Working Through It: Lifetime Experiences of Employment Discrimination Among Older Black Americans and Implications for Labor Force Participation, Job Dissatisfaction, and Mental Health in Older Adulthood.

OBJECTIVES: To examine lifetime experiences of employment discrimination and their association with Black older adults' employment status and well-being. METHODS: We use data from the Health and Retirement Study's leave-behind questionnaire to characterize lifetime experiences of being unfairly fired, not hired, or not promoted among Black older adults (N = 2948) and test associations with labor force status at age 62, job satisfaction among those working, and depressive symptoms. RESULTS: Employment discrimination was commonly reported by Black older adults, especially among men and those with college educations. Employment discrimination was not associated with employment status at age 62 but was associated with job dissatisfaction (OR = 2.00, p = .001) and depressive symptoms (Beta = 0.34, p < .001). DISCUSSION: Findings suggest a negative association between employment discrimination at any point in the life course and Black older adults' well-being. Employment discrimination is an obstacle to healthy aging, yet improved discrimination survey items are needed to fully capture its impact on Black Americans.

The Effects of Midlife Acute and Chronic Stressors on Black-White Differences in Cognitive Decline.

OBJECTIVES: Midlife stressors may be particularly consequential for cognitive performance and disparities in cognitive decline. This study examined Black-White differences in trajectories of cognition among middle-aged adults and the effects of acute and chronic stressors on these trajectories. METHODS: Data come from 4,011 cognitively healthy individuals aged 51-64 (620 Black and 3,391 White) who participated in the 2006-2018 waves of the Health and Retirement Study. Stressors included a count of recent life events and measures of financial strain and everyday discrimination. Global cognition was assessed using a modified version of the Telephone Interview for Cognitive Status. Linear mixed models with random slopes and intercepts assessed change in cognition over time. Race-by-time, race-by-stressor, time-by-stressor, and race-by-stressor-by-time interactions were assessed as were quadratic terms for time and each stressor. RESULTS: After adjusting for sociodemographic, health behaviors, and health-related factors, Black respondents had lower initial cognitive performance scores (b = -1.75, p < .001) but experienced earlier but slower decline in cognitive performance over time (Black × Time2 interaction: b = 0.02, p < .01). Financial strain, discrimination, and recent life events each had distinct associations with cognitive performance but did not influence racial differences in levels of or change in cognition over time. DISCUSSION: Middle-aged Black adults have lower initial cognition levels and experience earlier but less accelerated cognitive decline compared to White middle-aged adults. Midlife acute and chronic stressors influence baseline cognition but do so in different ways. Future research should examine the influence of other stressors on racial differences in cognitive decline at other points in the life course.

Differences in Social Determinants of Health Underlie Racial/Ethnic Disparities in Psychological Health and Well-Being: Study of 11,143 Older Adults.

OBJECTIVE: The authors sought to determine the impact of selected social determinants of health (SDoH) on psychological health and well-being (defined as depression, cognition, and self-rated health) among Black and Hispanic/Latinx adults relative to White adults 51-89 years of age. METHODS: Disparities in depressive symptomatology, cognition, and self-rated health were measured among 2,306 non-Hispanic/Latinx Black, 1,593 Hispanic/Latinx, and 7,244 non-Hispanic/Latinx White adults who participated in the Health and Retirement Study (N=11,143). Blinder-Oaxaca decomposition was used to examine whether differences in selected SDoH explained a larger share of the disparities than age, sex, measures of health, health behaviors, and health care utilization. Selected SDoH included education, parental education, number of years worked, marital status, veteran status, geographic residence, nativity status, income, and insurance coverage. RESULTS: Black and Hispanic/Latinx adults reported worse depressive symptomatology, cognition, and self-rated health than White adults. Selected SDoH were associated with a larger proportion of the Black-White disparities in depressive symptomatology (51%), cognition (39%), and self-rated health (37%) than were age, sex, measures of health, health behaviors, and health care utilization. SDoH were associated with a larger proportion of the Hispanic/Latinx-White disparity in cognition (76%) and self-rated health (75%), but age and physical health correlated with the disparity in depressive symptomatology (28%). Education, parental education, years worked, income, and insurance parity were SDoH associated with these disparities. CONCLUSIONS: Differences in SDoH underlie racial/ethnic disparities in depression, cognition, and self-rated health among older adults. Education, income, number of years worked, and insurance parity are key SDoH.

Impact of educational attainment on time to cognitive decline among marginalized older adults: Cohort study of 20,311 adults.

BACKGROUND: The effect of years of education on the maintenance of healthy cognitive functioning may differ by race and ethnicity given historical and ongoing inequities in educational quality. METHODS: We examined 20,311 Black, Latinx, and White adults aged 51-100 from the Health and Retirement Study (2008-2016). Telephone Interview for Cognitive Status-27 data was used to measure cognitive functioning. Generalized additive mixed models were stratified by race and ethnicity and educational attainment (≥12 vs. <12 years). Selected social determinants of health, all-cause mortality, time-varying health and healthcare utilization characteristics, and study wave were included as covariates. RESULTS: On average, Black and Latinx adults scored lower at baseline compared to White adults regardless of educational attainment (p < 0.001), with a significant overlap in the distributions of scores. The rate of cognitive decline was non-linear for Black, Latinx, and White adults (p < 0.001), and a period of stability was witnessed for those with higher educational attainment irrespective of race and ethnicity. Compared to Black, Latinx, and White adults with lower educational attainment, higher-educated White adults received the greatest protection from cognitive decline (13 years; 64 vs. 51), followed by Latinx (12 years; 67 vs. 55), and Black adults (10 years; 61 vs. 51). Latinx adults experienced cognitive decline beginning at a later age. CONCLUSIONS: The extent to which higher educational attainment protects adults from cognitive decline differs by race and ethnicity, such that higher-educated White adults received a greater benefit than higher-educated Black or Latinx adults.

Hope, Purpose, and Religiosity: The Impact of Psychosocial Resources on Trajectories of Depressive Symptoms Among Middle-Aged and Older Blacks.

Objective: We assessed the effects of hope, purpose in life, and religiosity on trajectories of depressive symptoms among middle-aged and older Blacks, with a focus on age differences in these associations. Methods: Data come from 1906 respondents from the 2006-2016 Health and Retirement Study. Linear mixed models were estimated and included interactions between age and time and between age and each psychosocial resource. Results: Depressive symptoms decreased for Blacks ages 51-64, did not change for those 65-74, and increased among Blacks age 75+. Hope and purpose in life were inversely associated with symptom levels but were not associated with change over time in symptomology. Associations were stronger among the youngest age group and weakest among the oldest. Religiosity was unrelated to depressive symptoms. Discussion: Psychosocial resources protect against depressive symptoms in age-dependent ways among middle-aged and older Blacks. Differences in these effects may be related to aging, cohort, and selection effects.

Stress is a Latent Construct: Exploring the Differential Experience of Stress and Discrimination on Depressive Symptoms Among Black Older Adults.

Objectives: While evidence highlights the detrimental mental health consequences of chronic stress exposure, the impact of this stress exposure on older Black Americans' mental health varies by exposure to other types of stressors like discrimination as well as subjective evaluations of stress like chronic stress appraisal. Methods: Using data from the 2010/2012 Health and Retirement Study, we use latent profile analysis (LPA) to describe 2,415 Black older adults experience with chronic stress exposure, appraisal, and discrimination and examine which stress contexts are associated with depressive symptomology. Results: Analyses revealed five stress clusters-demonstrating the diversity in the stress experience for older Black adults. Black older adults with stress profiles that include lower stress appraisal report fewer depressive symptoms regardless of number of stress exposures. Discussion: LPA is as an alternative approach to examining the stress-mental health link that can define stress profiles by both exposure and appraisal-based measures.

Effects of Stress Exposure Versus Appraisal on Episodic Memory Trajectories: Evidence for Risk and Resilience Among Black Older Adults.

OBJECTIVES: Chronic stressors, experienced disproportionately by Black older adults, are a risk factor for memory impairment. Racially patterned stress exposure may contribute to higher rates of Alzheimer's disease and related dementias (ADRD) among Black older adults compared with Whites, but less is known about the role of stress appraisal. This study examined whether chronic stress exposure mediates racial disparities in memory and whether stress appraisal moderates these associations. METHODS: Participants included 16,924 older adults (Mage = 67.39, 21% Black) from the 2010 and 2012 waves of the Health and Retirement Study who completed measures of chronic stress exposure (health, financial, housing, relationships, and caregiving) and appraisal. Latent growth curves modeled longitudinal performance on a word list memory task over 6 years. RESULTS: Black older adults reported greater stress exposure than Whites, and greater stress exposure partially mediated Black-White disparities in initial memory (standardized indirect effect = -0.002, p = .009). However, Black older adults appraised stressors as less upsetting than Whites. While stress appraisal did not moderate links between stress exposure and memory, appraising stressors as less upsetting was independently associated with better initial memory. Thus, Black-White disparities in initial memory was partially offset by Black participants' appraisal of stressors as less upsetting (standardized indirect effect = 0.002, p = .016). DISCUSSION: Reducing chronic stress exposure may reduce racial disparities in ADRD risk. The counteractive effect of stress appraisal on Black-White disparities in episodic memory highlights resilience factors among Black older adults that should be characterized in future research to move beyond deficit models of ADRD inequality.

Erratum to: The Importance of Air Quality Policy for Older Adults and Diverse Communities.

[This corrects the article DOI: 10.1093/ppar/praa036.].

Recommendations for Increasing Physician Provision of Pre-Exposure Prophylaxis: Implications for Medical Student Training.

There is growing evidence that pre-exposure prophylaxis (PrEP) prevents HIV acquisition. However, in the United States, approximately only 4% of people who could benefit from PrEP are currently receiving it, and it is estimated only 1 in 5 physicians has ever prescribed PrEP. We conducted a scoping review to gain an understanding of physician-identified barriers to PrEP provision. Four overarching barriers presented in the literature: Purview Paradox, Patient Financial Constraints, Risk Compensation, and Concern for ART Resistance. Considering the physician-identified barriers, we make recommendations for how physicians and students may work to increase PrEP knowledge and competence along each stage of the PrEP cascade. We recommend adopting HIV risk assessment as a standard of care, improving physician ability to identify PrEP candidates, improving physician interest and ability in encouraging PrEP uptake, and increasing utilization of continuous care management to ensure retention and adherence to PrEP.

Application of the Consolidated Framework for Implementation Research to Facilitate Delivery of Trauma-Informed HIV Care.

Background: The high prevalence of trauma and its negative impact on health among people living with HIV underscore the need for adopting trauma-informed care (TIC), an evidence-based approach to address trauma and its physical and mental sequelae. However, virtually nothing is known about factors internal and external to the clinical environment that might influence adoption of TIC in HIV primary care clinics. Methods: We conducted a pre-implementation assessment consisting of in-depth interviews with 23 providers, staff, and administrators at a large urban HIV care center serving an un-/under-insured population in the southern United States. We used the Consolidated Framework for Implementation Research (CFIR) to guide qualitative coding to ascertain factors related to TIC adoption. Results: Inner setting factors perceived as impacting TIC adoption within HIV primary care included relative priority, compatibility, available resources, access to knowledge and information (ie, training), and networks and communications. Relevant outer setting factors included patient needs/resources and cosmopolitanism (ie, connections to external organizations). Overall, the HIV care center exhibited high priority and compatibility for TIC adoption but displayed a need for system strengthening with regard to available resources, training, communications, cosmopolitanism, and patient needs/resources. Conclusions: Through identification of CFIR inner and outer setting factors that might influence adoption of TIC within an HIV primary care clinic, our findings begin to fill key knowledge gaps in understanding barriers and facilitators for adopting TIC in HIV primary care settings and highlight implementation strategies that could be employed to support successful TIC implementation.

The Effects of Perceived Stress and Cortisol Concentration on Antiretroviral Adherence When Mediated by Psychological Flexibility Among Southern Black Men Living with HIV.

This pilot study investigates the correlation between psychological stress and antiretroviral therapy (ART) adherence and plasma HIV RNA (viral load) as mediated by psychological flexibility among Black men in the south. Data were collected from 48 HIV-positive, low income Black men. Results indicate a strong positive correlation between perceived stress and psychological inflexibility (adjusted for age and income rs = 0.67; p < 0.001), a negative correlation between psychological inflexibility and ART adherence (adjusted rs = - 0.32; p = 0.03), a negative correlation between perceived stress and ART adherence (adjusted rs = - 0.45; p = 0.006), and a negative correlation between ART adherence and viral load (adjusted rs = - 0.37; p = 0.04). Our findings suggest stress decreases adherence to ART and viral suppression among Black men living with HIV. However, psychological flexibility did not mediate the relationship between stress and treatment adherence. Hair cortisol concentrations were high (mean of 34.2 pg/mg), but uncorrelated with adherence.

"What Doesn't Kill You, Makes You Stronger": Psychosocial Resources and the Mental Health of Black Older Adults.

A robust body of research has shown that Black Americans are less likely than Whites to have psychiatric disorders despite the social and economic disadvantage and systemic racism that they face. This mental health paradox has been demonstrated across all ages of the life course, including older adulthood. One of the prevailing explanations for the lower prevalence of psychiatric disorders among Blacks pertains to the influence of psychosocial resources on mental health. Psychosocial resources can directly or indirectly support mental health through physiological and psychological pathways. They can also mitigate the adverse effects of social stressors of discrimination and other stressors on psychological distress and mental illness. Black older adults may particularly benefit from psychosocial resources because they have had a lifetime of experiencing and overcoming adversity. Although this cycle of stress adaptation can wear away at the physical body, it may facilitate mental health resilience. In this chapter, we review research on the relationship between psychosocial resources and mental health. The chapter begins with a brief review of the Black-White mental health paradox and the mechanisms through which psychosocial resources operate to influence mental health. We then review research on intrapersonal, interpersonal, and community-level psychosocial resources that are particularly salient for Black Americans. Throughout the chapter we highlight research specifically focused on Black older adults and discuss the cultural relevance of each resource to their mental health and psychological functioning.

Black Older Adults in the Age of Biomarkers, Physical Functioning, and Genomics: Heterogeneity, Community Engagement, and Bioethics.

There are persistent disparities in all-cause mortality between Blacks and Whites in the United States. Black Americans also carry the greatest burden of morbidity from different diseases of aging including heart disease, stroke, hypertension, type 2 diabetes, and certain types of cancer. Health disparities research, and particularly race/ethnic comparison studies of physical health and aging, have consistently positioned Black health in frameworks of disadvantage, suggesting that regardless of the outcome, Black people are in worse states of health and well-being relative to Whites. Yet, extensive evidence suggests that there is significant within-group variability in the aging process among Black older adults. The use of biological, physical performance, and genomic data in survey settings offer new tools and insights to interrogate heterogeneity in Black health. This chapter examines indicators of biological, physical performance, and genetic markers of aging among a national sample of Black Americans ages 54+ years with the aim of addressing two questions about heterogeneity among Black older adults: (a) How do these measures vary by age and gender among Black older adults? (b) Which indicators predict health and mortality among Black older adults? The results indicate that biological, physical performance, and genomic measures of health, generally, have more variation than simple yes or no measures of a disease, condition, or diagnosis among Black older adults, providing counternarratives to the disadvantage frameworks that dominate characterizations of Black health and aging. However, bioethical challenges limit the utility of biomarkers, physical performance, and genomics measures for Black populations.

Measuring More Than Exposure: Does Stress Appraisal Matter for Black-White Differences in Anxiety and Depressive Symptoms Among Older Adults?

BACKGROUND AND OBJECTIVES: Prior research and theory suggest that exposure to objectively stressful events contributes to mental health disparities. Yet, blacks report higher cumulative stress exposure than whites but lower levels of common psychiatric disorders. In order to understand why blacks bear disproportionate stress exposure but similar or better mental health relative to whites, we need to consider race differences in not only stress exposure, but also stress appraisal-how upsetting stress exposures are perceived to be. RESEARCH DESIGN AND METHODS: We examine whether race differences in the number of reported chronic stressors across 5 domains (health, financial, residential, relationship, and caregiving) and their appraised stressfulness explain black-white differences in anxiety and depressive symptoms. Data come from 6019 adults aged older than 52 from the 2006 Health and Retirement Study. RESULTS: Older blacks in this sample experience greater exposure to chronic stressors but appraise stressors as less upsetting relative to whites. In fully adjusted models, stress exposure is related to higher levels of anxiety and depressive symptoms, and perceiving stress as upsetting is associated with higher symptomology for whites and blacks. We also find that blacks report greater anxiety symptoms but fewer depressive symptoms with more stress exposure relative to whites. Stress appraisal partially explains race differences in the association between stress exposure and anxiety symptoms and fully explains race differences in the association between exposure and depressive symptoms. DISCUSSION AND IMPLICATIONS: The relationship between race, chronic stress exposure, and mental health is mediated by stress appraisal. Stress appraisal provides insight on important pathways contributing to black-white mental health disparities in older adulthood.

When Is Hope Enough? Hopefulness, Discrimination and Racial/Ethnic Disparities in Allostatic Load.

Hopefulness is associated with better health and may be integral for stress adaptation and resilience. Limited research has prospectively examined whether hopefulness protects against physiological dysregulation or does so similarly for U.S. whites, blacks and Hispanics. We examined the association between baseline hopefulness and future allostatic load using data from the Health and Retirement Study (n = 8,486) and assessed differences in this association by race/ethnicity and experiences of discrimination. Four items measured hopefulness and allostatic load was a count of seven biomarkers for which a respondent's measured value was considered high-risk for disease. A dichotomous variable assessed whether respondents experienced at least one major act of discrimination in their lifetime. We used Poisson regression to examine the association between hopefulness and allostatic load and included a multiplicative interaction term to test racial/ethnic differences in this association. Subsequent analyses were stratified by race/ethnicity and tested the interaction between hopefulness and discrimination within each racial/ethnic group. Hopefulness was associated with lower allostatic load scores, but its effects varied significantly by race/ethnicity. Race-stratified analyses suggested that hopefulness was protective among whites and not associated with allostatic load among Hispanics irrespective of experiencing discrimination. Hopefulness was associated with lower allostatic load among blacks reporting discrimination but associated with higher allostatic load among those who did not. Findings suggest that hopefulness plays differing roles for older whites, blacks and Hispanics and, for blacks, its protective effects on physiological dysregulation are intricately tied to their experiences of discrimination.

Disentangling the Stress Process: Race/Ethnic Differences in the Exposure and Appraisal of Chronic Stressors Among Older Adults.

OBJECTIVES: Exposure to stressors is differentially distributed by race/ethnicity with minority groups reporting a higher stress burden than their white counterparts. However, to really understand the extent to which some groups bear a disproportionate stress burden, we need to consider race/ethnic differences in stress appraisal, specifically how upsetting stressors may be, in addition to stress exposure. We examine racial/ethnic differences in both the number of reported chronic stressors across five domains (health, financial, residential, relationship, and caregiving) and their appraised stressfulness among a diverse sample of older adults. METHOD: Data come from 6,567 adults ages 52+ from the 2006 Health and Retirement Study. RESULTS: Results show older blacks, U.S. and foreign-born Hispanics report more chronic stress exposure than whites and are two to three times as likely to experience financial strain and housing-related stress. Socioeconomic factors fully explain the Hispanic-white difference in stress exposure, but black-white differences remain. Despite experiencing a greater number of stressors, blacks and U.S.-born Hispanics are less likely to be upset by exposure to stressors than whites. U.S.-born Hispanics are less upset by relationship-based stressors specifically, while blacks are less upset across all stress domains in fully-adjusted models. Foreign-born Hispanics are only less upset by caregiving strain. DISCUSSION: The distinction between exposure and appraisal-based measures of stress may shed light on important pathways that differentially contribute to race/ethnic physical and mental health disparities.

Does Telomere Length Indicate Biological, Physical, and Cognitive Health Among Older Adults? Evidence from the Health and Retirement Study.

Telomere length (TL) has been suggested as a biomarker that can indicate individual variability in the rate of aging. Yet, it remains unclear whether TL is related to recognized indicators of health in an aging, older nationally representative sample. We examine whether TL is associated with 15 biological, physical, and cognitive markers of health among older adults ages 54+. TL was assayed from saliva using quantitative polymerase chain reaction (T/S ratio) in the 2008 Health and Retirement Study (n = 4,074). We estimated probability of high-risk levels across indictors of health by TL and age-singly and jointly. TL was associated with seven indicators of poor functioning: high-density lipoprotein and total cholesterol, cystatin C, pulse pressure, body mass index, lung function, and walking speed. However, after adjusting for age, associations were substantially attenuated; only associations with cholesterol and lung function remained significant. Additionally, findings show TL did not add to the predictive power of chronological age in predicting poor functioning. While TL may not be a useful clinical marker of functional aging in an older adult population, it may still play an important role in longitudinal studies in young and middle aged populations that attempt to understand aging.