Managing Complexity: Black Older Adults With Multimorbidity

BACKGROUND AND OBJECTIVES

Black older adults have higher rates of multimorbidity and receive less effective multimorbidity support than their white counterparts. Yet little is known about the experiences of Black older adults with multimorbidity that may be at the heart of those disparities and which are central to interventions and improving care for this population. In this study, we aimed to conceptualize the multimorbidity management (MM) experience for Black older adults.

RESEARCH DESIGN AND METHODS

As part of a larger study on Black older adults' multimorbidity and physician empathy, we conducted in-depth qualitative interviews with 30 Black older adults living in a large midwestern city in the United States aged 65 years and older with self-reported multimorbidity. We used grounded theory analysis to distill findings into a core conceptual category as well as component domains and dimensions.

RESULTS

"Managing complexity" emerged as the core category to describe MM in our sample. Managing complexity included domains of "social context," "daily logistics," "care time," and "care roles."

DISCUSSION AND IMPLICATIONS

We discuss how managing complexity is distinct from patient complexity and how it is related to cumulative inequality and precarity. Study findings have potential implications for intervention around provider education and empathy as well as for enabling agency of Black older adults with MM.

Examining Racial/Ethnic Disparities in Coping and Stress Within an Environmental Riskscape

Existing research on racial/ethnic differences in stress and coping is limited by small samples, single-item measures, and lack of inclusion of Mexican Americans. We address these gaps by analyzing data from the Texas City Stress and Health Study, a cross-sectional sample of Black (N = 257), White (N = 304), US-born (N = 689), and foreign-born (N = 749) Mexican Americans residing in proximity to a petrochemical complex. We compared active and avoidant coping by race/ethnicity and explored multivariable associations between coping and perceived stress. Black and foreign-born Mexican American respondents had the highest stressor exposure yet displayed different patterns of coping and perceived stress patterns. Active coping may be particularly effective for African Americans but may not offset extreme stress disparities. For Mexican Americans, the lack of association between coping and stress underscores the need for more work focused on the culturally diverse coping experiences.

Racial Residential Segregation and the Health of Black Youth With Type 1 Diabetes

OBJECTIVES

Black youth with type 1 diabetes (T1D) are at heightened risk for suboptimal glycemic control. Studies of neighborhood effects on the health of youth with T1D are limited. The current study investigated the effects of racial residential segregation on the diabetes health of young Black adolescents with T1D.

METHODS

A total of 148 participants were recruited from 7 pediatric diabetes clinics in 2 US cities. Racial residential segregation (RRS) was calculated at the census block group level based on US Census data. Diabetes management was measured via self-report questionnaire. Hemoglobin A1c (HbA1c) information was gathered from participants during home-based data collection. Hierarchical linear regression was used to test the effects of RRS while controlling for family income, youth age, insulin delivery method (insulin pump versus syringe therapy), and neighborhood adversity.

RESULTS

HbA1c was significantly associated with RRS in bivariate analyses, whereas youth-reported diabetes management was not. In hierarchical regression analyses, whereas family income, age, and insulin delivery method were all significantly associated with HbA1c in model 1, only RRS, age, and insulin delivery method were significantly associated with HbA1c in model 2. Model 2 explained 25% of the variance in HbA1c (P = .001).

CONCLUSIONS

RRS was associated with glycemic control in a sample of Black youth with T1D and accounted for variance in HbA1c even after controlling for adverse neighborhood conditions. Policies to reduce residential segregation, along with improved screening for neighborhood-level risk, hold the potential to improve the health of a vulnerable population of youth.

Health Management Occupations During COVID-19: Experiences of Older African Americans With Multimorbidity

Older African Americans with multimorbidity are at an especially high risk of adverse outcomes due to synergistic risks conferred by age, chronic disease burden and social determinants of health. Chronic condition self-management is one way older African Americans can use health management occupations and exercise agency to reduce their risk of becoming severely ill, and during the ongoing pandemic, of COVID-19 infection. The objective of this study was to understand how the COVID-19 pandemic shaped health management occupations of older African Americans. In-depth qualitative interviews were conducted with 30 African Americans aged 65 and older who reported having two or more chronic conditions. Data were analyzed using thematic analysis. Data suggest how key health management occupations (accessing care; managing medications, nutrition, and physical activity; and social and emotional health promotion and maintenance) were utilized and also shaped by the pandemic. Another key finding was perceived benefits of the pandemic on health and well-being.

Perceived Social Support and Latent Herpesvirus Reactivation: Testing Main and Stress-Buffering Effects in an Ethnically Diverse Sample of Adults

OBJECTIVE

Perceived social support is consistently associated with physical health outcomes, and one potential physiological mechanism underlying this association is immune function. In this study, we tested both the main and stress-buffering effects of perceived social support on cellular immunity measured via latent herpesvirus reactivation.

METHODS

Data were collected from a community-based sample of 1443 ethnically diverse adults between the ages of 25 and 90 years. Participants self-reported measures of perceived social support, stressful life events, daily hassles, and perceived stress, and provided a blood sample to assess antibody titers to the herpes simplex virus type 1 and Epstein-Barr virus (EBV).

RESULTS

In accordance with the main effect hypothesis, results indicated that perceived social support was directly associated with EBV viral capsid antigen antibody titers (β = -0.06, 95% confidence interval = -0.12 to -0.01, p = .029). Perceived social support, however, did not interact with stressful life events, daily hassles, or perceived stress to influence latent herpesvirus reactivation (p values > .05). Neither race/ethnicity nor age moderated any of the interactions between perceived social support and the stress measures on latent herpesvirus reactivation (p values > .10).

CONCLUSIONS

Overall, the current study supports the main effect hypothesis, according to which higher levels of perceived social support were associated with lower levels of herpesvirus antibody titers.

Effects of family and neighborhood risks on glycemic control among young black adolescents with type 1 diabetes: Findings from a multi-center study

While individual and family risk factors that contribute to health disparities in children with type 1 diabetes have been identified, studies on the effects of neighborhood risk factors on glycemic control are limited, particularly in minority samples. This cross-sectional study tested associations between family conflict, neighborhood adversity and glycemic outcomes (HbA1c) in a sample of urban, young Black adolescents with type 1 diabetes(mean age = 13.4 ± 1.7), as well as whether neighborhood adversity moderated the relationship between family conflict and HbA1c. Participants (N = 128) were recruited from five pediatric diabetes clinics in two major metropolitan US cities. Diabetes-related family conflict was measured via self-report questionnaire (Diabetes Family Conflict Scale; DFCS). Neighborhood adversity was calculated at the census block group level based on US census data. Indictors of adversity were used to calculate a neighborhood adversity index (NAI) for each participant. Median family income was $25,000, suggesting a low SES sample. In multiple regression analyses, DFCS and NAI both had significant, independent effects on glycemic control (β = 0.174, P = 0.034 and β = 0.226 P = 0.013, respectively) after controlling for child age, family socioeconomic status and insulin management regimen. Tests of effects of the NAI and DFCS interaction on HbA1c found no significant moderating effects of neighborhood adversity. Even within contexts of significant socioeconomic disadvantage, variability in degree of neighborhood adversity predicts diabetes-related health outcomes in young Black adolescents with type 1 diabetes. Providers should assess social determinants of health such as neighborhood resources that may impact adolescents' ability to maintain optimal glycemic control.

Neighborhood Characteristics and Frailty: A Scoping Review

BACKGROUND AND OBJECTIVES

Frailty is highly prevalent in later life and associated with early mortality and adverse health outcomes. The neighborhood has been identified as an important contributor to individual health, and neighborhood characteristics may contribute to frailty development. A scoping review was conducted of the peer-reviewed literature to better understand how physical and social neighborhood characteristics contribute to frailty.

RESEARCH DESIGN AND METHODS

Following an established scoping review methodology, we searched four peer-reviewed databases for relevant studies published from January 1, 2008, to December 31, 2018. Data extracted from studies included study characteristics, operationalization of neighborhood, the conceptual model of the neighborhood-frailty relationship, operationalization of frailty, and study findings for associations among neighborhood variables and frailty indicators.

RESULTS

A total of 522 articles were identified and 13 articles were included in the final data charting. Existing studies suggest that neighborhood characteristics are associated with frailty in later life. Few studies articulated a conceptual model identifying exact mechanisms through which neighborhood factors affected frailty. Studies designs were mostly cross-sectional. Longitudinal studies did not measure neighborhood characteristics over time. Studies varied considerably in how they operationalized the neighborhood. Frailty was most commonly assessed using a 5-point phenotype or a frailty index approach.

DISCUSSION AND IMPLICATIONS

Findings indicate that research on the relationship between neighborhood characteristics and frailty is an emerging area of inquiry. Additional studies are needed to more definitely explicate mechanisms through which neighborhoods contribute to, or protect older adults from, frailty.

Managing daily life among people with advanced cancer living at home: Responding to uncertainties related to shifting abilities, home care, and treatment

Introduction

People with advanced cancer are increasingly expected to live at home and manage the consequences of illness and treatment. The purpose of this study was to explore how people with advanced cancer manage the influence of home care and treatment on occupations and habits.

Method

Constructivist grounded theory guided the collection and analysis of data from 22 people with advanced cancer. Data were collected using in-depth interviews and participant diaries.

Findings

Uncertainty about abilities to engage in occupation and home care and treatment delivery disrupted participants’ daily life. Participants employed various strategies to manage uncertainties and to preserve a sense of agency and control.

Conclusions

This study provides insights into how people with advanced cancer manage and respond to the impact of illness, home care, and treatment in their daily life. The findings may aid occupational therapists to develop and deliver interventions that allow their patients to maintain a sense of agency in their daily life.

Socioeconomic status and differential psychological and immune responses to a human-caused disaster

OBJECTIVE

Individuals from different socioeconomic status (SES) backgrounds may respond variably to stressful events, and such differences are likely to contribute to health disparities. The current study leveraged data collected before and after a petrochemical explosion and aimed to investigate how individuals from different SES backgrounds responded to this unexpected stressor in terms of perceived social support, perceived stress, and systemic inflammation.

METHODS

Data were drawn from 124 participants (M_age = 55.9 ± 16.1 years, 69.4% female, 29.0% White) living close to a petrochemical complex where the explosion occurred in 2005. SES was assessed at baseline, and perceived stress and inflammatory markers (i.e., C-reactive protein [CRP], interleukin-6 [IL-6]) were assessed at both pre- and post-explosion. Perceived social support was assessed at post-explosion.

RESULTS

Lower SES was associated with less perceived social support. Lower SES was also associated with a larger increase in perceived stress and higher levels of IL-6, but not CRP. Perceived social support did not moderate or mediate the effects of SES on changes in perceived stress, IL-6, or CRP. The associations between SES and inflammatory markers were also not explained by changes in perceived stress.

CONCLUSION

Findings from this study support the idea that individuals from different SES backgrounds respond differently to stressors at both the psychosocial (perceived social support and perceived stress) and biological (inflammation) levels. Our findings also suggest that these two processes appear to act independently from each other.

RETHINKING RURAL GERONTOLOGY THROUGH A DEWEYAN PRAGMATIST PERSPECTIVE

Rural aging as we have conceived of it in the gerontological literature of the past 50 years no longer exists, if it ever did. In this presentation, we contribute toward a reframing of the discourse on rural aging through a critique of established views of rural aging as an ecological, cultural, and phenomenological experience. We argue that each view is limited in its ability to encapsulate the essence of rural living and community. Our critique provides a context for a dynamic perspective on rural aging that embraces the situational uniqueness of each rural environment. We introduce that perspective, based in John Dewey’s philosophy, and grounded in the idea of situationally defined manifestations of place integration within an ever-changing milieu. We conclude with a discussion of key implications, including how this perspective reshapes the roles of researchers and older rural residents in the process of ongoing rural gerontological inquiry.

Loss of Trust in the Neighborhood: The Experience of Older African Americans in Detroit

Objective

Although evidence suggests that neighborhood conditions are related to stress and health, the processes connecting neighborhood conditions and stress for older minorities is little explored. The purpose of this analysis is to contribute new insights into this issue.

Method

We conducted a qualitative analysis as part of a larger mixed methods study of 100 African Americans aged 55 years and older living in neighborhoods of varying quality in Detroit, Michigan. A subsample of (n = 20) older adults took photographs of bothersome aspects of their neighborhoods and participated in in-depth photo-elicitation interviews. Data were analyzed using a grounded theory approach.

Results

"Loss of trust in the neighborhood" emerged as the core category to explain how older African Americans in our sample experienced neighborhood stressors in their daily lives. Loss of trust in physical, social, and institutional dimensions of the neighborhood contributed to the core category.

Discussion

The life course of neighborhoods and the trust placed in them appears to be intimately connected to the well-being of older African Americans. We therefore hypothesize that a fundamental pathway through which neighborhood stressors are experienced for older African Americans in United States "Rust Belt" cities is the multifaceted loss of trust in the neighborhood.

Socioeconomic Status, Ecologically Assessed Social Activities, and Daily Cortisol Among Older Urban African Americans

Objectives: Higher socioeconomic status (SES) individuals report more social activities than their lower SES counterparts. Yet, SES and racial health disparities are often confounded. Here, we tested whether the frequency of engagement in social activities contributed to the association between SES and daily cortisol secretion among urban African American older adults. Methods: Ninety-two community-dwelling African Americans aged 55 years and older reported what they were doing at regular intervals across the day on an Android smartphone for seven consecutive days. They also provided four saliva samples at four time points a day during the same period. Results: Higher SES older adults engaged in proportionally more social activities than their lower SES counterparts. A greater relative frequency of weekly social activities was associated with a steeper diurnal cortisol decline. Higher SES was indirectly linked to a steeper cortisol decline via increased relative frequency of weekly social activities. Discussion: Our findings suggest that engagement in weekly social activities represents a behavioral intermediary for SES health disparities in endocrine function among older urban African American adults.

How accessible are grocery shops for people with dementia? A qualitative study using photo documentation and focus group interviews

BACKGROUND

People with dementia who live in ordinary housing need to perform activities outside the home such as visiting friends, talking walks and doing grocery shopping. This article identifies and examines characteristics that may influence accessibility in the space of a grocery shop as perceived by people with dementia.

METHODS

This is a qualitative study with a grounded theory approach. The data collection was done with two different methods. It started with photo documentation and continued with focus group interviews in combination with photo elicitation. Data from both photo documentation and focus groups were analysed according to a grounded theory approach.

RESULTS

The categories "illogical arrangement", "overload of products, information and people", "visual illusions" and "intrusive auditory stimuli" showed characteristics in the grocery shop that influenced how accessible and usable the informants experienced a shop to be. Furthermore, personal capacities in relation to the specific characteristics of the grocery shop space had an influence on how accessible and usable the informants experienced the grocery shop to be. Capacities to find, stay focused and concentrated, meet stress, remember, interpret and discriminate sensory impressions through hearing and sight came to the fore as important.

CONCLUSIONS

Characteristics of both the shop and the person need to be taken into account when supporting people with dementia in grocery shopping.

Identity and home: Understanding the experience of people with advanced cancer

The purpose of this study was to explore how the identity of people with advanced cancer is influenced by their experiences of living at home. A total of 28 in-depth interviews were conducted with 22 people with advanced cancer and four spouses. Grounded theory guided the collection and analysis of data. Home tours and associated field notes augmented the interview data. The analysis revealed that support of participants' identity was reflected in their abilities to live and occupy the home during daily activities, and in the ways the home and objects functioned as referents to themselves and their past. Threats to their identity ensued as the home environment became unmanageable during daily activities and as homecare professionals and assistive devices entered the home. By supporting people with advanced cancer in maintaining daily activities in the home and reducing changes in the home caused by homecare it is possible to reduce loss of identity.

Using a Smartphone-Based Ecological Momentary Assessment Protocol With Community Dwelling Older African Americans

OBJECTIVES

Little is known about the feasibility of smartphone-based Ecological Momentary Assessment (EMA) approaches to collect psychosocial data from older populations, especially disadvantaged older populations. In response to this gap, this report provides evidence of the feasibility and utility of a smartphone-based EMA approach for real-time assessment with older African Americans. In addition, we share lessons learned about how to improve utility.

METHODS

Ninety-seven older African Americans ages 55 and older (range: 55-95 years) used an Android smartphone loaded with an EMA application to provide data about their everyday activities and stress four times per day for seven consecutive days.

RESULTS

Exit interviews early in the study suggested enhancements to the EMA interface. Adherence was demonstrated with response completion rates of 92-98% on EMA measures and no participant attrition based on the EMA protocol.

DISCUSSION

Our findings suggest using a smartphone-based EMA approach for data collection is feasible and has utility with older African Americans. We most likely enhanced adherence by testing, training, monitoring, and adapting the EMA protocol using input from older adults early in the EMA design process.

Brief report: Neighborhood disadvantage and hair cortisol among older urban African Americans

Previous studies have shown that living in poor neighborhoods is associated with increased morbidity and mortality. However, researchers are now investigating the biological pathways responsible for the deleterious effects of neighborhood disadvantage on health. This study investigated whether neighborhood disadvantage (i.e., a measure of relative neighborhood quality derived by combining social and built environmental conditions) was associated with hair cortisol-a retrospective indicator of long-term hypothalamic pituitary adrenal (HPA) axis activation-and whether this link would be mediated by self-reported neighborhood satisfaction. Forty-nine older African Americans were recruited from thirty-nine Detroit census tracts across five strata of census tract adversity. Participants were interviewed face-to-face to collect psychosocial measures. Each provided a hair sample for analysis of cortisol. Multiple regression analyses revealed that higher neighborhood disadvantage was associated with higher levels of hair cortisol levels and that neighborhood satisfaction partially explained this association. These results are the first to our knowledge to demonstrate a direct link between neighborhood disadvantage and hair cortisol in a sample of older adults and to show that self-reported neighborhood satisfaction may be a psychological intermediary of this association.

Changing neighborhoods and occupations: Experiences of older African-Americans in Detroit

Neighborhood characteristics are relevant to understanding occupations and associated outcomes, yet few empirical studies have focused on neighborhood as the unit of analysis when examining person-environment-occupation relationships. The purpose of this report is to begin addressing that gap. We present findings from a qualitative investigation conducted as part of a larger mixed methods study of 100 African-Americans aged 55 and older living in a variety of neighborhood contexts. With a subsample of older adults (n = 20), we utilized participant-generated photos and photo-elicitation interviews to examine the question of how participation in everyday occupations changes (or not) for older African-Americans residing in urban neighborhoods that have undergone significant physical and socio-demographic changes. Data were analyzed using a thematic analysis approach in combination with a constant comparative method. Occupational change was conceptualized as four primary types: (a) spatio-temporal changes to participation in occupation, (b) changes to social participation, (c) heightened vigilance during daily occupations, and (d) actions to preserve and protect the neighborhood. The findings provide insights about the ways that neighborhood deterioration is related to occupational change. We discuss the potential impact of participants' occupational changes on health and well-being, and we assess the issue of neighborhood and occupation as relevant to occupational justice in urban contexts.

Retention of Rural Physicians: Place Integration and the Triumph of Habit

Retention of physicians continues to be a problem across much of rural North America, and research has neglected the sociogeographical process that leads to it. John Dewey's philosophy, including his insight into habits, suggests that retention is a process of “place integration” or “habitat” formation. A qualitative study of retention in Kentucky illustrates the process. For rural physicians this process revolves around the enhancement of security, freedom, identity, and meaning in place.

From Society to Self (and Back) through Place: Habit in Transactional Context

This argument extends the efforts of scholars of occupation and habit in several ways. It extends previous examinations of John Dewey's perspective on habit by bringing to the forefront his view of the social and moral dimensions of habit in the context of his larger metaphysical ground-map. That view suggests a habit process involving the transaction of the social and the individual, with habit as central to that transaction. Dewey's view is further enhanced with a portrayal of how it operates in the material experience of place and landscape. Examples from several scales of place are discussed to illustrate the essential role of material landscapes in this habit process. Using these analyses, the concept of rehabilitation is reconsidered.

Integrating the Science of Habit: Opportunities for Occupational Therapy

Chronic diseases are the leading causes of early morbidity and mortality in the United States. Because personal behaviors are the primary risk factors for developing chronic diseases, developing effective strategies to modify personal behaviors remains a national imperative. Occupational therapy can help address this problematic situation through interventions based on an understanding of habit and principles of habit modification. The objective of this paper is to provide an evidence-based argument for occupational therapy research and practice targeting health-promoting lifestyle behaviors as habits. We discuss empirical research conducted over the previous decade with a focus on the role of habit in daily behavior, key evidence-based strategies for changing existing habits and developing new habits, and recent advances in habit measurement in relation to issues of intervention design. Understanding habit development, function, and change offers a novel orientation for occupational therapy toward practice and research on many complex health problems.

The Possibilities for Activity Scale (PActS): Development, validity, and reliability

BACKGROUND

Laliberte Rudman proposed the concept of occupational possibilities to represent what older adults feel they "should be" and "could be" doing.

PURPOSE

This study aimed to develop and validate a measure of perceived occupational possibilities: the Possibilities for Activity Scale (PActS).

METHOD

Two factors of the PActS, activity expectations and activity self-efficacy, were operationalized in a 14-item instrument. The instrument was then evaluated with a sample of older adults diagnosed with cancer (n = 179).

FINDINGS

The PActS demonstrated promising internal consistency reliability (stratified coefficient α = .77) and construct-related (r = .58; p < .0001), structural (chi-square = 61.57; CFI = .97; RMSEA = .05; TLI = .96; NFL = .91) and known-groups validity.

IMPLICATIONS

The PActS appears to be a useful measure of internalized occupational possibilities for participation in activity for older adults with cancer. This scale can enhance the measurement of participation in activity by evaluating the perceptions of occupational possibilities.

New perspectives on old ideas: Viewing the anthro-OS/OT nexus in aging studies as a landscape for conceptual innovation

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Occupational therapy use by older adults with cancer

Occupational therapy may significantly improve cancer survivors' ability to participate in activities, thereby improving quality of life. Little is known, however, about the use of occupational therapy services by adults with cancer. The objective of this study was to understand what shapes patterns of occupational therapy use to help improve service delivery. We examined older (age >65 yr) adults diagnosed with breast, prostate, lung, or melanoma (skin) cancer between 2004 and 2007 (N = 27,131) using North Carolina Central Cancer Registry data linked to Medicare billing claims. Survivors who used occupational therapy within 1 yr before their cancer diagnosis were more likely to use occupational therapy after diagnosis but also experienced the highest levels of comorbidities. Survivors with Stage 4 cancers or lung cancer were less likely to use occupational therapy. These findings suggest possible disparities in utilization of occupational therapy by older adults with cancer.

Primary care availability and emergency department use by older adults: a population-based analysis

OBJECTIVES

To assess the relationship between the number of primary care providers (PCPs) in an area and emergency department (ED) visits by older adults.

DESIGN

Population-based cross-sectional observational study.

SETTING

Nonfederal EDs in North Carolina in 2010.

PARTICIPANTS

All older adults (n = 640,086) presenting to a nonfederal ED in North Carolina in 2010.

MEASUREMENTS

The primary outcome was the number of ED visits by older adults in each ZIP code per 100 adults aged 65 and older living in that ZIP code. A secondary outcome was the number of ED visits not resulting in hospital admission per 100 older adults. The primary predictor variable was the number of PCPs per 100 older residents for each ZIP code. Covariates included those representing healthcare need (Medicare hospitalizations, nursing home beds), predisposing factors for healthcare use (race, education, population density of older adults), and enabling factors (distance to the nearest ED).

RESULTS

In a multivariable regression model corrected for spatial clustering, ZIP code characteristics associated with ED visits included more hospitalizations by Medicare beneficiaries, more nursing home beds, and closer proximity to an ED. Number of PCPs per 100 older adult residents in each ZIP code was not associated with ED use, and the 95% confidence limit indicates at most a small effect of PCP availability on ED use.

CONCLUSION

These findings suggest that primary care availability has at most a limited effect on ED use by older adults in North Carolina.

Developing community based rehabilitation for cancer survivors: organizing for coordination and coherence in practice

Background

Increasing incidences of cancer combined with prolonged survival have raised the need for developing community based rehabilitation. The objectives of the analysis were to describe and interpret the key issues related to coordination and coherence of community-based cancer rehabilitation in Denmark and to provide insights relevant for other contexts.

Methods

Twenty-seven rehabilitation managers across 15 municipalities in Denmark comprised the sample. The study was designed with a combination of data collection methods including questionnaires, individual interviews, and focus groups. A Grounded Theory approach was used to analyze the data.

Results

A lack of shared cultures among health care providers and systems of delivery was a primary barrier to collaboration which was essential for establishing coordination of care. Formal multidisciplinary steering committees, team-based organization, and informal relationships were fundamental for developing coordination and coherence.

Conclusions

Coordination and coherence in community-based rehabilitation relies on increased collaboration, which may best be optimized by use of shared frameworks within and across systems. Results highlight the challenges faced in practical implementation of community rehabilitation and point to possible strategies for its enhancement.

Reactivation of herpes simplex virus type 1 is associated with cytomegalovirus and age

Recent studies have shown that cytomegalovirus (CMV) may be an emerging marker of immunosenescence. CMV can affect the immune system by directly infecting leukocytes and hematopoietic cells or by eliciting an expansion of oligoclonal CD8+ T cells/contraction of the naïve T cell compartment that may reduce the host's ability to fight other pathogens. To investigate further CMV-associated changes in immunity, a study was conducted with 1,454 adults (ages 25-91) to determine the association between CMV and reactivation of another latent herpesvirus, Herpes simplex virus type 1 (HSV-1), as indexed by antibody titers. Elevated antibody titers to latent HSV-1 were significantly associated with both CMV seropositivity and high CMV antibody levels. Evaluation by specific age groups (<45, 45-64, and 65+ years old) revealed that this association was detectable early in life (<45 years of age). Increases in HSV-1 antibodies by age occurred in CMV seropositive individuals but not CMV seronegative subjects. Within CMV seropositive subjects, increases in HSV-1 antibodies by age were only found in individuals with low CMV antibody levels as those with high CMV antibodies already exhibited elevated HSV-1 antibodies. These associations remained significant after accounting for body mass index, gender, and socioeconomic status. These results suggest that CMV can influence the immune response to another pathogen and support the concept that CMV may accelerate immunosenescence.

Disparities in post-acute rehabilitation care for joint replacement

OBJECTIVE

To determine the extent to which demographic and geographic disparities exist in the use of post-acute rehabilitation care (PARC) for joint replacement.

METHODS

We conducted a cross-sectional analysis of 2 years (2005 and 2006) of population-based hospital discharge data from 392 hospitals in 4 states (Arizona, Florida, New Jersey, and Wisconsin). A total of 164,875 individuals who were age ≥ 45 years, admitted to the hospital for a hip or knee joint replacement, and who survived their inpatient stay were identified. Three dichotomous dependent variables were examined: 1) discharge to home versus institution (i.e., skilled nursing facility [SNF] or inpatient rehabilitation facility [IRF]), 2) discharge to home with versus without home health (HH), and 3) discharge to an SNF versus an IRF. Multilevel logistic regression analyses were conducted to identify demographic and geographic disparities in PARC use, controlling for illness severity/comorbidities, hospital characteristics, and PARC supply. Interactions among race, socioeconomic, and geographic variables were explored.

RESULTS

Considering PARC as a continuum from more to less intensive care in regard to hours of rehabilitation per day (e.g., IRF→SNF→HH→no HH), the uninsured received less intensive care in all 3 models. Individuals receiving Medicaid and those of lower socioeconomic status received less intensive care in the HH versus no HH and SNF versus IRF models. Individuals living in rural areas received less intensive care in the institution versus home and HH versus no HH models. The effect of race was modified by insurance and by state. In most instances, minorities received less intensive care. PARC use varied by hospital.

CONCLUSION

Efforts to further understand the reasons behind these disparities and their effect on outcomes are needed.

Disparities in postacute rehabilitation care for stroke: an analysis of the state inpatient databases

OBJECTIVE

To determine the extent to which sociodemographic and geographic disparities exist in the use of postacute rehabilitation care (PARC) after stroke.

DESIGN

Cross-sectional analysis of data for 2 years (2005-2006) from the State Inpatient Databases.

SETTING

All short-term acute-care hospitals in 4 demographically and geographically diverse states.

PARTICIPANTS

Individuals (age, ≥45y; mean age, 72.6y) with a primary diagnosis of stroke who survived their inpatient stay (N=187,188). The sample was 52.4% women, 79.5% white, 11.4% black, and 9.1% Hispanic.

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURES

(1) Discharge to an institution versus home. (2) For those discharged to home, receipt of home health (HH) versus no HH care. (3) For those discharged to an institution, receipt of inpatient rehabilitation facility (IRF) or skilled nursing facility (SNF) care. Multilevel logistic regression analyses were conducted to identify sociodemographic and geographic disparities in PARC use, controlling for illness severity/comorbid conditions, hospital characteristics, and PARC supply.

RESULTS

Blacks, women, older individuals, and those with lower incomes were more likely to receive institutional care; Hispanics and the uninsured were less likely. Racial minorities, women, older individuals, and those with lower incomes were more likely to receive HH care; uninsured individuals were less likely. Blacks, women, older individuals, the uninsured, and those with lower incomes were more likely to receive SNF versus IRF care. PARC use varied significantly by hospital and geographic location.

CONCLUSIONS

Several sociodemographic and geographic disparities in PARC use were identified.

The socio-spatial neighborhood estimation method: an approach to operationalizing the neighborhood concept

The literature on neighborhoods and health highlights the difficulty of operationalizing "neighborhood" in a conceptually and empirically valid manner. Most studies, however, continue to define neighborhoods using less theoretically relevant boundaries, risking erroneous inferences from poor measurement. We review an innovative methodology to address this problem, called the socio-spatial neighborhood estimation method (SNEM). To estimate neighborhood boundaries, researchers used a theoretically informed combination of qualitative GIS and on-the-ground observations in Texas City, Texas. Using data from a large sample, we assessed the SNEM-generated neighborhood units by comparing intra-class correlation coefficients (ICCs) and multi-level model parameter estimates of SNEM-based measures against those for census block groups and regular grid cells. ICCs and criterion-related validity evidence using SF-36 outcome measures indicate that the SNEM approach to operationalization could improve inferences based on neighborhoods and health research.

Allostatic load in an environmental riskscape: the role of stressors and gender

Stressors are theorized to be associated with higher allostatic load (AL), a concept of physiological wear measured as a composite of physical biomarkers. Risk of high AL may vary by gender and may be intensified in places with significant environmental risks, otherwise known as 'environmental riskscapes'. Yet, no study has examined the relationship between stressors, gender, and allostatic load in an environmental riskscape. Using primary data collected in a sample (N=1072) exposed to various environmental and social stressors, we find that long-term residence in Texas City (30 or more years), residential proximity to petrochemical plants, perceived poor neighborhood conditions, and daily hassles are associated with higher allostatic load components. Variation in AL differs by gender and the types of biomarkers examined. Gender moderates the effect of length of residence in Texas City on cardiovascular health risk. We discuss our findings in light of current research on stressors, gender, allostatic load, and double jeopardy within environmental riskscapes.

Plasma cytokine levels in a population-based study: relation to age and ethnicity

BACKGROUND

Aging is one factor believed to contribute to processes that underlie chronic low-grade inflammation in older adults. Moreover, more recent studies have suggested that cytokine levels are influenced by ethnicity.

METHODS

In this study, we determined plasma cytokine profiles in a population-based sample (n = 1,411; aged 25-91 years) to determine the relationship between circulating cytokine levels, aging, and ethnicity. We measured interleukin-1 receptor antagonist (IL-1ra), interleukin (IL)-6, -10, C-reactive protein (CRP), and tumor necrosis factor-receptor 1 (TNF-r1).

RESULTS

IL-6 and TNF-r1 significantly increased with age, whereas IL-1ra, IL-10, and CRP did not significantly increase with age. After adjusting for age, non-Hispanic whites had significantly higher levels of IL-1ra than Mexican Americans, whereas non-Hispanic blacks had significantly higher levels of IL-6 and CRP than Mexican Americans as well as non-Hispanic whites. CRP levels in non-Hispanic blacks were no longer significantly higher after adjusting for body mass index (BMI), indicating that BMI is an important predictor of this inflammatory marker.

CONCLUSIONS

These results demonstrate that cytokine levels are influenced by both age and ethnicity. Furthermore, these results show that inflammatory profiles for Mexican Americans are lower than non-Hispanic whites and non-Hispanic blacks.

Feasibility and effects of preventive home visits for at-risk older people: design of a randomized controlled trial

BACKGROUND

The search for preventive methods to mitigate functional decline and unwanted relocation by older adults living in the community is important. Preventive home visit (PHV) models use infrequent but regular visits to older adults by trained practitioners with the goal of maintaining function and quality of life. Evidence about PHV efficacy is mixed but generally supportive. Yet interventions have rarely combined a comprehensive (biopsychosocial) occupational therapy intervention protocol with a home visit to older adults. There is a particular need in the USA to create and examine such a protocol.

METHODS/DESIGN

The study is a single-blind randomized controlled pilot trial designed to assess the feasibility, and to obtain preliminary efficacy estimates, of an intervention consisting of preventive home visits to community-dwelling older adults. An occupational therapy-based preventive home visit (PHV) intervention was developed and is being implemented and evaluated using a repeated measures design. We recruited a sample of 110 from a population of older adults (75+) who were screened and found to be at-risk for functional decline. Participants are currently living in the community (not in assisted living or a skilled nursing facility) in one of three central North Carolina counties. After consent, participants were randomly assigned into experimental and comparison groups. The experimental group receives the intervention 4 times over a 12 month follow-up period while the comparison group receives a minimal intervention of mailed printed materials. Pre- and post-intervention measures are being gathered by questionnaires administered face-to-face by a treatment-blinded research associate. Key outcome measures include functional ability, participation, life satisfaction, self-rated health, and depression. Additional information is collected from participants in the experimental group during the intervention to assess the feasibility of the intervention and potential modifiers. Fidelity is being addressed and measured across several domains.

DISCUSSION

Feasibility indications to date are positive. Although the protocol has some limitations, we expect to learn enough about the intervention, delivery and effects to support a larger trial with a more stringent design and enhanced statistical power.

TRIAL REGISTRATION

ClinicalTrials.gov ID NCT00985283.

Allostatic load among non-Hispanic Whites, non-Hispanic Blacks, and people of Mexican origin: effects of ethnicity, nativity, and acculturation

OBJECTIVES

We investigated ethnic differences in allostatic load in a population-based sample of adults living in Texas City, TX, and assessed the effects of nativity and acculturation status on allostatic load among people of Mexican origin.

METHODS

We used logistic regression models to examine ethnic variations in allostatic load scores among non-Hispanic Whites, non-Hispanic Blacks, and people of Mexican origin. We also examined associations between measures of acculturation and allostatic load scores among people of Mexican origin only.

RESULTS

Foreign-born Mexicans were the least likely group to score in the higher allostatic load categories. Among individuals of Mexican origin, US-born Mexican Americans had higher allostatic load scores than foreign-born Mexicans, and acculturation measures did not account for the difference.

CONCLUSIONS

Our findings expand on recent research from the National Health and Nutrition Examination Survey with respect to ethnicity and allostatic load. Our results are consistent with the healthy immigrant hypothesis (i.e., newer immigrants are healthier) and the acculturation hypothesis, according to which the longer Mexican immigrants reside in the United States, the greater their likelihood of potentially losing culture-related health-protective effects.

Herpesvirus reactivation and socioeconomic position: a community-based study

BACKGROUND

Elevated antibodies to latent herpesviruses have been demonstrated to be a reliable marker of diminished cellular immunity and recently have been associated with low socioeconomic position (SEP) in older adults. Extending these observations in a community-based study over a wide age range would provide an important new direction for investigating mechanisms underlying poor health outcomes in individuals with low SEP.

METHODS

Anti-herpes simplex virus (HSV)-1 and anti-Epstein-Barr virus (EBV) antibodies were measured in blood samples from 1457 adults aged 25-90. Regression models were then used to determine the relationships between viral reactivation, age, gender, ethnicity and SEP.

RESULTS

Individuals were significantly more likely to have higher antiviral antibodies (ie, reactivation) to both EBV and HSV-1 than one virus alone. Individuals in the lowest age group had less reactivation, whereas greater reactivation was observed in women and those with the least education. Compared to white non-Hispanics, Hispanics and black non-Hispanics experienced more viral reactivation. These relationships remained strong after controlling for sociodemographic factors as well as smoking status, body mass index and physical activity.

CONCLUSIONS

These results demonstrate that herpesvirus reactivation is associated with variables such as age, gender, ethnicity and education, and may play a role in poorer health outcomes in both younger and older adults.

Environmental hazards and stress: evidence from the Texas City Stress and Health Study

BACKGROUND

Substantial research has suggested that exposure to environmental health hazards, such as polluting industrial activity, has deleterious effects on psychological and physiological well-being. However, one gap in the existing literature is comparative analysis of objective and subjective exposure's relative association with various measurable outcomes of exposure.

METHODS

These relationships were explored within a community sample of 2604 respondents living near a large petrochemical complex in Texas City, Texas, USA. Objective exposure was investigated using distance of residence from a cluster of petrochemical plants and subjective exposure using residents' concern about potential health effects from those plants. Regression models were then used to examine how each type of exposure predicts perceived stress, physiological markers of stress and perceived health.

RESULTS

Results suggest that objective exposure was associated primarily with markers of physiological stress (interleukin-6 and viral reactivation), and subjective exposure (concern about petrochemical health risk) was associated with variables assessing perceived health.

CONCLUSIONS

From the analysis, it can be inferred that, in the context of an environmental hazard of this type, subjective exposure may be at least as important a predictor of poor health outcomes as objective exposure.

Perceived health change in the aftermath of a petrochemical accident: an examination of pre-accident, within-accident, and post-accident variables

BACKGROUND

Little research has been conducted on changes in perceived health after an industrial accident. Using data from an ongoing survey on stress and health in a petrochemical complex in Texas City, Texas, the associations of a petrochemical accident with perceived health changes were examined.

METHODS

The mean changes in perceived mental and physical health across pre-accident, within-accident, and post-accident categories were compared. The association of these categorical variables with the change in perceived mental and physical health using multiple regression was also examined.

RESULTS

Significant declines in both perceived mental and physical health were observed for the sample. Regression analyses showed that middle age, lower education level and reported damage in the neighbourhood were associated with decreases in perceived mental health. Lower education level, explosion impact, and distance from the explosion site were associated with decreases in perceived physical health.

CONCLUSIONS

These results indicate that both pre-accident and within-accident variables, such as education level and explosion impact, are associated with decreases in perceived physical and mental health. Even a modest event within the range of accidents and disasters was shown to be associated with negative health outcomes for a population-based sample.

Concern about petrochemical health risk before and after a refinery explosion

On March 23, 2005, a large explosion at an oil refinery in Texas City, Texas caused 15 deaths and approximately 170 injuries. Little is known about how such an industrial accident influences concern about environmental health risks. We used measures of environmental health concern about nearby petrochemical production with a sample of Texas City residents to understand patterns of concern and change in concern after an industrial accident, as well as individual and contextual factors associated with those patterns. Survey interviews with residents of Texas City, Texas (N= 315) both pre- and postexplosion using a brief Concern About Petrochemical Health Risk Scale (CAPHRS) and other questions were used to collect pertinent predictor information. CAPHRS baseline, postexplosion, and change scores were compared and modeled using ordinary least squares (OLS) regression and a mixed model. Higher preexplosion CAPHRS scores were predicted by younger adults, foreign-born Hispanics, non-Hispanic blacks, lower- and middle-income groups, and those who live with someone who has worked at the petrochemical plants. Higher CAPHRS change scores are predicted by the same variables (except income), as well as proximity to, or perception of, the explosion, and reports of neighborhood damage. Findings suggest these groups' concern scores could indicate a greater vulnerability to psychological and physical harm generated by concern and stress arising from local petrochemical activities. A clearer understanding of concern about actual environmental health risks in exposed populations may enhance the evolving theory of stress and coping and eventually enable public health professionals to develop appropriate mitigation strategies.

The need for the "new health geography" in epidemiologic studies of environment and health

Growth during the past decade in what can be broadly referred to as social and environmental epidemiologic research has been an important contributor to an emerging understanding of environment and health relationships. While the incorporation of geographic information systems as well as concepts such as "neighborhoods" might be viewed as evidence of social epidemiology moving closer to health geography, I argue that the two fields are not well aligned. Health geography has much more to contribute to studies of environment and health, and attention by social epidemiologists to those potential contributions could help rectify this misalignment. This paper suggests a number of geographic perspectives on health and environment that could create useful connections between geography and public health, via social epidemiology. To illustrate this potential, I use an ongoing study of a Texas community exposed to a large petrochemical complex-an inquiry constructed in the mode of social epidemiology - as a case in point. I apply several perspectives and concepts from geography to the case study. Cultural ecology, discourse materialized, political ecology, and territoriality are used to assess the Texas City situation and suggest important types of understandings that can enhance the social epidemiology approach to environment and health. I conclude with a discussion of the prospects for a social epidemiology infused with this type of geographic thought and analysis.

Spaces for inquiry into the role of place for older people's care

In this paper, I expand the scope of the two preceding papers and suggest emerging opportunities and needs relevant to future inquiry about place and older people. I cover these in three sections. The first section suggests several topical areas for inquiry: stress and health, social epidemiology and healthy ageing. The second section focuses on theoretical developments that could be extended to further inform research on place and older people. I discuss the concepts of therapeutic landscapes and home as well as actor-network theory and pragmatism. The last section briefly addresses methodological needs. I contend that while place is a complex object of inquiry, it is vital to older adults' well-being and offers many interesting and interdisciplinary avenues for important scholarly endeavour in nursing and related fields.

Using Deweyan philosophy to rename and reframe adaptation-to-environment

John Dewey's philosophy has been suggested as having been formative in the philosophy of occupational therapy, but the occupational therapy literature offers few analyses of Dewey's work and its implications for the discipline. I offer an abbreviated analysis of Deweyan philosophy and then assess how adequately that philosophical corpus has been interpreted in the occupational therapy literature. My conclusion is that significant inconsistencies exist between a Deweyan perspective and selected concepts in occupational therapy. I take particular issue with the concept of adaptation-to-environment and specifically with aspects of that conceptualization that I term "environment as container," "subjective-internalized focus," and "mechanization of processes." I offer an alternative concept, "place integration," that is more consistent with Dewey's philosophy. The advantages of the conceptual renaming and reframing are discussed.

A Deweyan case for the study of uncertainty in health geography

John Dewey long ago challenged the philosophical tradition by arguing that uncertainty is a central, but undertheorized, trait of existence. His challenge to philosophy is also a challenge to the social sciences, including those that focus on health. In this paper, I set out to accomplish two goals. One is to present Dewey's view on uncertainty and thereby develop an argument for an underappreciated theoretical construct. The second is to explore the congruence of uncertainty and health geography with a focus on uncertainty's meaning and validity for inquiry in a health geography context. I begin with an explication of Dewey's position on uncertainty and assess it within a larger philosophical milieu. I then discuss various implications of this view for health geography and argue that the Deweyan case for uncertainty fits the discipline well. In the final part of the paper, I share an analysis of assisted living for older persons that displays different forms of uncertainty playing important roles in the health and place experience. I conclude that Dewey's philosophical position on uncertainty is a potentially important avenue for further inquiry into health and place.

The process of mediated aging-in-place: a theoretically and empirically based model

Aging-in-place is a complex geographical process mediated by institutions and other social forces. Two relatively under-studied services based on an aging-in-place strategy are adult day centers (ADCs) and assisted living residences (ALRs). This paper begins by re-casting aging-in-place as a process of place integration, based on a combination of geographical theory and John Dewey's philosophy of experience. Using empirical evidence from qualitative fieldwork and analysis of that evidence, the paper then introduces a theoretical model of the place integration process for older adults using ADCs and ALRs. The analysis describes how the domains of home and community are central to the originating problematic situation of these persons. It suggests that 'socio-geographical differentiation of older adults' situations' is involved in these domain problems and describes how the process works to influence the core processes of place integration generated by the ADC or ALR setting. The analysis then explains three core processes of the model: 're-shaping the experiential context through space and place', 'creating meaning through place-centered activity', and 'contesting space and place'. The model also includes two final component processes. One is the distillate of the core processes, termed 'approximating home and community'. The other is 'instability as ongoing challenge' to place integration. A brief conclusion discusses theoretical and policy implications drawn from the study.