Exploring determinants of flourishing: a comprehensive network analysis of retirees in Taiwan.

BACKGROUND: Human flourishing is an emerging concept, extending beyond the conventional boundaries of subjective well-being and evolving into a comprehensive capture of the diverse dimensions of human life within complex societal structures. Therefore, moving away from traditional approaches centered on the single latent construct, this study aims to explore the multiple aspects of human flourishing and the intricate interplay of their contributing factors. METHODS: Data were collected from the Health and Living Environments Survey of Taiwanese Retirees during 2023 (valid sample n = 1,111). Human flourishing was measured using the Secure Flourish Index developed by Harvard University, which includes 12 indicators: (1) life satisfaction, (2) happiness, (3) mental health, (4) physical health, (5) meaning in life, (6) sense of purpose, (7) promoting good, (8) delaying gratification, (9) content relationships, (10) satisfying relationships, (11) financial stability, and (12) material stability. A mixed graphical network analysis was employed to analyze the related determinants, divided into four groups: (a) sociodemographic factors, (b) physical functions and health status, (c) social and family engagement, and (d) community environmental characteristics as nodes. RESULTS: We analyzed 31 variables and identified 133 nonzero edges out of 465 potential connections in the comprehensive network. Results showed that happiness and promoting good were the two most critical indicators influencing retirees' overall flourishing. Different flourishing indicators were also associated with various influential factors. For instance, personal characteristics, especially gender and education, emerged as central factors. Family caregiving negatively affected happiness and financial stability, whereas social engagement was positively associated with life satisfaction and meaning in life. Employment status had mixed effects, negatively associated with life satisfaction but positively associated with mental health. Community environments, such as a sense of community and neighborhood safety, generally enhanced flourishing. However, the accessibility of neighborhood resources was paradoxically associated with material stability, pointing to the complexity of environmental factors in human flourishing. CONCLUSION: This study provides a comprehensive network analysis that reveals intricate connections between personal, behavioral, and environmental factors, offering profound insights for targeted interventions to foster human flourishing.

Retirement planning and types of healthy lifestyle after retirement: a Nationwide Survey in Taiwan.

Limited research has examined the components of retirement planning and the effects on retirees' health behaviors. This study aims to explore whether retirement planning is associated with different types of healthy lifestyles after retirement. We conducted a nationwide Health and Retirement Survey in Taiwan and analyzed the data from 2015 to 2016. A total of 3128 retirees aged 50-74 years were included in the analysis. Twenty items on retirement planning from five categories were administered, and 20 health-related behaviors were used for measuring healthy lifestyles. Results showed that five types of healthy lifestyles were found from the 20 health behaviors by factor analysis. After controlling for all covariates, various components of retirement planning were associated with different types of lifestyles. Retirees having any item of retirement planning would significantly increase the score of 'healthy living'. Those with 1-2 items were also associated with the total score and the type of 'no unhealthy food'. However, those with ≥ 6 items were the only group positively related to the type of 'regular health checkups' but negatively to the type of 'good medication'. In conclusion, retirement planning offers a 'window of opportunity' for promoting healthy lifestyles after retirement. Pre-retirement planning should be advocated in the workplace to improve health-related behaviors, especially for those upcoming retired workers. In addition, a friendly environment and continuous programs should also be incorporated for better retirement life.

The long-term effects of dual caregiving on the caregivers' well-being among middle-aged and older adults in Taiwan.

OBJECTIVES: As life expectancy is prolonged, older people may face increased burdens related to supporting multi-generational family members. This study is aimed toward examining the effects of such an emerging type of informal care on the well-being of caregivers. METHODS: Participants aged 50 and over from the Taiwan Longitudinal Study on Aging (1996-2007, n = 4,217) were analyzed. We categorized caregiving status according to different care recipients: 1) older adults only, 2) grandchildren only, 3) both older adults and grandchildren (dual caregiving), and 4) non-caregivers. Well-being was measured based on depressive symptoms and degree of life satisfaction. Generalized Estimation Equation models were used to examine the association between types of caregiving and the caregivers' state of well-being. RESULTS: After adjusting for all covariates, caregivers of older adults had significantly more depressive symptoms and less life satisfaction than non-caregivers, especially when caregiving for adults with ADL problems. In contrast, caregivers of grandchildren were not significantly affect either depression or life satisfaction as compared with non-caregivers. Interestingly, caregiving for both older adults and grandchildren had no significant effect on depression but positively affected the degree of life satisfaction. CONCLUSION: Our findings highlight that simultaneously taking care of both older adults and grandchildren can buffer negative feelings in caregivers or even improve their mental health.

Social-Economic Environments and Depressive Symptoms in Community-Dwelling Adults: A Multi-Level Analysis for Two Nationwide Datasets in Taiwan.

Most studies have focused on factors associated with depression at the individual level, and evidence on ecological models linking social-economic features with depression is rare in Taiwan. This study aimed to use multi-level analysis to explore the effects of social-economic environments on depressive symptoms among Taiwanese adults. The 2009 National Health Interview Survey (NHIS) and the Age-Friendly Environments database were linked in this study. A total of 6602 adults aged 20 years and older were included in the analysis. A Chinese version of the 10-item CESD was used as the outcome measure. Three social indicators (population density, divorce rate, and crime rate) and three economic indicators (unemployment rate, per capita disposable income, and per capita government expenditures) at the ecological level were examined. Results showed that two social environments and two economic features were significantly associated with depressive symptoms. However, the effects of these factors were different by gender and age groups. The economic environments were critical for males and young adults aged 20-44 years old, whereas the social environments were significant for females and middle-aged and older adults. Intervention efforts for depression prevention should integrate ecological approaches into the effects of social-economic environments on depressive symptoms.

Opportunity for HiAP through a Healthy Cities initiative in Taiwan: a multiple streams analysis.

Health in All Policies (HiAP) is an effective approach to promote population health through addressing comprehensive social determinants of health. In 1997, the World Health Organization designed a 20-step protocol for developing a Healthy Cities (HC) project to build healthy public policies. Taiwan adopted the concept of HC in 2002 and established the first demonstration project in Tainan City in 2003. This study explores the impact of the HC initiative on the development of HiAP, as well as how a window of opportunities for HiAP was opened through the HC movement, using Tainan City as an example. Tainan was selected as the case for this study because of its relative maturity in the development of an HC initiative. A theory-driven thematic analysis was conducted in the study with archived documents between 2003 and 2010. We first adopted a Multiple Streams Approach to examine how the city government opened a window for HiAP through the HC initiative and then drew on the Maturity Model to evaluate the stage of HiAP in the Tainan HC project. After analyzing all related documents, we concluded that HiAP in the Tainan HC project had reached Stage V Institutionalization after 7 years. Key contexts, factors, challenges and strategies were identified. This study suggests that the HC initiative can indeed contribute to the development of HiAP and that the window was opened for HiAP through a concurrence of the three streams of problem, policy and politics along with the HC movement process.

Exploring the role of built environments and depressive symptoms in community-dwelling older adults: A case of Taiwan.

OBJECTIVES: Depression in older adults is a growing public health concern. However, limited research has focused on the issues of physical environments and depression in the elderly in Asia. The purpose of the study is to examine the relationship between the built environments and depressive symptoms in older adults using Taiwan as an example. METHODS: Two national datasets were used in this study, including the 2009 National Health Interview Survey and the 2006 National Land Use Investigation in Taiwan. A total of 2,155 older adults were recruited, and eight built environments were examined among 161 townships. Depressive symptoms were measured using a 10-item CES-D scale, and four sophisticated models were built using a multi-level analysis. RESULTS: Five types of built environments were found to be significantly associated with depressive symptoms in older adults. Among them, two types of built environments, 'health and medical services' and 'schools' were highly related to a lower CES-D score and lower odds of being depressed, whereas the other three built environments, 'cultural and historical facilities,' 'recreational and amusement areas,' and 'playgrounds and sports venues' were significantly associated with an increasing risk of being depressed. CONCLUSIONS: Different built environments had different effects on depression and some even showed a dose-response relationship. These results can help urban planners or city designers reconsider how to facilitate the construction of built environments in neighborhoods that will improve the mental health of older adults.

Effects of physical and social environments on the risk of dementia among Taiwanese older adults: a population-based case-control study.

BACKGROUND: Physical and social environments may influence cognition health in older adults. However, evidence regarding physical and social environments linked to dementia is lacking, especially in Asia. This study aims to explore the influence of physical and social environments on the incidence of dementia through a population-based case-control design in Taiwan. METHODS: We identified 26,206 incident cases with dementia aged≧65 years in 2010, with the same no. of controls from National Health Insurance claims. Environmental measures were collected from government statistics including three physical environments and three social environments. Multilevel logistic regression was used to estimate the odds ratios (ORs) and 95% confidence intervals (CI) of the association between dementia incidence and the environmental measures at the township level. RESULTS: We observed a significant reduction of 12% in the odds ratios of dementia in areas with higher availability of playgrounds and sport venues (OR 0.88, 95% CI 0.81-0.95), after controlling for individual and other environmental characteristics. Community center availability was also significantly associated with an 8% decreased odds for dementia (OR 0.92, 95% CI 0.87-0.99), but the association was not significant after further consideration of individual-level characteristics. Although higher odds of dementia were found in areas with high median annual family income (OR 1.14, 95% CI 1.04-1.25), such a significant relationship did not appear in the full model. CONCLUSIONS: Our study suggests that specific physical and social environmental features have different influences on the risk of dementia. Public health interventions may consider these environmental aspects for preventing dementia incidence.

Association of Environmental Features and the Risk of Alzheimer's Dementia in Older Adults: A Nationwide Longitudinal Case-Control Study.

Little is known about the association between environmental features and the risk of Alzheimer's dementia (AD). This study aims to investigate the association of physical and social environments with the incidence of AD. We identified 12,401 newly diagnosed AD cases aged ≥65 years in 2010, with the same no. of matched controls from National Health Insurance claims in Taiwan. Environmental data were collected from government statistics including three physical environments and three social environments. Multilevel logistic regression was conducted to calculate the odds ratios (OR) of AD in association with environmental features at the township level. Results showed that living in the areas with higher availability of playgrounds and sport venues was associated with a 3% decreased odds of AD (95% CI = 0.96-0.99), while higher density of elderly living alone was associated with a 5% increased odds of AD (95% CI = 1.01-1.11), after controlling for individual and other environmental factors. In further examination by urbanization level, the above relationships were found only in rural areas but not in urban areas. This study provides evidence that specific physical and social environmental features have different impacts on the risk of AD.

Association of the built environments and health-related quality of life in community-dwelling older adults: a cross-sectional study.

PURPOSE: The relationship between built environments and the quality of life (QoL) of the elderly has gained great attention in recent years. However, most QoL studies have been conducted in western countries; thus, limited research was found in Asia, in which the population density, urban forms, narrow roadways, and land use patterns are more compact and highly mixed in terms of use. Therefore, the purpose of this study was an interdisciplinary analysis of two national datasets, the National Land Use Investigation and the National Health Interview Survey, to explore the relationship between built environments and the health-related quality of life of older adults in Taiwan. METHODS: Eight types of built environments at the township level were calculated, and 1222 nationally representative older adults aged 65 and older were recruited. The outcome variable was health-related QoL as measured using the EQ-5D, including utility score and the EQ-VAS. Statistical methods included descriptive analysis, bivariate analysis, and mixed-effects logistic regression analysis, which were conducted using SAS 9.4 software. RESULTS: The results showed that a significant relationship exists between cultural and historical facilities and low EQ-VAS; none of the built environments were found to be related to the EQ-5D. Individual factors are the main determinants of the EQ-5D of older adults in Taiwan. Positive relationships were found if older adults were engaging in physical activities and social participation. CONCLUSIONS: We suggest that building a supportive environment in which elderly people could consistently engage in physical activities and social participation is another potential approach that might contribute to active aging.

Do Healthy City Performance Awards Lead to Health in All Policies? A Case of Taiwan.

The Healthy Cities (HC) Project, which was introduced by the World Health Organization (WHO) in 1986, has been recognized as the best setting approach for health promotion. However, very few studies have addressed how to use HC approaches to establish public policies in non-health departments in cities. This paper describes the strategies for the HC Performance Awards used in Taiwan to draw attention from different departments and to sustain intersectoral collaboration for the purpose of establishing Health in All Policies (HiAP). The methods include: (1) setting up the Taiwan Healthy City Alliance; (2) establishing HC Innovation Performance Awards; (3) reviewing the award applications according to seven criteria; and (4) analyzing the topic content of the award applications. We collected 961 HC award applications during 2013⁻2016 to analyze their content. The results showed that the number of applications increased nearly every year while significantly more non-health departments applied for the awards compared to health departments (73.3% vs. 26.7%). The award rates of non-health departments have also increased twice from 13.9% in 2013 to 25.8% in 2016. By examining the topics of the award winners, we concluded that "HC Innovation Performance Awards" indeed provide a role and opportunity for political involvement, intersectoral collaboration, co-opetition and capacity building that is necessary for establishing health in all policies.

The Relationship between Urbanization, the Built Environment, and Physical Activity among Older Adults in Taiwan.

Urbanization and ageing are global phenomena and offer unique challenges in different countries. A supportive environment plays a critical role in addressing the issue of behavioral change and health promotion among older adults. Many studies in the U.S., EU, and Australia have considered promoting physical activity in the community based on ecological models, whereas very few Asian studies have examined the relationships among urbanization, the built environment and physical activity in elderly at the ecological level, especially from a multi-level perspective. Due to the prevalence of post-war baby boomers and a very low birth-rate, the older population (aged 65 years old and older) in Taiwan has increased rapidly since 2011 and has exceeded the younger generation (0⁻14 years old) in 2017. Hence, the purpose of this study was first to examine the degree of urbanization in townships and the status of related built environments in Taiwan and then to investigate whether the built environment is associated with recommended amounts of physical activity among older adults. Three national datasets and a multi-level design were used in this research. Data at the individual level was obtained from the 2009 National Health Interview Survey (NHIS) which was taken from June 2009 to February 2010. Ecological data was obtained from the 2006 National Land Use Investigation of the National Geographic Information System and the 2010 Population and Housing Census. The analyses included a descriptive analysis, a bivariate analysis, a multiple logistic regression, and a multi-level analysis, utilizing a mostly hierarchical linear model (HLM). The results showed a significant relationship between factors at the environmental levels and physical activity in older adults. Urbanization, the built environment, and the median income of townships were positively correlated to the physical activity of the older adults. After controlling for individual-level factors, urbanization still exhibited this correlation. Parks and green spaces were associated with achieving the recommended amount of physical activity. However, there was no relationship after controlling for factors at the individual level. Detailed discussions were provided.

Associations between physical facilities and organizational participation and levels of physical activity of adults in Tainan, Taiwan.

BACKGROUND: During the past decade many studies have endeavored to evaluate the relationships between environmental attributes and physical activity, but there is limited data on this subject in Taiwan. This is the first study to investigate both objective and subjective environments in relation to different levels of physical activity in adults in Tainan, Taiwan. METHODS: A 2-stage survey examining relationships between physical and social environments and physical activity was designed. It was administered to a sample including 231 community directors and 804 randomly selected residents. Community audits and telephone interviews were used as the objective and subjective measures in the study, respectively. RESULTS: No correlation was found between the objective and the subjective measures of physical environments. Only the subjective measures were significantly related to city residents' physical activities. Perceived physical facility was found to be correlated with engagement in physical activity, whereas organizational participation was associated with the regularity of physical activity. Of the 4 types of leisure activity examined in this study, dancing and aerobic activities are more likely to be engaged in regularly. CONCLUSIONS: Factors associated with the regularity of physical activity are not the same as factors associated with engagement in physical activity.