 103: <6yrs � please spell out and write in a full sentence.

Thank you. We have updated this in the text.

Economic Hardship and Financial Measures

10. There is an unmatched question:

� P6 Line135: In the last three months I repaid the money I owned on time

� Table 1. (Borrow x The Network Survey Questions): Within the last six months, I repaid the money I owned on time

Thank you for catching this. The question should read “Within the last three months I repaid the money I owed on time.” We revised and updated the table.

11. Please say more about how you code variables that align with the four categories. What answers are considered as affirmative or negative? Which variables were reversely coded? Does a higher/lower score in each category (i.e., spend, save, borrow, plan) represent a higher level of financial health?

Thank you for this opportunity to clarify. Please see Lines 169-172 and Table 1.

12. Where does the Financial Behavior, Knowledge, and Self-Efficacy Scale come from? This a new term/concept that you need to explain.

Thank you for this comment. This scale comes from Danes et al. (1999); as this study is a financial empowerment study we used this scale to help assess our members’ post programmatic growth in financial behaviors, knowledge and self-efficacy. We have included a brief description in the text please see lines 152-153.

Statistical Analysis

13. P8 Line 158: Are economic hardship, food insecurity, energy insecurity, and housing insecurity all different concepts?

Thank you for catching this – we have placed parentheticals around food insecurity, energy insecurity and housing insecurity to more clearly indicate these are forms of economic hardship.

14. P8 Line 169: Why do authors use .35 as the cutoff value for factor loadings? If there is a reference, please cite it.

Line 210, Cite: Peres-Neto, P. R., Jackson, D. A., & Somers, K. M. (2003). Giving meaningful interpretation to ordination axes: assessing loading significance in principal component analysis. Ecology, 84(9), 2347-2363.

15. The sample size of this study is 373, which may fulfill the normality assumption. Please add more explanation of why authors used a nonparametric test (i.e., Mann-Whitney U Test) instead of t-test.

Thank you for this opportunity to clarify. As we have decided to enhance the robustness of our analyses, we have removed the Mann-Whitney U Test and instead have included a series of regressions.

16. P8 Line 161: Specify which energy security question is included (or excluded) in the analysis.

We apologize for the confusion. While the questions are from a validated energy insecurity screener, we chose to use them in our analysis as indicators of being unable to pay bills on time and have clarified this in the manuscript (lines 156-157).

Result

17. Table 2: How household food security, Hosing insecurity, and Energy insecurity are measured? If they are indicating the questions used in Table 1, you need to specify which one is which.

Thank you for this point. We have added in descriptions on these measurements. Please see lines 173-181.

18. Table 3: Please complete the table. What do the first and second columns stand for?

Thank you for catching this oversight. We have added column headers for this table.

19. It would be better to use the term “participants” instead of “members” of the program.

Please see our response above. All participants in The Network are referred to as “members” to reflect the peer format nature of the program to foster social capital, connection and belonging. We have added this text (please see lines 126)

20. Table 4: Mann-Whitney U Test is used to compare the mean value differences between two independent groups. Thus, you cannot use the term “Association.”

Thank you for pointing out the error in our language; we have since replaced the Mann-Whitney U tests with regression analyses.

Internal Validity

21. Please add tables for this part of the result. Also, authors need to provide more explanation about food insecurity, energy insecurity, and wages. Are food insecurity and energy insecurity subordinate to economic hardship? How are they measured?

Thank you for this suggestion. We have included the table, and we have provided citations for the food and energy insecurity measures, as well as provided more explanation for Figure 1, which depicts food and energy insecurity as types of economic hardship.

22. P13 Line 224-225: what are “other distinct constructs of economic hardship”? How can you say financial health is distinct from other distinct constructs of economic hardship? Is it tested?

Thank you for this point. As it has not been tested, we have removed this statement.

23. Where are the results for the Spearman rank test?

We have removed the Spearman and Mann-Whitney tests to make room for the logistic regressions to enhance the robustness of our analyses.

24. Again, Mann-Whitney U Test is not testing the association between two variables. Thus, you cannot say “the associations between our financial health measure and the domains of health were as we anticipated.” If you’d like to see the association or relationship between those variables, additional statistical tests are required (e.g., regression).

We have added logistic regression models to our analyses that examine the odds of depression and poor health with each of our financial health domains while adjusting for demographics and other “established” determinants of health to show that there is an independent association between health and aspects of financial health.

25. The section explaining Figure 1 is missing.

Thank you for pointing out this oversight. We have added text (see lines 96-98) explaining Figure 1.

26. Overall, check verb tenses. Some are used in present tenses, and some are used in past tenses.

Thank you for this comment. We have gone through and hopefully corrected these inconsistencies.

Reviewer #2:

This paper was well written and nicely conceptualized. I must say, however, that I was surprised a bit by the framing of the paper. The notion of financial health is really not a new concept. Financial health has its origins in the 1970s and 1980s. What has happened, unfortunately, is that health researchers, in general, have not gone back deeply enough when conducting literature reviews to find this early work. Much of the early work was published as family resource management, consumer economics, family economics, or under the broader categorization of family and consumer sciences. Beginning in 1990, the work on financial health transitioned to the field of financial counseling and planning. This paper references a few papers from the Journal of Financial Counseling and Planning; it is this type of journal where much of the early work was being published. The leading researchers in the field include O’Neill, Kim, and Xiao; however, their work is seldom published in health journals, which explains why health researchers often assume that there is a paucity of research in the area. Here is an example of the type of work that exists, but which is rarely cited in health journals:

Thank you for these comments and for providing examples of literature to include. We have updated our literature review.

I would like more information on the measure used in the study. The questions seem very similar to scaling items developed by Garman and his students Joo and Kim (e.g., InCharge Financial Distress/Financial Well-Being Scale: Development, Administration, and Score Interpretation).

As far as I know, this was one of the first dissertations on the topic of financial stressors, which is essentially what is being measured in the “new” scale: https://vtechworks.lib.vt.edu/handle/10919/30519 It is possible that the CFSI measure was developed totally independently of other work related to financial stress and financial stressors, but that seems somewhat unlikely given that any google scholar search would bring up some important past research. It is possible that had a literature review been added to the current paper, much of my concern/questioning would be addressed.

Thank you for this question, we have provided a review of the literature to hopefully provide some clarity. We have included some of the great work done by Garman and his colleagues in our literature review.

1. Is there a reason the paper is missing a review of literature? (The answer may be that it is not common for this journal to publish reviews of literature as an element of an accepted paper.)

Thank you for catching this. We have provided a review of the literature. Please see lines 77-118.

2. On p. 12, was the spend>save question included in any of the domains? The factor loadings are very small across the domains. If it was not included, why is it shown? If it was included, why?

The spend save question was not included in the final construction of any of the domains but was included in the initial PCA as a potentially relevant variable. We chose to include it in the table to be transparent about what variables were considered for the PCA, even if they were not statistically useful at the end. To avoid confusion, we have added text to the footnote to specify which variables contributed to each domain.

3. Given the sample size, and the demographic data available, why was the choice made to use a non-parametric bivariate test rather than a multivariate model? The literature shows that several demographic variables are typically associated with health and wealth outcomes. It seems like the Mann-Whitney U test would be the first stage level of analysis followed by a MANOVA or even a series of regressions.

Thank you for this suggestion. We have added multivariate logistic regression models to our analyses.

I do like how the authors have concluded that integrating financial health into a broader definition of health is important. It may take more papers like this to help shift the health research to this acknowledgement. I like the paper; my general conclusion is that this seems very brief given the topic; also, I do think a more robust series of tests would help the paper quite a bit.

Thank you for this comment, as well as your suggestions. We hope that our added literature review and additional analyses have strengthened our paper.

Submitted filename: Response to Reviewers.docx

Click here for additional data file.

10 Apr 2020

PONE-D-19-31725R1

Financial Health as a Measurable Social Determinant of Health

PLOS ONE

Dear Ms. Weida,

Thank you for submitting your manuscript to PLOS ONE. After careful consideration, we feel that it has merit but does not fully meet PLOS ONE’s publication criteria as it currently stands. Therefore, we invite you to submit a revised version of the manuscript that addresses the points raised during the review process.

Both of the reviewers have noted some copy-editing issues that need to be addressed before the paper is ready for publication. Once these edits have been made, I will review the resubmission for final determination.

We would appreciate receiving your revised manuscript by May 25 2020 11:59PM. When you are ready to submit your revision, log on to https://www.editorialmanager.com/pone/ and select the 'Submissions Needing Revision' folder to locate your manuscript file.

If you would like to make changes to your financial disclosure, please include your updated statement in your cover letter.

To enhance the reproducibility of your results, we recommend that if applicable you deposit your laboratory protocols in protocols.io, where a protocol can be assigned its own identifier (DOI) such that it can be cited independently in the future. For instructions see: http://journals.plos.org/plosone/s/submission-guidelines#loc-laboratory-protocols

Please include the following items when submitting your revised manuscript:

A rebuttal letter that responds to each point raised by the academic editor and reviewer(s). This letter should be uploaded as separate file and labeled 'Response to Reviewers'.

A marked-up copy of your manuscript that highlights changes made to the original version. This file should be uploaded as separate file and labeled 'Revised Manuscript with Track Changes'.

An unmarked version of your revised paper without tracked changes. This file should be uploaded as separate file and labeled 'Manuscript'.

Please note while forming your response, if your article is accepted, you may have the opportunity to make the peer review history publicly available. The record will include editor decision letters (with reviews) and your responses to reviewer comments. If eligible, we will contact you to opt in or out.

We look forward to receiving your revised manuscript.

Kind regards,

Heidi H Ewen, Ph.D.

Academic Editor

PLOS ONE

[Note: HTML markup is below. Please do not edit.]

Reviewers' comments:

Reviewer's Responses to Questions

Comments to the Author

1. If the authors have adequately addressed your comments raised in a previous round of review and you feel that this manuscript is now acceptable for publication, you may indicate that here to bypass the “Comments to the Author” section, enter your conflict of interest statement in the “Confidential to Editor” section, and submit your "Accept" recommendation.

Reviewer #1: All comments have been addressed

Reviewer #2: All comments have been addressed

**********

2. Is the manuscript technically sound, and do the data support the conclusions?

The manuscript must describe a technically sound piece of scientific research with data that supports the conclusions. Experiments must have been conducted rigorously, with appropriate controls, replication, and sample sizes. The conclusions must be drawn appropriately based on the data presented.

Reviewer #1: Yes

Reviewer #2: Yes

**********

3. Has the statistical analysis been performed appropriately and rigorously?

Reviewer #1: Yes

Reviewer #2: Yes

**********

4. Have the authors made all data underlying the findings in their manuscript fully available?

The PLOS Data policy requires authors to make all data underlying the findings described in their manuscript fully available without restriction, with rare exception (please refer to the Data Availability Statement in the manuscript PDF file). The data should be provided as part of the manuscript or its supporting information, or deposited to a public repository. For example, in addition to summary statistics, the data points behind means, medians and variance measures should be available. If there are restrictions on publicly sharing data—e.g. participant privacy or use of data from a third party—those must be specified.

Reviewer #1: Yes

Reviewer #2: Yes

**********

5. Is the manuscript presented in an intelligible fashion and written in standard English?

PLOS ONE does not copyedit accepted manuscripts, so the language in submitted articles must be clear, correct, and unambiguous. Any typographical or grammatical errors should be corrected at revision, so please note any specific errors here.

Reviewer #1: Yes

Reviewer #2: Yes

**********

6. Review Comments to the Author

Please use the space provided to explain your answers to the questions above. You may also include additional comments for the author, including concerns about dual publication, research ethics, or publication ethics. (Please upload your review as an attachment if it exceeds 20,000 characters)

Reviewer #1: The manuscript has been considerably improved and sophisticated. I have a few questions as follows:

1. Research question and Discussion

The answer to the first research question (i.e., introduce a construct of financial health into the domain of public health defined by more than just individual measures of economic hardship) is not clearly stated in the discussion section. Please add more explanations why and which part of your analyses can be the evidence of the distinction between financial health and economic hardship (indicated by food security, housing security, and energy security).

2. “To avoid collinearity due to the interrelated nature of energy security, housing security and food security, only questions relating to energy security were used for the PCA (p.10, line 119-201)”. If only energy security items were included in the PCA, how do we know financial health variables are distinct from housing security and food security?

3. As the sample represents low-income caregivers of young children, it would be more valuable if the discussion provides implications beneficial to this specific population.

Reviewer #2: Thank you for addressing my issues. The paper does need a bit of copy editing. This may be something the editorial office can help with (e.g., some of the discussion around the new logistic regression model was oddly written). Other than that, the additions to the paper were appropriate.

**********

7. PLOS authors have the option to publish the peer review history of their article (what does this mean?). If published, this will include your full peer review and any attached files.

If you choose “no”, your identity will remain anonymous but your review may still be made public.

Do you want your identity to be public for this peer review? For information about this choice, including consent withdrawal, please see our Privacy Policy.

Reviewer #1: No

Reviewer #2: No

[NOTE: If reviewer comments were submitted as an attachment file, they will be attached to this email and accessible via the submission site. Please log into your account, locate the manuscript record, and check for the action link "View Attachments". If this link does not appear, there are no attachment files to be viewed.]

While revising your submission, please upload your figure files to the Preflight Analysis and Conversion Engine (PACE) digital diagnostic tool, https://pacev2.apexcovantage.com/. PACE helps ensure that figures meet PLOS requirements. To use PACE, you must first register as a user. Registration is free. Then, login and navigate to the UPLOAD tab, where you will find detailed instructions on how to use the tool. If you encounter any issues or have any questions when using PACE, please email us at figures@plos.org. Please note that Supporting Information files do not need this step.

1 May 2020

Reviewer #1: The manuscript has been considerably improved and sophisticated. I have a few questions as follows:

1. Research question and Discussion

The answer to the first research question (i.e., introduce a construct of financial health into the domain of public health defined by more than just individual measures of economic hardship) is not clearly stated in the discussion section. Please add more explanations why and which part of your analyses can be the evidence of the distinction between financial health and economic hardship (indicated by food security, housing security, and energy security).

Thank you for the opportunity to provide more clarification. We added text in the discussion (please see lines 295-297).

2. “To avoid collinearity due to the interrelated nature of energy security, housing security and food security, only questions relating to energy security were used for the PCA (p.10, line 119-201)”. If only energy security items were included in the PCA, how do we know financial health variables are distinct from housing security and food security?

Thank you for this insight. The Spearman correlation tests between each domain of our financial health construct (as well as the overall score) and housing and food insecurity were provided as demonstration construct validity to show that financial health is distinct from housing and food insecurity. The text that we added in response to your previous question will likely help us to clarify for readers the intention of these results.

3. As the sample represents low-income caregivers of young children, it would be more valuable if the discussion provides implications beneficial to this specific population.

Thank you for this point. Please see lines 321-330. We have added narrative at the end of the discussion section (lines 332-339) that describes the implications of this study to benefit low-income families with young children.

Reviewer #2: Thank you for addressing my issues. The paper does need a bit of copy editing. This may be something the editorial office can help with (e.g., some of the discussion around the new logistic regression model was oddly written). Other than that, the additions to the paper were appropriate.

Thank you for the opportunity to correct these, we have taken time for more careful copyediting.

Submitted filename: Responses to Reviewers.docx

Click here for additional data file.

5 May 2020

Financial Health as a Measurable Social Determinant of Health

PONE-D-19-31725R2

Dear Dr. Weida,

We are pleased to inform you that your manuscript has been judged scientifically suitable for publication and will be formally accepted for publication once it complies with all outstanding technical requirements.

Within one week, you will receive an e-mail containing information on the amendments required prior to publication. When all required modifications have been addressed, you will receive a formal acceptance letter and your manuscript will proceed to our production department and be scheduled for publication.

Shortly after the formal acceptance letter is sent, an invoice for payment will follow. To ensure an efficient production and billing process, please log into Editorial Manager at https://www.editorialmanager.com/pone/, click the "Update My Information" link at the top of the page, and update your user information. If you have any billing related questions, please contact our Author Billing department directly at authorbilling@plos.org.

If your institution or institutions have a press office, please notify them about your upcoming paper to enable them to help maximize its impact. If they will be preparing press materials for this manuscript, you must inform our press team as soon as possible and no later than 48 hours after receiving the formal acceptance. Your manuscript will remain under strict press embargo until 2 pm Eastern Time on the date of publication. For more information, please contact onepress@plos.org.

With kind regards,

Heidi H Ewen, Ph.D.

Academic Editor

PLOS ONE

Additional Editor Comments (optional):

Reviewers' comments:

8 May 2020

PONE-D-19-31725R2

Financial Health as a Measurable Social Determinant of Health

Dear Dr. Weida:

I am pleased to inform you that your manuscript has been deemed suitable for publication in PLOS ONE. Congratulations! Your manuscript is now with our production department.

If your institution or institutions have a press office, please notify them about your upcoming paper at this point, to enable them to help maximize its impact. If they will be preparing press materials for this manuscript, please inform our press team within the next 48 hours. Your manuscript will remain under strict press embargo until 2 pm Eastern Time on the date of publication. For more information please contact onepress@plos.org.

For any other questions or concerns, please email plosone@plos.org.

Thank you for submitting your work to PLOS ONE.

With kind regards,

PLOS ONE Editorial Office Staff

on behalf of

Dr. Heidi H Ewen

Academic Editor

PLOS ONE