Consumer Views on Using Digital Data for COVID-19 Control in the United States

IMPORTANCE

Curbing COVID-19 transmission is currently the greatest global public health challenge. Consumer digital tools used to collect data, such as the Apple-Google digital contact tracing program, offer opportunities to reduce COVID-19 transmission but introduce privacy concerns.

OBJECTIVE

To assess uses of consumer digital information for COVID-19 control that US adults find acceptable and the factors associated with higher or lower approval of use of this information.

DESIGN, SETTING, AND PARTICIPANTS

This cross-sectional survey study obtained data from a nationally representative sample of 6284 US adults recruited by email from the web-based Ipsos KnowledgePanel in July 2020. Respondents evaluated scenarios reflecting uses of digital data for COVID-19 control (case identification, digital contact tracing, policy setting, and enforcement of quarantines).

MAIN OUTCOMES AND MEASURES

Levels of support for use of personal digital data in 9 scenarios to mitigate the spread of COVID-19 infection, rated on a Likert scale, ranging from 1 (strongly disagree) to 5 (strongly agree). Multivariable linear regression models were fitted for each scenario and included factors hypothesized to be associated with views about digital data use for COVID-19 mitigation measures. Black and Hispanic survey respondents were oversampled; thus, poststratification weights were used so that results are representative of the general US population.

RESULTS

Of 6284 individuals invited to participate in the study, 3547 responded, for a completion rate of 56%. A total of 1762 participants (52%) were female, 715 (21%) identified as Black, 790 (23%) identified as Hispanic, and 1224 (36%) were 60 years or older; mean (SD) age was 51.7 (16.6) years. Approval of scenarios was low, ranging from 28% to 43% (52%-67% when neutral responses were included). Differences were found based on digital data source (smartphone vs social media: coefficient, 0.29 [95% CI, 0.23-0.35]; P < .001; smart thermometer vs social media: coefficient, 0.09 [95% CI, 0.03-0.16]; P = .004). County COVID-19 rates (coefficient, -0.02; 95% CI, -0.16 to 0.13 for quartile 4 compared with quartile 1) and prior family diagnosis of COVID-19 (coefficient, 0.00; 95% CI, -0.25 to 0.25) were not associated with support. Compared with self-described liberal individuals, conservative (coefficient, -0.81; 95% CI, -0.96 to -0.66; P < .001) and moderate (coefficient, -0.52; 95% CI, -0.67 to -0.38; P < .001) individuals were less likely to support the scenarios. Similarly, large political differences were observed in support of the Apple-Google digital contact tracing program, with less support from conservative (coefficient, -0.99; 95% CI, -1.11 to -0.87; P < .001) and moderate (coefficient, -0.59; 95% CI, -0.69 to -0.48; P < .001) individuals compared with liberal individuals. Respondents from racial/ethnic minority groups were more supportive of the scenarios than were White, non-Hispanic respondents. For example, compared with White respondents, Black respondents were more supportive of the Apple-Google contact tracing program (coefficient, 0.20; 95% CI, 0.07-0.32; P = .002).

CONCLUSIONS AND RELEVANCE

In this survey study of US adults, many were averse to their information being used on digital platforms to mitigate transmission of COVID-19. These findings suggest that in current and future pandemics, public health departments should use multiple strategies to gain public trust and accelerate adoption of tools such as digital contact tracing applications.

Overdose Awareness and Reversal Trainings at Philadelphia Public Libraries

PURPOSE

To evaluate an overdose response training program in public libraries.

DESIGN

Mixed methods evaluation including pre- and post-intervention questionnaires and debriefing interviews.

SETTING

Ten Philadelphia public libraries.

SAMPLE

Overdose response training participants (library staff and community members).

INTERVENTION

Public, hour-long overdose response trainings run by the Philadelphia Department of Public Health, the Free Library of Philadelphia, and the University of Pennsylvania between March and December 2018.

MEASURES

Questionnaires assessed motivation for attending trainings, overdose response readiness, and intention to acquire and carry naloxone. Debriefing interviews elicited training feedback.

ANALYSIS

We assessed changes in overdose response readiness and intention to carry naloxone and performed thematic analysis on interview data.

RESULTS

At 29 trainings, 254 people attended, of whom 203 (80%) completed questionnaires and 23 were interviewed. 30% of participants had witnessed an overdose, but only 3% carried naloxone at baseline. Following training, overdose response readiness and intention to acquire/carry naloxone improved significantly (P < .01). Interviewees nonetheless noted that they experienced barriers to naloxone acquisition, including cost, stigma, and concern regarding future insurability. Trainings subsequently included naloxone distribution. Interviewees reported that public libraries were welcoming, nonstigmatizing venues.

CONCLUSION

In Philadelphia, library-based overdose response trainings were well-attended and reached a population with prior overdose encounters. Similar trainings could be deployed as a scalable overdose prevention strategy in the nation's 16 568 public libraries.

Evaluation of a multimedia marketing campaign to engage African American patients in glaucoma screening

Our objective was to determine which messaging approaches from a marketing campaign were most effective in recruiting African American individuals to a glaucoma screening and research study. We conducted a multimedia marketing campaign in Philadelphia from 01/31/2018 to 06/30/2018. Messaging approaches included radio advertisements and interviews (conducted in partnership with a local radio station with a large African American listener base), print materials, event tables, and online postings. Participants received free glaucoma screenings and the opportunity to enroll in our glaucoma genetics study. These screenings allowed individuals with glaucoma to receive a full examination and treatment plan with a glaucoma specialist, as well as to contribute to future efforts to identify genetic variants underlying this disease. We compared inquiry, enrollment, and cost yield for each messaging approach. Our campaign resulted in 154 unique inquiries, with 98 patients receiving glaucoma screenings (64%) and 60 patients enrolling in our study (39%). Commercials on WURD radio yielded the highest number of inquiries (62%) and enrollments (62%), but at relatively high cost ($814/enrolled patient). The most inexpensive approach that yielded more than five enrollments was postcards ($429/enrolled patient). Our campaign suggests that high-frequency commercials and postcards distributed at targeted healthcare locations are particularly effective and affordable options for connecting with the African American community. Our findings can help to inform recruitment efforts for other understudied diseases in minority populations.

Chronic Disease Self-Management During the Monthly SNAP Cycle (P04-193-19)

Objectives

This study explored chronic disease self-management over the monthly benefit cycle among primary food shoppers from households receiving Supplemental Nutrition Assistance Program (SNAP) benefits in Philadelphia, Pennsylvania.

Methods

In-depth interviews, participant observation and surveys were conducted with the primary food shopper of SNAP households (n = 18). Interviews and surveys were conducted in a clinical setting, at participants’ homes, and in food procurement settings including grocery stores, food pantries and soup kitchens.

Results

All households had at least one member with a chronic disease or condition; 5 with a diet-related chronic condition, 5 managing the chronic condition of a family member, and 13 with overweight or obesity. Households reported that the dietary demands of managing chronic illnesses were expensive and mentally taxing. Food and financial shortfalls at the end of the benefit cycle, as well as reliance on charitable food assistance programs, often had negative impacts on chronic disease self-management.

Conclusions

Drawing from nearly 50 hours of in-depth qualitative interviews with SNAP participants, this study highlights the dual cognitive burden of poverty and chronic disease and elucidates the particular challenges of food procurement and maintenance of diet quality throughout the benefit month faced by SNAP households with diet-related chronic diseases. Interventions targeted at reducing the cost of medically appropriate, healthy foods may help to improve chronic disease self-management within SNAP populations.

Funding Sources

This work was supported by the University of Pennsylvania Leonard Davis Institute of Health Economics, the University of Pennsylvania Graduate and Professional Student Assembly Provost Award for Interdisciplinary Innovation, the NIH NIDDK Pediatric Endocrine Fellowship Training in Diabetes Research, and the Investment for the Future Initiative in Community Practices, University of Pennsylvania School of Nursing. The sources of financial support had no role in the design, analysis, or writing of this abstract.

Reconciling opposing perceptions of access to physical activity in a gentrifying urban neighborhood

OBJECTIVE

We sought to understand perspectives on access to physical activity in a gentrifying neighborhood.

DESIGN

This qualitative descriptive study used street intercept interviews and photo documentation.

SAMPLE

Participants included members (n = 19) of a gentrifying neighborhood in a northeastern city.

RESULTS

Participants held markedly different perceptions of opportunities for physical activity. Some participants, particularly area university students or those who are identified as White, perceived the neighborhood as favorable to physical activity, with high walkability and abundant resources. Other participants, particularly those who identified as Black or African-American, felt it was difficult to be physically active because neighborhood recreation facilities are scarce or unaffordable and parks are poorly maintained or unsafe. Multiple participants noted strategies to overcome neighborhood barriers to physical activity. Regardless of neighborhood perceptions, family and friends played an important role in influencing physical activity.

CONCLUSIONS

Nurses must consider how disparities in actual and perceived access to neighborhood resources influence participation in physical activity, particularly in gentrifying neighborhood. Public health nurses are embedded in the neighborhoods that they serve, providing a unique opportunity to understand and address the impact of neighborhood on health.

Women’s Occupational Patterns and Later Life Physical Functioning

Objective: Timing and accumulation of work-related exposures may influence later life health. This study evaluates the association between women’s work patterns and physical functioning. Method: Work history and physical functioning information was collected at baseline for U.S. women ages 50 to 79 years in the Women’s Health Initiative Observational Study ( N = 75,507). We estimated life course workforce participation patterns using latent class analysis. Associations between work patterns and physical limitations were explored using modified Poisson regression. Results: Compared with working continuously, women who left the workforce early had 8% increased risk and women who worked intermittently had 5% reduced risk of physical limitations later in life. The negative association with intermittent workforce participation was stronger for women with substantively complex work (9% reduced risk) than for women with nonsubstantively complex work (2% reduced risk). Discussion: Life course work patterns and characteristics may contribute to physical functioning later in life among women.

Work Characteristics Associated with Physical Functioning in Women

Women make up almost half of the labor force with older women becoming a growing segment of the population. Work characteristics influence physical functioning and women are at particular risk for physical limitations. However, little research has explored the effects of work characteristics on women’s physical functioning. U.S. women between the ages of 50 and 79 were enrolled in the Women’s Health Initiative Observational Study between 1993 and 1998. Women provided job titles and years worked at their three longest-held jobs (n = 79,147). Jobs were linked to characteristics in the Occupational Information Network. Three categories of job characteristics related to substantive complexity, physical demand, and social collaboration emerged. The association between job characteristics and physical limitations in later life, measured using a SF-36 Physical Functioning score <25th percentile, was examined using modified Poisson regression. After controlling for confounding variables, high physical demand was positively associated with physical limitations (RR = 1.09 CI: 1.06–1.12) and substantively complex work was negatively associated (RR = 0.94, CI: 0.91–0.96). Jobs requiring complex problem solving, active learning, and critical thinking were associated with better physical functioning. Employers should explore opportunities to reduce strain from physically demanding jobs and incorporate substantively complex tasks into women’s work to improve long-term health.

A mixed methods study of individual and organizational factors that affect implementation of interventions for children with autism in public schools

Background

The significant lifelong impairments associated with autism spectrum disorder (ASD), combined with the growing number of children diagnosed with ASD, have created urgency in improving school-based quality of care. Although many interventions have shown efficacy in university-based research, few have been effectively implemented and sustained in schools, the primary setting in which children with ASD receive services. Individual- and organizational-level factors have been shown to predict the implementation of evidence-based interventions (EBIs) for the prevention and treatment of other mental disorders in schools, and may be potential targets for implementation strategies in the successful use of autism EBIs in schools. The purpose of this study is to examine the individual- and organizational-level factors associated with the implementation of EBIs for children with ASD in public schools.

Methods

We will apply the Domitrovich and colleagues (2008) framework that examines the influence of contextual factors (i.e., individual- and organizational-level factors) on intervention implementation in schools. We utilize mixed methods to quantitatively test whether the factors identified in the Domitrovich and colleagues (2008) framework are associated with the implementation of autism EBIs, and use qualitative methods to provide a more comprehensive understanding of the factors associated with successful implementation and sustainment of these interventions with the goal of tailoring implementation strategies.

Discussion

The results of this study will provide an in-depth understanding of individual- and organizational-level factors that influence the successful implementation of EBIs for children with ASD in public schools. These data will inform potential implementation targets and tailoring of strategies that will help schools overcome barriers to implementation and ultimately improve the services and outcomes for children with ASD.

Addressing cost barriers to medications: a survey of patients requesting financial assistance

OBJECTIVES

Given that many patients with chronic diseases face cost-related barriers to care, we evaluated patients' views on which providers (both physicians and nonphysicians) to involve and which methods to use to screen for those barriers. We also examined patients' preferences for how physicians consider cost-efficacy trade-offs in decisions.

STUDY DESIGN

A national survey of 1400 randomly sampled adults with a chronic disease seeking financial assistance (842 respondents).

METHODS

Participants rated their comfort with various providers and tools for identifying cost barriers. Then they rated a randomly assigned clinical vignette that described how a clinical decision was made in the context of a cost-efficacy tradeoff. Vignettes depicted 3 decision types: cost-conscious physician, cost-indifferent physician, or patient-directed. Comfort was rated from 1 to 10-ratings above 7 indicated high comfort.

RESULTS

More respondents reported high comfort with physicians screening for cost barriers (81.1%) than with pharmacists (74.8%; P=.002), nurses (69.4%; P<.001), professional counselors (68.3%; P<.001), and trained volunteers (50.5%; P<.001). Regarding screening for cost barriers using administrative records, more respondents reported higher comfort with doctors' offices (58.8%) than with insurance companies (53.3%; P=.03), but similar levels of comfort compared to pharmacies (62.1%; P=.17). Participants favored "patient-directed" decisions with physician input (odds ratio, 4.64; 95% CI, 3.14-6.84; P<.001) compared with "cost-conscious" decisions in which physicians unilaterally decided how to manage cost-efficacy tradeoffs.

CONCLUSIONS

Patients were open to a range of cost-barrier screening approaches, but most favor direct conversations with their doctor and shared decision making in decisions involving cost-efficacy trade-offs.

Practical guidance and ethical considerations for studies using photo-elicitation interviews

Photo-elicitation is a qualitative interviewing technique that has gained popularity in recent years. It is the foundation for photovoice projects and is a tool well-suited for community-based participatory research. Photo-elicitation yields rich data, and interview participants say these interviews encourage community awareness and engagement. This article draws on 9 studies, conducted by researchers at 3 institutions (the University of Pennsylvania, the Philadelphia Veterans Affairs Medical Center, and the Geisel School of Medicine at Dartmouth) in partnership with community-based organizations and students, in which 303 participants completed photo-elicitation interviews. We offer 8 practical suggestions for overcoming challenges encountered during photo-elicitation research and for managing ethical concerns about the use of visual data in public health research. Our guidelines can inform study design, protocol development, and institutional review board approval.

In an urban neighborhood, who is physically active and where?

Previous research has shown differences in adult physical activity (PA) levels within urban population, in what types of activities they participated, and where they were active. A sample of 514 urban Philadelphia adult residents was surveyed about level and location of PA. A majority (55.6%) of survey participants reported being vigorously or moderately active or walking enough to meet PA guidelines. A significantly higher proportion of men (vs. women), younger (vs. older) adults and people who were employed (vs. unemployed) met the PA guidelines. Most participants (87.5%) reported walking at least once within the previous week, while 79.3% reported engaging in moderate or vigorous activity. Of the participants who reported being moderately or vigorously active, 64.0% were physically active in indoors only, 22.6% were active in outdoors only, and 13.4% were active in both indoors and outdoors. Significantly fewer black women were active outdoors, compared to all other race/sex combinations (odds ratio = 0.43, p-value < 0.01). In this diverse sample of urban residents, outdoor PA was significantly less frequently reported than indoor PA, particularly for Black women. These findings could help inform urban PA interventions.

More than just an eyesore: local insights and solutions on vacant land and urban health

Vacant land is a significant economic problem for many cities, but also may affect the health and safety of residents. In order for community-based solutions to vacant land to be accepted by target populations, community members should be engaged in identifying local health impacts and generating solutions. We conducted 50 in-depth semi-structured interviews with people living in Philadelphia, Pennsylvania, a city with high vacancy, about the impact of vacant land on community and individual health and safety, as well as ideas for solutions to vacant land. Participants described a neighborhood physical environment dominated by decaying abandoned homes and overgrown vacant lots which affected community well-being, physical health, and mental health. Vacant land was thought to affect community well-being by overshadowing positive aspects of the community, contributing to fractures between neighbors, attracting crime, and making residents fearful. Vacant land was described as impacting physical health through injury, the buildup of trash, and attraction of rodents, as well as mental health through anxiety and stigma. Participants had several ideas for solutions to vacant land in their community, including transformation of vacant lots into small park spaces for the elderly and playgrounds for youth, and the use of abandoned homes for subsidized housing and homeless shelters. A few participants took pride in maintaining vacant lots on their block, and others expressed interest in performing maintenance but lacked the resources to do so. Public health researchers and practitioners, and urban planners should engage local residents in the design and implementation of vacant land strategies. Furthermore, municipalities should ensure that the health and safety impact of vacant land helps drive policy decisions around vacant land.

A nationwide study comparing end-of-life care for men and women veterans

BACKGROUND

The quality of end-of-life (EOL) care at Veterans Affairs Medical Centers (VAMC) has improved. To date, however, the quality and outcomes of end-of-life care delivered to women veterans have not been examined.

OBJECTIVE

The goal of this study was to evaluate gender differences in the quality of EOL care received by patients in VAMCs nationwide.

DESIGN

The study was conducted via retrospective medical chart review and telephone survey with next of kin of recently deceased inpatients.

SETTING/SUBJECTS

The chart review included records for all patients who died in acute and long-term care units in 145 VAMCs nationwide (n=36,618). For the survey, the documented next of kin were invited to respond on behalf of the deceased veteran; a total of 25,638 next of kin completed the survey.

MEASUREMENTS

Chart review measures included five indicators of optimal end-of-life care. Bereaved family survey items included one global and nine specific items (e.g., bereavement care, pain management) describing care in the last month of life.

RESULTS

Receipt of optimal end-of-life care did not differ significantly between women and men with respect to frequency of discussion of treatment goals with a family member, receipt of palliative consult, bereavement contact, and chaplain contact with a family member. Family members of women were more likely than those of men to report that the overall care provided to the veteran had been "excellent" (adjusted proportions: 63% versus 56%; odds ratio (OR)=1.33; 95% confidence interval (CI) 1.10-1.61; p=0.003).

CONCLUSIONS

In this nationwide study of all inpatient deaths in VAMCs, women received comparable and on some metrics better quality EOL care than that received by male patients.

Mortgage delinquency and changes in access to health resources and depressive symptoms in a nationally representative cohort of Americans older than 50 years

OBJECTIVES

We evaluated associations between mortgage delinquency and changes in health and health-relevant resources over 2 years, with data from the Health and Retirement Study, a longitudinal survey representative of US adults older than 50 years.

METHODS

In 2008, participants reported whether they had fallen behind on mortgage payments since 2006 (n = 2474). We used logistic regression to compare changes in health (incidence of elevated depressive symptoms, major declines in self-rated health) and access to health-relevant resources (food, prescription medications) between participants who fell behind on their mortgage payments and those who did not.

RESULTS

Compared with nondelinquent participants, the mortgage-delinquent group had worse health status and less access to health-relevant resources at baseline. They were also significantly more likely to develop incident depressive symptoms (odds ratio [OR] = 8.60; 95% confidence interval [CI] = 3.38, 21.85), food insecurity (OR = 7.53; 95% CI = 3.01, 18.84), and cost-related medication nonadherence (OR = 8.66; 95% CI = 3.72, 20.16) during follow-up.

CONCLUSIONS

Mortgage delinquency was associated with significant elevations in the incidence of mental health impairments and health-relevant material disadvantage. Widespread mortgage default may have important public health implications.

Foreclosure and health status

In 2009, more than 2.8 million housing units in the U.S. received a foreclosure notice. That represents about 1 in every 45 properties and a 120% increase in the number of foreclosed properties since 2007. Real estate experts predict even more foreclosures in 2010 as high unemployment continues. The cascading effects of the foreclosure crisis on the U.S. economy are all too clear; the effects on individuals' health status are less obvious. This Issue Brief summarizes two studies that examine the health implications of foreclosure and reveal a vulnerable population that may benefit from coordinated health and financial services.

Material resources and population health: disadvantages in health care, housing, and food among adults over 50 years of age

OBJECTIVES

We examined associations between material resources and late-life declines in health.

METHODS

We used logistic regression to estimate the odds of declines in self-rated health and incident walking limitations associated with material disadvantages in a prospective panel representative of US adults aged 51 years and older (N = 15,441).

RESULTS

Disadvantages in health care (odds ratio [OR] = 1.39; 95% confidence interval [CI] = 1.23, 1.58), food (OR = 1.69; 95% CI = 1.29, 2.22), and housing (OR = 1.20; 95% CI = 1.07, 1.35) were independently associated with declines in self-rated health, whereas only health care (OR = 1.43; 95% CI = 1.29, 1.58) and food (OR = 1.64; 95% CI = 1.31, 2.05) disadvantage predicted incident walking limitations. Participants experiencing multiple material disadvantages were particularly susceptible to worsening health and functional decline. These effects were sustained after we controlled for numerous covariates, including baseline health status and comorbidities. The relations between health declines and non-Hispanic Black race/ethnicity, poverty, marital status, and education were attenuated or eliminated after we controlled for material disadvantage.

CONCLUSIONS

Material disadvantages, which are highly policy relevant, appear related to health in ways not captured by education and poverty. Policies to improve health should address a range of basic human needs, rather than health care alone.

Lipoprotein (a) and coronary heart disease among women: beyond a cholesterol carrier?

AIMS

With its homology with plasminogen, lipoprotein(a) [Lp(a)] may be related to thrombosis and inflammation. We assessed the role of Lp(a) in coronary heart diseases (CHD) by a recently developed assay that is not affected by the plasminogen-like Kringle-type-2 repeats.

METHODS AND RESULTS

Of 32 826 women from the Nurses' Health Study, who provided blood at baseline, we documented 228 CHD events during 8 years of follow-up. Each case was compared with two matched controls. In a multivariable model adjusted for body mass index, family history, hypertension, diabetes, post-menopausal hormone use, physical activity, blood drawing characteristics, and alcohol intake, the odd ratio (OR) for Lp(a) levels > or =30 mg/dL was 1.9(95% CI: 1.3-3.0) when compared with those with Lp(a)<30 mg/dL. Women with high levels of both Lp(a) (> or =30 mg/dL) and fibrinogen (> or =400 mg/dL) had an OR of 3.2(95% CI: 1.6-6.5) for CHD, when compared with the combination of low levels (P interaction=0.05). Women with high levels of both Lp(a) and C-reactive protein (> or =3 mg/L) had an OR of 3.67(95% CI: 2.03-6.64) for CHD, when compared with the combination of low levels (P interaction=0.06).

CONCLUSION

Lp(a) levels >30 mg/dL are associated with twice the risk of CHD events among women and may be related to thrombosis and inflammation.

Homocysteine as a risk factor for coronary heart diseases and its association with inflammatory biomarkers, lipids and dietary factors

The causal relation of total Homocysteine (tHcy) to coronary heart diseases (CHD) is unclear. In vitro studies suggest a proinflammatory effect. Among 32,826 women from the Nurses' Health Study who provided blood samples in 1989-1990, 237 CHD events were documented during 8 years of follow-up. The cases (1:2) were matched to controls on age, smoking, and month of blood draw. Plasma tHcy was inversely associated with blood levels of folate (partial r = -0.3, P < 0.0001) and B1(2) (r = -0.2, P < 0.0001) and with dietary intake of folate (r = -0.1, P < 0.01) and B(2) vitamin (r = -0.1, P = 0.01). tHcy was positively associated with soluble tumor necrosis receptor (sTNF-R) 1 and 2 (partial r = 0.2, P < 0.0001). In a multivariate model adjusted for age, smoking, BMI, parental history, hypertension, diabetes, postmenopausal hormone use, physical activity and alcohol intake, the relative risk of CHD between the extreme quartiles of tHcy was 1.66 (95% CI; 1.05-2.64, P trend = 0.02). The association was not appreciably attenuated after further adjustments for sTNF-R1, sTNF-R2, CRP, or Total Cholesterol:/HDL-c ratio. tHcy is an independent risk predictor of CHD and modestly associated with TNF-receptors. However, the inflammatory biomarkers measured could not explain its role in CHD.

Social capital and successful aging: the role of senior housing

Social capital is defined as the resources available to individuals and groups through social connections and social relations with others. Access to social capital enables older citizens to maintain productive, independent, and fulfilling lives. As the U.S. population ages, accompanied by a rise in the prevalence of seniors living alone, the availability of social capital within communities will become an important ingredient of successful aging. Recent evidence suggests that many traditional forms of social capital in communities-as represented by civic engagement in local associations and by the extent of voluntarism and social trust-are on the decline. If this observation in correct, there is no simple solution to rebuilding this lost social capital. Novel forms of senior housing, such as planned care developments and assisted-living facilities, may offer promising modes of delivery of social capital to the aging population. However, assisted living remains financially inaccessible for a large segment of the U.S. population, so investment in communities "aging in place" may be the key to delivering the health dividends of social capital.