An Intersectional Approach to Examining Breast Cancer Screening among Subpopulations of Black Women in the United States.

This study examines breast cancer screening behavior among subpopulations of Black women in the United States. Binary logistic regression was used to analyze breast cancer screening among a nationally-representative sample (n = 9,783) of Black women-US-born, non-US-born Caribbean, and non-US-born African-from the 2011-2017 National Health Interview Survey dataset. Non-US-born African Black women were less likely to have breast cancer screening, compared to US-born Black women. Among non-US-born Black women, non-US-born Caribbean Black women were more likely to have had breast cancer screening. Differential healthcare access associated with nativity differences among Black women can be informing their breast cancer screening behaviors. Efforts to improve breast cancer outcomes among Black women can benefit from interventions that account for differential access to healthcare and breast cancer screening behaviors among subgroups of Black women.

Less Is (Often) More: Number of Children and Health Among Older Adults in 24 Countries.

OBJECTIVES: Previous evidence about the impact of parenthood on health for older adults is mixed, perhaps due to variation in number of children and context. Higher numbers of children could lead to support or strain, depending on individual and country contexts. Yet, no studies currently exist that examine associations between the number of children and several health indicators among older adults across multiple global regions. METHODS: We analyze cross-sectional data (1992-2017) of 166,739 adults aged 50+ across 24 countries from the Health and Retirement Study family of surveys to document associations between the number of children, treated as a categorical variable, and 5 health outcomes (self-rated health, activities of daily living limitations, instrumental activities of daily living limitations, chronic conditions, and depression). We perform multivariable analyses by estimating logistic regression models for each country and each outcome. RESULTS: Multiple comparisons between categories of number of children revealed at least 1 significant difference in each country, and a majority of significant differences indicated those with more children had poorer health. The risk of poorer health for parents of multiple children was observed in 15 countries, but in some countries, fewer children predict poorer health. The greatest number of differences was identified for depression and chronic conditions, and very few for functional limitations. DISCUSSION: We observe a greater probability that more children are associated with poorer health in later life, especially for chronic conditions and depression. However, a universal global or regional pattern could not be identified. These findings raise new questions about how country contexts shape fertility and health.

Widowhood, social networks, and mental health among Chinese older adults: The moderating effects of gender.

Objectives: This study aimed to examine the three-way interaction between widowhood, social ties, and gender and its effects on older adults' mental health, including depressive symptoms and life satisfaction, in the context of China. Methods: Participants were 7,601 Chinese older adults. Their social network was divided between family and friendship ties, and their mental health was measured by depressive symptoms and life satisfaction. Linear regression was employed to analyze the associations between widowhood, social networks, and mental health, as well as to explore the moderating effect of gender. Results: Widowhood is associated with more depressive symptoms, but not with life satisfaction, while family and friendship ties are associated with less depressive symptoms and greater life satisfaction. Furthermore, the lack of family ties is associated with more depressive symptoms for widowed men compared to married older men, while it is associated with lower life satisfaction for widowed women compared to married older women. Conclusion: Family ties are the most important social support resource for Chinese older adults, especially for the widowed group. The vulnerability of older widowed men who lack family ties in China deserves public concern and attention.

End-of-Life Experiences Among "Kinless" Older Adults: A Nationwide Register-Based Study.

Background: The population of older adults who are unpartnered and childless (i.e., "kinless") is increasing across the globe, and may be at risk for lower quality end-of-life (EoL) experiences due to lack of family support, assistance, and advocacy. Yet, little research exists on the EoL experiences of "kinless" older adults. Objectives: To document associations between family structure (i.e., presence or absence of partner or child) and intensity of EoL experiences (i.e., visits to medicalized settings before death). Design: The study design is a cross-sectional population-based register study of the population of Denmark. Subjects: Participants include all adults age 60 years and older who died of natural causes in Denmark from 2009 to 2016 (n = 137,599 decedents). Results: "Kinless" older adults (reference = has partner, has child) were the least likely group to visit the hospital (two or more times; odds ratio [OR] = 0.74, confidence interval [CI] = 0.70-0.77), emergency department (one or more times; OR = 0.90, CI = 0.86-0.93), and intensive care unit (one or more times; OR = 0.71, CI = 0.67-0.75) before death. Conclusions: "Kinless" older adults in Denmark were less likely to experience medically intensive care at the EoL. Further research is needed to understand factors associated with this pattern to ensure that all individuals receive high quality EoL care regardless of their family structure and family tie availability.

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

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

Loneliness before and during the COVID-19 pandemic-are unpartnered and childless older adults at higher risk?

COVID-19 mitigation efforts had the potential to exacerbate loneliness among older adults, particularly for the unpartnered or childless, yet specific studies on loneliness among these groups during the COVID-19 pandemic are lacking. Using data from the Survey of Health, Ageing and Retirement in Europe (SHARE) collected before (October 2019-March 2020) and during the pandemic (June-August 2020), we examine two loneliness outcomes: (1) "have you felt lonely recently?" (both datasets) and (2) "have you felt lonelier than before the pandemic?" (2020), and examine differences by partnership and parenthood status. Before COVID-19, those who lacked one tie but had the other (unpartnered parents or partnered childless) were at highest loneliness risk. During COVID-19, unpartnered and childless-especially unpartnered-remain at higher risk for loneliness, entering loneliness, and not "exiting" loneliness. We discuss these findings in light of family norms and needs in pandemic and non-pandemic times and provide recommendations for future research. Supplementary Information: The online version contains supplementary material available at 10.1007/s10433-022-00718-x.

A national profile of kinlessness at the end of life among older adults: Findings from the Health and Retirement Study.

BACKGROUND/OBJECTIVES: The majority of end-of-life (EOL) caregiving is provided by unpaid family members. An increasing number of older adults are kinless (without close family/partnerships) and may have insufficient caregiver support to remain at home at the EOL. We therefore determined what proportion of older adults are kinless at the EOL and assessed the association of kinlessness with EOL care. DESIGN: Retrospective analysis of Health and Retirement Study decedents, 2002-2015. SETTING: US population-based sample. PARTICIPANTS: Decedents age 51+ who died within 1 year of interview (n = 3844) and subset who are community-dwelling at last interview. MEASUREMENTS: Kinlessness was defined as lacking a spouse/partner and children. Primary outcome measure was location of death. Secondary outcome measures included contextual EOL measures such as symptom burden and caregiver support. RESULTS: A total of 7.4% of decedents were kinless at the EOL. Kinless decedents were more likely to be female, nonwhite, enrolled in Medicaid, living alone, or living in a nursing home prior to death. Although community-dwelling kinless decedents received fewer hours of caregiving per week at the EOL (34.7 vs. 56.2, p < 0.05) and were more likely to die in nursing homes (18.1% vs. 10.3%, p < 0.05) than those with kin, they did not have higher EOL symptom burden or treatment intensity (e.g., intensive care unit use). In multinomial logistic analysis controlling for demographic and illness characteristics, kinless decedents living in the community before death had a twofold increased risk of dying in the nursing home (odds ratio [OR] = 2.02 [95% confidence interval (CI) = 1.09-3.72]) and a trend toward increased risk of hospital death (OR = 1.60 [95% CI = 0.96-2.69]) versus home setting. CONCLUSIONS: Kinless individuals are more likely to die in nursing homes, even if they are living in the community in their last year of life. Expanded long-term care services and policies are needed to enable all older adults regardless of their family support systems to receive high-quality EOL care.

Childlessness and Health Among Older Adults: Variation Across Five Outcomes and 20 Countries.

OBJECTIVES: No previous study to the best of our knowledge has examined the association between childlessness and health using a wide range of countries and health outcomes. This study improves previous literature by examining the relationship between "childlessness" (1 = childless for any reason, 0 = parent of biological, step, or adopted child) and health across 20 countries and five health outcomes. METHODS: Drawing on cross-sectional harmonized data from the family of Health and Retirement Surveys across the United States (HRS, Wave 11), Europe (SHARE, Waves 4 and 5), Mexico (MHAS, Wave 3), and China (CHARLS, Wave 2), we use logistic regression models to estimate the association between childlessness and poor health (poor self-rated health, 1 or more ADL limitations, 1 or more IADL limitations, 1 or more chronic conditions, and depression) in a sample of adults aged 50 and older across 20 countries (N = 109,648). RESULTS: Our results point to an absence of associations between childlessness and health, and suggest that childlessness may be associated with better (e.g., Mexico, Hungary) or worse health (e.g., Austria, Estonia, Netherlands, Poland) in certain contexts and for certain measures. DISCUSSION: We discuss these findings in light of the meaning of childlessness, as well as cross-national economic, social, and cultural contexts to provide suggestions for aging policy and future research.

Associations between prevalent multimorbidity combinations and prospective disability and self-rated health among older adults in Europe.

BACKGROUND: Multimorbidity is associated with greater likelihood of disability, health-related quality of life, and mortality, greater than the risk attributable to individual diseases. The objective of this study is to examine the association between unique multimorbidity combinations and prospective disability and poor self-rated health (SRH) in older adults in Europe. METHODS: We conducted a prospective analysis using data from the Survey of Health, Ageing and Retirement in Europe in 2013 and 2015. We used hierarchical models to compare respondents with multiple chronic conditions to healthy respondents and respondents reporting only one chronic condition and made within-group comparisons to examine the marginal contribution of specific chronic condition combinations. RESULTS: Less than 20% of the study population reported having zero chronic conditions, while 50% reported having at least two chronic conditions. We identified 380 unique disease combinations among people who reported having at least two chronic conditions. Over 35% of multimorbidity could be attributed to five specific multimorbidity combinations, and over 50% to ten specific combinations. Overall, multimorbidity combinations that included high depressive symptoms were associated with increased odds of reporting poor SRH, and increased rates of ADL-IADL disability. CONCLUSIONS: Multimorbidity groups that include high depressive symptoms may be more disabling than combinations that include only somatic conditions. These findings argue for a continued integration of both mental and somatic chronic conditions in the conceptualization of multimorbidity, with important implications for clinical practice and healthcare delivery.

Alternatives to Aging Alone?: "Kinlessness" and the Importance of Friends Across European Contexts.

OBJECTIVES: Increasing numbers of older adults cross-nationally are without children or partners in later life and therefore likely have greater reliance on nonkin (e.g., friends). This pattern may be particularly pronounced in country contexts that emphasize friendship. This article hypothesizes that those who lack kin (e.g., children, partners) and/or who live in countries with a stronger emphasis on friendship have more friends in their networks. Although these hypothesized patterns are consistent with interdisciplinary literatures, they have not been tested empirically and therefore remain overlooked in current "aging alone" narratives. METHOD: This study combines individual-level data from the Survey of Health, Ageing, and Retirement in Europe (Wave 6) with nation-level data from the European Values Survey to estimate multilevel negative binomial models exploring number of friends among those aged more than 50 years who lack kin across 17 countries. RESULTS: Older adults who lack kin or whose kin are unavailable report more friends in their networks, particularly in countries with a higher percentage of people who believe that friends are "very important" in life. DISCUSSION: This article challenges dominating assumptions about "aging alone" that rely heavily on lack of family as an indicator of "alone." Future studies of "kinlessness" should consider the extent to which friendship is correlated with lack of kin, particularly in more socioeconomically developed countries. Previous research on "aging alone" may have overestimated risk in more privileged countries that already emphasize friendship, but underestimated risk in family-centered countries where "kinlessness" and alternative sources of support are less common.

Spousal Characteristics and Older Adults' Hospice Use: Understanding Disparities in End-of-Life Care.

BACKGROUND: Hospice use has been shown to benefit quality of life for patients with terminal illness and their families, with further evidence of cost savings for Medicare and other payers. While disparities in hospice use by patient diagnosis, race, and region are well documented and attention to the role of family members in end-of-life decision-making is increasing, the influence of spousal characteristics on the decision to use hospice is unknown. OBJECTIVES: To determine the association between spousal characteristics and hospice use. DESIGN: We used data from the Health and Retirement Study (HRS), a prospective cohort study, linked to the Dartmouth Atlas of Health Care and Medicare claims. SETTING: National study of 1567 decedents who were married or partnered at the time of death (2000-2011). MEASURES: Hospice use at least 1 day in the last year of life as measured via Medicare claims data. Spousal factors (e.g., education and health status) measured via survey. RESULTS: In multivariate models controlling for patient factors and regional variation, spouses with lower educational attainment than their deceased spouse had decreased likelihood of hospice use (odds ratio [OR] = 0.58; 95% confidence interval [CI] = 0.40-0.82). Health of the spouse was not significantly associated with likelihood of decedent hospice use in adjusted models. IMPLICATIONS: Although the health of the surviving spouse was not associated with hospice use, their educational level was a predictor of hospice use. Spousal and family characteristics, including educational attainment, should be examined further in relation to disparities in hospice use. Efforts to increase access to high-quality end-of-life care for individuals with serious illness must also address the needs and concerns of caregivers and family.

Care Preferences Among Middle-Aged and Older Adults With Chronic Disease in Europe: Individual Health Care Needs and National Health Care Infrastructure.

PURPOSE OF THE STUDY: The purpose of this study is to expand knowledge of care options for aging populations cross-nationally by examining key individual-level and nation-level predictors of European middle-aged and older adults' preferences for care. DESIGN AND METHODS: Drawing on data from the Survey of Health, Ageing and Retirement in Europe and the Organisation for Economic Co-operation and Development, we analyze old age care preferences of a sample of 6,469 adults aged 50 and older with chronic disease in 14 nations. Using multilevel modeling, we analyze associations between individual-level health care needs and nation-level health care infrastructure and preference for family-based (vs. state-based) personal care. RESULTS: We find that middle-aged and older adults with chronic disease whose health limits their ability to perform paid work, who did not receive personal care from informal sources, and who live in nations with generous long-term care funding are less likely to prefer family-based care and more likely to prefer state-based care. IMPLICATIONS: We discuss these findings in light of financial risks in later life and the future role of specialized health support programs, such as long-term care.

Race/Ethnic Differentials in the Health Consequences of Caring for Grandchildren for Grandparents.

OBJECTIVES: The phenomenon of grandparents caring for grandchildren is disproportionately observed among different racial/ethnic groups in the United States. This study examines the influence of childcare provision on older adults' health trajectories in the United States with a particular focus on racial/ethnic differentials. METHOD: Analyzing nationally representative, longitudinal data on grandparents over the age of 50 from the Health and Retirement Study (1998-2010), we conduct growth curve analysis to examine the effect of living arrangements and caregiving intensity on older adults' health trajectories, measured by changing Frailty Index (FI) in race/ethnic subsamples. We use propensity score weighting to address the issue of potential nonrandom selection of grandparents into grandchild care. RESULTS: We find that some amount of caring for grandchildren is associated with a reduction of frailty for older adults, whereas coresidence with grandchildren results in health deterioration. For non-Hispanic black grandparents, living in a skipped generation household appears to be particularly detrimental to health. We also find that Hispanic grandparents fare better than non-Hispanic black grandparents despite a similar level of caregiving and rate of coresidence. Finally, financial and social resources assist in buffering some of the negative effects of coresidence on health (though this effect also differs by race/ethnicity). DISCUSSION: Our findings suggest that the health consequences of grandchild care are mixed across different racial/ethnic groups and are further shaped by individual characteristics as well as perhaps cultural context.

Racial disparities in urologist visits among elderly men with prostate cancer: a cohort analysis of patient-related and county of residence-related factors.

BACKGROUND: Factors contributing to the lower likelihood of urologist follow-up among African American (AA) men diagnosed with prostate cancer may not be strictly related to patient factors. The authors investigated the relationship between crime, poverty, and poor housing, among others, and postdiagnosis urologist visits among AA and white men. METHODS: The authors used linked cancer registry and Medicare claims data from 1999 through 2007 for men diagnosed with American Joint Committee on Cancer stage I to III prostate cancer. The USA Counties and County Business Patterns data sets provided county-level data. Variance components models reported the percentage of variation attributed to county of residence. Postdiagnosis urologist visits for AA and white men were investigated using logistic and modified Poisson regression models. RESULTS: A total of 65,635 patients were identified; 87% of whom were non-Hispanic white and 9.3% of whom were non-Hispanic AA. Approximately 16% of men diagnosed with stage I to III prostate cancer did not visit a urologist within 1 year after diagnosis (22% of AA men and 15% of white men). County of residence accounted for 10% of the variation in the visit outcome (13% for AA men and 10% for white men). AA men were more likely to live in counties ranked highest in terms of poverty, occupied housing units with no telephone, and crime. AA men were less likely to see a urologist (odds ratio, 0.65 [95% confidence interval, 0.6-0.71]; rate ratio, 0.94 [95% confidence interval, 0.92-0.95]). The sign and magnitude of the coefficients for the county-level measures differed across race-specific regression models of urologist visits. CONCLUSIONS: Among older men diagnosed with stage I to III prostate cancer, the social environment appears to contribute to some of the disparities in postdiagnosis urologist visits between AA and white men.

Family ties and health cross-nationally: the contextualizing role of familistic culture and public pension spending in Europe.

OBJECTIVES: Although previous research theorizes that cross-national variation in the relationship between family ties and health is due to nation-level differences in culture and policy/economics, no study has examined this theorization empirically. METHOD: Using data from the Survey of Health, Ageing, and Retirement in Europe (SHARE) and the Organization for Economic Co-operation and Development (OECD), this study uses multilevel modeling to analyze individual-, nation-, and cross-level effects for 30,291 older adults in 14 nations. RESULTS: Family ties to spouses/partners and parents are associated with better health, but ties to coresident children are associated with poorer health in certain contexts. Familistic culture and public pension spending have a weak but statistically significant moderating effect on the relationship between intergenerational family ties and health. DISCUSSION: This article underscores the complexity of family and highlights the need for continued theorization and measurement at the nation level to promote older adults' health in diverse contexts.

Psychological well-being of the institutionalized and community-residing oldest old in China: the role of children.

Studies have shown that institutionalized older adults have worse psychological health than their community-residing counterparts. However, much less is known about this association in developing countries such as China with a rapidly aging population and a short history of institutional care. This article investigates the role of children in differences in psychological well-being between institutionalized and community-residing oldest-old adults in China. Using national data from the 1998, 2000, and 2002 waves of the Chinese Longitudinal Healthy Longevity Survey, results show that the institutionalized have significantly better psychological health-measured by positive affect, loneliness, and quality of life-than those living in the community. Furthermore, we find that the associations are moderated by child-related factors (number of children, proximity, and visits) and strengthened for the three measures of psychological well-being after adjustments for socioeconomic factors, social support, health behaviors, and health status. The results underscore the importance of family dynamics for the psychological health of the institutionalized population in a historically family-care oriented society.

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

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

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

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

Intergenerational Ties in Context: Grandparents Caring for Grandchildren in China.

Guided by theories and empirical research on intergenerational relationships, we examine the phenomenon of grandparents caring for grandchildren in contemporary China. Using a longitudinal dataset (China Health and Nutrition Survey), we document a high level of structural and functional solidarity in grandparent-grandchildren relationships. Intergenerational solidarity is indicated by a high rate of coresidence between grandchildren and grandparents, a sizable number of skipped-generation households (no parent present), extensive childcare involvement by non-coresidential grandparents, and a large amount of care provided by coresidential grandparents. Multivariate analysis further suggests that grandparents' childcare load is adaptive to familial needs, as reflected by the characteristics of the household, household members, and work activities of the mothers.

The strength of strong ties for older rural adults: regional distinctions in the relationship between social interaction and subjective well-being.

Classic and contemporary sociological theories suggest that social interaction differs in rural and urban areas. Intimate, informal interactions (strong ties) are theorized to characterize rural areas while urban areas may possess more formal and rationalized interactions (weak ties). Aging and social support literature stresses social interaction as a predictor of health among the aged. Using data from Wave III of the Americans' Changing Lives (ACL) study, this study examines the hypothesized differences between informal strong ties and formal weak ties on the subjective well-being of older adults in rural, urban, and suburban areas. Visiting with friends, neighbors, or relatives has a stronger positive effect on subjective well-being for rural older adults than urban. These findings highlight that: a) informal strong ties increase subjective well-being; and b) the effect of informal strong ties differs by region. We discuss the potential of our findings for policy and urge continued attention to regional variation in aging studies.