The Prospective Relationship Between Uptake of Earned Income Tax Credit (EITC), Financial Strain, and Health in Underserved Families

The Prospective Relationship Between Uptake of Earned Income Tax Credit (EITC), Financial Strain, and Health in Underserved Families | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article The Prospective Relationship Between Uptake of Earned Income Tax Credit (EITC), Financial Strain, and Health in Underserved Families Bengt B. Arnetz, Alesia Grinstead, Gabrielle Thomas, Matt Hetherwick, and 6 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-4472980/v1 This work is licensed under a CC BY 4.0 License Status: Published Journal Publication published 12 Jan, 2026 Read the published version in BMC Public Health → Version 1 posted 4 You are reading this latest preprint version Abstract The federal government offers earned income tax credit (EITC) to working low and middle-income families. Lack of knowledge and distrust in government result in a large proportion of qualified families does not uptake (‘claim”) EITC. The study objectives were to ( 1 ) determine whether a community derived EITC outreach campaign resulted in improved knowledge of EITC, and ( 2 ) examine the relationship between financial stress and self-rated health. A total of 215 women attending Women, Infants, and Children (WIC) centers in southeast Detroit, Michigan, were recruited in 2021. Participants filled out a survey at baseline, and after 6 and 12 months, respectively. The 1-year retention rate was 48% (n = 104). The survey contained questions on sociodemographics, financial stressors, exercise, health, and knowledge of EITC. At baseline, knowledge about EITC was low (mean 1.1 [SE 0.3] on a 0–10 visual analogue scale) but increased significantly during the first six months (2.9 [0.3]; p < .01). Approximately 38% of respondents worried about not having sufficient funds to pay for rent/mortgage at baseline, and almost 28% worried about not being able to buy nutritious meals for their families. Worry about paying for meals at the 6-month mid-point assessment was significantly related to self-rated health at 12 months (p = 0.013). Self-rated health at 12 months was significantly lower (-0.74; 95% confidence interval − 1.40, − 0.16) among those worrying vs not worrying about paying for meals. The model explained 5.6% (r 2 = 0.056) of the variance in self-rated health at 12-months. The study shows that knowledge about EITC is limited among qualified households. A community engaged EITC outreach campaign increased knowledge substantially. Financial strain is related to worsening self-rated health. EITC is an underused bipartisan, pro-employment supported federal program to address near-poverty and poverty among underserved families. Figures Figure 1 Figure 2 Figure 3 Introduction The detrimental effects on health from waking up every day not knowing how you will provide for your family, whether you will be able to pay the rent or mortgage or buy nutritious meals have multi-generational social, economic, and life course implications. 1–6 The mechanisms linking socioeconomic strain to adverse physical, emotional, cognitive, and social outcomes are complex, intertwined, and only partially understood. Proposed mechanisms include genotypic and phenotypic characteristics nested within a socioecological framework. Established and purported risk factors include psychological and coping factors, nutritional “choice”, food and housing insecurity, equitable access to high quality health care, education, employment conditions, including job insecurity, pay equity, environmental exposures, including environmental conditions at home, neighborhood, and other places the person spends their time. Systematic exposure to racism, discrimination, and “othering”, is all inter-woven within the above risk factors. 3,5,7–20 The United States federal government recognizes the detrimental effects on children growing up in households suffering from socioeconomic strain. To combat childhood near-poverty and poverty, it has introduced several programs to provide resources to low- and mid-income households. These include the Supplemental Nutrition Assistance Program (SNAP), also known as “food stamps”, childhood tax credit, and the largest federal anti-poverty program, earned income tax credit (EITC). 21 The EITC was enacted in 1975 on a temporary basis with a maximum credit of $ 400. It was extended several times before being made permanent through the passage of the Revenue Act of 1979, at which time the maximum credit was $ 500. 22 In addition to federal EITC, several states, including Michigan have matching EITC that complement the federal credits (percentages vary by state). Currently, the maximum federal EITC, for a household of 3 children, is $ 6,935. In 2023, Michigan raised the state match from 6.5 to 30%. Although several federal initiatives exist to address financial strain, a major policy implementation challenge is that eligible households are often unaware of their legislated right to these benefits. In 2018, it was estimated that only half of women that were pregnant, and one in four that had young children at home and qualified for SNAP received it. 22 For the same period, it was estimated that overall, only 80% of eligible households received EITC. The rates were even lower among minority groups, immigrants, and refugees. 21 Among those who lacked high school education, less than 45% had heard about EITC and only 26% had claimed it. 23 To receive EITC, tax returns must be filed. Once that has been done, the government will determine eligibility and pay out the credit, assuming no taxes are owed. However, lack of eligibility knowledge and the mere fear of being deported holds many eligible immigrant households back from applying. Fear of and mistrust in government is widespread and disproportionally more common among socioeconomically strained households. 24,25 This was a major challenge to the broader population's uptake of efficient public health efforts during Covid-19 which contributed to a disproportional morbidity and mortality burden among minority and underserved groups. 26,27 Several recent projects in the U.S., funded by the U.S. Department of Health and Human Services, Office of Minority Health, address strategies to enhance the uptake of EITC in eligible households. 23 Despite the EITC program’s substantial costs, and strong theoretical rationale for its beneficial effects on children and adult health and achievements, there are few prospective cohort studies on the efficacy of strategies to increase eligible households’ knowledge and uptake (“claiming”) of the EITC. 28 The growing focus on value-based healthcare has also increased the interest in addressing non-medical or social determinants of health factors. This is reflected in initiatives where the healthcare platform is used to enhance financial competency in underserved low- to mid-income families. There are promising results of improved attendance to post-partum pediatric child visits during the first 6 months of life following financial competency empowerment training. 29 A major concern with research on EITC uptake and impact on social determinants of health is the lack of truly community-based studies. EITC uptake studies are commonly based on administrative data, studies of EITC-like projects, for example, New York City Paycheck Plus, or Internal Revenue Service (IRS) derived modeling. 30,31 The lack of population-based data likely results in a substantial overestimation of the proportion of eligible, low-income, marginalized households that actually receive EITC. Based on the current understanding of why one of the United States’ largest anti-poverty, pro-work program is not used to a larger extent, especially among underserved and minoritized groups, there are at least three domains that need to be addressed: Household knowledge of the EITC, eligibility criteria, and application process. The belief that the government is a trustworthy, honest, and benevolent agency. Effectively addressing prior experiences of being marginalized, discriminated against, or otherwise adversely treated by federal, state, and local agencies. The overall objective of the current study was to determine the impact of a community centered EITC campaign on knowledge and awareness of EITC. Furthermore, the aim was to study the prospective relationship between financial hardship risks 23 and protective health behavior, respectively, and changes in self-rated health and well-being. 33 Methods This was a community-based participatory research project in collaboration with Arab Community Center for Economic and Social Service (ACCESS), American Accounting Society (AAS), and Women, Infants, and Children ACCESS, Dearborn, MI. In addition, a Project Steering Committee (PSC) was formed consisting of representatives from Dearborn Public Schools, Islamic Center of America, Dearborn Public Health Department, Samaritas, Macomb County Community Action Agency, the Holy Apostolic Catholic Assyrian Church of the East St. Mary’s Parish, 3D Consulting and Communications, and the University of Michigan-Dearborn. The role of the PSC was to ensure that the community was actively involved in all steps of the study, including the application for funding, development of the community outreach EITC information campaign, implementation, evaluation, and, eventually, initiatives to inform policy makers. Low- and middle-income Arab Americans is a rapidly growing yet underrepresented population in the United States. Data on the Arab American community is largely limited primarily because, until 2024, they have not been recognized as a distinct group on the US Census, leaving the community significantly underrepresented in most federal, state, and local research. The project was launched October 1, 2020. Baseline data collection was initiated June 6, 2021, and collection of the 12-month follow-up data was completed by September 26, 2022. The Michigan State University Institutional Review Board determined the project not to be research and therefore exempt (STUDY00005468). Research Participants and Recruitment. ACCESS’ two Women, Infants, and Children (WIC) programs were engaged in this project. The first program was in Dearborn, MI, and services clients in Wayne County. The second program was in Sterling Heights, MI, and services clients in Macomb County. Both programs shared the same senior manager and offered bilingual-speaking (English and Arabic) case managers and staff, which removed possible linguistic barriers for families seeking public services. The bilingual trained WIC staff at ACCESS carried out all recruitment. The original study design implied on-site recruitment as the mother and child visited WIC. However, before the actual accrual phase commenced, Covid-19 forced WIC to go virtual and visits were by videoconference or by phone. Study inclusion criteria were being a person of Arab American descent with low-to-moderate income residing in Southeast Michigan. Participants had to also qualify for EITC. Given the demographics serviced by ACCESS WIC programs, most clients either had children in their households or were pregnant. Since most participants attending ACCESS WIC are from low- to medium-income households, a vast majority of represented households qualified for EITC. Women contacting the WIC program were asked whether they would be interested in participating in a study about EITC. Those interested to learn more about the study received additional oral and written information in English or Arabic. Potential participants received extensive written information about the project and were able to pose questions. Those who decided to participate consented by responding affirmatively to a question at the beginning of the survey. If a person decided not to participate, they received the regular care that is part of any visit to WIC. It was made clear before consenting that the decision to participate or not would not impact their treatment at WIC or access to WIC services. Once consenting, the WIC personnel interviewed participants in English or Arabic. The staff recorded the respondents’ answers in a structured paper survey. Survey responses were entered by staff into an online, commercial survey system, Qualtrics. Upon each survey completion, the participant was mailed a thank you letter with a $ 10 Target gift card enclosed. All surveys were assigned a unique code to be able to individually track participants prospectively as they responded to an additional survey at six and 12 months, respectively. That is, the respondent received a total of 3 surveys including the baseline survey. The master list linking the unique participant code to a named person was kept locked up at WIC. The research team used the unique ID number to link surveys over time. The research team did not have access to any personal identifiable information. Community-derived and delivered EITC information campaign. The lack of published, community-based and evaluated EITC information campaigns provided the rationale for developing a campaign through a series of iterations. The ACCESS project coordinator worked closely with AAS and the ACCESS communications department. AAS incorporated what they deemed effective strategies from prior campaigns involving other minoritized communities to increase uptake of EITC. Based on prior experiences, it was agreed that slogans should be short, worded in concrete, simple, and direct language. Statements generated included: “It’s your money, get it back for FREE”, “What would you do with extra cash?”, and “Keep more money in your pocket”. ACCESS accredited services translated all community outreach information material into Arabic. The PSC provided feedback to ensure that the materials were culturally appropriate and linguistically accurate. A website was created that included information on the EITC and Child Tax Credit (CTC), and a link that detailed who qualified for EITC. There were also links to educational videos created by external agencies. The page provided contact information to the project coordinator along with instructions on how to make an appointment at ACCESS’ Volunteer Income Tax Assistance (VITA) tax clinics. During year 1 of the project, culturally relevant and responsive bilingual EITC messages were displayed on eleven billboards across the target areas within Southeast Michigan. In collaboration with former U.S. Congressperson Andy Levin and Congressperson Rashida Tlaib, a roundtable discussion was conducted via Facebook Live. Radio and newspaper ads were disseminated in community-based radio and news outlets with a large Arab American audience. A similar approach was used in the second year of the project to ensure that all material created and disseminated continued to be linguistically and culturally appropriate. During the second year, the campaign increased the use of social media and Public Service Announcement (PSA) videos created to educate community members about EITC and encourage them to utilize the free VITA tax clinics. The scripts for the videos were written in collaboration with AAS and the ACCESS communications department to ensure informational and cultural accuracy. In addition to being distributed at in-person outreach events, EITC flyers were shared on the ACCESS Instagram, Facebook, and X (formerly Twitter) accounts. Some posts were boosted through paid advertisements to expand reach. During the second year, 7 billboards were displayed across Southeast Michigan. Finally, Michigan Governor Gretchen Whitmer released a press release about EITC that was reposted on the ACCESS Facebook page. During year three of the community outreach educational campaign, a new strategy was adopted to expand the project’s informational reach even further. Most of the outreach funding was invested in digital marketing instead of print materials. Bilingual wallet cards with a QR code were created and distributed to community members at in-person outreach events to sign up and receive more information about the campaign and make appointments at tax clinics. The partnerships with a local Arab American-led marketing agency were expanded to create high-quality short educational videos. These were later shared and heavily promoted across Instagram and Facebook. The scripts for the videos were written by the ACCESS program coordinator and reviewed by AAS to ensure content accuracy. In addition to creating videos in Arabic, English videos were subtitled to address any linguistic barriers. The cards and videos were all reviewed by members of the PSC and AAS to ensure that they were well-suited for the target population. Survey content The baseline survey consisted of 30 questions largely composed of previously validated and published items. 34–36 The section on Sociodemographics included questions on Gender identity (“select all that applies”; man, women, transgender, transgender, non-binary, genderqueer, agender, questioning, additional identity ___, please specify, and prefer not to answer), current Employment status (employed – actively working. employed – currently furloughed, self-employed – actively working, self-employed – currently furloughed, unemployed, and retired), Marital status (never married, married, separated, divorced, widowed, and cohabiting), Number of children, Pregnancy status (select all that applies; current, last 6 months, gave birth: last year, more than a year ago, and none of the above), Living arrangement, (owns their own home, rent an apartment, rent a house, live with friends/family in my household, Live with friends/family in their household, and other, please specify), Educational attainment (no formal education, less than high school, high school graduate, some college no degree, associate’s degree, bachelor’s degree, Master’s degree, PhD or equivalent), and Household income (less than $ 10,000, $ 10,000 - $ 19,999, $ 20,000 - $ 34,999, $ 35,000 - $ 49,999, $ 50,000 - $ 74,999, $ 75,000 or more per year). There were also questions covering the frequency (never, 1–2, 3–4, and 5–6 times/week, and every day) of eating fruits (excluding juices) and vegetables. In terms of Health and Wellness , a set of validated visual analogue scales (VAS) was used to capture the following areas: “How is your health right now?”, “How is your energy level right now?”; “How do you rate your current sleep quality”; “How satisfied are you with your social life right now?”; How often do you exercise?” Responses were given on a VAS with descriptive names provided at the two extreme anchoring points, for example, Never and Every day, respectively. Scorings on the visual analogue scale ranged from 0 to 10. The section on Financial hardships and Protective health behavior included two questions that assessed frequency of financial concern: 1. How often are you worried about not having enough money to pay for rent/mortgage, and 2. How often are you worried about not having enough money to buy nutritious meals? Response alternatives were never, sometimes, usually, and always. These financial hardship questions have been associated with chronic financial stress. They are also risk factors for adverse childhood experiences (ACEs). 23 Protective health behavior was captured by assessing whether the participant had engaged in any physical activities or exercise (yes or no), such as running, calisthenics, golf, gardening, or walking exercise during the last month. Exercise has been shown to have beneficial effects in women exposed to adverse childhood events (ACEs) 23 . The survey included questions about respondents’ awareness of, knowledge about, and history of claiming earned income tax credit and child tax credit (CTC). The respective questions regarding EITC, were: “Have you heard of the term earned income tax credit (EITC)?” and “How would you rate your knowledge regarding EITC?” Response alternatives for awareness of EITC were no, yes, before today, yes, only today. The time frame today was used since the participant most likely would become aware of the terms during today’s visit. If yes, the respondent was asked whether they had heard about EITC through any or more of the following outlets: flyer/advertisement, social media (e.g., Facebook, Instagram, etc.), from a friend/relative, TV/radio/billboard, during a WIC clinic visit, or from tax consultant/others that assisted with filing tax returns. The participant was asked to mark all that apply. Response alternatives were no (scored 0) or yes ( 1 ). Responses were summed to a total Community Outreach Campaign Exposure Score (Campaign Score). The possible range of scores on the scale was 0, for no reported exposure to the campaign, to a high of 6. The participants rated their knowledge about EITC using a visual analog scale (VAS) ranging from 0 (very limited) to 10 (Excellent). Furthermore, we asked whether they expected to claim EITC in the future. Participants were also asked how they filed their most recent tax return (On their own, with the help from a friend/relative, using tax consultancy, e.g., H&R Block, using tax software, e.g., Turbo Tax, or with assistance from Accounting Aid Society (AAS). The survey concluded with questions about child tax credit (CTC). CTC survey items were designed the same as for EITC. The questions were: whether they had ever claimed CTC, and whether they planned on claiming CTC in the future. Finally, as a measure of general awareness of relevant policy initiatives, participants were asked whether they had heard about the American Rescue Plan Act of 2021 (yes, no). Data Analysis Statistical analysis included checking distribution of responses to the economic hardship, exercise, and health questions. Cross-sectional and longitudinal associations for discrete variables were tested using parametric, and non-parametric statistics when indicated as detailed below. Statistical significance was set at a two-sided p-value of < 0.5. Aim 1: Knowledge of EITC Aim1. The main outcome variable was knowledge of EITC using a 0–10 visual analogue scale as described above. Aim 2: Association between financial strain, protective behavior, and self-rated health Aim 2 was tested using linear regression analysis to determine whether changes in financial hardships and exercise habits, respectively, were predictive of 12-month health ratings. When modeling the discrete exposure variables financial hardships and exercise habits at the 6-month mid-point, we used logistic regression analysis. We used the mid-study (6-month) ratings of financial hardship and exercise habits, respectively, since this was determined to be the most valid assessment period to determine chronic exposure. Two groups were created. Participants that reported affirmative (Sometimes, often, always responses) to whether they worried about paying for mortgage/rent, or whether they worried about paying for nutritious meals were assigned a yes to the respective financial hardship question versus no (Never). Respondents who reported having exercised during the last month were classified as practicing the protective health behavior vs no. In all longitudinal analysis, we controlled for the baseline response on the respective outcome variables, for example, VAS ratings on a specific health question. Results A total of 215 participants responded to the baseline survey. Of these, 155 responded to the 6-month follow-up survey (retention rate of 74%). At the 12 months follow-up a total of 104 persons responded, representing a retention rate of 49% of the original cohort. A total of 93 participants (43%) responded to all three surveys. Out of the 215 participants recruited at baseline, 142 (142/215 = 66%) were between 25–34 years of age, and 73 (34%) were 35–44. There were 7 (7/214 = 3%) male participants and 207 (97%) females. One participant did not provide a response to gender. Participants were allowed to select multiple race/ethnicities. Most participants, 199 (199/215 = 93%) identified as Arab, followed by 79 (37%) Chaldean, 1 (1%) Assyrian, and 15 (7%) other Middle Eastern and North African (MENA). Around 95% of the respondents were married and 80% were unemployed, with no significant changes over time. Awareness of EITC Awareness of EITC increased significantly from 5/93 (5%) having awareness at baseline, to 26/93 (28%) at 6 months, and then decreased to 28/93 (29%) at 12 months (F (df=2) = 14.117, p < .001). The mean Campaign Score was 0.05 (S.E.M 0.02) at base, 0.31 (0.05) at 6 months, and 0.34 (0.06) at 12 months (F (df=2), 8.978, p < .001). Figure 1 shows that participants’ awareness of EITC increased over the one-year study period. Knowledge about EITC was low initially and increased during the first 6 months (F df 1, 27.489, < .001). After 6 months of the campaign, EITC knowledge had improved 316% (Baseline mean = 1.15, S.E.M. = 0.40; 6-Month = 3.63, 0.54) among those who responded to all three surveys. There were no significant differences at baseline in knowledge of EITC or self-rated health between those who responded to all three surveys and those who responded to one or two surveys. Inadvertently, the question about knowledge about EITC was not included in the 12-months follow-up survey. Figure 2 depicts that there was a significant increase in participants’ EITC community outreach information campaign scores (“Campaign Score’) over the project’s 12-months. Figure 3 reports self-ratings on the health items, and knowledge about EITC over the three assessments. Sleep quality increased during the first 6-months and then decreased slightly by the 12 months follow-up (F df 2, 3.739, < .05). Scorings on the other health measures did not change significantly over time. Table 1 shows that there were significant differences in the proportion of participants that reported financial hardships and regular exercise habits, respectively, over time. Almost 50% of those who responded to all three surveys worried about paying their rent and 20% worried about paying for nutritious meals at baseline. A total of 17% worried about both paying rent and buying nutritious meals. Less than half had exercised during the last month at baseline. Table 1 Financial hardship and physical activity over time (93 responded to all 3 surveys) Baseline 6-months 12-months Total F (p) n (%) n (%) n (%) n (%) Worry paying mortgage/rent No 47 (51%) 70 (75%) 60 (64%) 177 (63%) F df=2 = 36.034, (p < .001) 1 Yes 46 (49%) 23 (25%) 33 (36%) 102 (37%) Worry buying nutritious meals No 74 (80%) 72 (77%) 70 (75%) 216 (77%) F df=2 = 10.727, (p < .001) 1 Yes 19 (20%) 21 (23%) 23 (25%) 63 (23%) Physical activity No 59 (63%) 67 (72%) 58 (62%) 184 (66%) F df=2 = 13.021, (p < .001) 1 Yes 34 (37%) 26 (28%) 35 (38%) 95 (34%) Total n (%) 279 (33%) 279 (33%) 279 ( 33 ) 837 (100%) 1 Repeated measures test for trend. We also analyzed whether loss-to-follow-up was related to financial hardship and exercise habits responses, respectively, at baseline. Of those who responded to all three surveys, a greater proportion (49%, 46/93) worried about paying for mortgage/rent at baseline compared to those who responded to one or two surveys (31%, 38/124; Chi square df 1 , 7.436, p < 0.01). There were no significant differences at baseline between those who responded to all three surveys and those who responded to one or two in worrying about paying for nutritious meals or participation in physical activity. Logistic regression modeling was used to determine whether knowledge about the earned income tax credit (EITC) at baseline was related to the likelihood of worrying about not being able to afford paying for rent/mortgage at the 12-month follow-up, controlling for baseline worry to pay rent/mortgage. Knowledge of EITC at baseline was not a significant predictor. Findings were similar for the odds ratio for ranking worry about paying for nutritious meals at the 12-months follow-up based on the baseline rating. Knowledge of EITC at baseline was not predictive of ratings of worry paying for nutritious meals at the 12-month follow-up. Neither baseline exercise habits, nor baseline knowledge about EITC was predictive of the likelihood of exercising or not at the 12-month follow-up. At baseline, only 5% (5 of the 93 participants that responded to all three surveys) reported having been exposed to any of the media channels used to disseminate information about the EITC. At 6 months, exposure increased to 28% (26/93). At 12 months, the equivalent percentage was 30% (28/93). Differences in exposure to the EITC informational advertisements over time were significant (F (df=2) = 14.117, p < .001). Table 2 depicts that there were significant association between worrying about paying rent/mortgage and buying nutritious meals, respectively, at baseline and responses at the 12-month follow-up. The same findings held true in terms of financial hardship ratings at baseline and 6-month follow-up, and between the 6-month and 12-month follow-up (not shown). Table 2 Associations between financial hardship (worrying about paying for rent/mortgage, and buying nutritious meals, respectively) at baseline and the 12-month follow-up. Worry paying mortgage/rent at 12-month Total Chi Square (p) No Yes n (%) Worry paying mortgage/rent at baseline No 43 (84.3%) 8 (15.7%) 51 (50%) X 2 df= 1 =20.30, (p < .001) 1 Yes 21 (41.2%) 30 (58.8%) 51 (50%) Total n (%) 64 (63%) 38 (37%) 102 (100%) Worry buying nutritious meals at 12-month No Yes Worry buying nutritious meals at baseline No 67 (85.9%) 11 (14.1%) 78 (76%) X 2 df= 1 =26.05, (p < .001) 1 Yes 8 (33.3%) 16 (66.7%) 24 (24%) Total n (%) 75 (74%) 27 (26%) 102 (100%) 1 Chi Square test for associations. In terms of protective health behavior, Table 3 shows that at baseline, 40% (41/102) had exercised during the previous month. At the 12-month follow-up, 52% (53/102) reported having exercised during the previous month. Of the 41 persons that exercised at baseline, 78% (32/41) continued exercising at the 12-month follow-up. Among the 61 participants that did not exercise at baseline, 15% (9/61) had started exercising at the 12-month follow-up. Table 3 Associations between participation in physical activity at baseline and the 12-month follow-up. Participation in Leisure Time Physical Activity at 12-month Total Chi Square (p) No Yes n (%) Participation in Leisure Time Physical Activity at baseline No 52 (85%) 9 (15%) 61 (60%) X 2 df= 1 =40.863, (p < .001) 1 Yes 9 (22%) 32 (78%) 41 (40%) Total n (%) 61 (60%) 41 (40%) 102 (100%) 1 Chi Square test for associations. We modelled the relationship between exposure to financial hardship at the 6-month mid-point, captured by the two financial hardship questions: 1. Any worries about not being able to pay for nutritious meals as compared to no worries, or 2. Any worries not having enough money paying for rent/mortgage vs no worries, and health ratings at the 12-month follow-up. We compared ratings at the 12-month follow-up by group (having vs not having financial hardships at the 6-month mid-point). In all analyses we controlled for health ratings at baseline. As a protective factor, we used whether the respondent had exercised or not during the last month. Health Worry about paying for meals at the 6-month assessment was significantly related to self-rated health at 12 months (p = 0.013), controlling for baseline self-rated health. Self-rated health at 12 months was significantly lower (-0.74 units; 95% confidence interval − 1.40, − 0.16) among those worrying vs not worrying about paying for meals. The model explained 5.6% (r 2 = 0.056) of the variance in self-rated health at 12-month. Neither worrying vs not worrying about paying for rent/mortgage, nor exercising or not predicted changes in self-rated health. Energy Worry about paying for meals at the 6-month assessment was significantly related to self-rated energy at 12 months (p < 0.004), controlling for baseline self-rated energy. Self-rated energy at 12 months was significantly lower (-1.14 units; -1.91, -0.36) among those worrying vs not worrying about paying for meals. The model explained 20% (R 2 = 0.20). There was also a significant difference among those worrying vs not worrying about paying for rent/mortgage (p < 0.003, -1.10 units; -1.83, -0.39) in self-rated energy at 12 months. The model explained 21% (R 2 = 0.21). Exercise habits at the 6-month assessment was not related to self-rated energy at 12 months, controlling for baseline self-rated energy. Sleep Worry about paying for meals at the 6-month assessment was significantly related to self-rated sleep at 12 months (p < 0.01), controlling for baseline self-rated sleep. Self-rated sleep at 12 months was significantly lower (mean − 1.21 units;95% confidence interval − 1.93, -0.48) among those worrying vs not worrying about paying for meals. The model explained 26.3% (r 2 = 0.263) of the variance. Furthermore, there was a significant difference among those worrying vs not worrying about paying for rent/mortgage (p < 0.02, -0.81 units, -1.48, -0.14) in self-rated sleep at 12 months. Exercise habits at the 6-month assessment was related to self-rated sleep at 12 months (p < 0.001), controlling for baseline self-rated sleep. Those stating at 6 months that they exercised scored lower on sleep vs those that responded that they did not exercise (-0.98 units, -1.63, -0.32). The model explained 25% (R 2 = 0.25) of the variance. Thus, overall, financial hardship ratings at the 6-month mid-point were closely related to adverse health effects at the 12-month follow-up, controlling for baseline health scores. Differences across worry vs no worry translated into significant differences in both self-rated health, energy, and sleep. Worry about paying for rent was associated with lower ratings on self-rated energy and sleep. Exercise, on the other hand was only related to self-rated sleep. Interestingly, those exercising vs not exercising scored lower on sleep. Discussion Before the EITC community outreach information campaign was launched, knowledge of EITC was very limited. Following active campaigning, using increasingly broadening channels to communicate the message, there was a significant increase in knowledge about EITC. Still, the improvement was from a very low level, and additional strategies to ensure the target group is aware of their rights are needed. At baseline almost four out of ten households with children worried about how to pay for their rent/mortgage. Every fourth household worried about being able to afford paying for nutritious meals. Moreover, the strong association between the two financial hardship questions was evidenced by the fact that eight out of ten respondents that worried about how to pay for rent/mortgage also worried about how to pay for nutritious meals. Less than half were engaged or had engaged in physical activities. If a participant were worried about paying for rent/mortgage at baseline, the person was almost 13 times more likely to score the same at the 12-month follow-up. The same likelihood for a person worrying about paying for nutritious meals was almost 5 times higher. Of further concern is that the participants and members of their households are not only exposed to socioeconomic strain, but they often reside in disadvantaged neighborhoods which further adds to the toxic stress exposures. 38 At the aggregate group level, except for sleep scores, none of the self-rated health measures changed significantly over the 12-month follow-up period. This is in line with the fact that there were no significant changes in EITC allowance during this period, nor did we notice any substantial and lasting changes in financial hardship exposures. In terms of protective behavior, almost eight out of ten respondents that exercised at baseline also reported doing so at 12 months. Fifteen percent of those that did not exercise at baseline, took up exercise by the 12-month follow-up assessment. When we dichotomized the cohort into two groups in terms of reporting financial hardship or not, a very different pattern emerged. Exposure to financial hardships was related to worsening self-rated health, energy, and sleep over the 12-month follow-up period. Exercise was less of a determinant of self-rated health except for being predictive of changes in self-rated sleep. Interestingly, exercise was associated with worsening sleep over the study period. We don’t have any explanation for the inverse relationship between exercise and sleep quality. Self-rated health is one of the most reliable predictors of a person’s actual health trajectory over the next 5–10 years. 39–41 Thus, the study offers further support for the deleterious health effects of living under financial hardships. The study did not find any direct associations between knowledge of EITC and changes over time in financial hardships. This is also evidence of the magnitude of the problem of increasing knowledge of and trust in EITC in targeted communities, and the need for effective communal outreach strategies. Knowledge of the EITC program may need to be accompanied by building trust, which can take time to develop from external (i.e., repeated and diverse community outreach social media campaigns) and internal (i.e., opportunities for positive word of mouth to spread.) As we continue to follow this cohort, we will be able to determine whether the positive effects on knowledge of EITC translate into claiming more EITC. And, if that is the case, how it relates to financial hardship. Declarations Ethics approval and consent to participate Research was performed in accordance with the Declaration of Helsinki. All participants consented to be included in this study. Study was determined to be not research by the Michigan State University Institutional Review Board ID STUDY00005468. Consent for publication All participants included in this study were consented prior to inclusion. Only deidentified data was used in the generation of results and this manuscript. Availability of data and materials The datasets used and/or analyzed during the current study are available from the corresponding author on reasonable request. Competing interests All authors have expressed that they do not have any competing interests with this study. Funding The study was funded in whole by grant number 1 CPIMP201205-01-00 awarded to the Arab Community Center for Economic and Social Service (ACCESS) by the U.S. Department of Health and Human Services (HHS). Researchers at Michigan State University responsible for the evaluation was funded in whole by a subcontract from ACCESS. Authors contributions B.A. co-wrote the application together with an external grant writer, including the structure of the intervention and the evaluation logic model. B.A. was responsible for writing the institutional review board (IRB) protocol and the submission to the University’s IRB that determined the project was not research. Following funding, B.A., R.A., A.G., G.T., and M.H. finalized the project design, intervention content, and evaluation structure, with input from the project advisory board. R.A. and M.K. were responsible for all of the information-based community outreach. M.H. and G.T. conducted tax consultation for participants and served as the point of contact for the Accounting Aid Society. A.C. was responsible for linking de-identified survey data over time, and to maintain survey data. Under the supervision of B.A. and J.A., A.C. conducted some of the statistical analysis. W.M. ,E.A. and B.A. conducted the advanced statistical modeling. All authors contributed significantly to the final manuscript. All authors reviewed the final manuscript and approved it prior to submission. Acknowledgements We would like to thank all participants that took the time and effort to participate in the study. Opinions expressed are those of the authors and do not necessarily represent those of HHS, ACCESS, nor AAS. References Gallo LC, Matthews KA. Understanding the association between socioeconomic status and physical health: do negative emotions play a role? Research Support, Non-U.S. Gov't;, Research Support US, Gov't PHS. Review. Psychological bulletin . 2003 2003;129(1):10–51. 10.1037/0033-2909.129.1.10 . Matthews KA, Gallo LC. Psychological perspectives on pathways linking socioeconomic status and physical health.; Research Support, N.I.H., Extramural; Review. Annual review of psychology . 2011 2011;62:501 – 30. 10.1146/annurev.psych.031809.130711 . Matthews KA, Gallo LC, Taylor SE. Are psychosocial factors mediators of socioeconomic status and health connections? A progress report and blueprint for the future.; Review. Annals of the New York Academy of Sciences . 2010 2010;1186:146 – 73. 10.1111/j.1749-6632.2009.05332.x . Udalova V, Bhatia V, Polyakova M. Association of Family Income With Morbidity and Mortality Among US Lower-Income Children and Adolescents. JAMA Dec. 2022;27(24):2422–30. 10.1001/jama.2022.22778 . de la Rosa R, Zablotny D, Ye M, et al. Biological Burden of Adverse Childhood Experiences in Children. Psychosom Med 2023 Feb-Mar. 2023;01(2):108–17. 10.1097/PSY.0000000000001167 . Dunn KE, Turner GM, Oswald LM. Effects of Early Life Trauma on Risks for Adult Opioid Use Disorder Are Mediated by Stress and Occur Independent of Depression and Anxiety. J Addict Med 2022 Nov-Dec. 2022;01(6):709–15. 10.1097/ADM.0000000000001011 . Parletta N, Milte CM, Meyer BJ. Nutritional modulation of cognitive function and mental health.; Research Support, Non-U.S. Gov't; Review. J nutritional Biochem 2013 May (Epub 2013 Mar. 2013;24(5):725–43. 10.1016/j.jnutbio.2013.01.002 . Karcher NR, Barch DM. The ABCD study: understanding the development of risk for mental and physical health outcomes.; Research Support, N.I.H., Extramural; Review. Neuropsychopharmacology: official publication of the American College of Neuropsychopharmacology . 2021 01 (Epub 2020 Jun 2021;46(1):131–142. 10.1038/s41386-020-0736-6 . Slopen N, Heard-Garris N. Structural Racism and Pediatric Health-A Call for Research to Confront the Origins of Racial Disparities in Health. JAMA Pediatr Jan. 2022;01(1):13–5. 10.1001/jamapediatrics.2021.3594 . Bronfenbrenner U. The ecology of human development: experiments by nature and design. Harvard University Press; 1979. p. xv. Arnetz BB, Arnetz J, Harkema JR, et al. Neighborhood air pollution and household environmental health as it relates to respiratory health and healthcare utilization among elderly persons with asthma. J Asthma Jan. 2020;57(1):28–39. 10.1080/02770903.2018.1545856 . Nolen E, Cubbin C, Brewer M. The effect of maternal food insecurity transitions on housing insecurity in a population-based sample of mothers of young children. AIMS public health . 2022 2022;9(1):1–16. 10.3934/publichealth.2022001 . Brewis A, Workman C, Wutich A, Jepson W, Young S, Household Water Insecurity Experiences - Research Coordination N. Household water insecurity is strongly associated with food insecurity: Evidence from 27 sites in low- and middle-income countries, Research Support NIH, Extramural;, Support R, Research Support N-US. U.S. Gov't, Non-P.H.S. American journal of human biology: the official journal of the Human Biology Council . 2020 01 (Epub 2019 Aug 2020;32(1):e23309. 10.1002/ajhb.23309 . Hamad R, Niedzwiecki MJ. The short-term effects of the earned income tax credit on health care expenditures among US adults. Health Serv Res Dec. 2019;54(6):1295–304. 10.1111/1475-6773.13204 . Rostad WL, Ports KA, Tang S, Klevens J. Reducing the Number of Children Entering Foster Care: Effects of State Earned Income Tax Credits. Child Maltreat Nov. 2020;25(4):393–7. 10.1177/1077559519900922 . Klevens J, Schmidt B, Luo F, Xu L, Ports KA, Lee RD. Effect of the Earned Income Tax Credit on Hospital Admissions for Pediatric Abusive Head Trauma, 1995–2013. Public Health Rep. 2017;132(4):505–11. 10.1177/0033354917710905 . Moe CA, Kovski NL, Dalve K, et al. Cumulative Payments Through the Earned Income Tax Credit Program in Childhood and Criminal Conviction During Adolescence in the US. JAMA Netw Open Nov. 2022;01(11):e2242864. 10.1001/jamanetworkopen.2022.42864 . Yang G, Cao X, Li X, et al. Association of Unhealthy Lifestyle and Childhood Adversity With Acceleration of Aging Among UK Biobank Participants. JAMA Netw Open Sep. 2022;01(9):e2230690. 10.1001/jamanetworkopen.2022.30690 . Holz NE, Berhe O, Sacu S, et al. Early Social Adversity, Altered Brain Functional Connectivity, and Mental Health. Biol Psychiatry Mar. 2023;01(5):430–41. 10.1016/j.biopsych.2022.10.019 . Roberts AL, Zafonte R, Chibnik LB, et al. Association of Adverse Childhood Experiences With Poor Neuropsychiatric Health and Dementia Among Former Professional US Football Players. JAMA Netw Open Mar. 2022;01(3):e223299. 10.1001/jamanetworkopen.2022.3299 . Hamad R, Galea S. The Role of Health Care Systems in Bolstering the Social Safety Net to Address Health Inequities in the Wake of the COVID-19 Pandemic. JAMA Jul. 2022;05(1):17–8. 10.1001/jama.2022.10160 . Crandall-Hollick MF, A Novel Strategy for increasing Utilization of Earned Income Tax Credits and Reducing Adverse Childhood Experiences, Ford CL, Wallace SP, Newman PA, Lee S-J, Cunningham WE, Smith AC, Woerner J, Perera R, Haeny AM, Cox JM. An Investigation of Associations Between Race, Ethnicity, and Past Experiences of Discrimination with Medical Mistrust and COVID-19 Protective Strategies.;, Support R, Perales L, Holguin M, Komro KA, Dunlap P, Sroczynski N et al. 2022 1-27. 23. Maguire-Jack K, Solomon A, Greenberg S. : The EITC Access Project. Int Journal on Child Malt 2022;5473 – 486. doi:10.10007/s42448-022-00119-8 24. Ford CL, Wallace SP, Newman PA, Lee S-J, Cunningham WE. Belief in AIDS-related conspiracy theories and mistrust in the government: relationship with HIV testing among at-risk older adults.; Multicenter Study; Research Support, N.I.H., Extramural; Research Support, Non-U.S. Gov't. The Gerontologist . 2013 Dec (Epub 2013 Jan 2013;53(6):973 – 84. doi:10.1093/geront/gns192 25. Feingold E. The defeat of health care reform: misplaced mistrust in government. American journal of public health . 1995 1995;85(12):1619-22. 10.2105/ajph.85.12.1619 26 . Choi Y, Fox AM. Mistrust in public health institutions is a stronger predictor of vaccine hesitancy and uptake than Trust in Trump. Social science & medicine (1982) . 2022 12 (Epub 2022 Oct 2022;314:115440. doi:10.1016/j.socscimed.2022.115440 27. Smith AC, Woerner J, Perera R, Haeny AM, Cox JM. An Investigation of Associations Between Race, Ethnicity, and Past Experiences of Discrimination with Medical Mistrust and COVID-19 Protective Strategies.; Research Support, Non-U.S. Gov't. Journal of racial and ethnic health disparities . 2022 08 (Epub 2021 Jun 2022;9(4):1430–1442. doi:10.1007/s40615-021-01080-x 28. Liu PY, Beck AF, Lindau ST. A framework for cross-sector partnerships to address childhood adversity and improve life course health. Pediatrics . 2022;149(Supplement 5)29. Schickedanz A, Perales L, Holguin M. Clinic-Based Financial Coaching and Missed Pediatric Preventive Care: A Randomized Trial. Pediatrics . Feb 02 2023;doi:10.1542/peds.2021-054970 30. Courtin E, Aloisi K, Miller C, Allen HL, Katz LF, Muennig P. The Health Effects Of Expanding The Earned Income Tax Credit: Results From New York City. Health Aff (Millwood) . Jul 2020;39(7):1149–1156. doi:10.1377/hlthaff.2019.01556 31. Komro KA, Dunlap P, Sroczynski N Anti-poverty policy and health: Attributes and diffusion of state earned income tax credits across U.S. states from 1980 to 2020. PLoS One . 2020;15(11):e0242514. doi:10.1371/journal.pone.0242514. Rogers EM, Banks NF, Tomko PM, et al. Progressive Exercise Training Improves Cardiovascular Psychophysiological Outcomes in Young Adult Women with a History of Adverse Childhood Experiences. J Appl Physiol (1985) Feb. 2023;02. 10.1152/japplphysiol.00524.2022 . Hasson D, Arnetz BB, Theorell T, Anderberg UM. Predictors of self-rated health: a 12-month prospective study of IT and media workers. Popul Health Metr Jul. 2006;31:4:8. 10.1186/1478-7954-4-8 . Arnetz BB. Model development and research vision for the future of multiple chemical sensitivity. Scand J Work Environ Health Dec. 1999;25(6):569–73. 10.5271/sjweh.482 . Arnetz BB, Templin T, Saudi W, Jamil H. Obstructive sleep apnea, posttraumatic stress disorder, and health in immigrants. Psychosom Med Oct. 2012;74(8):824–31. 10.1097/PSY.0b013e31826bf1ec . Hasson D, Anderberg UM, Theorell T, Arnetz BB. Psychophysiological effects of a web-based stress management system: a prospective, randomized controlled intervention study of IT and media workers [ISRCTN54254861]. BMC Public Health Jul. 2005;25:5:78. 10.1186/1471-2458-5-78 . Sircar NR, Friedman EA. Financial security and public health: How basic income & cash transfers can promote health. Glob Public Health Dec. 2018;13(12):1878–88. 10.1080/17441692.2018.1460383 . Wadsworth ME, Raviv T, Santiago CD, Etter EM. Testing the adaptation to poverty-related stress model: predicting psychopathology symptoms in families facing economic hardship. J Clin Child Adolesc Psychol. 2011;40(4):646–57. 10.1080/15374416.2011.581622 . Anderzén I, Arnetz BB. Psychophysiological reactions to international adjustment. Results from a controlled, longitudinal study. Psychother Psychosom. 1999;68(2):67–75. 10.1159/000012315 . Halford C, Ekselius L, Anderzen I, Arnetz B, Svärdsudd K. Self-rated health, life-style, and psychoendocrine measures of stress in healthy adult women. Ups J Med Sci Nov. 2010;115(4):266–74. 10.3109/03009734.2010.496910 . Halford C, Anderzén I, Arnetz B. Endocrine measures of stress and self-rated health: a longitudinal study. J Psychosom Res Oct. 2003;55(4):317–20. 10.1016/s0022-3999(02)00634-7 . Additional Declarations No competing interests reported. Cite Share Download PDF Status: Published Journal Publication published 12 Jan, 2026 Read the published version in BMC Public Health → Version 1 posted Editorial decision: Revision requested 31 May, 2024 Editor assigned by journal 31 May, 2024 Submission checks completed at journal 31 May, 2024 First submitted to journal 24 May, 2024 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-4472980","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":308978019,"identity":"47b3b4d0-b8ef-45a3-905f-aad6ad63ae75","order_by":0,"name":"Bengt B. 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(F\u003csub\u003e(df=2) \u003c/sub\u003e= 14.117, p\u0026lt;.001).\u003c/p\u003e","description":"","filename":"floatimage1.jpeg","url":"https://assets-eu.researchsquare.com/files/rs-4472980/v1/fd53bfc2667216a2321f8bce.jpeg"},{"id":58384908,"identity":"42788c9a-cd93-4b39-8862-f8067dccfb06","added_by":"auto","created_at":"2024-06-14 18:38:12","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":17641,"visible":true,"origin":"","legend":"\u003cp\u003eCampaign Scores increased significantly over time. (F\u003csub\u003e(df=2) \u003c/sub\u003e= 30.880, p\u0026lt;.001).\u003c/p\u003e","description":"","filename":"floatimage2.png","url":"https://assets-eu.researchsquare.com/files/rs-4472980/v1/a21a2a5d34e76b66d9d991ae.png"},{"id":58384909,"identity":"8da4ce50-87c6-4140-afc2-3c8525f35c02","added_by":"auto","created_at":"2024-06-14 18:38:12","extension":"png","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":7095,"visible":true,"origin":"","legend":"\u003cp\u003eChanges in Health, Social Well-being ratings, and knowledge about EITC, over time.\u003c/p\u003e","description":"","filename":"Onlinedrawingimage1.png","url":"https://assets-eu.researchsquare.com/files/rs-4472980/v1/906f11f921304aa5eb3eabd1.png"},{"id":100614963,"identity":"67f46b81-bd45-4dc1-9399-b56c9c0795a3","added_by":"auto","created_at":"2026-01-19 17:29:01","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1041340,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-4472980/v1/491003e6-a67a-49f6-9bcb-48a38655f15e.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"The Prospective Relationship Between Uptake of Earned Income Tax Credit (EITC), Financial Strain, and Health in Underserved Families","fulltext":[{"header":"Introduction","content":"\u003cp\u003eThe detrimental effects on health from waking up every day not knowing how you will provide for your family, whether you will be able to pay the rent or mortgage or buy nutritious meals have multi-generational social, economic, and life course implications.\u003csup\u003e1\u0026ndash;6\u003c/sup\u003e The mechanisms linking socioeconomic strain to adverse physical, emotional, cognitive, and social outcomes are complex, intertwined, and only partially understood. Proposed mechanisms include genotypic and phenotypic characteristics nested within a socioecological framework. Established and purported risk factors include psychological and coping factors, nutritional \u0026ldquo;choice\u0026rdquo;, food and housing insecurity, equitable access to high quality health care, education, employment conditions, including job insecurity, pay equity, environmental exposures, including environmental conditions at home, neighborhood, and other places the person spends their time. Systematic exposure to racism, discrimination, and \u0026ldquo;othering\u0026rdquo;, is all inter-woven within the above risk factors.\u003csup\u003e3,5,7\u0026ndash;20\u003c/sup\u003e\u003c/p\u003e \u003cp\u003eThe United States federal government recognizes the detrimental effects on children growing up in households suffering from socioeconomic strain. To combat childhood near-poverty and poverty, it has introduced several programs to provide resources to low- and mid-income households. These include the Supplemental Nutrition Assistance Program (SNAP), also known as \u0026ldquo;food stamps\u0026rdquo;, childhood tax credit, and the largest federal anti-poverty program, earned income tax credit (EITC).\u003csup\u003e21\u003c/sup\u003e The EITC was enacted in 1975 on a temporary basis with a maximum credit of \u003cspan\u003e$\u003c/span\u003e400. It was extended several times before being made permanent through the passage of the Revenue Act of 1979, at which time the maximum credit was \u003cspan\u003e$\u003c/span\u003e500.\u003csup\u003e22\u003c/sup\u003e In addition to federal EITC, several states, including Michigan have matching EITC that complement the federal credits (percentages vary by state). Currently, the maximum federal EITC, for a household of 3 children, is \u003cspan\u003e$\u003c/span\u003e6,935. In 2023, Michigan raised the state match from 6.5 to 30%.\u003c/p\u003e \u003cp\u003eAlthough several federal initiatives exist to address financial strain, a major policy implementation challenge is that eligible households are often unaware of their legislated right to these benefits. In 2018, it was estimated that only half of women that were pregnant, and one in four that had young children at home and qualified for SNAP received it.\u003csup\u003e22\u003c/sup\u003e For the same period, it was estimated that overall, only 80% of eligible households received EITC. The rates were even lower among minority groups, immigrants, and refugees.\u003csup\u003e21\u003c/sup\u003e Among those who lacked high school education, less than 45% had heard about EITC and only 26% had claimed it.\u003csup\u003e23\u003c/sup\u003e\u003c/p\u003e \u003cp\u003eTo receive EITC, tax returns must be filed. Once that has been done, the government will determine eligibility and pay out the credit, assuming no taxes are owed. However, lack of eligibility knowledge and the mere fear of being deported holds many eligible immigrant households back from applying. Fear of and mistrust in government is widespread and disproportionally more common among socioeconomically strained households.\u003csup\u003e24,25\u003c/sup\u003e This was a major challenge to the broader population's uptake of efficient public health efforts during Covid-19 which contributed to a disproportional morbidity and mortality burden among minority and underserved groups.\u003csup\u003e26,27\u003c/sup\u003e\u003c/p\u003e \u003cp\u003eSeveral recent projects in the U.S., funded by the U.S. Department of Health and Human Services, Office of Minority Health, address strategies to enhance the uptake of EITC in eligible households.\u003csup\u003e23\u003c/sup\u003e Despite the EITC program\u0026rsquo;s substantial costs, and strong theoretical rationale for its beneficial effects on children and adult health and achievements, there are few prospective cohort studies on the efficacy of strategies to increase eligible households\u0026rsquo; knowledge and uptake (\u0026ldquo;claiming\u0026rdquo;) of the EITC.\u003csup\u003e28\u003c/sup\u003e The growing focus on value-based healthcare has also increased the interest in addressing non-medical or social determinants of health factors. This is reflected in initiatives where the healthcare platform is used to enhance financial competency in underserved low- to mid-income families. There are promising results of improved attendance to post-partum pediatric child visits during the first 6 months of life following financial competency empowerment training.\u003csup\u003e29\u003c/sup\u003e\u003c/p\u003e \u003cp\u003eA major concern with research on EITC uptake and impact on social determinants of health is the lack of truly community-based studies. EITC uptake studies are commonly based on administrative data, studies of EITC-like projects, for example, New York City Paycheck Plus, or Internal Revenue Service (IRS) derived modeling.\u003csup\u003e30,31\u003c/sup\u003e The lack of population-based data likely results in a substantial overestimation of the proportion of eligible, low-income, marginalized households that actually receive EITC.\u003c/p\u003e \u003cp\u003eBased on the current understanding of why one of the United States\u0026rsquo; largest anti-poverty, pro-work program is not used to a larger extent, especially among underserved and minoritized groups, there are at least three domains that need to be addressed:\u003c/p\u003e \u003cp\u003e \u003cul\u003e \u003cli\u003e \u003cp\u003eHousehold knowledge of the EITC, eligibility criteria, and application process.\u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003eThe belief that the government is a trustworthy, honest, and benevolent agency.\u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003eEffectively addressing prior experiences of being marginalized, discriminated against, or otherwise adversely treated by federal, state, and local agencies.\u003c/p\u003e \u003c/li\u003e \u003c/ul\u003e \u003c/p\u003e \u003cp\u003eThe \u003cspan type=\"Underline\" class=\"Underline\" name=\"Emphasis\"\u003eoverall objective\u003c/span\u003e of the current study was to determine the impact of a community centered EITC campaign on knowledge and awareness of EITC. Furthermore, the aim was to study the prospective relationship between financial hardship risks\u003csup\u003e23\u003c/sup\u003e and protective health behavior, respectively, and changes in self-rated health and well-being.\u003csup\u003e33\u003c/sup\u003e\u003c/p\u003e"},{"header":"Methods","content":"\u003cp\u003e This was a community-based participatory research project in collaboration with Arab Community Center for Economic and Social Service (ACCESS), American Accounting Society (AAS), and Women, Infants, and Children ACCESS, Dearborn, MI. In addition, a Project Steering Committee (PSC) was formed consisting of representatives from Dearborn Public Schools, Islamic Center of America, Dearborn Public Health Department, Samaritas, Macomb County Community Action Agency, the Holy Apostolic Catholic Assyrian Church of the East St. Mary\u0026rsquo;s Parish, 3D Consulting and Communications, and the University of Michigan-Dearborn. The role of the PSC was to ensure that the community was actively involved in all steps of the study, including the application for funding, development of the community outreach EITC information campaign, implementation, evaluation, and, eventually, initiatives to inform policy makers. Low- and middle-income Arab Americans is a rapidly growing yet underrepresented population in the United States. Data on the Arab American community is largely limited primarily because, until 2024, they have not been recognized as a distinct group on the US Census, leaving the community significantly underrepresented in most federal, state, and local research.\u003c/p\u003e \u003cp\u003eThe project was launched October 1, 2020. Baseline data collection was initiated June 6, 2021, and collection of the 12-month follow-up data was completed by September 26, 2022. The Michigan State University Institutional Review Board determined the project not to be research and therefore exempt (STUDY00005468).\u003c/p\u003e \u003cp\u003e \u003cspan type=\"Underline\" class=\"Underline\" name=\"Emphasis\"\u003eResearch Participants and Recruitment.\u003c/span\u003e \u003c/p\u003e \u003cp\u003eACCESS\u0026rsquo; two Women, Infants, and Children (WIC) programs were engaged in this project. The first program was in Dearborn, MI, and services clients in Wayne County. The second program was in Sterling Heights, MI, and services clients in Macomb County. Both programs shared the same senior manager and offered bilingual-speaking (English and Arabic) case managers and staff, which removed possible linguistic barriers for families seeking public services. The bilingual trained WIC staff at ACCESS carried out all recruitment.\u003c/p\u003e \u003cp\u003eThe original study design implied on-site recruitment as the mother and child visited WIC. However, before the actual accrual phase commenced, Covid-19 forced WIC to go virtual and visits were by videoconference or by phone. Study inclusion criteria were being a person of Arab American descent with low-to-moderate income residing in Southeast Michigan. Participants had to also qualify for EITC. Given the demographics serviced by ACCESS WIC programs, most clients either had children in their households or were pregnant. Since most participants attending ACCESS WIC are from low- to medium-income households, a vast majority of represented households qualified for EITC. Women contacting the WIC program were asked whether they would be interested in participating in a study about EITC. Those interested to learn more about the study received additional oral and written information in English or Arabic. Potential participants received extensive written information about the project and were able to pose questions. Those who decided to participate consented by responding affirmatively to a question at the beginning of the survey. If a person decided not to participate, they received the regular care that is part of any visit to WIC. It was made clear before consenting that the decision to participate or not would not impact their treatment at WIC or access to WIC services. Once consenting, the WIC personnel interviewed participants in English or Arabic. The staff recorded the respondents\u0026rsquo; answers in a structured paper survey. Survey responses were entered by staff into an online, commercial survey system, Qualtrics. Upon each survey completion, the participant was mailed a thank you letter with a \u003cspan\u003e$\u003c/span\u003e10 Target gift card enclosed. All surveys were assigned a unique code to be able to individually track participants prospectively as they responded to an additional survey at six and 12 months, respectively. That is, the respondent received a total of 3 surveys including the baseline survey. The master list linking the unique participant code to a named person was kept locked up at WIC. The research team used the unique ID number to link surveys over time. The research team did not have access to any personal identifiable information.\u003c/p\u003e \u003cp\u003e \u003cspan type=\"Underline\" class=\"Underline\" name=\"Emphasis\"\u003eCommunity-derived and delivered EITC information campaign.\u003c/span\u003e \u003c/p\u003e \u003cp\u003eThe lack of published, community-based and evaluated EITC information campaigns provided the rationale for developing a campaign through a series of iterations. The ACCESS project coordinator worked closely with AAS and the ACCESS communications department. AAS incorporated what they deemed effective strategies from prior campaigns involving other minoritized communities to increase uptake of EITC. Based on prior experiences, it was agreed that slogans should be short, worded in concrete, simple, and direct language. Statements generated included: \u0026ldquo;It\u0026rsquo;s your money, get it back for FREE\u0026rdquo;, \u0026ldquo;What would you do with extra cash?\u0026rdquo;, and \u0026ldquo;Keep more money in your pocket\u0026rdquo;. ACCESS accredited services translated all community outreach information material into Arabic. The PSC provided feedback to ensure that the materials were culturally appropriate and linguistically accurate. A website was created that included information on the EITC and Child Tax Credit (CTC), and a link that detailed who qualified for EITC. There were also links to educational videos created by external agencies. The page provided contact information to the project coordinator along with instructions on how to make an appointment at ACCESS\u0026rsquo; Volunteer Income Tax Assistance (VITA) tax clinics.\u003c/p\u003e \u003cp\u003eDuring year 1 of the project, culturally relevant and responsive bilingual EITC messages were displayed on eleven billboards across the target areas within Southeast Michigan. In collaboration with former U.S. Congressperson Andy Levin and Congressperson Rashida Tlaib, a roundtable discussion was conducted via Facebook Live. Radio and newspaper ads were disseminated in community-based radio and news outlets with a large Arab American audience.\u003c/p\u003e \u003cp\u003eA similar approach was used in the second year of the project to ensure that all material created and disseminated continued to be linguistically and culturally appropriate. During the second year, the campaign increased the use of social media and Public Service Announcement (PSA) videos created to educate community members about EITC and encourage them to utilize the free VITA tax clinics. The scripts for the videos were written in collaboration with AAS and the ACCESS communications department to ensure informational and cultural accuracy. In addition to being distributed at in-person outreach events, EITC flyers were shared on the ACCESS Instagram, Facebook, and X (formerly Twitter) accounts. Some posts were boosted through paid advertisements to expand reach. During the second year, 7 billboards were displayed across Southeast Michigan. Finally, Michigan Governor Gretchen Whitmer released a press release about EITC that was reposted on the ACCESS Facebook page.\u003c/p\u003e \u003cp\u003eDuring year three of the community outreach educational campaign, a new strategy was adopted to expand the project\u0026rsquo;s informational reach even further. Most of the outreach funding was invested in digital marketing instead of print materials. Bilingual wallet cards with a QR code were created and distributed to community members at in-person outreach events to sign up and receive more information about the campaign and make appointments at tax clinics. The partnerships with a local Arab American-led marketing agency were expanded to create high-quality short educational videos. These were later shared and heavily promoted across Instagram and Facebook. The scripts for the videos were written by the ACCESS program coordinator and reviewed by AAS to ensure content accuracy. In addition to creating videos in Arabic, English videos were subtitled to address any linguistic barriers. The cards and videos were all reviewed by members of the PSC and AAS to ensure that they were well-suited for the target population.\u003c/p\u003e \u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003eSurvey content\u003c/h2\u003e \u003cp\u003eThe baseline survey consisted of 30 questions largely composed of previously validated and published items.\u003csup\u003e34\u0026ndash;36\u003c/sup\u003e The section on \u003cspan type=\"Underline\" class=\"Underline\" name=\"Emphasis\"\u003eSociodemographics\u003c/span\u003e included questions on Gender identity (\u0026ldquo;select all that applies\u0026rdquo;; man, women, transgender, transgender, non-binary, genderqueer, agender, questioning, additional identity ___, please specify, and prefer not to answer), current Employment status (employed \u0026ndash; actively working. employed \u0026ndash; currently furloughed, self-employed \u0026ndash; actively working, self-employed \u0026ndash; currently furloughed, unemployed, and retired), Marital status (never married, married, separated, divorced, widowed, and cohabiting), Number of children, Pregnancy status (select all that applies; current, last 6 months, gave birth: last year, more than a year ago, and none of the above), Living arrangement, (owns their own home, rent an apartment, rent a house, live with friends/family in my household, Live with friends/family in their household, and other, please specify), Educational attainment (no formal education, less than high school, high school graduate, some college no degree, associate\u0026rsquo;s degree, bachelor\u0026rsquo;s degree, Master\u0026rsquo;s degree, PhD or equivalent), and Household income (less than \u003cspan\u003e$\u003c/span\u003e10,000, \u003cspan\u003e$\u003c/span\u003e10,000 - \u003cspan\u003e$\u003c/span\u003e19,999, \u003cspan\u003e$\u003c/span\u003e20,000 - \u003cspan\u003e$\u003c/span\u003e34,999, \u003cspan\u003e$\u003c/span\u003e35,000 - \u003cspan\u003e$\u003c/span\u003e49,999, \u003cspan\u003e$\u003c/span\u003e50,000 - \u003cspan\u003e$\u003c/span\u003e74,999, \u003cspan\u003e$\u003c/span\u003e75,000 or more per year). There were also questions covering the frequency (never, 1\u0026ndash;2, 3\u0026ndash;4, and 5\u0026ndash;6 times/week, and every day) of eating fruits (excluding juices) and vegetables.\u003c/p\u003e \u003cp\u003eIn terms of \u003cspan type=\"Underline\" class=\"Underline\" name=\"Emphasis\"\u003eHealth and Wellness\u003c/span\u003e, a set of validated visual analogue scales (VAS) was used to capture the following areas: \u0026ldquo;How is your health right now?\u0026rdquo;, \u0026ldquo;How is your energy level right now?\u0026rdquo;; \u0026ldquo;How do you rate your current sleep quality\u0026rdquo;; \u0026ldquo;How satisfied are you with your social life right now?\u0026rdquo;; How often do you exercise?\u0026rdquo; Responses were given on a VAS with descriptive names provided at the two extreme anchoring points, for example, Never and Every day, respectively. Scorings on the visual analogue scale ranged from 0 to 10.\u003c/p\u003e \u003cp\u003eThe section on \u003cspan type=\"Underline\" class=\"Underline\" name=\"Emphasis\"\u003eFinancial hardships and Protective health behavior\u003c/span\u003e included two questions that assessed frequency of financial concern: 1. How often are you worried about not having enough money to pay for rent/mortgage, and 2. How often are you worried about not having enough money to buy nutritious meals? Response alternatives were never, sometimes, usually, and always. These financial hardship questions have been associated with chronic financial stress. They are also risk factors for adverse childhood experiences (ACEs).\u003csup\u003e23\u003c/sup\u003e Protective health behavior was captured by assessing whether the participant had engaged in any physical activities or exercise (yes or no), such as running, calisthenics, golf, gardening, or walking exercise during the last month. Exercise has been shown to have beneficial effects in women exposed to adverse childhood events (ACEs)\u003csup\u003e23\u003c/sup\u003e.\u003c/p\u003e \u003cp\u003eThe survey included questions about respondents\u0026rsquo; \u003cspan type=\"Underline\" class=\"Underline\" name=\"Emphasis\"\u003eawareness\u003c/span\u003e of, \u003cspan type=\"Underline\" class=\"Underline\" name=\"Emphasis\"\u003eknowledge\u003c/span\u003e about, and history of \u003cspan type=\"Underline\" class=\"Underline\" name=\"Emphasis\"\u003eclaiming\u003c/span\u003e earned income tax credit and child tax credit (CTC). The respective questions regarding EITC, were: \u0026ldquo;Have you heard of the term earned income tax credit (EITC)?\u0026rdquo; and \u0026ldquo;How would you rate your knowledge regarding EITC?\u0026rdquo; Response alternatives for awareness of EITC were no, yes, before today, yes, only today. The time frame today was used since the participant most likely would become aware of the terms during today\u0026rsquo;s visit. If yes, the respondent was asked whether they had heard about EITC through any or more of the following outlets: flyer/advertisement, social media (e.g., Facebook, Instagram, etc.), from a friend/relative, TV/radio/billboard, during a WIC clinic visit, or from tax consultant/others that assisted with filing tax returns. The participant was asked to mark all that apply. Response alternatives were no (scored 0) or yes (\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e). Responses were summed to a total \u003cspan type=\"Underline\" class=\"Underline\" name=\"Emphasis\"\u003eCommunity Outreach Campaign Exposure Score (Campaign Score).\u003c/span\u003e The possible range of scores on the scale was 0, for no reported exposure to the campaign, to a high of 6.\u003c/p\u003e \u003cp\u003eThe participants rated their knowledge about EITC using a visual analog scale (VAS) ranging from 0 (very limited) to 10 (Excellent). Furthermore, we asked whether they expected to claim EITC in the future. Participants were also asked how they filed their most recent tax return (On their own, with the help from a friend/relative, using tax consultancy, e.g., H\u0026amp;R Block, using tax software, e.g., Turbo Tax, or with assistance from Accounting Aid Society (AAS). The survey concluded with questions about child tax credit (CTC). CTC survey items were designed the same as for EITC. The questions were: whether they had ever claimed CTC, and whether they planned on claiming CTC in the future. Finally, as a measure of general awareness of relevant policy initiatives, participants were asked whether they had heard about the American Rescue Plan Act of 2021 (yes, no).\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec4\" class=\"Section2\"\u003e \u003ch2\u003eData Analysis\u003c/h2\u003e \u003cp\u003eStatistical analysis included checking distribution of responses to the economic hardship, exercise, and health questions. Cross-sectional and longitudinal associations for discrete variables were tested using parametric, and non-parametric statistics when indicated as detailed below. Statistical significance was set at a two-sided p-value of \u0026lt;\u0026thinsp;0.5.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec5\" class=\"Section2\"\u003e \u003ch2\u003eAim 1: Knowledge of EITC\u003c/h2\u003e \u003cp\u003e \u003cspan type=\"Underline\" class=\"Underline\" name=\"Emphasis\"\u003eAim1.\u003c/span\u003e The main outcome variable was knowledge of EITC using a 0\u0026ndash;10 visual analogue scale as described above.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec6\" class=\"Section2\"\u003e \u003ch2\u003eAim 2: Association between financial strain, protective behavior, and self-rated health\u003c/h2\u003e \u003cp\u003e \u003cspan type=\"Underline\" class=\"Underline\" name=\"Emphasis\"\u003eAim 2\u003c/span\u003e was tested using linear regression analysis to determine whether changes in financial hardships and exercise habits, respectively, were predictive of 12-month health ratings. When modeling the discrete exposure variables financial hardships and exercise habits at the 6-month mid-point, we used logistic regression analysis. We used the mid-study (6-month) ratings of financial hardship and exercise habits, respectively, since this was determined to be the most valid assessment period to determine chronic exposure.\u003c/p\u003e \u003cp\u003eTwo groups were created. Participants that reported affirmative (Sometimes, often, always responses) to whether they worried about paying for mortgage/rent, or whether they worried about paying for nutritious meals were assigned a yes to the respective financial hardship question versus no (Never). Respondents who reported having exercised during the last month were classified as practicing the protective health behavior vs no. In all longitudinal analysis, we controlled for the baseline response on the respective outcome variables, for example, VAS ratings on a specific health question.\u003c/p\u003e \u003c/div\u003e"},{"header":"Results","content":"\u003cp\u003eA total of 215 participants responded to the baseline survey. Of these, 155 responded to the 6-month follow-up survey (retention rate of 74%). At the 12 months follow-up a total of 104 persons responded, representing a retention rate of 49% of the original cohort. A total of 93 participants (43%) responded to all three surveys. Out of the 215 participants recruited at baseline, 142 (142/215\u0026thinsp;=\u0026thinsp;66%) were between 25\u0026ndash;34 years of age, and 73 (34%) were 35\u0026ndash;44. There were 7 (7/214\u0026thinsp;=\u0026thinsp;3%) male participants and 207 (97%) females. One participant did not provide a response to gender. Participants were allowed to select multiple race/ethnicities. Most participants, 199 (199/215\u0026thinsp;=\u0026thinsp;93%) identified as Arab, followed by 79 (37%) Chaldean, 1 (1%) Assyrian, and 15 (7%) other Middle Eastern and North African (MENA). Around 95% of the respondents were married and 80% were unemployed, with no significant changes over time.\u003c/p\u003e \u003cdiv id=\"Sec8\" class=\"Section2\"\u003e \u003ch2\u003eAwareness of EITC\u003c/h2\u003e \u003cp\u003eAwareness of EITC increased significantly from 5/93 (5%) having awareness at baseline, to 26/93 (28%) at 6 months, and then decreased to 28/93 (29%) at 12 months (F\u003csub\u003e(df=2)\u003c/sub\u003e\u0026thinsp;=\u0026thinsp;14.117, p\u0026thinsp;\u0026lt;\u0026thinsp;.001). The mean Campaign Score was 0.05 (S.E.M 0.02) at base, 0.31 (0.05) at 6 months, and 0.34 (0.06) at 12 months (F\u003csub\u003e(df=2),\u003c/sub\u003e 8.978, p\u0026thinsp;\u0026lt;\u0026thinsp;.001).\u003c/p\u003e \u003cp\u003eFigure \u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e shows that participants\u0026rsquo; awareness of EITC increased over the one-year study period.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003eKnowledge about EITC was low initially and increased during the first 6 months (F\u003csub\u003edf 1,\u003c/sub\u003e 27.489, \u0026lt;\u0026thinsp;.001). After 6 months of the campaign, EITC knowledge had improved 316% (Baseline mean\u0026thinsp;=\u0026thinsp;1.15, S.E.M. = 0.40; 6-Month\u0026thinsp;=\u0026thinsp;3.63, 0.54) among those who responded to all three surveys. There were no significant differences at baseline in knowledge of EITC or self-rated health between those who responded to all three surveys and those who responded to one or two surveys. Inadvertently, the question about knowledge about EITC was not included in the 12-months follow-up survey.\u003c/p\u003e \u003cp\u003eFigure \u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003e depicts that there was a significant increase in participants\u0026rsquo; EITC community outreach information campaign scores (\u0026ldquo;Campaign Score\u0026rsquo;) over the project\u0026rsquo;s 12-months.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003eFigure \u003cspan refid=\"Fig3\" class=\"InternalRef\"\u003e3\u003c/span\u003e reports self-ratings on the health items, and knowledge about EITC over the three assessments. Sleep quality increased during the first 6-months and then decreased slightly by the 12 months follow-up (F\u003csub\u003edf 2,\u003c/sub\u003e 3.739, \u0026lt;\u0026thinsp;.05). Scorings on the other health measures did not change significantly over time.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003eTable\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e shows that there were significant differences in the proportion of participants that reported financial hardships and regular exercise habits, respectively, over time. Almost 50% of those who responded to all three surveys worried about paying their rent and 20% worried about paying for nutritious meals at baseline. A total of 17% worried about \u003cspan type=\"Underline\" class=\"Underline\" name=\"Emphasis\"\u003eboth\u003c/span\u003e paying rent and buying nutritious meals. Less than half had exercised during the last month at baseline.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eFinancial hardship and physical activity over time (93 responded to all 3 surveys)\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"7\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colspan=\"2\" morerows=\"1\" nameend=\"c2\" namest=\"c1\" rowspan=\"2\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eBaseline\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003e6-months\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003e12-months\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e \u003cp\u003eTotal\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c7\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eF (p)\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003en (%)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003en (%)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003en (%)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e \u003cp\u003en (%)\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e\u003cb\u003eWorry paying mortgage/rent\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003eNo\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e47 (51%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e70 (75%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e60 (64%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e177 (63%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eF\u003csub\u003edf=2\u003c/sub\u003e = 36.034, (p\u0026thinsp;\u0026lt;\u0026thinsp;.001)\u003csup\u003e\u003cb\u003e1\u003c/b\u003e\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003eYes\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e46 (49%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e23 (25%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e33 (36%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e102 (37%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e\u003cb\u003eWorry buying nutritious meals\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003eNo\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e74 (80%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e72 (77%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e70 (75%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e216 (77%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eF\u003csub\u003edf=2\u003c/sub\u003e = 10.727, (p\u0026thinsp;\u0026lt;\u0026thinsp;.001) \u003csup\u003e\u003cb\u003e1\u003c/b\u003e\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003eYes\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e19 (20%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e21 (23%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e23 (25%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e63 (23%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e\u003cb\u003ePhysical activity\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003eNo\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e59 (63%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e67 (72%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e58 (62%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e184 (66%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eF\u003csub\u003edf=2\u003c/sub\u003e = 13.021, (p\u0026thinsp;\u0026lt;\u0026thinsp;.001) \u003csup\u003e\u003cb\u003e1\u003c/b\u003e\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003eYes\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e34 (37%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e26 (28%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e35 (38%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e95 (34%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eTotal\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003en (%)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e279 (33%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e279 (33%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e279 (\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e33\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e837 (100%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003e \u003csup\u003e \u003cb\u003e1\u003c/b\u003e \u003c/sup\u003e Repeated measures test for trend.\u003c/p\u003e \u003cp\u003eWe also analyzed whether loss-to-follow-up was related to financial hardship and exercise habits responses, respectively, at baseline. Of those who responded to all three surveys, a greater proportion (49%, 46/93) worried about paying for mortgage/rent at baseline compared to those who responded to one or two surveys (31%, 38/124; Chi square \u003csub\u003edf 1\u003c/sub\u003e, 7.436, p\u0026thinsp;\u0026lt;\u0026thinsp;0.01). There were no significant differences at baseline between those who responded to all three surveys and those who responded to one or two in worrying about paying for nutritious meals or participation in physical activity.\u003c/p\u003e \u003cp\u003eLogistic regression modeling was used to determine whether knowledge about the earned income tax credit (EITC) at baseline was related to the likelihood of worrying about not being able to afford paying for rent/mortgage at the 12-month follow-up, controlling for baseline worry to pay rent/mortgage. Knowledge of EITC at baseline was not a significant predictor.\u003c/p\u003e \u003cp\u003eFindings were similar for the odds ratio for ranking worry about paying for nutritious meals at the 12-months follow-up based on the baseline rating. Knowledge of EITC at baseline was not predictive of ratings of worry paying for nutritious meals at the 12-month follow-up. Neither baseline exercise habits, nor baseline knowledge about EITC was predictive of the likelihood of exercising or not at the 12-month follow-up.\u003c/p\u003e \u003cp\u003eAt baseline, only 5% (5 of the 93 participants that responded to all three surveys) reported having been exposed to any of the media channels used to disseminate information about the EITC. At 6 months, exposure increased to 28% (26/93). At 12 months, the equivalent percentage was 30% (28/93). Differences in exposure to the EITC informational advertisements over time were significant (F\u003csub\u003e(df=2)\u003c/sub\u003e\u0026thinsp;=\u0026thinsp;14.117, p\u0026thinsp;\u0026lt;\u0026thinsp;.001).\u003c/p\u003e \u003cp\u003eTable\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e depicts that there were significant association between worrying about paying rent/mortgage and buying nutritious meals, respectively, at baseline and responses at the 12-month follow-up. The same findings held true in terms of financial hardship ratings at baseline and 6-month follow-up, and between the 6-month and 12-month follow-up (not shown).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eAssociations between financial hardship (worrying about paying for rent/mortgage, and buying nutritious meals, respectively) at baseline and the 12-month follow-up.\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"7\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colspan=\"2\" morerows=\"1\" nameend=\"c2\" namest=\"c1\" rowspan=\"2\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colspan=\"3\" nameend=\"c5\" namest=\"c3\"\u003e \u003cp\u003eWorry paying mortgage/rent at 12-month\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e \u003cp\u003eTotal\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c7\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eChi Square (p)\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003ctr\u003e \u003cth align=\"left\" colspan=\"2\" nameend=\"c4\" namest=\"c3\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e \u003cp\u003en (%)\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e\u003cb\u003eWorry paying mortgage/rent at baseline\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003eNo\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c4\" namest=\"c3\"\u003e \u003cp\u003e43 (84.3%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e8 (15.7%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e51 (50%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\" morerows=\"2\" rowspan=\"3\"\u003e \u003cp\u003eX\u003csup\u003e2\u003c/sup\u003e \u003csub\u003edf= 1\u003c/sub\u003e =20.30, (p\u0026thinsp;\u0026lt;\u0026thinsp;.001)\u003csup\u003e\u003cb\u003e1\u003c/b\u003e\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003eYes\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c4\" namest=\"c3\"\u003e \u003cp\u003e21 (41.2%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e30 (58.8%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e51 (50%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eTotal\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003en (%)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c4\" namest=\"c3\"\u003e \u003cp\u003e64 (63%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e38 (37%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e102 (100%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colspan=\"3\" nameend=\"c5\" namest=\"c3\"\u003e \u003cp\u003e\u003cb\u003eWorry buying nutritious meals at 12-month\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cb\u003eNo\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c5\" namest=\"c4\"\u003e \u003cp\u003e\u003cb\u003eYes\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e\u003cb\u003eWorry buying nutritious meals at baseline\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003eNo\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c4\" namest=\"c3\"\u003e \u003cp\u003e67 (85.9%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e11 (14.1%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e78 (76%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\" morerows=\"2\" rowspan=\"3\"\u003e \u003cp\u003eX\u003csup\u003e2\u003c/sup\u003e \u003csub\u003edf= 1\u003c/sub\u003e =26.05, (p\u0026thinsp;\u0026lt;\u0026thinsp;.001)\u003csup\u003e\u003cb\u003e1\u003c/b\u003e\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003eYes\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c4\" namest=\"c3\"\u003e \u003cp\u003e8 (33.3%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e16 (66.7%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e24 (24%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eTotal\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003en (%)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c4\" namest=\"c3\"\u003e \u003cp\u003e75 (74%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e27 (26%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e102 (100%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003e \u003csup\u003e \u003cb\u003e1\u003c/b\u003e \u003c/sup\u003e Chi Square test for associations.\u003c/p\u003e \u003cp\u003eIn terms of protective health behavior, Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e shows that at baseline, 40% (41/102) had exercised during the previous month. At the 12-month follow-up, 52% (53/102) reported having exercised during the previous month. Of the 41 persons that exercised at baseline, 78% (32/41) continued exercising at the 12-month follow-up. Among the 61 participants that did not exercise at baseline, 15% (9/61) had started exercising at the 12-month follow-up.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab3\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eAssociations between participation in physical activity at baseline and the 12-month follow-up.\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"6\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colspan=\"2\" morerows=\"1\" nameend=\"c2\" namest=\"c1\" rowspan=\"2\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colspan=\"2\" nameend=\"c4\" namest=\"c3\"\u003e \u003cp\u003eParticipation in Leisure Time Physical Activity at 12-month\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003eTotal\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eChi Square (p)\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003en (%)\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e\u003cb\u003eParticipation in Leisure Time Physical Activity at baseline\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003eNo\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e52 (85%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e9 (15%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e61 (60%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eX\u003csup\u003e2\u003c/sup\u003e \u003csub\u003edf= 1\u003c/sub\u003e =40.863, (p\u0026thinsp;\u0026lt;\u0026thinsp;.001) \u003csup\u003e\u003cb\u003e1\u003c/b\u003e\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003eYes\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e9 (22%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e32 (78%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e41 (40%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eTotal\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003en (%)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e61 (60%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e41 (40%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e102 (100%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003e \u003csup\u003e \u003cb\u003e1\u003c/b\u003e \u003c/sup\u003e Chi Square test for associations.\u003c/p\u003e \u003cp\u003eWe modelled the relationship between exposure to financial hardship at the 6-month mid-point, captured by the two financial hardship questions: 1. Any worries about not being able to pay for nutritious meals as compared to no worries, \u003cspan type=\"Underline\" class=\"Underline\" name=\"Emphasis\"\u003eor\u003c/span\u003e 2. Any worries not having enough money paying for rent/mortgage vs no worries, and health ratings at the 12-month follow-up. We compared ratings at the 12-month follow-up by group (having vs not having financial hardships at the 6-month mid-point). In all analyses we controlled for health ratings at baseline. As a protective factor, we used whether the respondent had exercised or not during the last month.\u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003eHealth\u003c/h3\u003e\n\u003cp\u003eWorry about paying for meals at the 6-month assessment was significantly related to self-rated health at 12 months (p\u0026thinsp;=\u0026thinsp;0.013), controlling for baseline self-rated health. Self-rated health at 12 months was significantly lower (-0.74 units; 95% confidence interval \u0026minus;\u0026thinsp;1.40, \u0026minus;\u0026thinsp;0.16) among those worrying vs not worrying about paying for meals. The model explained 5.6% (r\u003csup\u003e2\u003c/sup\u003e\u0026thinsp;=\u0026thinsp;0.056) of the variance in self-rated health at 12-month. Neither worrying vs not worrying about paying for rent/mortgage, nor exercising or not predicted changes in self-rated health.\u003c/p\u003e \u003cdiv id=\"Sec10\" class=\"Section2\"\u003e \u003ch2\u003eEnergy\u003c/h2\u003e \u003cp\u003eWorry about paying for meals at the 6-month assessment was significantly related to self-rated energy at 12 months (p\u0026thinsp;\u0026lt;\u0026thinsp;0.004), controlling for baseline self-rated energy. Self-rated energy at 12 months was significantly lower (-1.14 units; -1.91, -0.36) among those worrying vs not worrying about paying for meals. The model explained 20% (R\u003csup\u003e2\u003c/sup\u003e\u0026thinsp;=\u0026thinsp;0.20). There was also a significant difference among those worrying vs not worrying about paying for rent/mortgage\u003c/p\u003e \u003cp\u003e(p\u0026thinsp;\u0026lt;\u0026thinsp;0.003, -1.10 units; -1.83, -0.39) in self-rated energy at 12 months. The model explained 21% (R\u003csup\u003e2\u003c/sup\u003e\u0026thinsp;=\u0026thinsp;0.21). Exercise habits at the 6-month assessment was not related to self-rated energy at 12 months, controlling for baseline self-rated energy.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec11\" class=\"Section2\"\u003e \u003ch2\u003eSleep\u003c/h2\u003e \u003cp\u003eWorry about paying for meals at the 6-month assessment was significantly related to self-rated sleep at 12 months (p\u0026thinsp;\u0026lt;\u0026thinsp;0.01), controlling for baseline self-rated sleep. Self-rated sleep at 12 months was significantly lower (mean \u0026minus;\u0026thinsp;1.21 units;95% confidence interval \u0026minus;\u0026thinsp;1.93, -0.48) among those worrying vs not worrying about paying for meals. The model explained 26.3% (r\u003csup\u003e2\u003c/sup\u003e\u0026thinsp;=\u0026thinsp;0.263) of the variance. Furthermore, there was a significant difference among those worrying vs not worrying about paying for rent/mortgage (p\u0026thinsp;\u0026lt;\u0026thinsp;0.02, -0.81 units, -1.48, -0.14) in self-rated sleep at 12 months. Exercise habits at the 6-month assessment was related to self-rated sleep at 12 months (p\u0026thinsp;\u0026lt;\u0026thinsp;0.001), controlling for baseline self-rated sleep. Those stating at 6 months that they exercised scored lower on sleep vs those that responded that they did not exercise\u003c/p\u003e \u003cp\u003e(-0.98 units, -1.63, -0.32). The model explained 25% (R\u003csup\u003e2\u003c/sup\u003e\u0026thinsp;=\u0026thinsp;0.25) of the variance.\u003c/p\u003e \u003cp\u003eThus, overall, financial hardship ratings at the 6-month mid-point were closely related to adverse health effects at the 12-month follow-up, controlling for baseline health scores. Differences across worry vs no worry translated into significant differences in both self-rated health, energy, and sleep. Worry about paying for rent was associated with lower ratings on self-rated energy and sleep. Exercise, on the other hand was only related to self-rated sleep. Interestingly, those exercising vs not exercising scored lower on sleep.\u003c/p\u003e \u003c/div\u003e"},{"header":"Discussion","content":"\u003cp\u003eBefore the EITC community outreach information campaign was launched, knowledge of EITC was very limited. Following active campaigning, using increasingly broadening channels to communicate the message, there was a significant increase in knowledge about EITC. Still, the improvement was from a very low level, and additional strategies to ensure the target group is aware of their rights are needed.\u003c/p\u003e \u003cp\u003eAt baseline almost four out of ten households with children worried about how to pay for their rent/mortgage. Every fourth household worried about being able to afford paying for nutritious meals. Moreover, the strong association between the two financial hardship questions was evidenced by the fact that eight out of ten respondents that worried about how to pay for rent/mortgage also worried about how to pay for nutritious meals. Less than half were engaged or had engaged in physical activities. If a participant were worried about paying for rent/mortgage at baseline, the person was almost 13 times more likely to score the same at the 12-month follow-up. The same likelihood for a person worrying about paying for nutritious meals was almost 5 times higher. Of further concern is that the participants and members of their households are not only exposed to socioeconomic strain, but they often reside in disadvantaged neighborhoods which further adds to the toxic stress exposures.\u003csup\u003e38\u003c/sup\u003e\u003c/p\u003e \u003cp\u003eAt the aggregate group level, except for sleep scores, none of the self-rated health measures changed significantly over the 12-month follow-up period. This is in line with the fact that there were no significant changes in EITC allowance during this period, nor did we notice any substantial and lasting changes in financial hardship exposures. In terms of protective behavior, almost eight out of ten respondents that exercised at baseline also reported doing so at 12 months. Fifteen percent of those that did not exercise at baseline, took up exercise by the 12-month follow-up assessment.\u003c/p\u003e \u003cp\u003eWhen we dichotomized the cohort into two groups in terms of reporting financial hardship or not, a very different pattern emerged. Exposure to financial hardships was related to worsening self-rated health, energy, and sleep over the 12-month follow-up period. Exercise was less of a determinant of self-rated health except for being predictive of changes in self-rated sleep. Interestingly, exercise was associated with worsening sleep over the study period. We don\u0026rsquo;t have any explanation for the inverse relationship between exercise and sleep quality. Self-rated health is one of the most reliable predictors of a person\u0026rsquo;s actual health trajectory over the next 5\u0026ndash;10 years.\u003csup\u003e39\u0026ndash;41\u003c/sup\u003e Thus, the study offers further support for the deleterious health effects of living under financial hardships.\u003c/p\u003e \u003cp\u003eThe study did not find any direct associations between knowledge of EITC and changes over time in financial hardships. This is also evidence of the magnitude of the problem of increasing knowledge of and trust in EITC in targeted communities, and the need for effective communal outreach strategies. Knowledge of the EITC program may need to be accompanied by building trust, which can take time to develop from external (i.e., repeated and diverse community outreach social media campaigns) and internal (i.e., opportunities for positive word of mouth to spread.) As we continue to follow this cohort, we will be able to determine whether the positive effects on knowledge of EITC translate into claiming more EITC. And, if that is the case, how it relates to financial hardship.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eEthics approval and consent to participate\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eResearch was performed in accordance with the Declaration of Helsinki. All participants consented to be included in this study. Study was determined to be not research by the Michigan State University Institutional Review Board ID STUDY00005468.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAll participants included in this study were consented prior to inclusion. Only deidentified data was used in the generation of results and this manuscript.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of data and materials\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe datasets used and/or analyzed during the current study are available from the corresponding author on reasonable request.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAll authors have expressed that they do not have any competing interests with this study.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe study was funded in whole by grant number 1 CPIMP201205-01-00 awarded to the Arab Community Center for Economic and Social Service (ACCESS) by the U.S. Department of Health and Human Services (HHS). Researchers at Michigan State University responsible for the evaluation was funded in whole by a subcontract from ACCESS.\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors contributions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eB.A.\u0026nbsp;co-wrote the application together with an external grant writer, including the structure of the intervention and the evaluation logic model. B.A. was responsible for writing the institutional review board (IRB) protocol and the submission to the University\u0026rsquo;s IRB that determined the project was not research. Following funding, B.A.,\u0026nbsp;R.A.,\u0026nbsp;A.G., G.T.,\u0026nbsp;and M.H.\u0026nbsp;finalized the project design, intervention content, and evaluation structure, with input from the project advisory board. R.A. and M.K. were responsible for all of the information-based community outreach. M.H. and G.T. conducted tax consultation for participants and served as the point of contact for the Accounting Aid Society. A.C. was responsible for\u0026nbsp;linking de-identified survey data over time, and to\u0026nbsp;maintain survey data. Under the supervision of B.A. and J.A.,\u0026nbsp;A.C.\u0026nbsp;conducted some of the statistical analysis. W.M.\u0026nbsp;,E.A.\u0026nbsp;and B.A.\u0026nbsp;conducted the advanced statistical modeling. All authors contributed significantly to the final manuscript. All authors reviewed the final manuscript and approved it prior to submission.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgements\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;We would like to thank all participants that took the time and effort to participate in the study. Opinions expressed are those of the authors and do not necessarily represent those of HHS, ACCESS, nor AAS.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eGallo LC, Matthews KA. Understanding the association between socioeconomic status and physical health: do negative emotions play a role? Research Support, Non-U.S. Gov't;, Research Support US, Gov't PHS. Review. \u003cem\u003ePsychological bulletin\u003c/em\u003e. 2003 2003;129(1):10\u0026ndash;51. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1037/0033-2909.129.1.10\u003c/span\u003e\u003cspan address=\"10.1037/0033-2909.129.1.10\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMatthews KA, Gallo LC. Psychological perspectives on pathways linking socioeconomic status and physical health.; Research Support, N.I.H., Extramural; Review. \u003cem\u003eAnnual review of psychology\u003c/em\u003e. 2011 2011;62:501\u0026thinsp;\u0026ndash;\u0026thinsp;30. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1146/annurev.psych.031809.130711\u003c/span\u003e\u003cspan address=\"10.1146/annurev.psych.031809.130711\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMatthews KA, Gallo LC, Taylor SE. Are psychosocial factors mediators of socioeconomic status and health connections? A progress report and blueprint for the future.; Review. \u003cem\u003eAnnals of the New York Academy of Sciences\u003c/em\u003e. 2010 2010;1186:146\u0026thinsp;\u0026ndash;\u0026thinsp;73. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1111/j.1749-6632.2009.05332.x\u003c/span\u003e\u003cspan address=\"10.1111/j.1749-6632.2009.05332.x\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eUdalova V, Bhatia V, Polyakova M. Association of Family Income With Morbidity and Mortality Among US Lower-Income Children and Adolescents. JAMA Dec. 2022;27(24):2422\u0026ndash;30. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1001/jama.2022.22778\u003c/span\u003e\u003cspan address=\"10.1001/jama.2022.22778\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003ede la Rosa R, Zablotny D, Ye M, et al. Biological Burden of Adverse Childhood Experiences in Children. Psychosom Med 2023 Feb-Mar. 2023;01(2):108\u0026ndash;17. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1097/PSY.0000000000001167\u003c/span\u003e\u003cspan address=\"10.1097/PSY.0000000000001167\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eDunn KE, Turner GM, Oswald LM. Effects of Early Life Trauma on Risks for Adult Opioid Use Disorder Are Mediated by Stress and Occur Independent of Depression and Anxiety. J Addict Med 2022 Nov-Dec. 2022;01(6):709\u0026ndash;15. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1097/ADM.0000000000001011\u003c/span\u003e\u003cspan address=\"10.1097/ADM.0000000000001011\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eParletta N, Milte CM, Meyer BJ. Nutritional modulation of cognitive function and mental health.; Research Support, Non-U.S. Gov't; Review. J nutritional Biochem 2013 May (Epub 2013 Mar. 2013;24(5):725\u0026ndash;43. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1016/j.jnutbio.2013.01.002\u003c/span\u003e\u003cspan address=\"10.1016/j.jnutbio.2013.01.002\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eKarcher NR, Barch DM. The ABCD study: understanding the development of risk for mental and physical health outcomes.; Research Support, N.I.H., Extramural; Review. \u003cem\u003eNeuropsychopharmacology: official publication of the American College of Neuropsychopharmacology\u003c/em\u003e. 2021 01 (Epub 2020 Jun 2021;46(1):131\u0026ndash;142. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1038/s41386-020-0736-6\u003c/span\u003e\u003cspan address=\"10.1038/s41386-020-0736-6\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSlopen N, Heard-Garris N. Structural Racism and Pediatric Health-A Call for Research to Confront the Origins of Racial Disparities in Health. JAMA Pediatr Jan. 2022;01(1):13\u0026ndash;5. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1001/jamapediatrics.2021.3594\u003c/span\u003e\u003cspan address=\"10.1001/jamapediatrics.2021.3594\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBronfenbrenner U. The ecology of human development: experiments by nature and design. Harvard University Press; 1979. p. xv.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eArnetz BB, Arnetz J, Harkema JR, et al. Neighborhood air pollution and household environmental health as it relates to respiratory health and healthcare utilization among elderly persons with asthma. J Asthma Jan. 2020;57(1):28\u0026ndash;39. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1080/02770903.2018.1545856\u003c/span\u003e\u003cspan address=\"10.1080/02770903.2018.1545856\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eNolen E, Cubbin C, Brewer M. The effect of maternal food insecurity transitions on housing insecurity in a population-based sample of mothers of young children. \u003cem\u003eAIMS public health\u003c/em\u003e. 2022 2022;9(1):1\u0026ndash;16. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.3934/publichealth.2022001\u003c/span\u003e\u003cspan address=\"10.3934/publichealth.2022001\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBrewis A, Workman C, Wutich A, Jepson W, Young S, Household Water Insecurity Experiences - Research Coordination N. Household water insecurity is strongly associated with food insecurity: Evidence from 27 sites in low- and middle-income countries, Research Support NIH, Extramural;, Support R, Research Support N-US. U.S. Gov't, Non-P.H.S. \u003cem\u003eAmerican journal of human biology: the official journal of the Human Biology Council\u003c/em\u003e. 2020 01 (Epub 2019 Aug 2020;32(1):e23309. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1002/ajhb.23309\u003c/span\u003e\u003cspan address=\"10.1002/ajhb.23309\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eHamad R, Niedzwiecki MJ. The short-term effects of the earned income tax credit on health care expenditures among US adults. Health Serv Res Dec. 2019;54(6):1295\u0026ndash;304. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1111/1475-6773.13204\u003c/span\u003e\u003cspan address=\"10.1111/1475-6773.13204\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eRostad WL, Ports KA, Tang S, Klevens J. Reducing the Number of Children Entering Foster Care: Effects of State Earned Income Tax Credits. Child Maltreat Nov. 2020;25(4):393\u0026ndash;7. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1177/1077559519900922\u003c/span\u003e\u003cspan address=\"10.1177/1077559519900922\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eKlevens J, Schmidt B, Luo F, Xu L, Ports KA, Lee RD. Effect of the Earned Income Tax Credit on Hospital Admissions for Pediatric Abusive Head Trauma, 1995\u0026ndash;2013. Public Health Rep. 2017;132(4):505\u0026ndash;11. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1177/0033354917710905\u003c/span\u003e\u003cspan address=\"10.1177/0033354917710905\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMoe CA, Kovski NL, Dalve K, et al. Cumulative Payments Through the Earned Income Tax Credit Program in Childhood and Criminal Conviction During Adolescence in the US. JAMA Netw Open Nov. 2022;01(11):e2242864. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1001/jamanetworkopen.2022.42864\u003c/span\u003e\u003cspan address=\"10.1001/jamanetworkopen.2022.42864\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eYang G, Cao X, Li X, et al. Association of Unhealthy Lifestyle and Childhood Adversity With Acceleration of Aging Among UK Biobank Participants. JAMA Netw Open Sep. 2022;01(9):e2230690. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1001/jamanetworkopen.2022.30690\u003c/span\u003e\u003cspan address=\"10.1001/jamanetworkopen.2022.30690\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eHolz NE, Berhe O, Sacu S, et al. Early Social Adversity, Altered Brain Functional Connectivity, and Mental Health. Biol Psychiatry Mar. 2023;01(5):430\u0026ndash;41. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1016/j.biopsych.2022.10.019\u003c/span\u003e\u003cspan address=\"10.1016/j.biopsych.2022.10.019\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eRoberts AL, Zafonte R, Chibnik LB, et al. Association of Adverse Childhood Experiences With Poor Neuropsychiatric Health and Dementia Among Former Professional US Football Players. JAMA Netw Open Mar. 2022;01(3):e223299. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1001/jamanetworkopen.2022.3299\u003c/span\u003e\u003cspan address=\"10.1001/jamanetworkopen.2022.3299\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eHamad R, Galea S. The Role of Health Care Systems in Bolstering the Social Safety Net to Address Health Inequities in the Wake of the COVID-19 Pandemic. JAMA Jul. 2022;05(1):17\u0026ndash;8. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1001/jama.2022.10160\u003c/span\u003e\u003cspan address=\"10.1001/jama.2022.10160\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eCrandall-Hollick MF, A Novel Strategy for increasing Utilization of Earned Income Tax Credits and Reducing Adverse Childhood Experiences, Ford CL, Wallace SP, Newman PA, Lee S-J, Cunningham WE, Smith AC, Woerner J, Perera R, Haeny AM, Cox JM. An Investigation of Associations Between Race, Ethnicity, and Past Experiences of Discrimination with Medical Mistrust and COVID-19 Protective Strategies.;, Support R, Perales L, Holguin M, Komro KA, Dunlap P, Sroczynski N et al. 2022 1-27. 23. Maguire-Jack K, Solomon A, Greenberg S. : The EITC Access Project. \u003cem\u003eInt Journal on Child Malt\u003c/em\u003e 2022;5473\u0026thinsp;\u0026ndash;\u0026thinsp;486. doi:10.10007/s42448-022-00119-8 24. Ford CL, Wallace SP, Newman PA, Lee S-J, Cunningham WE. Belief in AIDS-related conspiracy theories and mistrust in the government: relationship with HIV testing among at-risk older adults.; Multicenter Study; Research Support, N.I.H., Extramural; Research Support, Non-U.S. Gov't. \u003cem\u003eThe Gerontologist\u003c/em\u003e. 2013 Dec (Epub 2013 Jan 2013;53(6):973\u0026thinsp;\u0026ndash;\u0026thinsp;84. doi:10.1093/geront/gns192 25. Feingold E. The defeat of health care reform: misplaced mistrust in government. \u003cem\u003eAmerican journal of public health\u003c/em\u003e. 1995 1995;85(12):1619-22. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.2105/ajph.85.12.1619 26\u003c/span\u003e\u003cspan address=\"10.2105/ajph.85.12.1619 26\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e. Choi Y, Fox AM. Mistrust in public health institutions is a stronger predictor of vaccine hesitancy and uptake than Trust in Trump. \u003cem\u003eSocial science \u0026amp; medicine (1982)\u003c/em\u003e. 2022 12 (Epub 2022 Oct 2022;314:115440. doi:10.1016/j.socscimed.2022.115440 27. Smith AC, Woerner J, Perera R, Haeny AM, Cox JM. An Investigation of Associations Between Race, Ethnicity, and Past Experiences of Discrimination with Medical Mistrust and COVID-19 Protective Strategies.; Research Support, Non-U.S. Gov't. \u003cem\u003eJournal of racial and ethnic health disparities\u003c/em\u003e. 2022 08 (Epub 2021 Jun 2022;9(4):1430\u0026ndash;1442. doi:10.1007/s40615-021-01080-x 28. Liu PY, Beck AF, Lindau ST. A framework for cross-sector partnerships to address childhood adversity and improve life course health. \u003cem\u003ePediatrics\u003c/em\u003e. 2022;149(Supplement 5)29. Schickedanz A, Perales L, Holguin M. Clinic-Based Financial Coaching and Missed Pediatric Preventive Care: A Randomized Trial. \u003cem\u003ePediatrics\u003c/em\u003e. Feb 02 2023;doi:10.1542/peds.2021-054970 30. Courtin E, Aloisi K, Miller C, Allen HL, Katz LF, Muennig P. The Health Effects Of Expanding The Earned Income Tax Credit: Results From New York City. \u003cem\u003eHealth Aff (Millwood)\u003c/em\u003e. Jul 2020;39(7):1149\u0026ndash;1156. doi:10.1377/hlthaff.2019.01556 31. Komro KA, Dunlap P, Sroczynski N Anti-poverty policy and health: Attributes and diffusion of state earned income tax credits across U.S. states from 1980 to 2020. \u003cem\u003ePLoS One\u003c/em\u003e. 2020;15(11):e0242514. doi:10.1371/journal.pone.0242514.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eRogers EM, Banks NF, Tomko PM, et al. Progressive Exercise Training Improves Cardiovascular Psychophysiological Outcomes in Young Adult Women with a History of Adverse Childhood Experiences. J Appl Physiol (1985) Feb. 2023;02. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1152/japplphysiol.00524.2022\u003c/span\u003e\u003cspan address=\"10.1152/japplphysiol.00524.2022\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eHasson D, Arnetz BB, Theorell T, Anderberg UM. Predictors of self-rated health: a 12-month prospective study of IT and media workers. Popul Health Metr Jul. 2006;31:4:8. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1186/1478-7954-4-8\u003c/span\u003e\u003cspan address=\"10.1186/1478-7954-4-8\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eArnetz BB. Model development and research vision for the future of multiple chemical sensitivity. Scand J Work Environ Health Dec. 1999;25(6):569\u0026ndash;73. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.5271/sjweh.482\u003c/span\u003e\u003cspan address=\"10.5271/sjweh.482\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eArnetz BB, Templin T, Saudi W, Jamil H. Obstructive sleep apnea, posttraumatic stress disorder, and health in immigrants. Psychosom Med Oct. 2012;74(8):824\u0026ndash;31. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1097/PSY.0b013e31826bf1ec\u003c/span\u003e\u003cspan address=\"10.1097/PSY.0b013e31826bf1ec\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eHasson D, Anderberg UM, Theorell T, Arnetz BB. Psychophysiological effects of a web-based stress management system: a prospective, randomized controlled intervention study of IT and media workers [ISRCTN54254861]. BMC Public Health Jul. 2005;25:5:78. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1186/1471-2458-5-78\u003c/span\u003e\u003cspan address=\"10.1186/1471-2458-5-78\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSircar NR, Friedman EA. Financial security and public health: How basic income \u0026amp; cash transfers can promote health. Glob Public Health Dec. 2018;13(12):1878\u0026ndash;88. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1080/17441692.2018.1460383\u003c/span\u003e\u003cspan address=\"10.1080/17441692.2018.1460383\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eWadsworth ME, Raviv T, Santiago CD, Etter EM. Testing the adaptation to poverty-related stress model: predicting psychopathology symptoms in families facing economic hardship. J Clin Child Adolesc Psychol. 2011;40(4):646\u0026ndash;57. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1080/15374416.2011.581622\u003c/span\u003e\u003cspan address=\"10.1080/15374416.2011.581622\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eAnderz\u0026eacute;n I, Arnetz BB. Psychophysiological reactions to international adjustment. Results from a controlled, longitudinal study. Psychother Psychosom. 1999;68(2):67\u0026ndash;75. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1159/000012315\u003c/span\u003e\u003cspan address=\"10.1159/000012315\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eHalford C, Ekselius L, Anderzen I, Arnetz B, Sv\u0026auml;rdsudd K. Self-rated health, life-style, and psychoendocrine measures of stress in healthy adult women. Ups J Med Sci Nov. 2010;115(4):266\u0026ndash;74. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.3109/03009734.2010.496910\u003c/span\u003e\u003cspan address=\"10.3109/03009734.2010.496910\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eHalford C, Anderz\u0026eacute;n I, Arnetz B. Endocrine measures of stress and self-rated health: a longitudinal study. J Psychosom Res Oct. 2003;55(4):317\u0026ndash;20. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1016/s0022-3999(02)00634-7\u003c/span\u003e\u003cspan address=\"10.1016/s0022-3999(02)00634-7\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-public-health","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"pubh","sideBox":"Learn more about [BMC Public Health](http://bmcpublichealth.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/pubh/default.aspx","title":"BMC Public Health","twitterHandle":"@BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"","lastPublishedDoi":"10.21203/rs.3.rs-4472980/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-4472980/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003eThe federal government offers earned income tax credit (EITC) to working low and middle-income families. Lack of knowledge and distrust in government result in a large proportion of qualified families does not uptake (\u0026lsquo;claim\u0026rdquo;) EITC. The study objectives were to (\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e) determine whether a community derived EITC outreach campaign resulted in improved knowledge of EITC, and (\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e) examine the relationship between financial stress and self-rated health.\u003c/p\u003e \u003cp\u003eA total of 215 women attending Women, Infants, and Children (WIC) centers in southeast Detroit, Michigan, were recruited in 2021. Participants filled out a survey at baseline, and after 6 and 12 months, respectively. The 1-year retention rate was 48% (n\u0026thinsp;=\u0026thinsp;104). The survey contained questions on sociodemographics, financial stressors, exercise, health, and knowledge of EITC.\u003c/p\u003e \u003cp\u003eAt baseline, knowledge about EITC was low (mean 1.1 [SE 0.3] on a 0\u0026ndash;10 visual analogue scale) but increased significantly during the first six months (2.9 [0.3]; p\u0026thinsp;\u0026lt;\u0026thinsp;.01). Approximately 38% of respondents worried about not having sufficient funds to pay for rent/mortgage at baseline, and almost 28% worried about not being able to buy nutritious meals for their families. Worry about paying for meals at the 6-month mid-point assessment was significantly related to self-rated health at 12 months (p\u0026thinsp;=\u0026thinsp;0.013). Self-rated health at 12 months was significantly lower (-0.74; 95% confidence interval \u0026minus;\u0026thinsp;1.40, \u0026minus;\u0026thinsp;0.16) among those worrying vs not worrying about paying for meals. The model explained 5.6% (r\u003csup\u003e2\u003c/sup\u003e\u0026thinsp;=\u0026thinsp;0.056) of the variance in self-rated health at 12-months.\u003c/p\u003e \u003cp\u003eThe study shows that knowledge about EITC is limited among qualified households. A community engaged EITC outreach campaign increased knowledge substantially. Financial strain is related to worsening self-rated health. EITC is an underused bipartisan, pro-employment supported federal program to address near-poverty and poverty among underserved families.\u003c/p\u003e","manuscriptTitle":"The Prospective Relationship Between Uptake of Earned Income Tax Credit (EITC), Financial Strain, and Health in Underserved Families","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2024-06-14 18:38:08","doi":"10.21203/rs.3.rs-4472980/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2024-05-31T08:14:32+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2024-05-31T06:44:13+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2024-05-31T06:44:12+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Public Health","date":"2024-05-24T14:10:00+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-public-health","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"pubh","sideBox":"Learn more about [BMC Public Health](http://bmcpublichealth.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/pubh/default.aspx","title":"BMC Public Health","twitterHandle":"@BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"170df9b9-101d-4ce2-b701-1a1111001fb6","owner":[],"postedDate":"June 14th, 2024","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[],"tags":[],"updatedAt":"2026-01-19T16:51:23+00:00","versionOfRecord":{"articleIdentity":"rs-4472980","link":"https://doi.org/10.1186/s12889-025-25962-5","journal":{"identity":"bmc-public-health","isVorOnly":false,"title":"BMC Public Health"},"publishedOn":"2026-01-12 16:31:01","publishedOnDateReadable":"January 12th, 2026"},"versionCreatedAt":"2024-06-14 18:38:08","video":"","vorDoi":"10.1186/s12889-025-25962-5","vorDoiUrl":"https://doi.org/10.1186/s12889-025-25962-5","workflowStages":[]},"version":"v1","identity":"rs-4472980","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-4472980","identity":"rs-4472980","version":["v1"]},"buildId":"qtupq5eGEP_6zYnWcrvyt","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}