Framing Later Life Vulnerability during the COVID-19 Pandemic: A Content Analysis of Newspaper Coverage in Canada and the United States.

This study explores vulnerability narratives used in relation to older adults and others during the COVID-19 pandemic. A mixed-method content analysis was conducted of 391 articles published in two major newspapers in Canada and the USA during the first wave of the pandemic. The findings indicated that during the early months of the pandemic, limited attention was directed towards its impact on older adults or other 'vulnerable' subpopulations in both countries. Where evident, intrinsic (individual-level) risk factors were most consistently used to frame the vulnerability of older adults. In contrast, vulnerability was more likely to be framed as structural with regard to other subpopulations (e.g., ethno-racial minorities). These narratives also differed somewhat in Canadian and US newspapers. The framing of older adults as intrinsically vulnerable reflects ageist stereotypes and promotes downstream policy interventions. Greater attention is needed to the role of structural factors in influencing pandemic-related outcomes among older adults.

Mental Health Benefits and Detriments of Caregiving Demands: A Nonlinear Association in the Canadian Longitudinal Study on Aging.

OBJECTIVES: This study examines whether the association between caregiving demands and mental health is non-linear and also, whether this non-linear association is contingent on the marital status of the caregiver. METHODS: We analyze the data from the Canadian Longitudinal Study on Aging, applying OLS regression and quadratic interaction terms. RESULTS: A lower level of demands is salubriously associated with symptoms of depression and life satisfaction, but this association becomes deleterious at higher levels of demands. Moreover, a connection to a marital partner extends the benefits of caregiving demands and stems the adverse consequences. DISCUSSION: This research shows that acts of caregiving may not themselves be detrimental. Instead, the degree and way in which caregiving relates to mental health may vary by both the extent of the demands of the caregiving role and familial relationships in which caregivers are embedded.

Internal Migration and the Health of Middle-Aged and Older Persons in China: The Healthy Migrant Effect Reconsidered.

This study investigates associations between internal migration and health among middle-aged and older adults in China, including variations associated with type of migration (rural-to-urban, urban-to-rural, rural-to-rural, urban-to-urban). Data were drawn from China's Health and Retirement Longitudinal Study (2011, 2013, 2015). Lagged panel and fixed-effect regression models address associations between migration and health outcomes (self-rated health, depression) while controlling for pre-migration and post-migration selection effects. The results reveal the positive implications of rural-to-urban migration for the self-rated health of middle-aged but not older adults. They also point to the positive effects of migration within and to rural areas for the self-rated and mental health of older adults. Overall, although migration may be beneficial to the health of internal migrants in China, complexities associated with age, type of migration, and the health outcome involved need to be taken into account.

Social Determinants of Racial Disparities in Cognitive Functioning in Later Life in Canada.

Objective: The objectives of this study were (a) to assess the nature and extent of racial disparities in cognitive functioning among older adults in Canada, and (b) to assess the role of socioeconomic factors and patterned health behaviors as social determinants of racial disparities in cognitive functioning. Method: Data were drawn from the 2009-2010 Canadian Community Health Survey. The study sample included 20,646 people aged 60 years or older. Ordered logistic regression analyses were carried out to test hypotheses linking race, socioeconomic factors, and patterned health behaviors, and cognitive functioning. Results: Our findings revealed a racial gap in cognitive functioning among older adults in Canada. This gap was, in part, mediated by socioeconomic inequalities (in income and food security) and socially patterned behaviors (i.e., drinking, physical activity levels). However, socioeconomic status (SES) and behavioral factors appeared to operate independently of one another. Discussion: The findings suggest a need to focus on the direct effects of race as well as its indirect effects, through socioeconomic factors and patterned health behaviors, for an understanding of racial disparities in cognitive functioning.

Long-Term Care Service Trajectories and Their Predictors for Persons Living With Dementia: Results From a Canadian Study.

OBJECTIVE: We used latent transition analysis to explore common long-term care (LTC) service trajectories and their predictors for older adults with dementia. METHOD: Using linked administrative data collected over a 4-year interval (2008-2011), the study sample included 3,541 older persons with dementia who were clients of publicly funded LTC in British Columbia, Canada. RESULTS: Our results revealed relatively equal reliance on home care (HC) and facility-based residential care (RC) as starting points. HC service users were further differentiated into "intermittent HC" and "continuous HC" groups. Mortality was highest for the RC group. Age, changes in cognitive performance, and activities of daily living were important predictors of transitions into HC or RC. DISCUSSION: Reliance on HC and RC by persons with dementia raises critical questions about ensuring that an adequate range of services is available in local communities to support aging in place and to ensure appropriate timing for entry into institutions.

Marital and Cohabiting Union Dissolution in Middle and Later Life.

This study examined the timing and risk factors for subsequent union disruption among individuals who were in a marital or cohabiting union at age 45, focusing particularly on the role of prior union history and children. Using retrospective data on union histories from the 2007 Canadian General Social Survey ( n = 17,194), the results of life-table analysis revealed that individuals in cohabiting relationships faced a greater risk of union disruption in middle or later life than those who were married. Cox proportional hazard models showed that both union biography (duration, remarriage/repartnership) and family biography (children born inside/outside union, child age) influenced union dissolution through separation or divorce, but their impact differed depending on union type and gender. These findings suggest that when it comes to marriage and cohabitation, the middle and later years of life are neither a clear continuation nor a complete departure from earlier patterns.

Long-term Care Trajectories in Canadian Context: Patterns and Predictors of Publicly Funded Care.

Objectives: Drawing on a structural life course perspective (LCP), we examined the most common trajectories experienced by older long-term care (LTC; home and community-based care, assisted living, and nursing home care) recipients. The overall sequencing of care transitions was considered along with the role of social structural location, social and economic resources, and health factors in influencing them. Method: Latent class and latent transition analyses were conducted using administrative data obtained over a 4-year period for clients aged 65 and older (n = 2,951) admitted into publicly funded LTC in 1 Canadian health region. Results: Four main LTC trajectories were identified within which a wider range of more specific or secondary subtrajectories were embedded. These were shaped by social structural factors (age, gender, rural-urban residence), social and economic resources (marital status, income, payment for services), and health factors (chronic conditions, functional and cognitive impairment and decline, problematic behaviors). Discussion: Our findings support the utility of a structural LCP for understanding LTC trajectories in later life. In doing so, they also reveal avenues for enhancing equitable access to care and the need for options that would increase continuity and minimize unnecessary, untimely, or undesirable transitions.

Janus at the Crossroads: Perspectives on Long-term Care Trajectories for Older Women With Dementia in a Canadian Context.

PURPOSE OF THE STUDY: Janus, the two-faced, Roman god of beginnings and transitions, is used as a metaphor to explore our personal narratives and our quantitative research on the experiences of older women with dementia in long-term care (LTC). Two research questions are addressed: (a) How do our quantitative data map onto our mothers' experiences? (b) What lessons do our mothers' experiences offer for the care of older women with dementia? DESIGN AND METHODS: Informed by a life-course perspective, we triangulate administrative data on 3,717 women with dementia receiving LTC in British Columbia, Canada, with personal narratives-the stories of our mothers who made the transition from home care into residential (nursing home) care. RESULTS: Our quantitative data reveal that the home care to residential care transition is the most common LTC trajectory for women with dementia who are most likely to be widowed and living alone in suburban areas. On entry into residential care, they exhibit greater frailty in terms of activities of daily living, cognition, aggression, and incontinence. Our personal narrative data on our mothers reveals that the relatively straightforward pathways through LTC for women with dementia, are often considerably more complex in a real-world context. Attention is drawn to the public and private services, hospitalization patterns, and substantial communication gaps experienced by our moms and families. IMPLICATIONS: A life-course perspective, and qualitative and quantitative data facilitate understanding the care journeys-health and service trajectories of older women with dementia.

Income Inequities in Health Care Utilization among Adults Aged 50 and Older.

Equitable access to and utilization of health services is a primary goal for many health care systems, particularly in countries with universal publicly funded systems. Despite concerns regarding potentially adverse implications of the 1990s' health care policy and other reforms, whether and how income inequalities in service utilization changed remains unclear. This study addressed the impact of income on physician and hospital utilization from 1992-2002 among adults aged 50 and older in British Columbia. Those with lower incomes were found less likely to access general practitioner and specialist services but more likely to access hospital services. Income-related disparities in physician care increased over time; hospital care declined. Volume of GP and hospital care was inversely associated with income; these differences increased regarding GP services only. Findings of declines in hospital-care access, accompanied by increasing income-related disparities in physician-services access, show that inequities are increasing within Canada's health care system.

Caregiver Stress and Mental Health: Impact of Caregiving Relationship and Gender.

PURPOSE OF THE STUDY: This study compared the stress and mental health implications of caregiving to a spouse, children, siblings, other family members, friends, and others among middle-aged and older male and female caregivers. DESIGN AND METHODS: Multivariate regression analyses were conducted using 2007 Canadian General Social Survey data collected on a subsample of caregivers aged 45 and older. RESULTS: Our analyses revealed that for women, caring for a spouse or children was more stressful and detrimental to mental health than caring for parents or others. Similarly, for men, caring for a spouse and for children was more stressful than caring for others but did not adversely affect overall mental health. IMPLICATIONS: The findings suggest that spousal and child caregiving tend to be more rather than less stressful and detrimental to middle-aged and older caregivers' mental health than is caregiving to most others but that gender differences need to be considered.

Relocation and Social Support Among Older Adults in Rural China.

OBJECTIVES: China's economic reforms have led to millions of citizens being relocated to support infrastructure development, reduce poverty, and address ecological, disaster-related and other concerns. This study expands on previous research on the implications of relocation in China by examining the impact of rural elders' relocation on the perceived availability of emotional, instrumental, and financial support. METHODS: Data were drawn from the Ankang Study of Aging and Health conducted with a representative sample of 1,062 rural residents aged 60 and over living in Ankang, China. Two-stage probit and least squares regression models assessed the impact of relocation on familial and nonfamilial emotional, instrumental, and financial support. RESULTS: Relocation was negatively associated with the number of social support resources that older adults perceived as being available. Although this was the case with regard to both familial and nonfamilial support, it was particularly evident with regard to family support and, within families, with regard to instrumental rather than financial or emotional support. DISCUSSION: Relocation has negative implications for the number of social support resources perceived to be available by older adults in rural China. China will need to come to terms with how to provide for the instrumental support needs of an aging society.

Marital status, childlessness, and social support among older Canadians.

Despite evidence of increasing diversification of family structures, little is known regarding implications of marital and parental status for access to social support in later life. Using data from Statistics Canada's 2007 General Social Survey, this study assessed the impact of marital and parental status intersections on social support among adults aged 60 and older (n = 11,503). Two-stage probit regression models indicated that among those who were currently married or separated/divorced, childless individuals were more likely to report instrumental (domestic, transportation) and emotional support from people outside the household. Conversely, among never-married or widowed older adults, being childless was associated with reduced domestic support but without differences in other support domains. Findings suggest that marital and parental status intersections are not uniformly positive, neutral, or negative regarding implications for extra-household social support. Future work should address complexities of these relationships in order to better understand rapidly changing family structures.

Polypharmacy meets polyherbacy: pharmaceutical, over-the-counter, and natural health product use among Canadian adults.

OBJECTIVES: Natural health products (NHP) are increasingly being used to supplement prescription medications (PM) and over-the-counter (OTC) products. The objective of this study was to examine patterns of overall health product use and how these patterns are associated with social and health factors. METHODS: We used direct health measures data from the Canada Health Measures Survey (CHMS) Cycle 1.0 (2007/2009) to examine recent product use among adults aged 18-79 years (n=3,721). Latent class analyses were used to detect use (propensity) and intensity of use among users of all three product types. Associations between social and health covariates and product patterns were examined using linear and multinomial logit regression procedures. RESULTS: Three latent classes of health product use were identified. The largest (43%) was characterized by a high probability of PM and NHP but not OTC use. Class two (37%), in contrast, had a low probability of using any of the three health products. Class three (20%) had a high probability of PM and OTC but not NHP use. Age, gender, immigrant status, household size, co-morbidity, perceived health status, and having a regular doctor were associated with these patterns of use. Analyses of intensity of product use among users revealed seven distinct classes; these were differentiated by age, household size, co-morbidity and weight (BMI status). CONCLUSION: If defining polypharmacy or polyherbacy is based simply on number of health products used, then for Canadians under age 80 neither practice appeared to be widespread. More work needs to be done to define the "poly" in polypharmacy and polyherbacy. This will inform the conversation on appropriate product use, particularly given that about one half of Canadians used medications and NHPs concurrently.

Trends and predictors of publicly subsidized chiropractic service use among adults age 50+.

OBJECTIVES: This article examines trends in and predictors of publicly subsidized chiropractic use from 1991 to 2000, a decade characterized by health care system reforms throughout North America. SAMPLE: The sample included adults age 50+ who visited a publicly subsidized chiropractor in the Canadian province of British Columbia during the study period. DESIGN: Administrative claims data for chiropractic service use were drawn from the Medical Services Plan (MSP) Master file in the British Columbia Linked Health Data resource. The MSP Master file contains claims reported for every provincially insured medical service and supplementary health benefit including chiropractic visits. RESULTS: Joinpoint regression analyses demonstrate that while annual rates of chiropractic users did not change over the decade, visit rates decreased during this period. Predictors of a greater number of chiropractic visits include increasing age, female gender, urban residence, low to moderate income, and use of chiropractic services earlier in the decade. CONCLUSIONS: The trend toward decreasing visit rates over the 1990s both conflicts with and is consistent with findings from other North American chiropractic studies using similar time periods. Results indicating that low and moderate income and advancing age predict more frequent chiropractic service are novel. However, given that lower income and older individuals were exempted from chiropractic service limits during this period, these results suggest support for the responsive nature of chiropractic use to financial barriers.

Gender and remission of mental illness.

OBJECTIVES: There is a well-established association between gender and the prevalence of mental illness. The objective of this study was to determine whether gender also influences the timing of remission from illness. The regression analysis undertaken considered remission in terms of all ICD-9 mental disorders (codes 290-314). This analysis compares males and females on average length of treatment for mental illness and examines whether any gender differences in remission are generalized or disorder specific. METHODS: The statistical analysis was based on longitudinal (1990-2001) administrative data on 5,118 females and 2,470 males. The target population represented all individuals with an ICD-9 diagnosis of mental illness who were treated through the Medical Services Plan in British Columbia. The regression analysis used the generalized estimating equations method to model differences in length of treatment. RESULTS: There was a non-significant bivariate relation between gender and the timing of remission from mental illness. However, the multivariate findings demonstrated that a significant gender effect on remission emerges after controls were introduced for demographic and socio-economic characteristics. In particular, the timing of remission was somewhat longer for females. This effect was generalized and not restricted to specific illnesses. CONCLUSIONS: The emergence of a significant effect after considering demographic and socio-economic characteristics suggests that a social disadvantage within the male sample (more single males) was suppressing a small negative effect of female gender on the timing of remission. In other words, a social disadvantage among males concealed an unexplained female disadvantage in remission.

Home care and health reform: changes in home care utilization in one Canadian province, 1990-2000.

PURPOSE: This study examines population-based trends in home care service utilization, alone and in conjunction with hospitalizations, during a period of health reform in Canada. It focuses on the extent to which observed trends suggest enhanced community-based care relative to three competing hypotheses: cost-cutting, medicalization, and profitization. DESIGN AND METHODS: Analyses drew on administrative health data from the province of British Columbia for the period from 1990 through 2000. Annual trends in age- and gender-adjusted utilization rates are examined by use of joinpoint regression; multivariate analyses draw on generalized linear modeling. RESULTS: Home support claims decreased significantly during the study period. There was less evidence of decline with regard to home nursing care claims and the extent of both home support and home nursing care. Intensity of care increased for home support services but decreased somewhat for home nursing care. Multivariate analyses revealed a decline in joint use of home support and hospital care and little change in joint use of home nursing and hospital care. Similarities as well as differences in trends are evident across age groups. IMPLICATIONS: The findings suggest a reduction and reallocation of health services in general rather than a shift of focus toward community-based care. In this way, they appear more consistent with a cost-reduction hypothesis than with expectations of enhanced community-based care that are generated by recent health reform initiatives.

In the absence of cancer registry data, is it sensible to assess incidence using hospital separation records?

BACKGROUND: Within the health literature, a major goal is to understand distribution of service utilisation by social location. Given equivalent access, differential incidence leads to an expectation of differential service utilisation. Cancer incidence is differentially distributed with respect to socioeconomic status. However, not all jurisdictions have incidence registries, and not all registries allow linkage with utilisation records. The British Columbia Linked Health Data resource allows such linkage. Consequently, we examine whether, in the absence of registry data, first hospitalisation can act as a proxy measure for incidence, and therefore as a measure of need for service. METHODS: Data are drawn from the British Columbia Linked Health Data resource, and represent 100% of Vancouver Island Health Authority cancer registry and hospital records, 1990-1999. Hospital separations (discharges) with principal diagnosis ICD-9 codes 140-208 are included, as are registry records with ICDO-2 codes C00-C97. Non-melanoma skin cancer (173/C44) is excluded. Lung, colorectal, female breast, and prostate cancers are examined separately. We compare registry and hospital annual counts and age-sex distributions, and whether the same individuals are represented in both datasets. Sensitivity, specificity and predictive values are calculated, as is the kappa statistic for agreement. The registry is designated the gold standard. RESULTS: For all cancers combined, first hospitalisation counts consistently overestimate registry incidence counts. From 1995-1999, there is no significant difference between registry and hospital counts for lung and colorectal cancer (p = 0.42 and p = 0.56, respectively). Age-sex distribution does not differ for colorectal cancer. Ten-year period sensitivity ranges from 73.0% for prostate cancer to 84.2% for colorectal cancer; ten-year positive predictive values range from 89.5% for female breast cancer to 79.35% for prostate cancer. Kappa values are consistently high. CONCLUSION: Claims and registry databases overlap with an appreciable proportion of the same individuals. First hospital separation may be considered a proxy for incidence with reference to colorectal cancer since 1995. However, to examine equity across cancer health services utilisation, it is optimal to have access to both hospital and registry files.

The devil is in the details: trends in avoidable hospitalization rates by geography in British Columbia, 1990-2000.

BACKGROUND: Researchers and policy makers have focussed on the development of indicators to help monitor the success of regionalization, primary care reform and other health sector restructuring initiatives. Certain indicators are useful in examining issues of equity in service provision, especially among older populations, regardless of where they live. AHRs are used as an indicator of primary care system efficiency and thus reveal information about access to general practitioners. The purpose of this paper is to examine trends in avoidable hospitalization rates (AHRs) during a period of time characterized by several waves of health sector restructuring and regionalization in British Columbia. AHRs are examined in relation to non-avoidable and total hospitalization rates as well as by urban and rural geography across the province. METHODS: Analyses draw on linked administrative health data from the province of British Columbia for 1990 through 2000 for the population aged 50 and over. Joinpoint regression analyses and t-tests are used to detect and describe trends in the data. RESULTS: Generally speaking, non-avoidable hospitalizations constitute the vast majority of hospitalizations in a given year (i.e. around 95%) with AHRs constituting the remaining 5% of hospitalizations. Comparing rural areas and urban areas reveals that standardized rates of avoidable, non-avoidable and total hospitalizations are consistently higher in rural areas. Joinpoint regression results show significantly decreasing trends overall; lines are parallel in the case of avoidable hospitalizations, and lines are diverging for non-avoidable and total hospitalizations, with the gap between rural and urban areas being wider at the end of the time interval than at the beginning. CONCLUSION: These data suggest that access to effective primary care in rural communities remains problematic in BC given that rural areas did not make any gains in AHRs relative to urban areas under recent health sector restructuring initiatives. It remains important to continue to monitor the discrepancy between them as a reflection of inequity in service provision. In addition, it is important to consider alternative explanations for the observed trends paying particular attention to the needs of rural and urban populations and the factors influencing local service provision.

Immigrant status and unmet health care needs.

OBJECTIVES: To compare whether unmet health needs differ between immigrants and non-immigrants, and examine whether help-seeking characteristics account for any unmet needs disparities. METHODS: The data are from the Canadian Community Health Survey Cycle 1.1, conducted by Statistics Canada in 2000-2001. The study sample includes 16,046 immigrants and 102,173 non-immigrants aged 18 and older from across Canada. The study employs logistic regression models to examine whether help-seeking behaviours explain unmet needs differences. RESULTS: Logistic regression analysis indicates that immigrants have a 12% (95% CI: 6-18) lower all-cause unmet needs risk (odds ratio) than non-immigrants after controlling for differences in help-seeking characteristics. The unmet needs risk among long-term immigrants (15 years of residence and more), however, is similar to non-immigrants after considering these characteristics. We found differences between immigrants and non-immigrants in reasons for unmet needs, with more immigrants believing that the care would be inadequate, not knowing where to access health care, and having foreign language problems. CONCLUSIONS: The Canadian health care system delivers sufficient health care to immigrants, even though the poverty rate and proportion of visible minorities are comparatively higher within this subpopulation. Nonetheless, these results indicate that some immigrant-specific health care access barriers may exist.

Hydra revisited: substituting formal for self- and informal in-home care among older adults with disabilities.

PURPOSE: In response to concerns among policymakers and others that increases in the availability of publicly funded formal services will lead to reductions in self- and informal care, this study examines the relationship between the extent of formal in-home care received and levels of self- and informal care. DESIGN AND METHODS: Two-stage least squares regression analyses were conducted, using data drawn from interviews conducted with a sample of 661 older users and nonusers of publicly subsidized home care services. RESULTS: No evidence was found to indicate that more extensive use of formal services is associated with less extensive self- or informal care. This is true among those receiving publicly subsidized services as well as those required to pay part or all of the cost of the in-home services they receive. IMPLICATIONS: The findings provide little support for the substitution hypothesis that an increase in the use of formal in-home services will tend to erode levels of informal or self-care.