Background Over-indebtedness is currently rising in high-income countries. Millions of citizens are confronted with the persistent situation when household income and assets are insufficient to cover payment obligations and living expenses. Previous research shows that over-indebtedness increases the risk of various adverse health effects. However, its association with sleep problems has not yet been examined. The objective of this study was to investigate the association between over-indebtedness and sleep problems and sleep medication use. Methods A cross-sectional study on over-indebtedness (OID survey) was conducted in 70 debt advisory centres in Germany in 2017 that included 699 over-indebted respondents. The survey data were combined with the nationally representative German Health Interview and Examination Survey for Adults (DEGS1; n = 7987). We limited analyses to participants with complete data on all sleep variables (OID: n = 538, DEGS1: n = 7447). Descriptive analyses and logistic regression analyses were used to examine the association between over-indebtedness and difficulty initiating and maintaining sleep, and sleep medication use. Results A higher prevalence of sleep problems and sleep medication use was observed among over-indebted individuals compared to the general population. After adjustment for socio-economic and health factors (age, sex, education, marital status, employment status, subjective health status and mental illness), over-indebtedness significantly increased the risk of difficulties with sleep onset (adjusted odds ratio (aOR) 1.79, 95%-confidence interval (CI) 1.45–2.21), sleep maintenance (aOR 1.45, 95%-CI 1.17–1.80) and sleep medication use (aOR 3.94, 95%-CI 2.96–5.24). Conclusions Evidence suggests a strong association between over-indebtedness and poor sleep and sleep medication use independent of conventional socioeconomic measures. Considering over-indebtedness in both research and health care practice will help to advance the understanding of sleep disparities, and facilitate interventions for those at risk. Trial registration German Clinical Trials Register: DRKS00013100 (OID survey, ArSemü); Date of registration: 23.10.2017; Date of enrolment of the first participant: 18.07.2017, retrospectively registered. Electronic supplementary material The online version of this article (10.1186/s12889-019-7231-1) contains supplementary material, which is available to authorized users.

In developed countries, millions of households are over-indebted, and the number continues to rise. Studies have found an increased risk of adverse health effects among individuals that cannot cover payment obligations with available assets persistently. However, little is known about the role of over-indebtedness in pain. This study examined the association between over-indebtedness and pain and pain medication use.A cross-sectional study conducted among over-indebted individuals in 70 debt advisory centres in Germany (OID-survey; n = 699) was linked to the nationally representative German Health Interview and Examination Survey for Adults (DEGS1; n = 7987). Descriptive statistics and logistic regression analyses were used to examine the association between over-indebtedness and pain and pain medication use among participants with valid data on both outcome variables (n = 7560).Pain was experienced by over-indebted individuals more frequently (71.3%) compared to the general population (59.6%) whereas the prevalence of pain medication use was similar in both samples (DEGS1 12.6% vs. OID-survey 13.1%). Over-indebtedness significantly increased the odds of pain (aOR 1.30; 95%-CI 1.07–1.59) after adjusting for socioeconomic, demographic and health factors. The over-indebted were significantly less likely to use pain medication compared to the general population after adjustment (aOR 0.76; 95%-CI 0.58–0.99).Taking over-indebtedness into account as risk factor for pain and restricted pain medication use in research and clinical practice will help to advance the understanding of pain disparities, develop suitable interventions for preventive action and promote accessible pain management among those at risk.

BackgroundMillions of citizens in high-income countries face over-indebtedness that implies being unable to cover payment obligations with available income and assets on an ongoing basis. Studies have shown an association between over-indebtedness and health outcomes, independent of standard socioeconomic status measures. Patterns of cost-related medication nonadherence (CRN) among over-indebted individuals are yet unclear. The aim of this study was to examine the frequency of nonadherence to prescribed medications due to cost, and to identify risk factors for CRN among over-indebted individuals in Germany.MethodsIn 2017, we conducted a cross-sectional survey among over-indebted individuals recruited in 70 debt advice agencies in North Rhine-Westphalia, Germany. Data on CRN in the last 12 months (i.e. not filling prescriptions, skipping or decreasing doses of prescribed medication due to financial problems) were collected by a survey using a self-administered written questionnaire that was returned by 699 individuals with a response rate of 50.2%. Prevalence of CRN was assessed using descriptive statistics. Multiple logistic regression analysis was performed to examine risk factors of CRN, including participants enrolled in statutory health insurance with complete data (n = 521).ResultsThe prevalence of CRN was 33.6%. The chronically ill had significantly greater odds of cost-related medication nonadherence (aOR 1.96; 95% CI 1.27–3.03) than individuals without a chronic illness. CRN was more likely to occur in individuals who had discussed financial problems with their general practitioner (aOR 1.58; 95% CI 1.01–2.47). There was no association between CRN and other sociodemographic factors or socioeconomic status.ConclusionsMedication nonadherence due to financial pressures is common among over-indebted citizens enrolled in statutory health insurance in Germany. Stakeholders in social policy, research and health care need to address over-indebtedness to develop strategies to safeguard access to relevant medications, especially among those with high morbidity.Trial registrationArzneimittelkonsum, insbesondere Selbstmedikation bei überschuldeten Bürgerinnen und Bürgern in Nordrhein-Westfalen (ArSemü), (engl. ‘Medication use, particularly self-medication among over-indebted citizens in North Rhine-Westphalia’), German Clinical Trials Register: DRKS00013100. Date of registration: 23.10.2017. Date of enrolment of the first participant: 18.07.2017, retrospectively registered.