Integrating perspectives of transgender and gender-diverse youth, family members, and professionals to support their health and wellbeing - a mixed-method study protocol.

BACKGROUND: The current literature highlights a strong link between the poor health outcomes of transgender and gender diverse (TGD) individuals and their negative experiences in various areas of life. Most of these publications rely on adults' memories, lacking a focus on the current experiences and needs of young transgender and gender-diverse individuals. Furthermore, previous studies on support for these young people often solely consider the perspectives of TGD adults or professionals and rarely involve parents' viewpoints. METHODS: This study will use a mixed sequential method with a participatory approach. Firstly, the qualitative phase will explore the difficulties and needs of TGD (15-20 years old) and of the families and professionals who support them. Results from this part will be used to develop the questionnaire for the quantitative phase, with the help of a community board. Secondly, based on participatory epidemiological research, the quantitative phase will use an intersectional perspective to measure the impact of individual and structural factors on the quality of life and well-being of transgender and gender-diverse young people. Finally, a co-creation phase will be undertaken to formulate recommendations based on the results of the first two phases. DISCUSSION: This research aims at better understanding the influence of gender identity on the quality of life and health of TGD young people and their families and to identify protective and risk factors that affect their vulnerabilities. ETHICS AND DISSEMINATION: This study has been approved by the Ethics Committee of the Erasme Faculty Hospital (CCB B4062023000140). As this research is participatory and part of a PhD dissertation, we aim to disseminate the results through our partners' networks and structures locally, and internationally through conferences and peer-reviewed journals.

Bedtime negative affect, sleep quality and subjective health in rural China.

BACKGROUND: The overall level of negative affect (NeA) has been linked to impaired health. However, whether the diurnal timing of NeA matters and whether the NeA-health relationship is mediated by sleep quality remain unclear. METHODS: Using a longitudinal dataset (2006, 2009 and 2014 waves) consisting of 1959 participants, we examined the within-person impact of both bedtime NeA and non-bedtime NeA measured by Day Reconstruction Method (DRM) on subjective health measured by Visual Analogue Scale (VAS), and the mediating effect of sleep quality on the NeA-health relationships by fixed effect models. RESULTS: Bedtime NeA predicted poorer health, while non-bedtime NeA was unrelated to health. The deleterious impact of bedtime NeA reduced and became non-significant after sleep quality was controlled for. Bedtime NeA also significantly predicted impaired sleep quality. CONCLUSIONS: Bedtime NeA is a stronger predictor of poorer health than non-bedtime NeA, and the deleterious influence of bedtime NeA on health seems to operate through poor sleep quality. Therefore, interventions to reduce bedtime NeA could potentially improve subsequent sleep quality, thereby protecting people to some extent from impaired health status.

Subjective Wellbeing in Rural China: How Social Environments Influence the Diurnal Rhythms of Affect.

Although the diurnal rhythms of affect influence people's health and behavior, there is a lack of evidence from rural China, where the types and timing of social activities may differ from Western contexts. In this study, a total of 2847 Chinese rural residents from three provinces of China are interviewed using the abbreviated Day Reconstruction Method (DRM) questionnaire. Diurnal rhythms of three affective subjective wellbeing (SWB) indicators-positive affect (PoA), negative affect (NeA), and net affect are analyzed by multilevel models. Our results show PoA and net affect generally increase in magnitude throughout the day with two peaks around noon and in the evening, respectively; whereas, there is an overall decline in NeA as the day passes with two troughs occurring at lunchtime and in the evening. These patterns, however, flatten considerably, with the lunchtime peaks in PoA and net affect (and trough in NeA) disappearing entirely, after further controlling for two social environmental factors-activity type and the quality of social interaction. This study, set in rural China, corroborates the diurnal rhythms of affect from prior Western research to some extent, and highlights that social environmental factors have a significant effect on diurnal rhythms of affect in the rural Chinese context. It is possible that the diurnal rhythms of affect could change in response to stimulation from the environment. Improving some social environmental factors, such as organizing pleasant activities and creating a friendly interactive environment, could contribute to the increase in positive affect and decline in negative affect, thereby enhancing the quality of life.

The relationship between rural to urban migration in China and risk of depression in later life: An investigation of life course effects.

BACKGROUND: Migrating between rural and urban areas over the life course profoundly shapes the conditions of later life. In the Chinese context, living in urban areas with an urban Hukou is associated with socioeconomic advantage. This study attempts to investigate how migration into urban areas in China is related to these processes and the association with risk of depression in later life by focusing on the timing and the type of migration (rural-urban residential mobility and/or institutional transition of Hukou status). METHODS: We use sequence analysis to identify migration trajectories in the China Health and Retirement Longitudinal Study. Then we estimate how and why these trajectories are associated with risk of depression at older ages using a random intercept hierarchical linear model, distinguishing between three levels: city, household and individual. RESULTS: The type of migration path taken over the life course is differentially associated with mental wellbeing in later life in China. Urban migration with rural-urban Hukou conversion during young adulthood is associated with lower levels of depression in later life. Urban migration at older ages regardless of Hukou transitions is protective against depression in old age. Formal social protection, particularly having a private pension, contributes substantially to the mental health advantage of social groups with an urban Hukou. Informal social mechanisms such as familial support are relevant, but only explain a small part of the differences in mental health. CONCLUSION: Having an urban Hukou has an independent protective role in shaping mental wellbeing in later life in China, potentially in part due to the entitlement to a private pension attached to this status. With weakening informal support in contemporary China, enhanced formal social protections in the form of adequate pensions should be put in place to mitigate structural inequalities associated with migration in old age.

Age Takes Hold of Us by Surprise: Conceptualizing Vulnerabilities in Aging as the Timing of Adverse Events.

OBJECTIVES: Aging in the public eye can be distilled to a limited number of adverse events, such as loss of health, partnership and wealth. While these events are a constitutive part of "normal aging," they do not occur uniformly at the same time point in the life course. This study investigates to what extent bereavement, functional health loss, and onset of poverty are adequate markers of aging, and illustrates inequalities in their timing according to cohort, gender, class, education, and ethnicity. METHODS: The English Longitudinal Study of Ageing (ELSA), collected over seven waves (2002-2016) (n = 7,890) is examined in an event history framework. Cox proportional hazard models are used with the Andersen Gill extension in case of multiple failures per respondent. RESULTS: Persistent associations of lower occupational class, lower education, and having a black or minority ethnic background are found with increased hazards of functional health loss and wealth loss. Earlier born cohorts have lower hazards for functional health loss, wealth loss, and bereavement. Women have higher hazards for bereavement, and lower hazards for wealth loss. DISCUSSION: The timing of adverse events is a crucial gateway through which existing social inequalities are transferred into unequal aging pathways.

Putting cumulative (dis)advantages in context: Comparing the role of educational inequality in later-life functional health trajectories in England and Germany.

BACKGROUND: The cumulative (dis)advantage (CAD) perspective more and more is examined in a comparative way, to highlight the role of context in generating inequality over the life course. This study adds to this field of research by examining trajectories of activities of daily living (ADL) in later life by educational level in a country comparison of England and Germany, emphasizing differing institutional conditions. METHOD: Data used are the English Longitudinal Study of Ageing (ELSA; 11,352 individuals) and the German subsample of the Survey of Health and Retirement in Europe (SHARE; 5,573 individuals). Using population averaged Poisson panel regression models, 12-year trajectories of six birth cohorts are investigated, covering the age range of 50 to 90 years. RESULTS: Respondents in England have a higher level of limitations at age 50, and more limited increases over age than in Germany. An educational gradient exists in both countries at age 50. Notably, the educational gradient increases for more recently born cohorts, but declines with increasing age in England, while in Germany educational differences increase for more recently born cohort only. DISCUSSION: The current study indicates that CAD processes between educational groups are context sensitive. While England showed convergence of disparities with increasing age, in Germany no differential development was found.

Metabolic dysregulation in vitamin E and carnitine shuttle energy mechanisms associate with human frailty.

Global ageing poses a substantial economic burden on health and social care costs. Enabling a greater proportion of older people to stay healthy for longer is key to the future sustainability of health, social and economic policy. Frailty and associated decrease in resilience plays a central role in poor health in later life. In this study, we present a population level assessment of the metabolic phenotype associated with frailty. Analysis of serum from 1191 older individuals (aged between 56 and 84 years old) and subsequent longitudinal validation (on 786 subjects) was carried out using liquid and gas chromatography-mass spectrometry metabolomics and stratified across a frailty index designed to quantitatively summarize vulnerability. Through multivariate regression and network modelling and mROC modeling we identified 12 significant metabolites (including three tocotrienols and six carnitines) that differentiate frail and non-frail phenotypes. Our study provides evidence that the dysregulation of carnitine shuttle and vitamin E pathways play a role in the risk of frailty.

New horizons in frailty: the contingent, the existential and the clinical.

In the past decade, frailty research has focused on refinement of biomedical tools and operationalisations, potentially introducing a reductionist approach. This article suggests that a new horizon in frailty lies in a more holistic approach to health and illness in old age. This would build on approaches that view healthy ageing in terms of functionality, in the sense of intrinsic capacity in interplay with social environment, whilst also emphasising positive attributes. Within this framework, frailty is conceptualised as originating as much in the social as in the biological domain; as co-existing with positive attributes and resilience, and as situated on a continuum with health and illness. Relatedly, social science-based studies involving interviews with, and observations of, frail, older people indicate that the social and biographical context in which frailty arises might be more impactful on the subsequent frailty trajectory than the health crisis which precipitates it. For these reasons, the article suggests that interpretive methodologies, derived from the social sciences and humanities, will be of particular use to the geriatrician in understanding health, illness and frailty from the perspective of the older person. These may be included in a toolkit with the purpose of identifying how biological and social factors jointly underpin the fluctuations of frailty and in designing interventions accordingly. Such an approach will bring clinical approaches closer to the views and experiences of older people who live with frailty, as well as to the holistic traditions of geriatric medicine itself.

A Longitudinal Study of Allostatic Load in Later Life: The Role of Sex, Birth Cohorts, and Risk Accumulation.

Are challenging life courses associated with more wear and tear on the biological level? This study investigates this question from a life-course perspective by examining the influence of life-course risk accumulation on allostatic load (AL), considering the role of sex and birth cohorts. Using biomarker data collected over three waves (2004, 2008, and 2012) of the English Longitudinal Study of Ageing ( N = 3,824) in a growth curve framework, AL trajectories over a period of 8 years are investigated. Our results illustrate that AL increases substantially in later life. Men have higher AL than women, but increases are similar for both sexes. Older cohorts have both higher levels and a steeper increase of AL over time. Higher risk accumulation over the life course goes hand in hand with higher AL levels and steeper trajectories, contributing to the body of evidence on cumulative (dis)advantage processes in later life.

Genome-wide scan of depressive symptomatology in two representative cohorts in the United States and the United Kingdom.

Unlike the diagnosed Major Depressive Disorder, depressive symptomatology in the general population has received less attention in genome-wide association scan (GWAS) studies. Here we report a GWAS study on depressive symptomatology using a discovery-replication design and the following approaches: To improve the robustness of the phenotypic measure, we used longitudinal data and calculated mean scores for at least 3 observations for each individual. To maximize replicability, we used nearly identical genotyping platforms and identically constructed phenotypic measures in both the Discovery and Replication samples. We report one genome-wide significant hit; rs58682566 in the EPG5 gene was associated (p = 3.25E-08) with the mean of the depression symptom in the Discovery sample, without confirmation in the Replication sample. We also report 4 hits exceeding the genome-wide suggestive significance level with nominal replications. Rs11774887, rs4147527 and rs1379328, close to the SAMD12 gene, were associated with the mean depression symptom score (P-values in Discovery sample: 4.58E-06, 7.65E-06 and 7.66E-06; Replication sample: 0.049, 0.029 and 0.030, respectively). Rs13250896, located in an intergenic region, was associated with the mean score of the three somatic items of the depression symptoms score (p = 3.31E-07 and 0.042 for the Discovery and Replication samples). These results were not supported by evidence in the literature. We conclude that despite the strengths of our approach, using robust phenotypic measures and samples that maximize replicability potential, this study does not provide compelling evidence of a single genetic variant's significant role in depressive symptomatology.

Does Pain Predict Frailty in Older Men and Women? Findings From the English Longitudinal Study of Ageing (ELSA).

Background: Pain has been suggested to act as a stressor during aging, potentially accelerating declines in health and functioning. Our objective was to examine the longitudinal association between self-reported pain and the development, or worsening, of frailty among older men and women. Methods: The study population consisted of 5,316 men and women living in private households in England, mean age 64.5 years, participating in the English Longitudinal Study of Ageing (ELSA). Data from Waves 2 and 6 of ELSA were used in this study with 8 years of follow-up. At Wave 2, participants were asked whether they were "often troubled with pain" and for those who reported yes, further information regarding the intensity of their pain (mild, moderate, or severe) was collected. Socioeconomic status (SES) was assessed using information about the current/most recent occupation and also net wealth. A frailty index (FI) was generated, with the presence of frailty defined as an FI >0.35. Among those without frailty at Wave 2, the association between pain at Wave 2 and frailty at Wave 6 was examined using logistic regression. We investigated whether pain predicted change in FI between Waves 2 and 6 using a negative binomial regression model. For both models adjustments were made for age, gender, lifestyle factors, depressive symptoms, and socioeconomic factors. Results: At Wave 2, 455 (19.7%) men and 856 (28.7%) women reported they often experienced moderate or severe pain. Of the 5,159 participants who were nonfrail at Wave 2, 328 (6.4%) were frail by Wave 6. The mean FI was 0.11 (standard deviation [SD] = 0.1) at Wave 2 and 0.15 (SD = 0.1) at Wave 6. After adjustment for age, gender, body mass index, lifestyle factors, and depressive symptoms, compared to participants reporting no pain at Wave 2 those reporting moderate (odds ratio [OR] = 3.08, 95% confidence interval [CI] = 2.28, 4.16) or severe pain (OR = 3.78, 95% CI = 2.51, 5.71) were significantly more likely to be frail at Wave 6. This association persisted after further adjustment for either occupational class and/or net wealth level. Compared to those without pain, those with mild, moderate, or severe pain were also more likely to develop worsening frailty, as assessed using the FI, and this association persisted after adjustment for SES. There was no evidence that the association between pain and frailty was influenced by gender. Conclusion: Pain is associated with an increased risk and intensity of frailty in older men and women. Socioeconomic factors contribute to the occurrence of frailty; though in our study do not explain the relationship between pain and frailty.

Life-history data.

Life-history data are quantitative, retrospective and autobiographical data collected through event-history calendars. By mimicking the structure of our memories, these instruments can gather reliable information on different dimensions of the lifecourse. Life-history data enable the duration, timing and ordering of events to be brought to the foreground of analysis. Extending the scope of lifecourse research, life-history data make it possible to examine the long-term effects of past policies with more precision and detail.

Life Course Pathways to Later Life Wellbeing: A Comparative Study of the Role of Socio-Economic Position in England and the U.S.

The influence of early life, accumulation and social mobility on wellbeing in later life in the U.S. and England is investigated. Using cross-sectional data from the Health and Retirement Study (HRS) and the English Longitudinal Study of Ageing (ELSA), we estimate multivariate regressions of hedonic and eudemonic measures of wellbeing on these life course mechanisms, controlling for age, gender, ethnic background, partnership status, health and wealth. On the level of the life course mechanisms, there is mixed evidence regarding the critical impact of early life, strong evidence for an association between accumulation and eudemonic wellbeing and a moderate negative effect of downward social mobility. While the relation between hedonic wellbeing and life course mechanisms is unclear or in a different direction than anticipated, eudemonic wellbeing is clearly related to accumulation and mobility in both countries and to early life in the U.S. On the societal level, the major observation is that the life course has a larger influence in the U.S. than in England.

Sexual Health and Positive Subjective Well-Being in Partnered Older Men and Women.

OBJECTIVES: We examine the associations between different patterns of sexual behavior and function and three indicators of subjective well-being (SWB) covering eudemonic, evaluative, and affective well-being in a representative sample of partnered older people. METHOD: Using data from a Sexual Relationships and Activities Questionnaire (SRA-Q) in Wave 6 of the English Longitudinal Study of Ageing, latent class analysis identified groups characterized by distinctive patterns of sexual behavior and function and then examined their link to SWB. Eudemonic SWB was measured using a revised 15-item version of the CASP-19, evaluative SWB using the Satisfaction With Life Scale, and affective SWB using the 8-item version of the Centre for Epidemiologic Studies-Depression scale. RESULTS: Sexual behavior and function was best described by six classes among men and five classes among women. These ranged from high sexual desire, frequent partnered sexual activities, and few sexual problems (Class 1) to low sexual desire, infrequent/no sexual activity, and problems with sexual function (Class 5([women])/6([men])). Men and women who reported either infrequent/no sexual activity, or were sexually active but reported sexual problems, generally had lower SWB than those individuals identified in Class 1. Poorer SWB in men was more strongly associated with sexual function difficulties, whereas in women desire and frequency of partnered activities appeared more important in relation to SWB. DISCUSSION: Within the context of a partnered relationship continuing sexual desire, activity and functioning are associated with higher SWB, with distinctive patterns for women and men.

Comparison of hypertension healthcare outcomes among older people in the USA and England.

BACKGROUND: The USA and England have very different health systems. Comparing hypertension care outcomes in each country enables an evaluation of the effectiveness of each system. METHOD: The English Longitudinal Study of Ageing and the Health and Retirement Survey are used to compare the prevalence of controlled, uncontrolled and undiagnosed hypertension within the hypertensive population (diagnosed or measured within the survey data used) aged 50 years and above in the USA and in England. RESULTS: Controlled hypertension is more prevalent within the hypertensive population in the USA (age 50-64: 0.53 (0.50 to 0.57) and age 65+: 0.51 (0.49 to 0.53)) than in England (age 50-64: 0.45 (0.42 to 0.48) and age 65+: 0.42 (0.40 to 0.45)). This difference is driven by lower undiagnosed hypertension in the USA (age 50-64: 0.18 (0.15-0.21) and age 65+: 0.13 (0.12 to 0.14)) relative to England (age 50-64: 0.26 (0.24 to 0.29) and age 65+: 0.22 (0.20 to 0.24)). The prevalence of uncontrolled hypertension within the hypertensive population is very similar in the USA (age 50-64: 0.29 (0.26 to 0.32) and age 65+: 0.36 (0.34 to 0.38)) and England (age 50-64: 0.29 (0.26 to 0.32) and age 65+: 0.36 (0.34 to 0.39)). Hypertension care outcomes are comparable across US insurance categories. In both countries, undiagnosed hypertension is positively correlated with wealth (ages 50-64). Uncontrolled hypertension declines with rising wealth in the USA. CONCLUSIONS: Different diagnostic practices are likely to drive the cross-country differences in undiagnosed hypertension. US government health systems perform at least as well as private healthcare and are more equitable in the distribution of care outcomes. Higher undiagnosed hypertension among the affluent may reflect less frequent medical contact.

Genetic variant of Interleukin-18 gene is associated with the Frailty Index in the English Longitudinal Study of Ageing.

BACKGROUND: The term frailty refers to a condition of increased vulnerability to stressors among older people, leading to a decline in homeostatic reserve. Frailty often leads to falls, hospitalisation and mortality, hence its importance for the delivery of health care to older adults. The pathophysiological mechanisms behind frailty are not well understood, but the decreased steroid-hormone production and elevated chronic systemic inflammation of older people appear to be major contributors. METHOD: We used a sample of 3,160 individuals aged 50 or older from the English Longitudinal Study of Ageing and assessed their frailty status according to a Frailty Index. We selected 620 single nucleotide polymorphisms in genes involved in the steroid hormone or inflammatory pathways. We performed linear association analysis. The outcome variable was the square root transformation of the Frailty Index, with age and sex entered as covariates. RESULTS: The strongest signal was detected in the pro-inflammatory Interleukin-18 gene (rs360722, P = 0.0021, ß = -0.015). Further significant signals were observed in the Interleukin-12 (rs4679868, P = 0.0062, ß = -0.008 and rs9852519, P = 0.0077, ß = -0.008), low density lipoprotein receptor-related protein 1 (rs1799986, P = 0.0065, ß = 0.011) and Selectin-P (rs6131, P = 0.0097, ß = -0.01) genes. None of these associations remain significant after Bonferroni correction. CONCLUSIONS: We show potential associations between genetic variants of four genes and the frailty index. These genes are involved in the cholesterol transport and inflammatory pathway and, as such, our results provide further support for the involvement of the immunological processes in frailty of the elderly.

Cohort differences in the levels and trajectories of frailty among older people in England.

BACKGROUND: The level of frailty in the older population across age cohorts and how this changes is a factor in determining future care costs and may also influence the extent of socioeconomic and gender inequalities in frailty. METHODS: We model cohort-specific trajectories in frailty among the community dwelling population older than 50 years, using five waves (2002-2010) of the English Longitudinal Study of Ageing. We stratify our analysis by wealth and gender and use a frailty index, based on accumulation of 'deficits'. RESULTS: For males and females between the ages of 50 and 70 in 2002, frailty trajectories for adjacent age cohorts converge. However, levels of frailty are higher in recent compared with earlier cohorts at the older ages (for cohorts aged over 70 in 2002). These cohort differences are largest in the poorest wealth group, while for the most affluent, frailty trajectories overlap across all adjacent cohorts suggesting no change across cohorts. CONCLUSIONS: A key driver of the cohort differences in frailty that we observe is likely to be increased survival of frail individuals. Importantly, this paper illustrates that the social conditions experienced across the wealth distribution impacts on the rate of deficit accumulation in older populations. Our results on trajectories of frailty between 2002 and 2010 are pessimistic and, in the context of rising life expectancies, suggest that poorer older people in particular spend additional years of life in a frail state.

The Multidimensional Structure of Subjective Well-Being In Later Life.

Subjective well-being can be measured in different ways, depending on the conceptual perspective one adopts. Hedonic well-being, emphasising emotions and evaluation, is often contrasted with eudemonic well-being, stressing self-actualisation and autonomy. In this paper we investigate the background, structure and compatibility of empirical measures of hedonic and eudemonic well-being in the English Longitudinal Study of Ageing (ELSA). We use a confirmatory factor approach to investigate the internal of structure of the General Health Questionnaire (GHQ), Centre for Epidemiological Studies Depression scale (CES-D), Satisfaction with Life scale (SWLS) and CASP, a measure of quality of life in old age. In a second step, we examine the higher order structure of well-being using these measures. Next to highlighting specific issues about the structure of these measures in connection to older populations, we illustrate that a threefold structure, distinguishing affective, cognitive and eudemonic aspects of well-being, is more informative than the two dimensional hedonic and eudemonic well-being that is often propagated.

Does the level of wealth inequality within an area influence the prevalence of depression amongst older people?

This paper considers whether the extent of inequality in house prices within neighbourhoods of England is associated with depressive symptoms in the older population using the English Longitudinal Study of Ageing. We consider two competing hypotheses: first, the wealth inequality hypothesis which proposes that neighbourhood inequality is harmful to health and, second, the mixed neighbourhood hypothesis which suggests that socially mixed neighbourhoods are beneficial for health outcomes. Our results are supportive of the mixed neighbourhood hypothesis, we find a significant association between neighbourhood inequality and depression with lower levels of depression amongst older people in neighbourhoods with greater house price inequality after controlling for individual socio-economic and area correlates of depression. The association between area inequality and depression is strongest for the poorest individuals, but also holds among the most affluent. Our results are in line with research that suggests there are social and health benefits associated with economically mixed communities.

Aging and subjective well-being in later life.

OBJECTIVES: This paper examines age-related changes in subjective well-being (SWB) in later life using multiple measures that cover eudemonic, evaluative, and affective dimensions of well-being. METHOD: Using data from 5 waves of respondents aged 50 and older from the English Longitudinal Study of Ageing (2002-11), we fit multilevel linear growth curve models to examine the cohort differences and individual aging effects on quality of life, depressive symptomatology, and life satisfaction. RESULTS: Older cohorts are shown to have equivalent or better SWB than younger cohorts for each well-being measure. Nonetheless, individual aging effects for each well-being measure were observed with deterioration in well-being being greatest in older cohorts, even when adjusting for age-related changes in later life, including widowhood, retirement, and declining health. DISCUSSION: The results suggest that although older cohorts enjoy higher levels of SWB than their younger counterparts when under similar circumstances, they experience sharper declines, especially in the very oldest cohorts. The findings demonstrate the importance of separating out cohort differences and aging effects and also of taking into account the multidimensionality of SWB to determine the point at which age deterioration begins to occur across different measures.