Life Space and Activity Space Measurement: Making 'Room' for Structural Racism.

As we age, the ability to move is foundational to health. Life space is one measure of a person's ability to move and engage in activity beyond the home. A separate but related concept is activity space, a measurement of a person's spatial behaviors and visited locations that include social networks, neighborhoods, and institutions. In this article, we integrate the literature on life space and activity space discussing how physical function is not only determined by individual capabilities, but also by the surrounding social and environmental factors which may limit their agency. We show how structural racism contributes to inequities within this paradigm linking related concepts of movement, agency, belonging, and timing. We also explore implications for research and theory for mobility, social connection, and activity.

Food insecurity gaps in the Supplemental Nutrition Assistance Program based on disability status.

BACKGROUND: Households including someone with disabilities experience disproportionately high food insecurity rates and likely face disproportionate barriers accessing Supplemental Nutrition Assistance Program (SNAP) benefits. OBJECTIVE: This article aims to examine the role of SNAP with regard to food insecurity disparities based on disability status. METHODS: Modified Poisson regression models examined food insecurity risk based on disability status (household includes no one with disabilities vs. those with work-limiting disabilities or non-work-limiting disabilities) among 2018 Survey of Income and Program Participation households eligible for SNAP (income ≤130% of the poverty threshold). Weighted estimates were used to account for the study design and non-response. RESULTS: Households including someone with work-limiting disabilities were more than twice as likely to be food insecure than households including no one with disabilities (PR = 2.16, 95% CI: 1.90, 2.45); households including someone with non-work-limiting disabilities were 65% more likely (PR = 1.65, 95% CI: 1.39, 1.95). However, disparities were more pronounced among households not participating in SNAP (PR = 2.67, 95% CI: 2.22, 3.23 for work-limiting disabilities and PR = 1.86, 95% CI: 1.44, 2.40 for non-work-limiting disabilities) than SNAP-participating households (PR = 1.71, 95% CI: 1.45, 2.03 and PR = 1.46, 95% CI: 1.17, 1.82, respectively). Approximately 4.2 million low-income U.S. households including someone with disabilities are food insecure. Of these, 1.4 million were not participating in SNAP and another 2.8 million households were food insecure despite participating in SNAP. CONCLUSIONS: Access to SNAP benefits is not proportionate to the scale of food insecurity among households that include people with disabilities. Action is needed to strengthen food assistance for those with disabilities.

Supplemental Nutrition Assistance Program Access and Racial Disparities in Food Insecurity.

Importance: Racially minoritized people experience disproportionately high rates of food insecurity. The Supplemental Nutrition Assistance Program (SNAP) reduces food insecurity. Objective: To evaluate SNAP access with regard to racial disparities in food insecurity. Design, Setting, and Participants: This cross-sectional study used data from the 2018 Survey of Income and Program Participation (SIPP). On the basis of random sampling strategies, 44 870 households were eligible for the SIPP, and 26 215 (58.4%) participated. Sampling weights accounted for survey design and nonresponse. Data were analyzed from February 25 to December 12, 2022. Exposures: This study examined disparities based on household racial composition (entirely Asian, entirely Black, entirely White, and multiple races or multirace based on SIPP categories). Main Outcomes and Measures: Food insecurity during the prior year was measured using the validated 6-item US Department of Agriculture Food Security Survey Module. SNAP participation during the prior year was classified based on whether anyone in the household received SNAP benefits. Modified Poisson regression tested hypothesized disparities in food insecurity. Results: A total of 4974 households that were eligible for SNAP (income ≤130% of the poverty threshold) were included in this study. A total of 218 households (5%) were entirely Asian, 1014 (22%) were entirely Black, 3313 (65%) were entirely White, and 429 (8%) were multiracial or of other racial groups. Adjusting for household characteristics, households that were entirely Black (prevalence rate [PR], 1.18; 95% CI, 1.04-1.33) or multiracial (PR, 1.25; 95% CI, 1.06-1.46) were more likely to be food insecure than entirely White households, but associations differed depending on SNAP participation. Among households that did not participate in SNAP, those that were entirely Black (PR, 1.52; 97.5% CI, 1.20-1.93) or multiracial (PR, 1.42; 97.5% CI, 1.04-1.94) were more likely to be food insecure than White households; however, among SNAP participants, Black households were less likely than White households to be food insecure (PR, 0.84; 97.5% CI, 0.71-0.99). Conclusions and Relevance: In this cross-sectional study, racial disparities in food insecurity were found among low-income households that do not participate in SNAP but not among those that do, suggesting that access to SNAP should be improved. These results also highlight the need to examine the structural and systemic racism in food systems and in access to food assistance that may contribute to disparities.

Food Insecurity and Cognitive Trajectories in Community-Dwelling Medicare Beneficiaries 65 Years and Older.

Importance: Food insecurity has a known association with prevalent impaired cognition. However, it is unknown whether food insecurity has a longitudinal association with cognitive decline among older adults. Objective: To determine whether food insecurity is associated with a faster decline in cognitive function among community-dwelling older adults. Design, Setting, and Participants: This retrospective cohort study used data from a nationally representative sample of Medicare beneficiaries 65 years and older recruited for the National Health and Aging Trends Study (NHATS). Community-dwelling NHATS participants were followed up for a maximum of 7 years (mean [SD] follow-up duration, 5.4 [1.1] years). Data were collected from January 1, 2012, to December 31, 2020, and analyzed from December 23, 2021, to December 6, 2022. Exposures: Self-reported food insecurity assessed from 2012 to 2019. Main Outcomes and Measures: Primary outcomes were immediate memory, delayed memory, and executive function collected from 2013 to 2020. Immediate and delayed recall were assessed by a 10-item word-list memory task (range, 0-10, with higher scores indicating more words recalled). Executive function was measured by the clock drawing test (range, 0-5, with higher scores indicating more accurate depiction of a clock). Each year's cognitive functions were linked to the prior year's food insecurity data. Linear mixed-effects models with random slopes and intercepts were used to examine the association between food insecurity and cognitive decline. Analytic weights in each year were applied to represent community-dwelling Medicare beneficiaries 65 years and older in 2011. Results: Of 3037 participants, a weighted 57.8% (raw count, 1345) were younger than 75 years, 56.2% (raw count, 1777) were women, and most (84.9% [raw count, 2268]) were White. Over 7 years, 417 (weighted proportion, 12.1%) experienced food insecurity at least once. Food insecurity was associated with a faster decline in executive function in a fully adjusted model: the mean difference of annual change in executive function score between people exposed to and not exposed to food insecurity was -0.04 (95% CI, -0.09 to -0.003) points. However, food insecurity was not associated with changes in immediate and delayed memory (0.01 [95% CI, -0.05 to 0.08] and -0.01 [95% CI, -0.08 to 0.06], respectively). Conclusions and Relevance: Among community-dwelling older adults, food insecurity was prevalent and associated with a decline in executive function. Interventions and policies aiming to increase healthy food access or reduce food insecurity should be assessed for their impact on older adults' cognitive outcome.

The relationship between older adults' technology use, in-person engagement, and pandemic-related mental health.

OBJECTIVE: The objectives of this study are to 1) describe changes in in-person communication/activity and changes in older adult technology use during the COVID-19 pandemic and 2) examine whether less in-person communication/activity mediates the relationship between pandemic-related mental health and technology use. METHOD: Linear regressions (stratified by age and financial strain) and structural equation modeling were employed using a nationally representative, cross-sectional survey of 3,188 older adults from the 2020 National Health and Aging Trends Study's COVID-19 Questionairre. RESULTS: Older adults engaged in more technology-based activity (b = 0.24; p<.001), more technology-based health care communication (b = 0.22; p<.001), and more technology-based food acquisition (b = 0.21; p<.001) during the COVID-19 pandemic, as compared to before the pandemic. Results indicate that adults <80 years old demonstrated greater increases in technology-based activity, technology-based health communication, and technology-based food acquisition, compared to adults ≥80 years old. Change in in-person communication significantly mediated the relationship between pandemic-related mental health and technology-based communication (standardized coefficient= -0.012; p=.005), and change in in-person activity significantly mediated the relationship between pandemic-related mental health and technology-based activity (standardized coefficient= -0.017; p=.020). CONCLUSIONS: This study suggests that older adults are utilizing technology more, and therefore should be considered in technology design and dissemination. Technology use could be an important positive response to help those with pandemic related worries stay safely engaged with friends and family. Technologies should be produced that are modifiable for older adults with disabilities and affordable for older adults with fixed incomes.

Social Norms About Handling Financial Challenges in Relation to Health-Protective Capacity Among Low-Income Older Adults.

BACKGROUND AND OBJECTIVES: Despite evidence linking financial challenges to poor health among older adults, effective interventions are lacking. This study examined the experience of living with financial challenges, useful strategies to handle them, and social norms that may constrain options and decision-making. RESEARCH DESIGN AND METHODS: This two-staged qualitative study recruited low-income older adults from the United States Baltimore City area. First, semistructured individual interviews examined older adults' experiences and strategies used to handle financial challenges. Then, vignette-based focus groups examined relevant social norms. Transcripts were coded, and hierarchical themes were described using thematic analysis. RESULTS: Two themes were generated. First, the social norms relevant to financial challenges share a common underlying assumption of personal responsibility. Second, social norms about personal responsibility are inconsistent with the experiences of older adults facing financial challenges, who typically lack control over their situation and face structural barriers to preventing and handling financial challenges. Differences between statements related to norms and personal responsibility were found across six subthemes, including how finances should be handled to prevent financial challenges, the causes of financial challenges, asking for help from community resources, navigating community resources, getting help from family, and cutting back to handle financial challenges. DISCUSSION AND IMPLICATIONS: The disconnect between social norms and the reality of financial challenges among older adults may explain why so many older adults cut back to the point of foregoing necessities. There is an urgent need to strengthen the social safety net and remove normative barriers to services.

Caregiving-Related Work Productivity Loss Among Employed Family and Other Unpaid Caregivers of Older Adults.

OBJECTIVES: Although nearly half of all family and unpaid caregivers to older adults work, little is known about short-term work impacts of caregiving using measures encompassing both missed work time and reduced productivity while physically at work. We quantify the prevalence, costs, and correlates of caregiving-related work productivity loss. METHODS: We used the 2015 National Study of Caregiving and National Health and Aging Trends Study to estimate caregiving-related work absences (absenteeism) and reduced productivity while at work (presenteeism). We calculated costs of lost productivity using hours lost, compensation, and a wage multiplier, accounting for the additional cost of replacing employee time. We examined correlates of caregiving-related absenteeism and presenteeism separately, using multivariable logistic regression models, adjusting for caregiver sociodemographic characteristics, occupation and hours worked, role overload, older adult health, use of respite care, support groups, flexible workplace schedules, help from family or friends, and caregiver training. RESULTS: Nearly 1 in 4 (23.3%) of the estimated 8.8 million employed family caregivers reported either absenteeism or presenteeism over a 1-month period owing to caregiving. Among those affected, caregiving reduced work productivity by one-third on average-or an estimated $5600 per employee when annualized across all employed caregivers-primarily because of reduced performance while present at work. Productivity loss was higher among caregivers of older adults with significant care needs and varied according to sociodemographic characteristics and caregiver supports. CONCLUSIONS: Findings emphasize the potential economic value of targeted policy intervention to support working caregivers.

The development of the Supplemental Nutrition Assistance Program enrollment accessibility (SNAP-access) score.

BACKGROUND: The Supplemental Nutrition Assistance Program (SNAP) is a federal public benefit providing food assistance to millions of Americans. However, it is typically administered by states, creating potential variation in accessibility and transparency of information about enrollment for people with disabilities. OBJECTIVE: To develop and demonstrate the use of a method to assess the accessibility and transparency of information about the disability-inclusive process and practices of SNAP enrollment. METHODS: Cross-sectional data was collected from SNAP landing and enrollment webpages from all 50 U.S. states, the District of Columbia, and New York City from June-August 2021. Based on principles of universal design and accessibility, scores were determined for each SNAP program across three areas: flexibility in the enrollment process (6 points), efficiency of finding information about enrollment on SNAP websites (6 points), and the accessibility of SNAP webpages (6 points). Total scores were the sum of these sub-categories (18 points maximum). RESULTS: Of the 52 SNAP programs assessed, mean scores were 10.66 (SD = 2.51) for the total score, 2.67 (SD = 0.91) for flexibility in the enrollment process, 3.32 (SD = 1.19) for efficiency of finding information about enrollment on SNAP websites, and 4.67 (SD = 1.72) for the accessibility of SNAP webpages. No programs received the maximum flexibility score (6 points) on flexibility, 2 programs received the maximum on efficiency, and 31 programs the maximum on accessibility. CONCLUSIONS: We found differences in the accessibility, flexibility, and efficiency of SNAP program enrollment information available on SNAP websites and outline room for improvement across all three of these areas.

Financial Contributions and Experiences of Non-Spousal, Employed Family Caregivers.

The economic impacts of caring for an older adult may be amplified for employed family and unpaid caregivers. We examine out-of-pocket spending among employed, retired, and unemployed caregivers. Among employed caregivers, we identify correlates of spending and assess whether spending and work productivity loss contribute to financial burden. Analyses use the 2015 National Health and Aging Trends Study (NHATS) and National Study of Caregiving. We find that employed caregivers incur more out-of-pocket spending on caregiving than retired and unemployed counterparts. Employed caregivers spending more than $500 out-of-pocket provide more hours of care and assist older adults with greater impairment. Among employed family caregivers, caregiver and care recipient Medicaid enrollment, spending, and work productivity loss are associated with financial burden. Findings suggest that caregiving exacerbates economic well-being among employed caregivers, particularly for those with socioeconomic vulnerability.

Propensity score weighted associations between financial strain and subsequent inflammatory biomarkers of aging among a representative sample of U.S. older adults.

BACKGROUND: Despite known socioeconomic disparities in aging-related outcomes, the underlying physiologic mechanisms are understudied. This study applied propensity score weighting to estimate the effect of financial strain on inflammation-related aging biomarkers among a national sample of older adults. METHODS: Financial strain severe enough to lack money for housing, utilities, medical/prescription bills or food was measured among 4,593 community-dwelling National Health and Aging Trends Study participants aged ≥ 65 years in 2016. Inverse probability propensity score weights were generated based on 2015 background characteristics, including age, gender, race/ethnicity, income to poverty ratio, education, occupation, home ownership, retirement, Sect. 8 housing, Medicaid, food/energy assistance, childhood health, marital status, and U.S. region. Sampling weights additionally accounted for study design and non-response. RESULTS: In propensity score-weighted analyses adjusting for age, gender, race/ethnicity, 2017 income to poverty ratio and education, those with 2016 financial strain had 15% higher IL-6 (p = 0.026) and 20% higher CRP levels (p = 0.002) in 2017 than those who were not strained, but did not differ with regard to hemoglobin A1c or CMV. In weighted comparisons, those with financial strain did not differ from those without with regard any 2015 background characteristics. CONCLUSIONS: These results strengthen the etiologic evidence suggesting that financial strain increases inflammatory biomarkers among older adults. Importantly, inflammation is likely a key physiologic pathway contributing to socioeconomic disparities. Therefore, research is needed to address financial strain.

The effect of COVID-19 pandemic-related financial challenges on mental health and well-being among US older adults.

BACKGROUND: Despite profound financial challenges during the COVID-19 pandemic, there is a gap in estimating their effects on mental health and well-being among older adults. METHODS: The National Health and Aging Trends Study is an ongoing nationally representative cohort study of US older adults. Outcomes included mental health related to COVID-19 (scores averaged across eight items ranging from one to four), sleep quality during COVID-19, loneliness during COVID-19, having time to yourself during COVID-19, and hopefulness during COVID-19. Exposures included income decline during COVID-19 and financial difficulty due to COVID-19. Propensity score weighting produced covariate balance for demographic, socioeconomic, household, health, and well-being characteristics that preceded the pandemic to estimate the average treatment effect. Sampling weights accounted for study design and non-response. RESULTS: In weighted and adjusted analyses (n = 3257), both income decline during COVID-19 and financial difficulty due to COVID-19 were associated with poorer mental health related to COVID-19 (b = -0.159, p < 0.001 and b = -0.381, p < 0.001, respectively), poorer quality sleep (OR = 0.63, 95% CI: 0.46, 0.86 and OR = 0.42, 95% CI: 0.30, 0.58, respectively), more loneliness (OR = 1.53, 95% CI: 1.16, 2.02 and OR = 2.72, 95% CI: 1.96, 3.77, respectively), and less time to yourself (OR = 0.54, 95% CI: 0.40, 0.72 and OR = 0.37, 95% CI: 0.27, 0.51, respectively) during COVID-19. CONCLUSIONS: Pandemic-related financial challenges are associated with worse mental health and well-being regardless of pre-pandemic characteristics, suggesting that they are distinct social determinants of health for older adults. Timely intervention is needed to support older adults experiencing pandemic-related financial challenges.

Exploring Challenges and Strategies in Partnering With Community-Based Organizations to Advance Intervention Development and Implementation With Older Adults.

Minoritized older adults face multiple health inequities and disparities, but are less likely to benefit from evidence-based health care interventions. With the increasing diversity of the U.S. aging population, there is a great promise for gerontology researchers to partner with racial/ethnic minority organizations and underrepresented communities to develop and implement evidence-based health interventions. Community-Based Participatory Research and Implementation Science offer guidance and strategies for researchers to develop and sustain community partnerships. However, researchers partnering with community organizations continue to face challenges in these collaborations, study outcomes, and sustainability. This may be especially true for those junior in their career trajectory or new to community-engaged research. The purpose of this forum article is to detail critical challenges that can affect gerontology researcher-community partnerships and relationships from the perspective of researchers. Seven challenges (pre- or mid-intervention design, implementation, and postimplementation phases) described within the Equity-focused Implementation Research for health programs framework are identified and discussed. Potential solutions are also presented. Planning for potential obstacles of the researcher-community partnerships can inform innovative solutions that will facilitate successful partnerships, thereby promoting the advancement of collaborative research between academic institutions and community organizations to improve older adult health outcomes.

Supplemental nutrition assistance program 2009 expansion and cardiometabolic markers among low-income adults.

A 2009 Supplemental Nutrition Assistance Program (SNAP) policy change that expanded eligibility and increased benefit amounts has been associated with reduced food insecurity. This study tests the hypothesis that the SNAP policy change corresponds with improved stress- and nutrition-sensitive cardiometabolic markers. This study included non-pregnant participants aged 18-59 with annual family incomes ≤185% of the federal poverty guideline from the repeated cross-sectional NHANES study. Those living in SNAP eligible households (income ≤130% of the poverty guideline) were compared to those who were likely non-eligible (income 131%-≤185%). Difference-in-differences analyses compared hemoglobin A1c (%), CRP (mg/dL), total cholesterol (mg/dL), LDL (mg/dL) and waist circumference (cm) across groups before (2007-2008) and after (2009-2010) the SNAP policy change. Sampling weights were applied. Adjusting for demographic, socioeconomic, household and health factors, there were statistically significant difference-in-differences estimates for hemoglobin A1c (p = 0.003, n = 3723) and total cholesterol (p = 0.028, n = 3710). SNAP eligible adults had no difference in hemoglobin A1c after the policy change and, among those less than 40 years of age, 5 mg/dL lower total cholesterol levels whereas likely non-SNAP eligible adults had 0.14% higher hemoglobin A1c and no difference in total cholesterol after the policy change. The 2009 SNAP expansion was associated with improved nutrition-sensitive cardiometabolic markers in SNAP-eligible adults. This study found less of an upward trend in hemoglobin A1c levels for young and middle aged adults and decreased total cholesterol for young adults. These results highlight the potential role of SNAP to prevent costly chronic conditions among low-income U.S. adults.

Community-dwelling older adults who are low-income and disabled weathering financial challenges.

Despite interventions aiming to improve outcomes among older adults experiencing financial challenges, the challenges and strategies employed to handle them are poorly understood. This study examined the experiences of financial challenges among low-income adults aged ≥65 years. Eleven semi-structured interviews were analyzed using thematic analyses. An overarching theme was "I guess it balances", capturing attempts to maintain hope and proactively address challenges despite stress, uncertainty and limitations. Balancing was demonstrated within four domains, including cognitive bandwidth ("think a lot" versus "I don't dwell on that"), emotional experience ("depressing" versus "be thankful"), learned resilience ("that was a shock" versus "there's always a way"), and meeting daily needs ("we learned to do without" versus "take a dollar and stretch it"). Participants described being weathered by challenges and using predominately high-effort coping strategies to weather the challenges. These findings call for strengthening the safety net for older adults facing financial challenges.

Residential Street Block Disorder and Biological Markers of Aging in Older Adults: The National Health and Aging Trends Study.

BACKGROUND: Residential environments are associated with older adults' health, but underlying physiologic causal mechanisms are not well understood. As adults age, street blocks are likely more relevant to their health than the larger neighborhood environment. This study examined the effects of adverse street block conditions on aging biomarkers among older adults. METHODS: We included community-dwelling Medicare beneficiaries aged 67 and older with 2017 biomarker data from the nationally representative National Health and Aging Trends Study (n = 4357). Street block disorder in 2016 was measured using interviewer report of any trash/glass/litter, graffiti, or vacant buildings on participants' blocks. Propensity score models were used to create balanced groups with regard to multiple 2015 participant characteristics, including demographic, socioeconomic, residence, and early-life characteristics. Linear regressions modeled street block disorder as a predictor of 4 aging biomarkers, hemoglobin A1C, high-sensitivity C-reactive protein, interleukin-6, and cytomegalovirus antibodies, before and after applying propensity score weighting. RESULTS: Adjusting for participant sociodemographic characteristics and applying propensity score weights, living on a block with any disorder was associated with 2% higher mean hemoglobin A1C levels (95% confidence interval [CI]: 0.002-0.03), 13% higher C-reactive protein (95% CI: 0.03-0.23), 10% higher interleukin-6 (95% CI: 0.02-0.19), and 19% more cytomegalovirus antibodies (95% CI: 0.09-0.29) compared to living on a block with no disorder. CONCLUSIONS: Street block disorder predicted subsequent aging biomarkers after applying a propensity score approach to account for confounding among a national sample of older adults. Targeting street-level residential contexts for intervention may reduce the risk for poor health in older adults.

Race, ethnicity, poverty and the social determinants of the coronavirus divide: U.S. county-level disparities and risk factors.

BACKGROUND: Communities with more Black or Hispanic residents have higher coronavirus rates than communities with more White residents, but relevant community characteristics are underexplored. The purpose of this study was to investigate poverty-, race- and ethnic-based disparities and associated economic, housing, transit, population health and health care characteristics. METHODS: Six-month cumulative coronavirus incidence and mortality were examined using adjusted negative binomial models among all U.S. counties (n = 3142). County-level independent variables included percentages in poverty and within racial/ethnic groups (Black, Hispanic, Native American, Asian), and rates of unemployment, lacking a high school diploma, housing cost burden, single parent households, limited English proficiency, diabetes, obesity, smoking, uninsured, preventable hospitalizations, primary care physicians, hospitals, ICU beds and households that were crowded, in multi-unit buildings or without a vehicle. RESULTS: Counties with higher percentages of Black (IRR = 1.03, 95% CI: 1.02-1.03) or Hispanic (IRR = 1.02, 95% CI: 1.01-1.03) residents had more coronavirus cases. Counties with higher percentages of Black (IRR = 1.02, 95% CI: 1.02-1.03) or Native American (IRR = 1.02, 95% CI: 1.01-1.04) residents had more deaths. Higher rates of lacking a high school diploma was associated with higher counts of cases (IRR = 1.03, 95% CI: 1.01-1.05) and deaths (IRR = 1.04, 95% CI: 1.01-1.07). Higher percentages of multi-unit households were associated with higher (IRR = 1.02, 95% CI: 1.01-1.04) and unemployment with lower (IRR = 0.96, 95% CI: 0.94-0.98) incidence. Higher percentages of individuals with limited English proficiency (IRR = 1.09, 95% CI: 1.04-1.14) and households without a vehicle (IRR = 1.04, 95% CI: 1.01-1.07) were associated with more deaths. CONCLUSIONS: These results document differential pandemic impact in counties with more residents who are Black, Hispanic or Native American, highlighting the roles of residential racial segregation and other forms of discrimination. Factors including economic opportunities, occupational risk, public transit and housing conditions should be addressed in pandemic-related public health strategies to mitigate disparities across counties for the current pandemic and future population health events.

Prevalence and Characteristics of Non-US-Born and US-Born Health Care Professionals, 2010-2018.

Importance: Immigration to the US results in greater racial/ethnic diversity. However, the contribution of immigration to the diversity of the US health care professional (HCP) work force and its contribution to health care are poorly documented. Objective: To examine the sociodemographic characteristics and workforce outcomes of non-US-born and US-born HCPs. Design, Setting, and Participants: This cross-sectional study used national US Census Bureau data on US-born and non-US-born HCPs from the American Community Survey between 2010 and 2018. Demographic characteristics and occupational data for physicians, advanced practice registered nurses, physician assistants, registered nurses, licensed practical nurses or licensed vocational nurses, and other HCPs were included for analysis. Data were analyzed between December 2020 and February 2021. Exposures: Nativity status, defined as US-born HCP vs non-US-born HCP (further stratified by <10 years or ≥10 years of stay in the US). Main Outcomes and Measures: Annual hours worked, proportion of work done at night, residence in medically underserved areas and populations, and work in skilled nursing/home health settings. Inverse probability weighting of 3 nativity status groups was carried out using logistic regression. F test statistics were used to test across-group differences. Data were weighted using American Community Survey sampling weights. Results: Of a total of 657 455 HCPs analyzed (497 180 [75.5%] women; mean [SD] age, 43.7 [13.0] years; 518 317 [75.6%] White, 54 233 [10.8%] Black, and 60 680 [9.6%] Asian), non-US-born HCPs (105 331 in total) represented 17.3% (95% CI, 17.2%-17.4%) of HCPs between 2010 and 2018. They were older (mean [SD] age, 44.7 [11.6] years) and had more education (75 227 [70.1%] HCPs completed college) compared with US-born HCPs (mean [SD] age, 43.4 [13.3] years; 304 601 [55.2%] completed college). Nearly half of non-US-born HCPs (47 735 [43.0%]) were Asian. In major metropolitan areas, non-US-born HCPs represented 40% or more of all HCPs. Compared with US-born HCPs, non-US-born HCPs with less than 10 years and 10 or more years of stay worked 32.3 hours (95% CI, 19.2 to 45.4 hours) and 71.6 hours (95% CI, 65.1 to 78.2 hours) more per year, respectively. Compared with US-born HCPs, non-US-born HCPs were more likely to reside in areas with shortages of health care professionals (estimated percentage: <10 years, 75.3%; ≥10 years, 62.8% vs US-born, 8.3%) and work in home health settings (estimated percentage: <10 years, 17.5%; ≥10 years, 13.1% vs US-born, 12.8%). Conclusions and Relevance: The contributions of non-US-born HCPs to US health care are substantial and vary by profession. Greater efforts should be made to streamline their immigration process and to harmonize training and licensure requirements.

Home and Neighborhood Context of Falls Among Black and White Older Americans.

Objectives: To examine social and physical environmental fall-risk factors in a nationally representative sample of community-living older adults overall and by racial group. Methods: We used data from the 2015 and 2016 rounds of the National Health and Aging Trends Study (n = 5581) linked to census tract measures from the American Community Survey. Recurrent falls are defined as 2+ self-reported falls over 12 months. Results: Older adults with recurrent falls were more likely to have lower education, lower income, financial hardship, live in homes with disorder and disrepair and in neighborhoods without sidewalks, with high social deprivation, and in nonmetropolitan counties. Home disrepair, lack of sidewalks, and residence in a nonmetropolitan county were important fall-risk factors among White older adults only. Financial hardship was an important risk factor among Black older adults. Discussion: Environmental factors are associated with recurrent falls among older Americans and should be incorporated into fall-risk profiles and prevention efforts.

Neighborhood Characteristics and Cardiovascular Biomarkers in Middle-Aged and Older Adults: the Baltimore Memory Study.

Neighborhood greenness has been linked to better cardiovascular health, but little is known about its association with biomarkers related to cardiovascular risk. Adverse neighborhood conditions, such as disorder and socioeconomic disadvantage, are associated with higher cardiovascular biomarker levels, but these relationships may differ in neighborhoods with more greenness. This study evaluated cross-sectional associations of validated measures of neighborhood greenness, disorder, and socioeconomic disadvantage with cardiovascular biomarkers in middle-aged and older adults living in Baltimore City. The sample included 500 adults, aged 57-79 years, enrolled in the Baltimore Memory Study and living in Baltimore City during 2009-2010. Multi-level log-gamma regressions examined associations between the three neighborhood characteristics and seven cardiovascular biomarkers. Models additionally evaluated the effect modification by neighborhood greenness on associations of neighborhood disorder and socioeconomic disadvantage with the biomarkers. Adjusting for covariates and neighborhood greenness, greater neighborhood disorder was associated with higher C-reactive protein (exp ß = 1.21, SE = 0.11, p = 0.035) and serum amyloid A (exp ß = 1.28, SE = 0.12, p = 0.008), while greater neighborhood socioeconomic disadvantage was associated with higher tumor necrosis factor alpha (exp ß = 1.24, SE = 0.12, p = 0.019). Higher neighborhood greenness was associated with lower soluble vascular cell adhesion molecule-1, accounting for disorder (exp ß = 0.70, SE = 0.10, p = 0.010) and socioeconomic disadvantage (exp ß = 0.73, SE = 0.10, p = 0.025). There was no evidence of effect modification among neighborhood characteristics. The findings suggest that neighborhood effects on cardiovascular health may be mediated through cardiovascular biomarker levels, and that socioeconomic disadvantage, disorder, and greenness may each be important features of neighborhoods.

Dissecting the Racial/Ethnic Disparity in Frailty in a Nationally Representative Cohort Study with Respect to Health, Income, and Measurement.

BACKGROUND: Racial/ethnic frailty prevalence disparities have been documented. Better elucidating how these operate may inform interventions to eliminate them. We aimed to determine whether physical frailty phenotype (PFP) prevalence disparities (i) are explained by health aspects, (ii) vary by income, or (iii) differ in degree across individual PFP criteria. METHODS: Data came from the 2011 National Health and Aging Trends Study baseline evaluation. The study sample (n = 7,439) included persons in all residential settings except nursing homes. Logistic regression was used to achieve aims (i)-(iii) listed above. In (i), health aspects considered were body mass index (BMI) status and number of chronic diseases. Analyses incorporated sampling weights and adjusted for sociodemographic factors. RESULTS: Comparisons are versus non-Hispanic whites: Non-Hispanic blacks (odds ratio [OR] = 1.46, 95% confidence interval [CI]: 1.21-1.76) and Hispanics (1.56, 1.20-2.03) continued to have higher odds of frailty after accounting for BMI status and number of chronic diseases. Non-Hispanic blacks had elevated odds of frailty in all income quartiles, including the highest (OR = 2.19, 1.24-3.397). Racial/ethnic disparities differed considerably across frailty criteria, ranging from a twofold increase in odds of slowness to a 25%-30% decrease in odds of self-reported exhaustion. CONCLUSIONS: BMI and disease burden do not explain racial/ethnic frailty disparities. Black-white disparities are not restricted to low-income groups. Racial/ethnic differences vary considerably by NHATS PFP criteria. Our findings support the need to better understand mechanisms underlying elevated frailty burden in older non-Hispanic black and Hispanic Americans, how phenotypic measures capture frailty in racial/ethnic subgroups and, potentially, how to create assessments more comparable by race/ethnicity.