Life Space and Activity Space Measurement: Making 'Room' for Structural Racism

As we age, the ability to move is foundational to health. Life space is one measure of a person's ability to move and engage in activity beyond the home. A separate but related concept is activity space, a measurement of a person's spatial behaviors and visited locations that include social networks, neighborhoods, and institutions. In this article, we integrate the literature on life space and activity space discussing how physical function is not only determined by individual capabilities, but also by the surrounding social and environmental factors which may limit their agency. We show how structural racism contributes to inequities within this paradigm linking related concepts of movement, agency, belonging, and timing. We also explore implications for research and theory for mobility, social connection, and activity.

Food insecurity gaps in the Supplemental Nutrition Assistance Program based on disability status

BACKGROUND

Households including someone with disabilities experience disproportionately high food insecurity rates and likely face disproportionate barriers accessing Supplemental Nutrition Assistance Program (SNAP) benefits.

OBJECTIVE

This article aims to examine the role of SNAP with regard to food insecurity disparities based on disability status.

METHODS

Modified Poisson regression models examined food insecurity risk based on disability status (household includes no one with disabilities vs. those with work-limiting disabilities or non-work-limiting disabilities) among 2018 Survey of Income and Program Participation households eligible for SNAP (income ≤130% of the poverty threshold). Weighted estimates were used to account for the study design and non-response.

RESULTS

Households including someone with work-limiting disabilities were more than twice as likely to be food insecure than households including no one with disabilities (PR = 2.16, 95% CI: 1.90, 2.45); households including someone with non-work-limiting disabilities were 65% more likely (PR = 1.65, 95% CI: 1.39, 1.95). However, disparities were more pronounced among households not participating in SNAP (PR = 2.67, 95% CI: 2.22, 3.23 for work-limiting disabilities and PR = 1.86, 95% CI: 1.44, 2.40 for non-work-limiting disabilities) than SNAP-participating households (PR = 1.71, 95% CI: 1.45, 2.03 and PR = 1.46, 95% CI: 1.17, 1.82, respectively). Approximately 4.2 million low-income U.S. households including someone with disabilities are food insecure. Of these, 1.4 million were not participating in SNAP and another 2.8 million households were food insecure despite participating in SNAP.

CONCLUSIONS

Access to SNAP benefits is not proportionate to the scale of food insecurity among households that include people with disabilities. Action is needed to strengthen food assistance for those with disabilities.

Supplemental Nutrition Assistance Program Access and Racial Disparities in Food Insecurity

Importance

Racially minoritized people experience disproportionately high rates of food insecurity. The Supplemental Nutrition Assistance Program (SNAP) reduces food insecurity.

Objective

To evaluate SNAP access with regard to racial disparities in food insecurity.

Design, Setting, and Participants

This cross-sectional study used data from the 2018 Survey of Income and Program Participation (SIPP). On the basis of random sampling strategies, 44 870 households were eligible for the SIPP, and 26 215 (58.4%) participated. Sampling weights accounted for survey design and nonresponse. Data were analyzed from February 25 to December 12, 2022.

Exposures

This study examined disparities based on household racial composition (entirely Asian, entirely Black, entirely White, and multiple races or multirace based on SIPP categories).

Main Outcomes and Measures

Food insecurity during the prior year was measured using the validated 6-item US Department of Agriculture Food Security Survey Module. SNAP participation during the prior year was classified based on whether anyone in the household received SNAP benefits. Modified Poisson regression tested hypothesized disparities in food insecurity.

Results

A total of 4974 households that were eligible for SNAP (income ≤130% of the poverty threshold) were included in this study. A total of 218 households (5%) were entirely Asian, 1014 (22%) were entirely Black, 3313 (65%) were entirely White, and 429 (8%) were multiracial or of other racial groups. Adjusting for household characteristics, households that were entirely Black (prevalence rate [PR], 1.18; 95% CI, 1.04-1.33) or multiracial (PR, 1.25; 95% CI, 1.06-1.46) were more likely to be food insecure than entirely White households, but associations differed depending on SNAP participation. Among households that did not participate in SNAP, those that were entirely Black (PR, 1.52; 97.5% CI, 1.20-1.93) or multiracial (PR, 1.42; 97.5% CI, 1.04-1.94) were more likely to be food insecure than White households; however, among SNAP participants, Black households were less likely than White households to be food insecure (PR, 0.84; 97.5% CI, 0.71-0.99).

Conclusions and Relevance

In this cross-sectional study, racial disparities in food insecurity were found among low-income households that do not participate in SNAP but not among those that do, suggesting that access to SNAP should be improved. These results also highlight the need to examine the structural and systemic racism in food systems and in access to food assistance that may contribute to disparities.

Caregiving-Related Work Productivity Loss Among Employed Family and Other Unpaid Caregivers of Older Adults

OBJECTIVES

Although nearly half of all family and unpaid caregivers to older adults work, little is known about short-term work impacts of caregiving using measures encompassing both missed work time and reduced productivity while physically at work. We quantify the prevalence, costs, and correlates of caregiving-related work productivity loss.

METHODS

We used the 2015 National Study of Caregiving and National Health and Aging Trends Study to estimate caregiving-related work absences (absenteeism) and reduced productivity while at work (presenteeism). We calculated costs of lost productivity using hours lost, compensation, and a wage multiplier, accounting for the additional cost of replacing employee time. We examined correlates of caregiving-related absenteeism and presenteeism separately, using multivariable logistic regression models, adjusting for caregiver sociodemographic characteristics, occupation and hours worked, role overload, older adult health, use of respite care, support groups, flexible workplace schedules, help from family or friends, and caregiver training.

RESULTS

Nearly 1 in 4 (23.3%) of the estimated 8.8 million employed family caregivers reported either absenteeism or presenteeism over a 1-month period owing to caregiving. Among those affected, caregiving reduced work productivity by one-third on average-or an estimated $5600 per employee when annualized across all employed caregivers-primarily because of reduced performance while present at work. Productivity loss was higher among caregivers of older adults with significant care needs and varied according to sociodemographic characteristics and caregiver supports.

CONCLUSIONS

Findings emphasize the potential economic value of targeted policy intervention to support working caregivers.

Food Insecurity and Cognitive Trajectories in Community-Dwelling Medicare Beneficiaries 65 Years and Older

Importance

Food insecurity has a known association with prevalent impaired cognition. However, it is unknown whether food insecurity has a longitudinal association with cognitive decline among older adults.

Objective

To determine whether food insecurity is associated with a faster decline in cognitive function among community-dwelling older adults.

Design, Setting, and Participants

This retrospective cohort study used data from a nationally representative sample of Medicare beneficiaries 65 years and older recruited for the National Health and Aging Trends Study (NHATS). Community-dwelling NHATS participants were followed up for a maximum of 7 years (mean [SD] follow-up duration, 5.4 [1.1] years). Data were collected from January 1, 2012, to December 31, 2020, and analyzed from December 23, 2021, to December 6, 2022.

Exposures

Self-reported food insecurity assessed from 2012 to 2019.

Main Outcomes and Measures

Primary outcomes were immediate memory, delayed memory, and executive function collected from 2013 to 2020. Immediate and delayed recall were assessed by a 10-item word-list memory task (range, 0-10, with higher scores indicating more words recalled). Executive function was measured by the clock drawing test (range, 0-5, with higher scores indicating more accurate depiction of a clock). Each year's cognitive functions were linked to the prior year's food insecurity data. Linear mixed-effects models with random slopes and intercepts were used to examine the association between food insecurity and cognitive decline. Analytic weights in each year were applied to represent community-dwelling Medicare beneficiaries 65 years and older in 2011.

Results

Of 3037 participants, a weighted 57.8% (raw count, 1345) were younger than 75 years, 56.2% (raw count, 1777) were women, and most (84.9% [raw count, 2268]) were White. Over 7 years, 417 (weighted proportion, 12.1%) experienced food insecurity at least once. Food insecurity was associated with a faster decline in executive function in a fully adjusted model: the mean difference of annual change in executive function score between people exposed to and not exposed to food insecurity was -0.04 (95% CI, -0.09 to -0.003) points. However, food insecurity was not associated with changes in immediate and delayed memory (0.01 [95% CI, -0.05 to 0.08] and -0.01 [95% CI, -0.08 to 0.06], respectively).

Conclusions and Relevance

Among community-dwelling older adults, food insecurity was prevalent and associated with a decline in executive function. Interventions and policies aiming to increase healthy food access or reduce food insecurity should be assessed for their impact on older adults' cognitive outcome.

The relationship between older adults' technology use, in-person engagement, and pandemic-related mental health

OBJECTIVE

The objectives of this study are to 1) describe changes in in-person communication/activity and changes in older adult technology use during the COVID-19 pandemic and 2) examine whether less in-person communication/activity mediates the relationship between pandemic-related mental health and technology use.

METHOD

Linear regressions (stratified by age and financial strain) and structural equation modeling were employed using a nationally representative, cross-sectional survey of 3,188 older adults from the 2020 National Health and Aging Trends Study's COVID-19 Questionairre.

RESULTS

Older adults engaged in more technology-based activity (b = 0.24; p<.001), more technology-based health care communication (b = 0.22; p<.001), and more technology-based food acquisition (b = 0.21; p<.001) during the COVID-19 pandemic, as compared to before the pandemic. Results indicate that adults <80 years old demonstrated greater increases in technology-based activity, technology-based health communication, and technology-based food acquisition, compared to adults ≥80 years old. Change in in-person communication significantly mediated the relationship between pandemic-related mental health and technology-based communication (standardized coefficient= -0.012; p=.005), and change in in-person activity significantly mediated the relationship between pandemic-related mental health and technology-based activity (standardized coefficient= -0.017; p=.020).

CONCLUSIONS

This study suggests that older adults are utilizing technology more, and therefore should be considered in technology design and dissemination. Technology use could be an important positive response to help those with pandemic related worries stay safely engaged with friends and family. Technologies should be produced that are modifiable for older adults with disabilities and affordable for older adults with fixed incomes.

Financial Contributions and Experiences of Non-Spousal, Employed Family Caregivers

The economic impacts of caring for an older adult may be amplified for employed family and unpaid caregivers. We examine out-of-pocket spending among employed, retired, and unemployed caregivers. Among employed caregivers, we identify correlates of spending and assess whether spending and work productivity loss contribute to financial burden. Analyses use the 2015 National Health and Aging Trends Study (NHATS) and National Study of Caregiving. We find that employed caregivers incur more out-of-pocket spending on caregiving than retired and unemployed counterparts. Employed caregivers spending more than $500 out-of-pocket provide more hours of care and assist older adults with greater impairment. Among employed family caregivers, caregiver and care recipient Medicaid enrollment, spending, and work productivity loss are associated with financial burden. Findings suggest that caregiving exacerbates economic well-being among employed caregivers, particularly for those with socioeconomic vulnerability.

The development of the Supplemental Nutrition Assistance Program enrollment accessibility (SNAP-access) score

BACKGROUND

The Supplemental Nutrition Assistance Program (SNAP) is a federal public benefit providing food assistance to millions of Americans. However, it is typically administered by states, creating potential variation in accessibility and transparency of information about enrollment for people with disabilities.

OBJECTIVE

To develop and demonstrate the use of a method to assess the accessibility and transparency of information about the disability-inclusive process and practices of SNAP enrollment.

METHODS

Cross-sectional data was collected from SNAP landing and enrollment webpages from all 50 U.S. states, the District of Columbia, and New York City from June-August 2021. Based on principles of universal design and accessibility, scores were determined for each SNAP program across three areas: flexibility in the enrollment process (6 points), efficiency of finding information about enrollment on SNAP websites (6 points), and the accessibility of SNAP webpages (6 points). Total scores were the sum of these sub-categories (18 points maximum).

RESULTS

Of the 52 SNAP programs assessed, mean scores were 10.66 (SD = 2.51) for the total score, 2.67 (SD = 0.91) for flexibility in the enrollment process, 3.32 (SD = 1.19) for efficiency of finding information about enrollment on SNAP websites, and 4.67 (SD = 1.72) for the accessibility of SNAP webpages. No programs received the maximum flexibility score (6 points) on flexibility, 2 programs received the maximum on efficiency, and 31 programs the maximum on accessibility.

CONCLUSIONS

We found differences in the accessibility, flexibility, and efficiency of SNAP program enrollment information available on SNAP websites and outline room for improvement across all three of these areas.

Exploring Challenges and Strategies in Partnering With Community-Based Organizations to Advance Intervention Development and Implementation With Older Adults

Minoritized older adults face multiple health inequities and disparities, but are less likely to benefit from evidence-based health care interventions. With the increasing diversity of the U.S. aging population, there is a great promise for gerontology researchers to partner with racial/ethnic minority organizations and underrepresented communities to develop and implement evidence-based health interventions. Community-Based Participatory Research and Implementation Science offer guidance and strategies for researchers to develop and sustain community partnerships. However, researchers partnering with community organizations continue to face challenges in these collaborations, study outcomes, and sustainability. This may be especially true for those junior in their career trajectory or new to community-engaged research. The purpose of this forum article is to detail critical challenges that can affect gerontology researcher-community partnerships and relationships from the perspective of researchers. Seven challenges (pre- or mid-intervention design, implementation, and postimplementation phases) described within the Equity-focused Implementation Research for health programs framework are identified and discussed. Potential solutions are also presented. Planning for potential obstacles of the researcher-community partnerships can inform innovative solutions that will facilitate successful partnerships, thereby promoting the advancement of collaborative research between academic institutions and community organizations to improve older adult health outcomes.

Propensity score weighted associations between financial strain and subsequent inflammatory biomarkers of aging among a representative sample of U.S. older adults

BACKGROUND

Despite known socioeconomic disparities in aging-related outcomes, the underlying physiologic mechanisms are understudied. This study applied propensity score weighting to estimate the effect of financial strain on inflammation-related aging biomarkers among a national sample of older adults.

METHODS

Financial strain severe enough to lack money for housing, utilities, medical/prescription bills or food was measured among 4,593 community-dwelling National Health and Aging Trends Study participants aged ≥ 65 years in 2016. Inverse probability propensity score weights were generated based on 2015 background characteristics, including age, gender, race/ethnicity, income to poverty ratio, education, occupation, home ownership, retirement, Sect. 8 housing, Medicaid, food/energy assistance, childhood health, marital status, and U.S. region. Sampling weights additionally accounted for study design and non-response.

RESULTS

In propensity score-weighted analyses adjusting for age, gender, race/ethnicity, 2017 income to poverty ratio and education, those with 2016 financial strain had 15% higher IL-6 (p = 0.026) and 20% higher CRP levels (p = 0.002) in 2017 than those who were not strained, but did not differ with regard to hemoglobin A1c or CMV. In weighted comparisons, those with financial strain did not differ from those without with regard any 2015 background characteristics.

CONCLUSIONS

These results strengthen the etiologic evidence suggesting that financial strain increases inflammatory biomarkers among older adults. Importantly, inflammation is likely a key physiologic pathway contributing to socioeconomic disparities. Therefore, research is needed to address financial strain.

The effect of COVID-19 pandemic-related financial challenges on mental health and well-being among U.S. older adults

Background

Despite profound financial challenges during the COVID‐19 pandemic, there is a gap in estimating their effects on mental health and well‐being among older adults.

Methods

The National Health and Aging Trends Study is an ongoing nationally representative cohort study of US older adults. Outcomes included mental health related to COVID‐19 (scores averaged across eight items ranging from one to four), sleep quality during COVID‐19, loneliness during COVID‐19, having time to yourself during COVID‐19, and hopefulness during COVID‐19. Exposures included income decline during COVID‐19 and financial difficulty due to COVID‐19. Propensity score weighting produced covariate balance for demographic, socioeconomic, household, health, and well‐being characteristics that preceded the pandemic to estimate the average treatment effect. Sampling weights accounted for study design and non‐response.

Results

In weighted and adjusted analyses (n = 3257), both income decline during COVID‐19 and financial difficulty due to COVID‐19 were associated with poorer mental health related to COVID‐19 (b = −0.159, p < 0.001 and b = −0.381, p < 0.001, respectively), poorer quality sleep (OR = 0.63, 95% CI: 0.46, 0.86 and OR = 0.42, 95% CI: 0.30, 0.58, respectively), more loneliness (OR = 1.53, 95% CI: 1.16, 2.02 and OR = 2.72, 95% CI: 1.96, 3.77, respectively), and less time to yourself (OR = 0.54, 95% CI: 0.40, 0.72 and OR = 0.37, 95% CI: 0.27, 0.51, respectively) during COVID‐19.

Conclusions

Pandemic‐related financial challenges are associated with worse mental health and well‐being regardless of pre‐pandemic characteristics, suggesting that they are distinct social determinants of health for older adults. Timely intervention is needed to support older adults experiencing pandemic‐related financial challenges.

Supplemental nutrition assistance program 2009 expansion and cardiometabolic markers among low-income adults

A 2009 Supplemental Nutrition Assistance Program (SNAP) policy change that expanded eligibility and increased benefit amounts has been associated with reduced food insecurity. This study tests the hypothesis that the SNAP policy change corresponds with improved stress- and nutrition-sensitive cardiometabolic markers. This study included non-pregnant participants aged 18-59 with annual family incomes ≤185% of the federal poverty guideline from the repeated cross-sectional NHANES study. Those living in SNAP eligible households (income ≤130% of the poverty guideline) were compared to those who were likely non-eligible (income 131%-≤185%). Difference-in-differences analyses compared hemoglobin A1c (%), CRP (mg/dL), total cholesterol (mg/dL), LDL (mg/dL) and waist circumference (cm) across groups before (2007-2008) and after (2009-2010) the SNAP policy change. Sampling weights were applied. Adjusting for demographic, socioeconomic, household and health factors, there were statistically significant difference-in-differences estimates for hemoglobin A1c (p = 0.003, n = 3723) and total cholesterol (p = 0.028, n = 3710). SNAP eligible adults had no difference in hemoglobin A1c after the policy change and, among those less than 40 years of age, 5 mg/dL lower total cholesterol levels whereas likely non-SNAP eligible adults had 0.14% higher hemoglobin A1c and no difference in total cholesterol after the policy change. The 2009 SNAP expansion was associated with improved nutrition-sensitive cardiometabolic markers in SNAP-eligible adults. This study found less of an upward trend in hemoglobin A1c levels for young and middle aged adults and decreased total cholesterol for young adults. These results highlight the potential role of SNAP to prevent costly chronic conditions among low-income U.S. adults.

Dissecting the Racial/Ethnic Disparity in Frailty in a Nationally Representative Cohort Study with Respect to Health, Income, and Measurement

BACKGROUND

Racial/ethnic frailty prevalence disparities have been documented. Better elucidating how these operate may inform interventions to eliminate them. We aimed to determine whether physical frailty phenotype (PFP) prevalence disparities (i) are explained by health aspects, (ii) vary by income, or (iii) differ in degree across individual PFP criteria.

METHODS

Data came from the 2011 National Health and Aging Trends Study baseline evaluation. The study sample (n = 7,439) included persons in all residential settings except nursing homes. Logistic regression was used to achieve aims (i)-(iii) listed above. In (i), health aspects considered were body mass index (BMI) status and number of chronic diseases. Analyses incorporated sampling weights and adjusted for sociodemographic factors.

RESULTS

Comparisons are versus non-Hispanic whites: Non-Hispanic blacks (odds ratio [OR] = 1.46, 95% confidence interval [CI]: 1.21-1.76) and Hispanics (1.56, 1.20-2.03) continued to have higher odds of frailty after accounting for BMI status and number of chronic diseases. Non-Hispanic blacks had elevated odds of frailty in all income quartiles, including the highest (OR = 2.19, 1.24-3.397). Racial/ethnic disparities differed considerably across frailty criteria, ranging from a twofold increase in odds of slowness to a 25%-30% decrease in odds of self-reported exhaustion.

CONCLUSIONS

BMI and disease burden do not explain racial/ethnic frailty disparities. Black-white disparities are not restricted to low-income groups. Racial/ethnic differences vary considerably by NHATS PFP criteria. Our findings support the need to better understand mechanisms underlying elevated frailty burden in older non-Hispanic black and Hispanic Americans, how phenotypic measures capture frailty in racial/ethnic subgroups and, potentially, how to create assessments more comparable by race/ethnicity.

Race, ethnicity, poverty and the social determinants of the coronavirus divide: U.S. county-level disparities and risk factors

Background

Communities with more Black or Hispanic residents have higher coronavirus rates than communities with more White residents, but relevant community characteristics are underexplored. The purpose of this study was to investigate poverty-, race- and ethnic-based disparities and associated economic, housing, transit, population health and health care characteristics.

Methods

Six-month cumulative coronavirus incidence and mortality were examined using adjusted negative binomial models among all U.S. counties (n = 3142). County-level independent variables included percentages in poverty and within racial/ethnic groups (Black, Hispanic, Native American, Asian), and rates of unemployment, lacking a high school diploma, housing cost burden, single parent households, limited English proficiency, diabetes, obesity, smoking, uninsured, preventable hospitalizations, primary care physicians, hospitals, ICU beds and households that were crowded, in multi-unit buildings or without a vehicle.

Results

Counties with higher percentages of Black (IRR = 1.03, 95% CI: 1.02–1.03) or Hispanic (IRR = 1.02, 95% CI: 1.01–1.03) residents had more coronavirus cases. Counties with higher percentages of Black (IRR = 1.02, 95% CI: 1.02–1.03) or Native American (IRR = 1.02, 95% CI: 1.01–1.04) residents had more deaths. Higher rates of lacking a high school diploma was associated with higher counts of cases (IRR = 1.03, 95% CI: 1.01–1.05) and deaths (IRR = 1.04, 95% CI: 1.01–1.07). Higher percentages of multi-unit households were associated with higher (IRR = 1.02, 95% CI: 1.01–1.04) and unemployment with lower (IRR = 0.96, 95% CI: 0.94–0.98) incidence. Higher percentages of individuals with limited English proficiency (IRR = 1.09, 95% CI: 1.04–1.14) and households without a vehicle (IRR = 1.04, 95% CI: 1.01–1.07) were associated with more deaths.

Conclusions

These results document differential pandemic impact in counties with more residents who are Black, Hispanic or Native American, highlighting the roles of residential racial segregation and other forms of discrimination. Factors including economic opportunities, occupational risk, public transit and housing conditions should be addressed in pandemic-related public health strategies to mitigate disparities across counties for the current pandemic and future population health events.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12889-021-11205-w.

Race, ethnicity, poverty and the social determinants of the coronavirus divide: U.S. county-level disparities and risk factors

BACKGROUND

Communities with more Black or Hispanic residents have higher coronavirus rates than communities with more White residents, but relevant community characteristics are underexplored. The purpose of this study was to investigate poverty-, race- and ethnic-based disparities and associated economic, housing, transit, population health and health care characteristics.

METHODS

Six-month cumulative coronavirus incidence and mortality were examined using adjusted negative binomial models among all U.S. counties (n = 3142). County-level independent variables included percentages in poverty and within racial/ethnic groups (Black, Hispanic, Native American, Asian), and rates of unemployment, lacking a high school diploma, housing cost burden, single parent households, limited English proficiency, diabetes, obesity, smoking, uninsured, preventable hospitalizations, primary care physicians, hospitals, ICU beds and households that were crowded, in multi-unit buildings or without a vehicle.

RESULTS

Counties with higher percentages of Black (IRR = 1.03, 95% CI: 1.02-1.03) or Hispanic (IRR = 1.02, 95% CI: 1.01-1.03) residents had more coronavirus cases. Counties with higher percentages of Black (IRR = 1.02, 95% CI: 1.02-1.03) or Native American (IRR = 1.02, 95% CI: 1.01-1.04) residents had more deaths. Higher rates of lacking a high school diploma was associated with higher counts of cases (IRR = 1.03, 95% CI: 1.01-1.05) and deaths (IRR = 1.04, 95% CI: 1.01-1.07). Higher percentages of multi-unit households were associated with higher (IRR = 1.02, 95% CI: 1.01-1.04) and unemployment with lower (IRR = 0.96, 95% CI: 0.94-0.98) incidence. Higher percentages of individuals with limited English proficiency (IRR = 1.09, 95% CI: 1.04-1.14) and households without a vehicle (IRR = 1.04, 95% CI: 1.01-1.07) were associated with more deaths.

CONCLUSIONS

These results document differential pandemic impact in counties with more residents who are Black, Hispanic or Native American, highlighting the roles of residential racial segregation and other forms of discrimination. Factors including economic opportunities, occupational risk, public transit and housing conditions should be addressed in pandemic-related public health strategies to mitigate disparities across counties for the current pandemic and future population health events.

Residential Street Block Disorder and Biological Markers of Aging in Older Adults: The National Health and Aging Trends Study

BACKGROUND

Residential environments are associated with older adult health, but underlying physiologic causal mechanisms are not well understood. As adults age, street blocks are likely more relevant to their health than the larger neighborhood environment. This study examined the effects of adverse street block conditions on aging biomarkers among older adults.

METHODS

We included community-dwelling Medicare beneficiaries aged 67 and older with 2017 biomarker data from the nationally representative National Health and Aging Trends Study (n=4,357). Street block disorder in 2016 was measured using interviewer report of any trash/glass/litter, graffiti, or vacant buildings on participants' blocks. Propensity score models were used to create balanced groups with regard to multiple 2015 participant characteristics, including demographic, socioeconomic, residence, and early life characteristics. Linear regressions modeled street block disorder as a predictor of four aging biomarkers, hemoglobin A1C, high-sensitivity C-reactive protein, interleukin-6, and cytomegalovirus antibodies, before and after applying propensity score weighting.

RESULTS

Adjusting for participant sociodemographic characteristics and applying propensity score weights, living on a block with any disorder was associated with 2% higher mean hemoglobin A1C levels (95% CI: 0.002-0.03), 13% higher C-reactive protein (95% CI: 0.03-0.23), 10% higher interleukin-6 (95% CI: 0.02-0.19), and 19% more cytomegalovirus antibodies (95% CI: 0.09-0.29) compared to living on a block with no disorder.

CONCLUSIONS

Street block disorder predicted subsequent aging biomarkers after applying a propensity score approach to account for confounding among a national sample of older adults. Targeting street-level residential contexts for intervention may reduce risk for poor health in older adults.

Home and Neighborhood Context of Falls Among Black and White Older Americans

Objectives: To examine social and physical environmental fall-risk factors in a nationally representative sample of community-living older adults overall and by racial group. Methods: We used data from the 2015 and 2016 rounds of the National Health and Aging Trends Study (n = 5581) linked to census tract measures from the American Community Survey. Recurrent falls are defined as 2+ self-reported falls over 12 months. Results: Older adults with recurrent falls were more likely to have lower education, lower income, financial hardship, live in homes with disorder and disrepair and in neighborhoods without sidewalks, with high social deprivation, and in nonmetropolitan counties. Home disrepair, lack of sidewalks, and residence in a nonmetropolitan county were important fall-risk factors among White older adults only. Financial hardship was an important risk factor among Black older adults. Discussion: Environmental factors are associated with recurrent falls among older Americans and should be incorporated into fall-risk profiles and prevention efforts.

Prevalence and Characteristics of Non-US-Born and US-Born Health Care Professionals, 2010-2018

Importance

Immigration to the US results in greater racial/ethnic diversity. However, the contribution of immigration to the diversity of the US health care professional (HCP) work force and its contribution to health care are poorly documented.

Objective

To examine the sociodemographic characteristics and workforce outcomes of non-US-born and US-born HCPs.

Design, Setting, and Participants

This cross-sectional study used national US Census Bureau data on US-born and non-US-born HCPs from the American Community Survey between 2010 and 2018. Demographic characteristics and occupational data for physicians, advanced practice registered nurses, physician assistants, registered nurses, licensed practical nurses or licensed vocational nurses, and other HCPs were included for analysis. Data were analyzed between December 2020 and February 2021.

Exposures

Nativity status, defined as US-born HCP vs non-US-born HCP (further stratified by <10 years or ≥10 years of stay in the US).

Main Outcomes and Measures

Annual hours worked, proportion of work done at night, residence in medically underserved areas and populations, and work in skilled nursing/home health settings. Inverse probability weighting of 3 nativity status groups was carried out using logistic regression. F test statistics were used to test across-group differences. Data were weighted using American Community Survey sampling weights.

Results

Of a total of 657 455 HCPs analyzed (497 180 [75.5%] women; mean [SD] age, 43.7 [13.0] years; 518 317 [75.6%] White, 54 233 [10.8%] Black, and 60 680 [9.6%] Asian), non-US-born HCPs (105 331 in total) represented 17.3% (95% CI, 17.2%-17.4%) of HCPs between 2010 and 2018. They were older (mean [SD] age, 44.7 [11.6] years) and had more education (75 227 [70.1%] HCPs completed college) compared with US-born HCPs (mean [SD] age, 43.4 [13.3] years; 304 601 [55.2%] completed college). Nearly half of non-US-born HCPs (47 735 [43.0%]) were Asian. In major metropolitan areas, non-US-born HCPs represented 40% or more of all HCPs. Compared with US-born HCPs, non-US-born HCPs with less than 10 years and 10 or more years of stay worked 32.3 hours (95% CI, 19.2 to 45.4 hours) and 71.6 hours (95% CI, 65.1 to 78.2 hours) more per year, respectively. Compared with US-born HCPs, non-US-born HCPs were more likely to reside in areas with shortages of health care professionals (estimated percentage: <10 years, 75.3%; ≥10 years, 62.8% vs US-born, 8.3%) and work in home health settings (estimated percentage: <10 years, 17.5%; ≥10 years, 13.1% vs US-born, 12.8%).

Conclusions and Relevance

The contributions of non-US-born HCPs to US health care are substantial and vary by profession. Greater efforts should be made to streamline their immigration process and to harmonize training and licensure requirements.

Socioeconomic disparities in six-year incident dementia in a nationally representative cohort of U.S. older adults: an examination of financial resources

Background

Less educational training is consistently associated with incident dementia among older adults, but associations between income and financial strain with incident dementia have not been well tested in national samples. This is an important gap because, like education, financial resources are potentially modifiable by policy change and strengthening the social safety net. This study tested whether financial resources (income and financial strain) predict six-year incident dementia independent of education and occupation.

Methods

The National Health and Aging Trends Study is a prospective cohort study that recruited a nationally representative sample of U.S. Medicare beneficiaries aged ≥65 years. Incident dementia (2013 to 2018) was classified based on diagnosis, cognitive test scores or proxy-reported changes among participants dementia-free in 2012 (n = 3785). Baseline socioeconomic measures included income to poverty ratio (analyzed separately for those < 500% vs. ≥500% poverty threshold), financial strain, education and history of professional occupation. Discrete time survival analysis applied survey weights to account for study design and nonresponse. Coefficients were standardized to compare the strength of associations across the four socioeconomic measures.

Results

Adjusting for socioeconomic measures, demographic characteristics, home ownership, retirement, chronic conditions, smoking, BMI and depressive symptoms, higher income (hazard OR = 0.84, 95% CI: 0.74, 0.95 among those < 500% poverty) and higher education (hOR = 0.73, 95% CI: 0.65, 0.83) were associated with lower odds, and financial strain with higher odds (hOR = 1.20, 95% CI: 1.09, 1.31), of incident dementia.

Conclusion

Low income and greater financial strain predict incident dementia among older adults and associations are comparable to those of low education among U.S. older adults. Interventions to mitigate financial strain through improving access to economic opportunity and strengthening safety net programs and improving access to them in low income groups may complement other ongoing efforts to prevent dementia.

Longitudinal and reciprocal associations between financial strain, home characteristics and mobility in the National Health and Aging Trends Study

BACKGROUND

Older adults need homes that suit their physical capacity. Financial strain may limit home repairs and modifications and prompt relocations; repairing, relocating or modifying may increase financial strain. Likewise, reciprocal relationships may exist between financial strain and home characteristics and mobility; financial strain and home characteristics may influence mobility and mobility declines may increase financial strain, limit home repairs and modifications and prompt relocations. We test cross-lagged associations between financial strain, home disorder, relocation, home modifications and mobility.

METHODS

In the National Health and Aging Trends Study, ability to complete a walking test, speed among those able to complete, financial strain, home disorder, relocating and modifying the home were recorded annually for 3 years (2012-2014). Structural equation models separately examined ability to walk and walking speed among those able, accounting for sociodemographic characteristics, social support, health prior health characteristics and autoregressive effects. Sampling weights accounted for the complex survey design and non-response over time.

RESULTS

In both models (n = 3234 and n = 2467), financial strain predicted greater home disorder and vice versa, but cross-lagged associations were not found with relocating and modifications. Greater home disorder predicted lower odds of ability to walk and slower speed among those able. Financial strain and home modifications predicted lower odds of ability to walk. Also, faster walking speed predicted lower odds of subsequent financial strain and lower subsequent home disorder scores and ability to walk predicted less subsequent home disorder and lower odds of relocating.

CONCLUSIONS

Home disorder links financial strain with reduced mobility in a national sample of U.S. older adults. Cross-lagged associations between financial strain and home disorder and between home disorder and mobility suggest reciprocal effects that may accumulate over time. Also, financial strain, reduced mobility, relocations and modifications predicted greater home disorder. Together, these results highlight home disorder as a social determinant of mobility for older adults. Greater attention should be given to repairing and modifying home environments and supporting stable housing for older adults with financial strain.

Longitudinal and reciprocal associations between financial strain, home characteristics and mobility in the National Health and Aging Trends Study

Background

Older adults need homes that suit their physical capacity. Financial strain may limit home repairs and modifications and prompt relocations; repairing, relocating or modifying may increase financial strain. Likewise, reciprocal relationships may exist between financial strain and home characteristics and mobility; financial strain and home characteristics may influence mobility and mobility declines may increase financial strain, limit home repairs and modifications and prompt relocations. We test cross-lagged associations between financial strain, home disorder, relocation, home modifications and mobility.

Methods

In the National Health and Aging Trends Study, ability to complete a walking test, speed among those able to complete, financial strain, home disorder, relocating and modifying the home were recorded annually for 3 years (2012–2014). Structural equation models separately examined ability to walk and walking speed among those able, accounting for sociodemographic characteristics, social support, health prior health characteristics and autoregressive effects. Sampling weights accounted for the complex survey design and non-response over time.

Results

In both models (n = 3234 and n = 2467), financial strain predicted greater home disorder and vice versa, but cross-lagged associations were not found with relocating and modifications. Greater home disorder predicted lower odds of ability to walk and slower speed among those able. Financial strain and home modifications predicted lower odds of ability to walk. Also, faster walking speed predicted lower odds of subsequent financial strain and lower subsequent home disorder scores and ability to walk predicted less subsequent home disorder and lower odds of relocating.

Conclusions

Home disorder links financial strain with reduced mobility in a national sample of U.S. older adults. Cross-lagged associations between financial strain and home disorder and between home disorder and mobility suggest reciprocal effects that may accumulate over time. Also, financial strain, reduced mobility, relocations and modifications predicted greater home disorder. Together, these results highlight home disorder as a social determinant of mobility for older adults. Greater attention should be given to repairing and modifying home environments and supporting stable housing for older adults with financial strain.

Socioeconomic Status, Race/Ethnicity, and Diurnal Cortisol Trajectories in Middle-Aged and Older Adults

Objectives

Slow afternoon cortisol decline may be a marker of aging. We hypothesize that lower socioeconomic status (SES) and African American race are associated with lower waking cortisol and slower afternoon decline.

Method

Six salivary cortisol samples, collected within a 24-hr period from 566 cohort participants aged 56-78 years, were examined in random-effects models. SES measures included socioeconomic vulnerability (household income and assets <500% of poverty) and education (≥college, some college, and ≤high school). African Americans were compared with all others.

Results

Adjusting for age and sex, intermediate, but not low, education was associated with approximately 17% lower average waking cortisol and 1% slower decline, compared with high education. Socioeconomic vulnerability was not associated with waking cortisol or linear decline. Accounting for African American race/ethnicity, socioeconomic vulnerability was associated with a 3% faster decline, and education was not associated with cortisol. African Americans had 26% lower average waking cortisol and 1% slower decline than others.

Discussion

African American race/ethnicity, but not lower SES, was associated with lower waking cortisol and slower afternoon decline in middle-aged and older adults. This pattern is likely a marker of earlier biological aging in vulnerable groups. Race/ethnicity may compete with SES as a measure of cumulative vulnerability.

Food assistance is associated with decreased nursing home admissions for Maryland's dually eligible older adults

BACKGROUND

Although it has long been known that a broad range of factors beyond medical diagnoses affect health and health services use, it has been unclear whether additional income can decrease health service use. We examined whether Supplemental Nutrition Assistance Program (SNAP) receipt is associated with subsequent nursing home entry among low income older adults.

METHODS

We examined the 77,678 older adults dually eligible for Medicaid and Medicare in Maryland, 2010-2012. Zero inflated negative binomial regression, adjusting for demographic and health factors, tested the association of either lagged SNAP enrollment or lagged benefit amount with nursing home admission. We used Heckman two-step model results to calculate potential savings of SNAP enrollment through reduced nursing home admissions and reduced duration.

RESULTS

Only 53.4% received SNAP in 2012, despite being income-eligible. SNAP participants had a 23% reduced odds of nursing home admission than nonparticipants (95% CI: 0.75-0.78). For SNAP participants, an additional $10 of monthly SNAP assistance was associated with lower odds of admission (OR = 0.93, 95% CI: 0.93-0.93), and fewer days stay among those admitted (IRR = 0.99, 95% CI: 0.98-0.99). Providing SNAP to all 2012 sample nonparticipants could be associated with $34 million in cost savings in Maryland.

CONCLUSIONS

SNAP is underutilized and may reduce costly nursing home use among high-risk older adults. This study has policy implications at the State and Federal levels which include expanding access to SNAP and enhancing SNAP amounts.

Does the Supplemental Nutrition Assistance Program Affect Hospital Utilization Among Older Adults? The Case of Maryland

This study sought to examine whether Supplemental Nutrition Assistance Program (SNAP) participation and benefit levels are associated with reduced subsequent hospital and emergency department utilization in low-income older adults. Study participants were 68,956 Maryland residents aged ≥65 years who were dually enrolled in Medicare and Medicaid (2009–2012). Annual inpatient hospital days and costs and emergency department visits were modeled as a function of either 1-year lagged SNAP participation or lagged SNAP benefit amounts, controlling for sociodemographic characteristics, autoregressive effects, year, health status, and Medicaid participation. SNAP participation (adjusted odds ratio [aOR] = 0.96, 95% confidence interval [CI]: 0.93, 0.99), and, among participants, each $10 increase in monthly benefits (aOR = 0.99, 95% CI: 0.99–0.99) are associated with a reduced likelihood of hospitalization, but not emergency department use. The authors estimate that enrolling the 47% of the 2012 population who were eligible nonparticipants in SNAP could have been associated with $19 million in hospital cost savings. Accounting for the strong effects of health care access, this study finds that SNAP is associated with reduced hospitalization in dually eligible older adults. Policies to increase SNAP participation and benefit amounts in eligible older adults may reduce hospitalizations and health care costs for older dual eligible adults living in the community.

Community Characteristics are Associated with Blood Pressure Levels in a Racially Integrated Community

Community problems have been associated with higher, and community resources and social cohesion with lower, blood pressure. However, prior studies have not accounted for potential confounding by residential racial segregation. This study tested associations between community characteristics and blood pressure levels and prevalent hypertension in a racially integrated community. The Exploring Health Disparities in Integrated Communities Study measured blood pressure in residents of two contiguous racially integrated and low-income US Census Tracts. Community characteristics included a standardized community problem score and binary indicators for community social cohesion, having a community leader available, and having at least one community resource observed on the participant's block. In adjusted models, greater community problems and proximity to resources were associated with lower systolic (β = -2.020, p = 0.028; β = -4.132, p = 0.010) and diastolic (β = -1.261, p = 0.038; β = -2.290, 0.031) blood pressure, respectively, among whites (n = 548). Social cohesion was associated with higher systolic (β = 4.905, p = 0.009) and diastolic blood pressure (β = 3.379, p = 0.008) among African Americans (n = 777). In one racially integrated low-income community, community characteristics were associated with blood pressure levels, and associations differed by race. Directions of associations for two findings differed from prior studies; greater community problem was associated with lower blood pressure in whites and community social cohesion was associated with higher blood pressure in African Americans. These findings may be due to exposure to adverse environmental conditions and hypertensive risk factors in this low-income community.

Social engagement and chronic disease risk behaviors: the Multi-Ethnic Study of Atherosclerosis

OBJECTIVE

Although engagement in social networks is important to health, multiple different dimensions exist. This study identifies which dimensions are associated with chronic disease risk behaviors.

METHODS

Cross-sectional data on social support, loneliness, and neighborhood social cohesion from 5381 participants, aged 45-84 from the Multi-Ethnic Study of Atherosclerosis was used.

RESULTS

After adjusting for individual characteristics and all social engagement variables, social support was associated with lower smoking prevalence (PR=0.88, 95% CI: 0.82, 0.94), higher probability of having quit (PR=1.03, 95% CI: 1.01, 1.06) and a slightly higher probability of achieving physical activity recommendations (PR=1.03, 95% CI: 1.01, 1.06). Neighborhood social cohesion was associated with very slightly higher probability of achieving recommended (PR=1.03, 95% CI: 1.01, 1.05) or any regular (PR=1.0, 95% CI: 1.01, 1.04) physical activity, and a higher probability of consuming at least five daily fruit and vegetable servings (PR=1.05, 95% CI: 1.01, 1.09).

CONCLUSIONS

Both social support and neighborhood social cohesion, a less commonly considered aspect of social engagement, appear to be important for chronic disease prevention interventions and likely act via separate pathways.

Household and neighborhood conditions partially account for associations between education and physical capacity in the National Health and Aging Trends Study

Socioeconomic resources, such as education, prevent disability but are not readily modifiable. We tested the hypothesis that household and neighborhood conditions, which may be modifiable, partially account for associations between education and physical capacity in a population-based sample of older adults. The National Health and Aging Trends Study measured education (<high school, high school, some college, and ≥Bachelor's), household and neighborhood conditions, using a 16-item environmental checklist and a 3-item social cohesion scale, and physical capacity with the Short Physical Performance Battery (SPPB), grip strength and peak expiratory flow. Structural equation models were used to decompose total educational effects into direct effects and indirect effects via household and neighborhood conditions, using sample weights and adjusting for age, sex, race/ethnicity, marital status, household size, BMI, self-reported health, and number of medical conditions in 6874 community-dwelling participants. Education was directly associated with SPPB scores (β = 0.055, p < 0.05) and peak flow (β = 0.095, p < 0.05), but not grip strength. Also, indirect effects were found for household disorder with SPPB scores (β = 0.013, p < 0.05), grip strength (β = 0.007, p < 0.05), and peak flow (β = 0.010, p < 0.05). Indirect effects were also found for street disorder with SPPB scores (β = 0.012, p < 0.05). Indirect effects of household and neighborhood conditions accounted for approximately 35%, 27% and 14% of the total association between education and SPPB scores, grip strength level, and peak expiratory flow level, respectively. Household disorder and street disorder partially accounted for educational disparities in physical capacity. However, educational disparities in SPPB scores and peak expiratory flow persisted after accounting for household and neighborhood conditions and chronic conditions, suggesting additional pathways. Interventions and policies aiming to support aging in place should consider addressing household-level and street-level disorder.

Developing Behavioral Theory With the Systematic Integration of Community Social Capital Concepts

Health behavior theories state that social environments influence health behaviors, but theories of how this occurs are relatively underdeveloped. This article systematically surveys community social capital concepts in health behavior literature and proposes a conceptual framework that integrates these concepts into existing behavioral theory. Fifty-three studies tested associations between community social capital concepts and physical activity (38 studies), smoking (19 studies), and diet (2 studies). Trustworthiness of community members was consistently associated with more health-promoting and less disease-promoting behaviors in 19 studies. Neighborly reciprocity showed mixed results in 10 studies. Reporting a good sense of community was associated with more physical activity in only 5 of 16 studies. Neighborhood collective efficacy, which includes social cohesion and informal social control, was inconsistently associated with behaviors in 22 studies. Behavioral social norms were associated with smoking and physical activity in 2 of 6 studies, and neighborhood modeling of physical activity was associated with increased activity in 12 of 17 studies, with 1 opposing result. This review identifies several community social capital-related concepts that are, at times, associated with both health-promoting and disease-promoting behaviors and often have no associations. Theory explains these findings by describing the relationships and interactions among these concepts. Using these findings, this article proposes a conceptual framework that integrates community social capital concepts into existing behavioral theory. Iterative empirically based theory development is needed to address these concepts, which affect behaviors. These results can also inform theoretically based community-based and socially tailored interventions.

Financial Strain Is Associated with Malnutrition Risk in Community-Dwelling Older Women

This study examined the relationship between financial strain, or difficulty acquiring necessities, and malnutrition risk in a community dwelling sample of frail and nonfrail women aged 70-79 in the Women's Health and Aging Study (n = 679). Malnutrition risk was measured with a modified version of the Mini-Nutritional Assessment Short Form (MNA-SF) and defined as a score <11, financial strain was measured by (1) sufficiency of money on a monthly basis and (2) adequacy of income for food, and income was measured by ordinal categories. Mean (SD) modified MNA-SF score was 12.2 (1.80), and 14.7% of women had malnutrition risk. Women who usually did not have enough money to make ends meet had more than four-fold increased odds of malnutrition risk (OR = 4.54; 95% CI: 2.26, 9.14) compared to their counterparts who had some money left over each month. This was only slightly attenuated after control for income and education, (OR = 4.08; 95% CI: 1.95, 8.52) remaining robust. These results show an association between financial strain and malnutrition risk, independent of income, in older women. Self-reported financial strain may be preferable to income as a screener for malnutrition risk in older adults in clinical and research settings.