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

BACKGROUND

The overall level of negative affect (NeA) has been linked to impaired health. However, whether the diurnal timing of NeA matters and whether the NeA-health relationship is mediated by sleep quality remain unclear.

METHODS

Using a longitudinal dataset (2006, 2009 and 2014 waves) consisting of 1959 participants, we examined the within-person impact of both bedtime NeA and non-bedtime NeA measured by Day Reconstruction Method (DRM) on subjective health measured by Visual Analogue Scale (VAS), and the mediating effect of sleep quality on the NeA-health relationships by fixed effect models.

RESULTS

Bedtime NeA predicted poorer health, while non-bedtime NeA was unrelated to health. The deleterious impact of bedtime NeA reduced and became non-significant after sleep quality was controlled for. Bedtime NeA also significantly predicted impaired sleep quality.

CONCLUSIONS

Bedtime NeA is a stronger predictor of poorer health than non-bedtime NeA, and the deleterious influence of bedtime NeA on health seems to operate through poor sleep quality. Therefore, interventions to reduce bedtime NeA could potentially improve subsequent sleep quality, thereby protecting people to some extent from impaired health status.

Could diabetes prevention programmes result in the widening of sociodemographic inequalities in type 2 diabetes? Comparison of survey and administrative data for England

BACKGROUND

The NHS Diabetes Prevention Programme (DPP) in England is a behavioural intervention for preventing type 2 diabetes mellitus (T2DM) among people with non-diabetic hyperglycaemia (NDH). How this programme affects inequalities by age, sex, limiting illnesses or disability, ethnicity or deprivation is not known.

METHODS

We used multinomial and binary logistic regression models to compare whether the population with NDH at different stages of the programme are representative of the population with NDH: stages include (1) prevalence of NDH (using survey data from UK Household Longitudinal Study (n=794) and Health Survey for England (n=1383)); (2) identification in primary care and offer of programme (using administrative data from the National Diabetes Audit (n=1 267 350)) and (3) programme participation (using programme provider records (n=98 024)).

RESULTS

Predicted probabilities drawn from the regressions with demographics as each outcome and dataset identifier as predictors showed that younger adults (aged under 40) (4% of the population with NDH (95% CI 2.4% to 6.5%)) and older adults (aged 80 and above) (12% (95% CI 9.5% to 14.2%)) were slightly under-represented among programme participants (2% (95% CI 1.8% to 2.2%) and 8% (95% CI 7.8% to 8.2%) of programme participants, respectively). People living in deprived areas were under-represented in eight sessions (14% (95% CI 13.7% to 14.4%) vs 20% (95% CI 16.4% to 23.6%) in the general population). Ethnic minorities were over-represented among offers (35% (95% CI 35.1% to 35.6%) vs 13% (95% CI 9.1% to 16.4%) in general population), though the proportion dropped at the programme completion stage (19% (95% CI 18.5% to 19.5%)).

CONCLUSION

The DPP has the potential to reduce ethnic inequalities, but may widen socioeconomic, age and limiting illness or disability-related inequalities in T2DM. While ethnic minority groups are over-represented at the identification and offer stages, efforts are required to support completion of the programme. Programme providers should target under-represented groups to ensure equitable access and narrow inequalities in T2DM.

No Substitute for In-Person Interaction: Changing Modes of Social Contact during the Coronavirus Pandemic and Effects on the Mental Health of Adults in the UK

Life-course theories on how social relationships affect mental health are limited in causal claims. The restrictions in social contact during the coronavirus pandemic provided a natural experiment that modified the frequency of in-person contact and allowed us to estimate the effect of changes in in-person social contact frequency on mental health in four large nationally representative age-cohorts of adults living in the UK. There was consistent evidence of a small but statistically significant effect of less frequent social contact on anxiety-depression. Online modes of social contact did not compensate for the restrictions in in-person social contact during the pandemic. Young adults who increased their online social media frequency during the pandemic experienced a deterioration in mental health. Life-course theories cannot ignore the importance of the mode of social contact for social relationships, especially during young adulthood.

Household wealth, neighbourhood deprivation and frailty amongst middle-aged and older adults in England: a longitudinal analysis over 15 years (2002-2017)

BACKGROUND

frailty is a condition of reduced function and health due to ageing processes and is associated with a higher risk of falls, hospitalisation, disability and mortality.

OBJECTIVE

to determine the relationship between household wealth and neighbourhood deprivation with frailty status, independently of demographic factors, educational attainment and health behaviours.

DESIGN

population-based cohort study.

SETTING

communities in England.

SUBJECTS

in total 17,438 adults aged 50+ from the English Longitudinal Study of Ageing.

METHODS

multilevel mixed-effects ordered logistic regression was used in this study. Frailty was measured using a frailty index. We defined small geographic areas (neighbourhoods) using English Lower layer Super Output Areas. Neighbourhood deprivation was measured by the English Index of Multiple Deprivation, grouped into quintiles. Health behaviours included in this study are smoking and frequency of alcohol consumption.

RESULTS

the proportion of respondents who were prefrail and frail were 33.8% [95% confidence interval (CI) 33.0-34.6%] and 11.7 (11.1-12.2)%, respectively. Participants in the lowest wealth quintile and living in the most deprived neighbourhood quintile had 1.3 (95% CI = 1.2-1.3) and 2.2 (95% CI = 2.1-2.4) times higher odds of being prefrail and frail, respectively, than the wealthiest participants living in the least deprived neighbourhoods Living in more deprived neighbourhood and poorer wealth was associated with an increased risk of becoming frail. Those inequalities did not change over time.

CONCLUSIONS

in this population-based sample, living in a deprived area or having low wealth was associated with frailty in middle-aged and older adults. This relationship was independent of the effects of individual demographic characteristics and health behaviours.

A prospective analysis examining frailty remission and the association with future falls risk in older adults in England

BACKGROUND

Previous research has shown older adults experience dynamic changes in frailty status. This study aimed to determine the occurrence of sustained frailty remission and how remission is associated with falls risk.

METHODS

Participants who contributed data to the analysis were in the English Longitudinal Study of Ageing from Waves 1 to 8 (2002-2017). Frailty was defined across waves using the frailty index and categorised into robust, pre-frail and frail. We classified participants who improved their frailty category from Wave 1 (2002) to Wave 2 (2004) and sustained/improved category again into Wave 3 (2006) and compared them with those who were either robust or frail across Waves 1-3. Cox proportional hazard modelling was used to determine the risk of incident falls reported at Waves 4-8, with results expressed as hazard ratios and 95% confidence intervals.

RESULTS

Of 2,564 participants, 389 (15·2%) improved frailty category and sustained this during Waves 2-3, 1,489 (58·1%) remained robust and 686 (26·8%) remained frail during Waves 1-3. During the 10-year period (Waves 4-8), a total of 549 participants reported a fall. Compared with those who remained frail during Waves 1-3, those who with sustained frailty remission had a lower risk of future falls (HR 0·41; 95% CI = 0·36-0·45).

CONCLUSIONS

Frailty remission is possible and can be sustained across 5 years. There is a lower risk of future falls in those who sustain frailty remission compared with those who remain frail.

Prediction of bullying at work: A data-driven analysis of the Finnish public sector cohort study

AIM

To determine the extent to which change in (i.e., start and end of) workplace bullying can be predicted by employee responses to standard workplace surveys.

METHODS

Responses to an 87-item survey from 48,537 Finnish public sector employees at T1 (2017-2018) and T2 (2019-2020) were analyzed with least-absolute-shrinkage-and-selection-operator (LASSO) regression. The predictors were modelled both at the individual- and the work unit level. Outcomes included both the start and the end of bullying. Predictive performance was evaluated with C-indices and density plots.

RESULTS

The model with best predictive ability predicted the start of bullying with individual-level predictors, had a C-index of 0.68 and included 25 variables, of which 6 remained in a more parsimonious model: discrimination at work unit, unreasonably high workload, threat that some work tasks will be terminated, working in a work unit where everyone did not feel they are understood and accepted, having a supervisor who was not highly trusted, and a shorter time in current position. Other models performed even worse, either from the point of view of predictive performance, or practical useability.

DISCUSSION

While many bivariate associations between socioeconomic characteristics, work characteristics, leadership, team climate, and job satisfaction were observed, reliable individualized detection of individuals at risk of becoming bullied at workplace was not successful. The predictive performance of the developed risk scores was suboptimal, and we do not recommend their use as an individual-level risk prediction tool. However, they might be useful tool to inform decision-making when planning the contents of interventions to prevent bullying at an organizational level.

Diabetes Prevention Programme and socioeconomic inequalities in Type 2 Diabetes in England

 

The National Diabetes Prevention Programme (DPP) in England is a behavioural intervention for preventing Type 2 Diabetes Mellitus (T2DM) among people with non-diabetic hyperglycaemia (NDH, HbA1c 42-47 mmol/mol or 6.0-6.4%). How this programme affects inequalities by age, gender, disability, ethnicity, or deprivation is not known. We used multinomial logistic regression models to compare population characteristics at three stages along the prevention programme pathway: prevalence of NDH [using survey data from UK Household Longitudinal Study (N = 794) and Health Survey for England (N = 1,383)]; identification in primary care and offer of the programme [using administrative data from the National Diabetes Audit (N = 1,267,350)]; and programme participation [using programme provider records (N = 98,024)]). Younger adults (aged under 40) [4% of the NDH population (95% CIs 2%-6%)] and older adults (aged 80 and above) [12% (95%CIs 10%-14%] were both underrepresented amongst DPP participants [2% of DPP participants (95%CIs 1.8%-2.2%) and 8% (95%CIs 7.7%-8.3%) respectively]. People with disabilities were underrepresented in the DPP [15% (95%CIs 14.9%-15.1%) vs 60% (95%CIs 58%-62%)] compared to the general population. People living in more deprived areas were under-represented [14% (95% CIs 13.7%-14.3%) vs 20% (95%CIs 16%-24%) in the general population]. Ethnic minorities were overrepresented [36% (95%CIs 35.8%-36.2%) vs 13% (95%CIs 9%-17%) in the general population] among DPP referrals, though the proportion dropped at programme completion stage [19% (95%CI 18.5%-19.5%)]. The DPP has the potential to reduce ethnic inequalities but may widen socioeconomic, age, and disability-related inequalities in T2DM. Whilst ethnic minority groups are overrepresented at identification and offer stage, efforts are required to support the completion of the programme. Programme providers should target underrepresented groups to ensure equitable access and narrow inequalities in T2DM.

Key messages

• The DPP intervention may result in a widening of socioeconomic and disability related inequalities amongst people with NDH as the programme had fewer adults in deprived areas and with a disability.

• The programme has the potential to reduce ethnic inequalities, but efforts are required to support the completion of the programme by minority ethnic groups.

The mental health impact of COVID-19 and lockdown-related stressors among adults in the UK

BACKGROUND

The COVID-19 pandemic in the UK and subsequent lockdown may have affected the mental health of the population. This study examines whether there was an increase in the prevalence and incidence of common mental disorders (CMD) in the UK adult population during the first months of lockdown and whether changes in CMD were associated with stressors related to the pandemic and lockdown.

METHODS

Longitudinal data from the UK Household Longitudinal Study waves 10-11: 2019-2020 and waves 1-4 of the COVID-19 monthly surveys in April (n = 17 761) to July 2020 (n = 13 754), a representative sample of UK adult population, were analysed. CMD was measured using the 12-item General Health Questionnaire (GHQ-12) (cut-off >2). Changes in CMD were analysed in relation to COVID-19 and social stressors.

RESULTS

Around 29% of adults without CMD less than a year earlier had a CMD in April 2020. However, by July 2020, monthly incidence of CMD had reduced to 9%. Most employment, financial and psychological 'shocks' were at their highest levels in April and reduced steadily in later months. Despite the lifting of some lockdown conditions by July, stressors related to loneliness, unemployment, financial problems and domestic work continued to influence CMD.

CONCLUSION

Some COVID-19 policy responses such as furloughing may have been effective in mitigating the increase in CMD for some groups of employees. Despite some reduction in levels of pandemic and lockdown-related stressors by the middle of 2020, loneliness and financial stressors remained key determinants of incidence in CMD among the UK adult population.

Understanding the longitudinal dynamics of rural-urban mental health disparities in later life in China

OBJECTIVES

Understanding longitudinal patterns of rural-urban mental health disparities is vital for effective intervention and policy development in China. However, few studies have estimated separate effects of birth-cohort and ageing and examined the role of community resources on health inequalities.

METHODS

Drawing data from the China Health and Retirement Longitudinal Study (2011-2018), this study employed multilevel modelling to identify the mental health trajectories of rural, peri-urban, urban older adults by cohort and the community effects.

RESULTS

The changes in the mental health gap between rural, peri-urban and urban older adults over time varied by birth cohorts. Among younger cohorts aged under 65, the mental health disparities between rural, peri-urban and urban residents increased as they got older. Underdeveloped community infrastructure greatly explained the rural health disadvantage.

CONCLUSION

The study indicates increasing rural-urban health disparities at the onset of later life. Improving community infrastructure in rural and peri-urban areas is vital to minimise rural-urban health gaps.

Home modifications and disability outcomes: A longitudinal study of older adults living in England

Background

There is limited evidence on the protective effect of housing modifications on disability outcomes among older adults. We examined whether external and internal housing modifications reduce the risk of a range of disability outcomes among older adults living in England.

Methods

We analysed adults aged 60 and over from the English Longitudinal Study of Ageing, initially recruited in 2002/03. The longitudinal sample consisted of 32,126 repeated observations from 10,459 individuals across 6 waves with an average follow-up of 11·3 years. Participants were asked if their homes had external (widened doorways, ramps, automatic doors, parking and lift) and internal (rails, bathroom/kitchen modifications, chair lift) housing modifications. Mobility impairment was measured through reported difficulties in 10 activities including walking, climbing, getting up, reaching and lifting. Five disability outcomes were analysed (falls in the previous two years, pain, poor self-rated health, no social activities, and moving home within next two years) using two-way fixed effect models, controlling for key risk factors for disability.

Findings

Greater mobility impairments increased the probability of falls, pain and poor self-rated health although this effect was significantly moderated by external housing modifications. Among older adults with severe mobility impairments, external housing modifications reduced the probability of falls by 3% (1%-6%), pain by 6% (4%-8%), and poor health by 4% (2%-5%). Moreover, external housing modifications reduced the probability of no social activities by 6% (5%-7%) and moving home by 4% (2%-5%) even among those without any mobility impairments. Internal housing modifications had similar, but less consistent effects on the disability outcomes.

Interpretation

There was strong evidence that external housing modifications protected against a range of disability outcomes. Studies on reducing disability in ageing populations need to consider the role of housing modifications as key interventions to promote healthy ageing in place.

Funding

Economic and Social Research Council ES/R008930/1 and ES/S012567/1

The validity of the residuals approach to measuring resilience to adverse childhood experiences

BACKGROUND

Resilience is broadly defined as the ability to maintain or regain functioning in the face of adversity. Recent work to harmonise the quantification and definition of resilience quantifies resilience as the residual variance in psychosocial functioning that remains after accounting for adversity exposure. However, there have been no published studies that have formally investigated the validity of this approach. Considering this, we examine the construct and predictive validity of the residuals approach using participants from the Avon Longitudinal Study of Parents and Children (ALSPAC), a multigenerational, longitudinal cohort study.

METHODS

We regressed exposures of adolescent adversity on adolescent psychopathology scores using the Strength and Difficulties Questionnaire and obtained the residual variance. We investigated construct validity by analysing whether previously identified demographic and resilience factors significantly predicted resilience. Predictive validity of resilience was investigated by comparing the predictive power of resilience with other determinants of psychosocial functioning on two developmental outcomes: depressive symptoms at 18 years, measured by the Short Moods and Feelings Questionnaire, and NEET (Not in Employment, Education or Training) status at 17 and 23 years. The associations between depressive symptoms at 18, resilience, ACEs and covariates were tested using multiple linear regression. NEET status at 17 and 23 were run as separate binary multiple logistic regression models to test associations with resilience and known demographics previously associated with NEET status.

RESULTS

Seven previously identified protective factors, including self-esteem, positive sibling relationship, temperament, and positive perception of school, significantly predicted resilience to adolescent psychopathology, thus providing strong construct validity. Resilience significantly predicted a reduction in depressive symptoms at 18 years, and significantly decreased the likelihood of having NEET status at both 17 years and 23 years, even after taking into account early childhood adversity and other risk factors. None of the socioeconomic factors were significantly associated with resilience.

CONCLUSIONS

Our study demonstrates that the residuals method of operationalising resilience has good construct and predictive validity yet recommend replication studies. It has the potential to advance research into the mechanisms and modifiability of resilience.

TRIAL REGISTRATION

Not applicable.

Biological costs and benefits of social relationships for men and women in adulthood: The role of partner, family and friends

Despite numerous studies on social relationships and health, the empirical focus has often been on middle-aged or older adults, even though young adulthood is a period of considerable change in social networks. We investigated whether the associations between social relationships and allostatic load, a multisystem physiological dysregulation index that reflects chronic stress responses, vary by type of relationship and stages of the lifecourse. Relationships with spouse/partner, immediate family and friends were assessed in terms of emotional support and social strain. Poisson regression models on multiple imputed data sets from waves 2-3 (2010-2012) of the UK Household Longitudinal Study (N = 10,380) were estimated. Social strain, particularly from partners and immediate family, appeared to elicit greater stress related dysregulation during early adulthood (age 21-34 years), corresponding to a predicted difference in the allostatic load index (range 0-12) between high and low strained relationships of 1.1 (95% CI: 0.5-1.6) among young women and 0.6 (95% CI: -0.04 to 1.2) among young men. There was little evidence of an association between allostatic load and any of the social relationships among older men and women. Models of social relationships over the lifecourse need to take account of how stressful social relationships become biologically embedded in early adulthood.

Genetic Variants Associated With Resilience in Human and Animal Studies

Resilience is broadly defined as the ability to maintain or regain functioning in the face of adversity and is influenced by both environmental and genetic factors. The identification of specific genetic factors and their biological pathways underpinning resilient functioning can help in the identification of common key factors, but heterogeneities in the operationalisation of resilience have hampered advances. We conducted a systematic review of genetic variants associated with resilience to enable the identification of general resilience mechanisms. We adopted broad inclusion criteria for the definition of resilience to capture both human and animal model studies, which use a wide range of resilience definitions and measure very different outcomes. Analyzing 158 studies, we found 71 candidate genes associated with resilience. OPRM1 (Opioid receptor mu 1), NPY (neuropeptide Y), CACNA1C (calcium voltage-gated channel subunit alpha1 C), DCC (deleted in colorectal carcinoma), and FKBP5 (FKBP prolyl isomerase 5) had both animal and human variants associated with resilience, supporting the idea of shared biological pathways. Further, for OPRM1, OXTR (oxytocin receptor), CRHR1 (corticotropin-releasing hormone receptor 1), COMT (catechol-O-methyltransferase), BDNF (brain-derived neurotrophic factor), APOE (apolipoprotein E), and SLC6A4 (solute carrier family 6 member 4), the same allele was associated with resilience across divergent resilience definitions, which suggests these genes may therefore provide a starting point for further research examining commonality in resilience pathways.

Adverse employment histories and allostatic load: associations over the working life

Background

Most studies on the health impact of occupational stress use single-point measures of stress at work. This study analyses the associations of properties of entire employment trajectories over an extended time period with a composite score of allostatic load (AL).

Methods

Data come from the French CONSTANCES cohort, with information on adverse employment histories between ages 25 and 45 and a composite score of AL (based on 10 biomarkers, range 0–10) among people aged 45 or older (47 680 women and 45 035 men). Data were collected by questionnaires (including retrospective employment histories) or by health examinations (including blood-based biomarkers). We distinguish six career characteristics: number of temporary jobs, number of job changes, number of unemployment periods, years out of work, mode occupational position and lack of job promotion.

Results

For both men and women, results of negative binomial regressions indicate that adverse employment histories are related to higher levels of AL, particularly histories that are characterised by a continued disadvantaged occupational position, repeated periods of unemployment or years out of work. Findings are adjusted for partnership, age and education, and respondents with a health-related career interruption or early retirement are excluded.

Conclusions

Our study highlights physiological responses as a mechanism through which chronic stress during working life is linked to poor health and calls for intervention efforts among more disadvantaged groups at early stages of labour market participation.

The Role of Facets of Job Satisfaction in the National and Socioeconomic Differences in Overall Job Satisfaction: A Comparison Between Studies of Civil Servants in Great Britain and Japan

OBJECTIVE

To explore national and socioeconomic differences in overall job satisfaction, we examined whether those differences can be explained by what job-related factors.

METHODS

Our datasets for this study are from the Whitehall II study and the Japan Civil Servant Study. Of the participants who were 5540 cases, with 3250 people from Great Britain and 2290 from Japan.

RESULTS

The odds ratio for job dissatisfaction was more than double in Japan compared with Britain. However, after adjusting the related factors-especially the facets of job satisfaction variables-the difference was reversed. Also, regarding the occupational differences, lower occupational grades had lower risks of overall job dissatisfaction, after adjusting for related factors.

CONCLUSIONS

The national and socioeconomic differences in overall job satisfaction were strongly related to facets of job satisfaction rather than job stress factors.

Psychotropic medication before and after disability retirement by pre-retirement perceived work-related stress

BACKGROUND

Retirement has been associated with improved mental health, but it is unclear how much this is due to the removal of work-related stressors. We examined rates of psychotropic medication use before and after the transition to disability retirement due to mental, musculoskeletal and other causes by pre-retirement levels of perceived work stress (effort-reward imbalance, ERI).

METHODS

Register-based date and diagnosis of disability retirement of 2766 participants of the Finnish Public Sector study cohort were linked to survey data on ERI, social- and health-related covariates, and to national records on prescribed reimbursed psychotropic medication, measured as defined daily doses (DDDs). Follow-up for DDDs was 2-5 years before and after disability retirement. We assessed differences in the levels of DDDs before and after retirement among those with high vs. low level of pre-retirement ERI with repeated measures regression.

RESULTS

Those with high (vs. low) levels of ERI used slightly more psychotropic medication before disability retirement due to mental disorders [rate ratio (RR) 1.14, 95% confidence intervals (CI) 0.94-1.37], but after retirement this difference attenuated (RR 0.94, 95% CI 0.80-1.10, P for interaction 0.02). Such a change was not observed for the other causes of disability retirement.

CONCLUSIONS

The level of psychotropic medication use over the transition to disability retirement due to mental, but not musculoskeletal or other, causes was modified by pre-retirement perceived work-related stress. This suggests that among people retiring due to mental disorders those who had stressful jobs benefit from retirement more than those with low levels of work-related stress.

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

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

24 Loneliness, Social Isolation and Frailty Among Older Adults in England: Results From the English Longitudinal Study of Ageing

Introduction

Ten percent of over 65 s and between a quarter and half of over 85 s are frail. Loneliness and social isolation are associated with increased falls, rates of hospitalisation and mortality. Lonely and socially isolated older adults may also be at risk of frailty. We examined the relationship between loneliness, social isolation and incident frailty among older adults in England longitudinally over 12 years.

Methods

The study sample are 9,171 older adults aged ≥50 years participating in a population representative longitudinal panel survey, the English Longitudinal Study of Ageing Waves 2–8. To define frailty across the biannual waves, we used the Frailty Index (FI), analysed continuously and into categories (FI ≤0.08 non-frail, 0.08–0.25 pre-frail and ≥ 0.25–1 frail). We used baseline (Wave 2): loneliness measure using the UCLA 3-item loneliness scale; social isolation measure using previously reported method (Banks et al. The Institute for Fiscal Studies. 2006.). Both were categorised into low/medium/high. To examine relationships, we used linear mixed methods modelling (for the continuous FI), and Cox proportional hazard model (for the categorical FI).

Results

Loneliness (β = 0.023; 95% CI = 0.022, 0.025) and social isolation (β = 0.007; 95% CI = 0.003, 0.010) were significantly associated with increased FI, after adjusting for cofounders (gender, age, marital status, smoking status and wealth). There was a 60% greater relative risk of belonging to the frail class with a medium loneliness score compared to low (HR = 1.570; 95% CI 1.492, 1.652) and a 160% greater relative risk with high loneliness score compared to low (HR = 2.621; 95% CI 2.488, 2.761). Although less pronounced, there was a 1% greater relative risk of developing frailty with a medium social isolation score compared to low (HR = 1.010, 95% CI 1.010, 1.197) and a 30% greater relative risk with high social isolation score compared to low (HR = 1.267; 95% CI 1.154, 1.390).

Conclusions

Our research indicates both loneliness and social isolation increase risk of developing frailty, expanding on previous evidence. This provides further support to the importance of understanding approaches to promote social inclusion of older adults.

Does the association between cognition and education differ between older adults with gradual or rapid trajectories of cognitive decline?

Education is associated with improved baseline cognitive performance in older adults, but the association with maintenance of cognitive function is less clear. Education may be associated with different types of active cognitive reserve in those following different cognitive trajectories. We used data on n = 5642 adults aged >60 from the English Longitudinal Study of Aging (ELSA) over 5 waves (8 years). We used growth mixture models to test if the association between educational attainment and rate of change in verbal fluency or immediate recall varied by latent class trajectory. For recall, 91.5% (n = 5164) of participants were in a gradual decline class and 8.5% (n = 478) in a rapid decline class. For fluency, 90.0% (n = 4907) were in a gradual decline class and 10.0% (n = 561) were in a rapid decline class. Educational attainment was associated with improved baseline performance for both verbal fluency and recall. In the rapidly declining classes, educational attainment was not associated with rate of change for either outcome. In the verbal fluency gradual decline class, education was associated with higher (an additional 0.05-0.38 words per 2 years) or degree level education (an additional 0.04-0.42 words per 2 years) when compared to those with no formal qualifications. We identified no evidence of a protective effect of education against rapid cognitive decline. There was some evidence of active cognitive reserve for verbal fluency but not recall, which may reflect a small degree of domain-specific protection against age-related cognitive decline.

Frailty among Older Adults and Its Distribution in England

Background: Information on the spatial distribution of the frail population is crucial to inform service planning in health and social care. Objectives: To estimate small-area frailty prevalence among older adults using survey data. To assess whether prevalence differs between urban, rural, coastal and inland areas of England. Design: Using data from the English Longitudinal Study of Ageing (ELSA), ordinal logistic regression was used to predict the probability of frailty, according to age, sex and area deprivation. Probabilities were applied to demographic and economic information in 2020 population projections to estimate the district-level prevalence of frailty. Results: The prevalence of frailty in adults aged 50+ (2020) in England was estimated to be 8.1 [95% CI 7.3-8.8]%. We found substantial geographic variation, with the prevalence of frailty varying by a factor of 4.0 [3.5-4.4] between the most and least frail areas. A higher prevalence of frailty was found for urban than rural areas, and coastal than inland areas. There are widespread geographic inequalities in healthy ageing in England, with older people in urban and coastal areas disproportionately frail relative to those in rural and inland areas. Conclusions: Interventions aimed at reducing inequalities in healthy ageing should be targeted at urban and coastal areas, where the greatest benefit may be achieved.

Going beyond the mean in examining relationships of adolescent non-cognitive skills with health-related quality of life and biomarkers in later-life

Several studies have established associations between early-life non-cognitive skills and later-life health and health behaviours. However, no study addresses the more important policy concern about how this relationship varies along the health distribution. We use unconditional quantile regression to analyse the effects of adolescent non-cognitive skills across the distributions of the health-related quality of life at age 50 and biomarkers at age 45 years. We examine the effects of measures of conscientiousness, agreeableness and neuroticism recorded at age 16 for 3585 individuals from the National Child Development Study. Adolescent conscientiousness is positively associated with ability to cope with stress and negatively associated with risk of cardiovascular disease in middle-age. Adolescent agreeableness is associated with higher health-related quality of life and lower physiological 'wear and tear', but negatively associated with ability to cope with stress in middle-age. Adolescent neuroticism is associated with lower health-related quality of life, higher physiological 'wear and tear', and a higher risk of cardiovascular disease in middle-age. All of these associations are stronger at the lower end of the health distribution except for the cardiovascular risk biomarkers. These associations are robust to correcting for attrition using inverse probability weighting and consistent with causal bounds assuming proportional selection on observables and unobservables. They suggest policies that improve non-cognitive skills in adolescence could offer most long-term health benefit to those with the poorest health.

Cognitively stimulating activities and risk of probable dementia or cognitive impairment in the English Longitudinal Study of Ageing

Objectives

To examine the association between cognitive stimulating activities (CSA) in later life (internet/email use, employment, volunteering, evening classes, social club membership and newspaper reading) and risk of cognitive impairment or dementia using marginal structural models to account for time-varying confounding affected by prior exposure.

Methods

Data were used from the English Longitudinal Study of Ageing waves 1 (2002) to 7 (2014), a nationally representative sample of adults in England aged ≥50. Self-reported participation in CSAs were measured as binary exposures from waves 2 (2004) to 6 (2012), with final sample sizes between n = 3937 and n = 2530 for different CSAs. Baseline exposure and covariates were used to create inverse probability of treatment and censoring weights (IPTCW). IPTCW repeated measures Poisson and linear regression were used to estimate each CSAs effect on risk of probable cognitive impairment or dementia at wave 7 (defined as a score of ≤11/27 on a modified telephone interview for cognitive status (TICS-27)). Results were compared to standard regression adjustment.

Results

Internet use at any wave (Risk ratios between 0.62 and 0.69) and volunteering in waves 3 to 6 (RRs between 0.516 and 0.633) were associated with reduced risk of cognitive impairment in IPTCW models. Standard estimates were similar for both internet use and volunteering.

Newspaper reading (RR 95% Confidence interval 0.74–0.99) and social club membership (RR 95% CI 0.54–0.86) at wave 6 were significantly associated with risk of cognitive impairment in standard models, but not in the IPTCW models (RR 95% CI 0.82–1.11 and 0.60–1.08 respectively). Employment and evening classes were not associated with cognitive impairment in either model.

Conclusions

We found that volunteering and internet use were associated with reduced risk of cognitive impairment. Associations between newspaper reading or social club membership and cognitive impairment may be due to time-varying confounding affected by prior exposure.

•

Confounding affected by past exposure is a problem in studies of cognitive function.

•

We addressed this using inverse probability weighted marginal structural models.

•

Volunteering and internet use were protective against cognitive impairment.

•

Other cognitively stimulating activities were protective with standard regression.

•

But these associations were non-significant in the marginal structural models.

Sociodemographic disparities in non-diabetic hyperglycaemia and the transition to type 2 diabetes: evidence from the English Longitudinal Study of Ageing

AIM

To explore whether there are social inequalities in non-diabetic hyperglycaemia (NDH) and in transitions to type 2 diabetes mellitus and NDH low-risk status in England.

METHODS

Some 9143 men and women aged over 50 years were analysed from waves 2, 4, 6 and 8 (2004-2016) of the English Longitudinal Study of Ageing (ELSA). Participants were categorized as: NDH 'low-risk' [HbA_1c < 42 mmol/mol (< 6.0%)], NDH [HbA_1c 42-47 mmol/mol (6.0-6.4%)] and type 2 diabetes [HbA_1c > 47 mmol/mol (> 6.4%)]. Logistic regression models estimated the association between sociodemographic characteristics and NDH, and the transitions from NDH to diagnosed or undiagnosed type 2 diabetes and low-risk status in future waves.

RESULTS

NDH was more prevalent in older participants, those reporting a disability, those living in deprived areas and in more disadvantaged social classes. Older participants with NDH were less likely to progress to undiagnosed type 2 diabetes [odds ratio (OR) 0.27, 95% confidence interval (CI) 0.08, 0.96]. NDH individuals with limiting long-standing illness (OR 1.72, 95% CI 1.16, 2.53), who were economically inactive (OR 1.60, 95% CI 1.02, 2.51) or from disadvantaged social classes (OR 1.63, 95% CI 1.02, 2.61) were more likely to progress to type 2 diabetes. Socially disadvantaged individuals were less likely (OR 0.64, 95% CI 0.41, 0.98) to progress to NDH low-risk status.

CONCLUSIONS

There were socio-economic differences in NDH prevalence, transition to type 2 diabetes and transition to NDH low-risk status. Disparities in transitions included the greater likelihood of disadvantaged social groups with NDH developing type 2 diabetes and greater likelihood of advantaged social groups with NDH becoming low-risk. These socio-economic differences should be taken into account when targeting prevention initiatives.

Occupational social class trajectories in physical functioning among employed women from midlife to retirement

Background

Prior analyses of class differences in health trajectories among employees have often omitted women and transitions to retirement. We examined social class trajectories in physical functioning among Finnish female employees from midlife to retirement age, and whether transitions to retirement modified these trajectories.

Methods

Data were derived from mail surveys at Phases 1–3 (2000–2012) among employees of the City of Helsinki, Finland, aged 40–60 at baseline (n = 8960, 80% women, response rates 69–83%). We included respondents to any of the Phases 1–3 aged 40–72 (n = 6976). We distinguished higher and lower social classes, and employment statuses, i.e. employed, mandatorily retired and disability-retired. Short Form 36 physical component summary was used to measure physical functioning. Mixed-effect growth curve models were used to assess the association of social class and employment status with functioning over age.

Results

For employed women, physical functioning deteriorated faster in the lower than in the higher class, with class trajectories widening in ages 40–65. After mandatory retirement, functioning deteriorated in both classes, whereas after disability retirement, functioning improved. Across employment statuses, functioning converged at older ages, and the disability-retired caught up with the better functioning of the employed and mandatorily retired. Employment status modified the trajectories, as among the continuously employed and mandatorily retired women functioning deteriorated, but among the disability-retired, trajectories improved and reached a similar level with employed and mandatorily retired women. Social class inequalities remained in all employment status groups.

Conclusions

Overall, our results suggest evidence for the cumulative disadvantage model, with accumulating work exposures among lower classes potentially contributing to their trajectories of ill health.

Retirement and Socioeconomic Differences in Diurnal Cortisol: Longitudinal Evidence From a Cohort of British Civil Servants

Objectives

Early old age and the period around retirement are associated with a widening in socioeconomic inequalities in health. There are few studies that address the stress-biological factors related to this widening. This study examined whether retirement is associated with more advantageous (steeper) diurnal cortisol profiles, and differences in this association by occupational grade.

Method

Data from the 7th (2002–2004), 8th (2006), and 9th (2007–09) phases of the London-based Whitehall II civil servants study were analysed. Thousand hundred and forty three respondents who were employed at phase 8 (mean age 59.9 years) and who had salivary cortisol measured from five samples collected across the day at phases 7 and 9 were analysed.

Results

Retirement was associated with steeper diurnal slopes compared to those who remained in work. Employees in the lowest grades had flatter diurnal cortisol slopes compared to those in the highest grades. Low-grade retirees in particular had flatter diurnal slopes compared to high-grade retirees.

Discussion

Socioeconomic differences in a biomarker associated with stress increase, rather than decrease, around the retirement period. These biological differences associated with transitions into retirement for different occupational groups may partly explain the pattern of widening social inequalities in health in early old age.

Re-employment, job quality, health and allostatic load biomarkers: prospective evidence from the UK Household Longitudinal Study

Background

There is little evidence on whether becoming re-employed in poor quality work is better for health and well-being than remaining unemployed. We examined associations of job transition with health and chronic stress-related biomarkers among a population-representative cohort of unemployed British adults.

Methods

A prospective cohort of 1116 eligible participants aged 35 to 75 years, who were unemployed at wave 1 (2009/10) of the UK Household Longitudinal Study, were followed up at waves 2 (2010/11) and 3 (2011/12) for allostatic load biomarkers and self-reported health. Negative binomial and multiple regression models estimated the association between job adversity and these outcomes.

Results

Compared with adults who remained unemployed, formerly unemployed adults who transitioned into poor quality jobs had higher levels of overall allostatic load (0.51, 0.32–0.71), log HbA1c (0.06, <0.001–0.12), log triglycerides (0.39, 0.22–0.56), log C-reactive protein (0.45, 0.16–0.75), log fibrinogen (0.09, 0.01–0.17) and total cholesterol to high-density lipoprotein (HDL) ratio (1.38, 0.88–1.88). Moreover, physically healthier respondents at wave 1 were more likely to transition into good quality and poor quality jobs after 1 year than those who remained unemployed.

Conclusions

Formerly unemployed adults who transitioned into poor quality work had greater adverse levels of biomarkers compared with their peers who remained unemployed. The selection of healthier unemployed adults into these poor quality or stressful jobs was unlikely to explain their elevated levels of chronic stress-related biomarkers. Job quality cannot be disregarded from the employment success of the unemployed, and may have important implications for their health and well-being.

An application of Bayesian measurement invariance to modelling cognition over time in the English Longitudinal Study of Ageing

OBJECTIVES

Recommended cut-off criteria for testing measurement invariance (MI) using the comparative fit index (CFI) vary between -0.002 and -0.01. We compared CFI results with those obtained using Bayesian approximate MI for cognitive function.

METHODS

We used cognitive function data from Waves 1-5 of the English Longitudinal Study of Ageing (ELSA; Wave 1 n = 11,951), a nationally representative sample of English adults aged ≥50. We tested for longitudinal invariance using CFI and approximate MI (prior for a difference between intercepts/loadings ~N(0,0.01)) in an attention factor (orientation to date, day, week, and month) and a memory factor (immediate and delayed recall, verbal fluency, and a prospective memory task).

RESULTS

Conventional CFI criteria found strong invariance for the attention factor (CFI + 0.002) but either weak or strong invariance for the memory factor (CFI -0.004). The approximate MI results also supported strong MI for attention but found 9/20 intercepts or thresholds were noninvariant for the memory factor. This supports weak rather than strong invariance.

CONCLUSIONS

Within ELSA, the attention factor is suitable for longitudinal analysis but not the memory factor. More generally, in situations where the appropriate CFI criteria for invariance are unclear, Bayesian approximate MI could alternatively be used.

Socioeconomic and ethnic inequalities in oral health among children and adolescents living in England, Wales and Northern Ireland

Objectives

Although adolescence is a sensitive developmental period in oral health, the social equalization hypothesis that suggests health inequalities attenuate in adolescence has not been examined. This study analyses whether the socioeconomic gap and ethnic disadvantage in oral health among children aged 5 reduces among adolescents aged 15.

Methods

Data from the cross‐sectional Children's Dental Health Survey 2013 were analysed, comprising of 8541 children aged 5, 8, 12 and 15 attending schools in England, Wales and Northern Ireland. Oral health indicators included decayed and filled teeth, plaque, gingivitis and periodontal health. Ethnicity was measured using the 2011 UK census ethnic categories. Socioeconomic position was measured by family, school and residential deprivation. Negative binomial and probit regression models estimated the levels of oral health by ethnicity and socioeconomic position, adjusted for demographic and tooth characteristics.

Results

The predicted rate of decayed teeth for White British/Irish children aged 5 was 1.54 (95%CI 1.30‐1.77). In contrast, the predicted rate for Indian and Pakistani children was about 2‐2.5 times higher. At age 15, ethnic differences had reduced considerably. Family deprivation was associated with higher levels of tooth decay among younger children but not among adolescents aged 15. The influence of residential deprivation on the rate of tooth decay and filled teeth was similar among younger and older children. Moreover, inequalities in poor periodontal health by residential deprivation was significantly greater among 15‐year‐old children compared to younger children.

Conclusions

This study found some evidence of smaller ethnic and family socioeconomic differences in oral health among British adolescents compared to younger children. However, substantial differences in oral health by residential deprivation remain among adolescents. Community levels of deprivation may be particularly important for the health of adolescents.

Oral Health-A Neglected Aspect of Subjective Well-Being in Later Life

Objectives

This study examined whether oral health is a neglected aspect of subjective well-being (SWB) among older adults. The key research question was whether deterioration in oral health among dentate older adults living in England was associated with decreases in SWB, using measures of eudemonic, evaluative, and affective dimensions of well-being.

Methods

This secondary analysis used data from the third (2006-2007) and fifth (2010-2011) waves of respondents aged 50 and older from the English Longitudinal Study of Ageing (ELSA). We fitted multivariable regression models to examine the effects of changes in oral impacts on daily life and edentulism (complete tooth loss) on SWB (quality of life, life satisfaction, and depressive symptomatology).

Results

A worsening in both oral health measures was associated with an increase in depressive symptoms even after adjusting for time-varying confounders including declining health, activities of daily living, and reduced social support. Becoming edentate was also associated with decreases in quality of life and life satisfaction.

Discussion

A deterioration in oral health and oral health-related quality of life increases the risk of depressive symptoms among older adults and highlights the importance of oral health as a determinant of subjective well-being in later life.

Is socioeconomic segregation of the poor associated with higher premature mortality under the age of 60? A cross-sectional analysis of survey data in major Indian cities

OBJECTIVES

Although urbanisation is generally associated with poverty reduction in low-income and middle-income countries, it also results in increased socioeconomic segregation of the poor. Cities with higher levels of socioeconomic segregation tend to have higher mortality rates, although the evidence is based on ecological associations. The paper examines whether socioeconomic segregation of the poor is associated with higher under-60 years ('premature') mortality risk in Indian cities and whether this association is confounded by contextual and compositional sociodemographic and socioeconomic factors.

SETTING AND PARTICIPANTS

A population representative sample of over one million from 39 427 households living in 1876 urban wards within 59 Indian districts (cities) from the third (2008) District Level Household Survey (DLHS-3).

PRIMARY OUTCOME AND OTHER MEASURES

The outcome was any death under the age of 60 reported by households in the preceding 4years of the DLHS-3. Socioeconomic segregation, estimated at the district (city) level, was measured using an isolation index of the poor and the index of dissimilarity.

RESULTS

Poor households living in cities where the poor were more isolated had higher probabilities of premature mortality than poor households living in cities where the poor were less isolated. In contrast, it did not matter whether rich households lived in more or less socioeconomically segregated cities. A 1 SD increase in the isolation index was associated with an absolute increase of 1.1% in the probability of premature mortality for the poorest households.

CONCLUSION

Increasing segregation of the poor may result in higher premature mortality. As low-income and middle-income countries become increasingly urbanised, there is a risk that this may lead to increased segregation of the poor as well as increased premature mortality.

Assessment of progress towards universal health coverage for people with disabilities in Afghanistan: a multilevel analysis of repeated cross-sectional surveys

BACKGROUND

Since 2002, Afghanistan has made much effort to achieve universal health coverage. According to the UN Sustainable Development Goal 3, target eight, the provision of quality care to all must include usually underserved groups, including people with disabilities. We investigated whether a decade of international investment in the Afghan health system has brought quality health care to this group.

METHODS

We used data from two representative household surveys, one done in 2005 and one in 2013, in 13 provinces of Afghanistan, that included questions about activity limitations and functioning difficulties, socioeconomic factors, perceived availability of health care, and experience with coverage of health-care needs. We used multilevel modelling and tests for interaction to investigate factors associated with differences in perception between timepoints and whether village remoteness affected changes in perception.

FINDINGS

The 2005 survey included 334 people, and the 2013 survey included 961 people. Mean age, employment, and asset levels of participants with disabilities increased slightly between 2005 and 2013, but the level of education decreased. Formal education and higher asset level were associated with improved availability of health care and positive experience with coverage of health-care needs, whereas being employed was only associated with the latter. Perceived availability of health care and positive experience with coverage of health-care needs significantly worsened in 2013 compared with in 2005 (227 [69%] perceived that services were available in 2005 vs 405 [44%] in 2013, p<0·0001; 255 [78%] perceived a positive experience in 2005 vs 410 [45%] in 2013, p<0·0001). Village remoteness increased in 2013 (no connectivity by paved road 186 [57%] in 2005 vs 797 [87%] in 2013, p<0·0001; mean time to reach health-care facility 64·3 min [SD 167·7] vs 84·4 min [107·7], p<0·0001) and negatively affected perception of health-care availability.

INTERPRETATION

Perceived availability of health care and experience with health-care coverage have not greatly improved for people with disabilities in Afghanistan, particularly in remote areas. Health policy in Afghanistan will need to address attitudinal, social, and accessibility barriers to health care.

FUNDING

Swedish International Development Agency.

Does public transport use prevent declines in walking speed among older adults living in England? A prospective cohort study

OBJECTIVES

Although there is some evidence that public transport use confers public health benefits, the evidence is limited by cross-sectional study designs and health-related confounding factors. This study examines the effect of public transport use on changes in walking speed among older adults living in England, comparing frequent users of public transport to their peers who did not use public transport because of structural barriers (poor public transport infrastructure) or through choice.

DESIGN

Prospective cohort study.

SETTING

England, UK.

PARTICIPANTS

Older adults aged ≥60 years eligible for the walking speed test. 6246 individuals at wave 2 (2004-2005); 5909 individuals at wave 3 (2006-2007); 7321 individuals at wave 4 (2008-2009); 7535 individuals at wave 5 (2010-2011) and 7664 individuals at wave 6 (2012-2013) of the English Longitudinal Study of Ageing.

MAIN OUTCOME MEASURE

The walking speed was estimated from the time taken to walk 2.4 m. Fixed effects models and growth curve models were used to examine the associations between public transport use and walking speed.

RESULTS

Older adults who did not use public transport through choice or because of structural reasons had slower walking speeds (-0.02 m/s (95% CI -0.03 to -0.003) and -0.02 m/s (95% CI -0.03 to -0.01), respectively) and took an extra 0.07 s to walk 2.4 m compared with their peers who used public transport frequently. The age-related trajectories of decline in walking speed were slower for frequent users of public transport compared with non-users.

CONCLUSIONS

Frequent use of public transport may prevent age-related decline in physical capability by promoting physical activity and lower limb muscle strength among older adults. The association between public transport use and slower decline in walking speed among older adults is unlikely to be confounded by health-related selection factors. Improving access to good quality public transport could improve the health of older adults.

North-South disparities in English mortality1965-2015: longitudinal population study

BACKGROUND

Social, economic and health disparities between northern and southern England have persisted despite Government policies to reduce them. We examine long-term trends in premature mortality in northern and southern England across age groups, and whether mortality patterns changed after the 2008-2009 Great Recession.

METHODS

Population-wide longitudinal (1965-2015) study of mortality in England's five northernmost versus four southernmost Government Office Regions - halves of overall population.

MAIN OUTCOME MEASURE

directly age-sex adjusted mortality rates; northern excess mortality (percentage excess northern vs southern deaths, age-sex adjusted).

RESULTS

From 1965 to 2010, premature mortality (deaths per 10 000 aged <75 years) declined from 64 to 28 in southern versus 72 to 35 in northern England. From 2010 to 2015 the rate of decline in premature mortality plateaued in northern and southern England. For most age groups, northern excess mortality remained consistent from 1965 to 2015. For 25-34 and 35-44 age groups, however, northern excess mortality increased sharply between 1995 and 2015: from 2.2% (95% CI -3.2% to 7.6%) to 29.3% (95% CI 21.0% to 37.6%); and 3.3% (95% CI -1.0% to 7.6%) to 49.4% (95% CI 42.8% to 55.9%), respectively. This was due to northern mortality increasing (ages 25-34) or plateauing (ages 35-44) from the mid-1990s while southern mortality mainly declined.

CONCLUSIONS

England's northern excess mortality has been consistent among those aged <25 and 45+ for the past five decades but risen alarmingly among those aged 25-44 since the mid-90s, long before the Great Recession. This profound and worsening structural inequality requires more equitable economic, social and health policies, including potential reactions to the England-wide loss of improvement in premature mortality.

Can sleep disturbance influence changes in mental health status? Longitudinal research evidence from ageing studies in England and Japan

BACKGROUND

Little is known about the role of sleep disturbance in relation to changes in depressive states. We used data obtained from the participants aged 65 and over in the English Longitudinal Study of Ageing (ELSA, waves four and five, N = 3108) and the Japan Gerontological Evaluation Study (JAGES, 2010 and 2013 sweeps, N = 7527) to examine whether sleep disturbance is longitudinally associated with older adults' patterns of depressive states.

METHODS

We created four patterns of depressive states (non-case, recovered, onset, repeatedly depressive) by combining responses to the measures (scoring four or more on seven items from the Center for Epidemiological Studies Depression Scale for the ELSA participants and scoring five or more for the Geriatric Depression Scale-15 for the JAGES participants) obtained at the baseline and follow-up. Sleep disturbance was assessed through responses to three questions on sleep problems. Age, sex, partnership status, household equivalised income, alcohol and cigarette use, and physical function were treated as confounders in this study. Additionally, information on sleep medication was available in JAGES and was included in the statistical models.

RESULTS

More ELSA participants were non-depressive cases and reported no sleep disturbances compared with the JAGES participants. Findings from multinomial logistic regression analysis showed that more sleep disturbance was associated with the onset group in ELSA (RRR = 2.37, 95% CI = 1.44-3.90) and JAGES (RRR = 2.41, 95% CI = 1.79-3.25) as well as the recovery (RRR = 3.42, 95% CI = 1.98-5.90, RRR = 2.71, 95% CI = 1.95-3.75) and repeatedly depressed group (RRR = 7.24, 95% CI = 3.91-13.40, RRR = 5.16, 95% CI = 3.82-6.98).

CONCLUSIONS

Findings suggest that the association between sleep disturbance and depression in older adults is complex.

The role of qualitative research in adding value to a randomised controlled trial: lessons from a pilot study of a guided e-learning intervention for managers to improve employee wellbeing and reduce sickness absence

BACKGROUND

Despite the growing popularity of mixed-methods studies and considerable emphasis on the potential value of qualitative research to the trial endeavour, there remains a dearth of published studies reporting on actual contribution. This paper presents a critically reflective account of our experience of the actual value of undertaking qualitative research alongside a pilot cluster randomised controlled trial of a guided e-learning intervention for managers in an NHS Mental Health Trust to improve employee wellbeing and reduce sickness absence. For the qualitative study we undertook 36 in-depth interviews with key informants, managers and employees. We observed and took in-depth field notes of 10 meetings involving managers and employees at the Trust, and the two qualitative researchers acted as participant observers at steering committee and monthly research team meetings. We adopted a narrative methodological orientation alongside a thematic approach to data analysis, eliciting a rich account of the complexities of managing stress at work.

RESULTS

We identified two key overarching roles played by the qualitative research: 'problematising' and 'contextualising'. Specifically, the qualitative data revealed and challenged assumptions embedded in the trial about the nature of the learning process, and exposed the slippery and contested nature of abstracted variables, on which a trial depends. The qualitative data challenged the trial's logic model, and provided a rich understanding of the context within which the trial and intervention took place.

CONCLUSIONS

While acknowledging the ever-present tension in mixed-methods research between the requirements of quantitative research to represent the social world as abstracted variables, and the goal of qualitative research to explore and document the complexity of social phenomena, we adopted a pragmatic position that enabled us to engage with this tension in a productive and partially integrative way. Our critically reflective account of the praxis of integration illuminated opportunities and challenges for maximising the value of qualitative research to a trial. This paper sets out tangible illustrative lessons for other mixed-methods researchers endeavouring to get the most from qualitative research.

TRIAL REGISTRATION

This study is registered as ISRCTN58661009 . Registration was submitted on 22 April 2013 and completed on 17 June 2013.

Health as a predictor of early retirement before and after introduction of a flexible statutory pension age in Finland

BACKGROUND

Little is known of how pension reforms affect the retirement decisions of people with different health statuses, although this is crucial for the understanding of the broader societal impact of pension policies and for future policy development. We assessed how the Finnish statutory pension age reform introduced in 2005 influenced the role of health as a predictor of retirement.

METHODS

We used register-based data and cox regression analysis to examine the association of health (measured by purchases of psychotropic medication, hospitalizations due to circulatory and musculoskeletal diseases, and the number of any prescription medications) with the risk of retirement at age 63-64 among those subject to the old pension system with fixed age limit at 65 (pre-reform group born in 1937-1941) and the new flexible system with 63 as the lower age limit (post-reform group born in 1941-1945) while controlling for socio-demographic factors.

RESULTS

Retirement at age 63-64 was more likely among the post- than the pre-reform group (HR = 1.50; 95% CI 1.43-1.57). This reform-related increase in retirement was more pronounced among those without a history of psychotropic medication or hospitalizations due to circulatory and musculoskeletal diseases, as well as among those with below median level medication use. As a result, poor health became a weaker predictor of retirement after the reform.

CONCLUSION

Contrary to the expectations of the Finnish pension reform aimed at extending working lives, offering choice with respect to the timing of retirement may actually encourage healthy workers to choose earlier retirement regardless of the provided economic incentives for continuing in work.

Pilot study of a cluster randomised trial of a guided e-learning health promotion intervention for managers based on management standards for the improvement of employee well-being and reduction of sickness absence: GEM Study

OBJECTIVES

To investigate the feasibility of recruitment, adherence and likely effectiveness of an e-learning intervention for managers to improve employees' well-being and reduce sickness absence.

METHODS

The GEM Study (guided e-learning for managers) was a mixed methods pilot cluster randomised trial. Employees were recruited from four mental health services prior to randomising three services to the intervention and one to no-intervention control. Intervention managers received a facilitated e-learning programme on work-related stress. Main outcomes were Warwick Edinburgh Mental Wellbeing Scale (WEMWBS), 12-item GHQ and sickness absence <21 days from human resources. 35 in-depth interviews were undertaken with key informants, managers and employees, and additional observational data collected.

RESULTS

424 of 649 (65%) employees approached consented, of whom 350 provided WEMWBS at baseline and 284 at follow-up; 41 managers out of 49 were recruited from the three intervention clusters and 21 adhered to the intervention. WEMWBS scores fell from 50.4-49.0 in the control (n=59) and 51.0-49.9 in the intervention (n=225), giving an intervention effect of 0.5 (95% CI -3.2 to 4.2). 120/225 intervention employees had a manager who was adherent to the intervention. HR data on sickness absence (n=393) showed no evidence of effect. There were no effects on GHQ score or work characteristics. Online quiz knowledge scores increased across the study in adherent managers. Qualitative data provided a rich picture of the context within which the intervention took place and managers' and employees' experiences of it.

CONCLUSIONS

A small benefit from the intervention on well-being was explained by the mixed methods approach, implicating a low intervention uptake by managers and suggesting that education alone may be insufficient. A full trial of the guided e-learning intervention and economic evaluation is feasible. Future research should include more active encouragement of manager motivation, reflection and behaviour change.

TRIAL REGISTRATION NUMBER

ISRCTN58661009.

Does the timing of parental migration matter for child growth? A life course study on left-behind children in rural China

Background

China’s unprecedented internal migration has left 61 million rural children living apart from parents. This study investigates how being left behind is associated with children’s growth, by examining children’s height and weight trajectories by age, testing the accumulation and critical period life course hypotheses.

Methods

Data were drawn from five waves of the China Health and Nutrition Survey (CHNS). Multiple cohorts of children under 6 years old from 1997–2009 were examined (N = 2,555). Growth curve models investigated whether height and weight trajectories differ for children who were left behind at different stages of the life course: in early childhood (from ages 0–5 but not afterwards), in later childhood (from ages 6 to 17 only), and in both early and later childhood (from ages 0–5 and from ages 6–17), compared to their peers from intact households.

Results

Boys who were left behind at different life stages of childhood differed in height and weight growth compared with boys from intact families. No significant associations were found for girls. As young boys turned into adolescents, those left behind in early childhood tended to have slower height growth and weight gain than their peers from intact households. There was a 2.8 cm difference in the predicted heights of boys who were left behind in early childhood compared to boys from intact households, by the age of 14. Similarly, the difference in weight between the two groups of boys was 5.3 kg by the age of 14.

Conclusions

Being left behind during early childhood, as compared to not being left behind, could lead to slower growth rates of height and weight for boys. The life course approach adopted in this study suggests that early childhood is a critical period of children’s growth in later life, especially for boys who are left behind. The gender paradox in China, where sons are preferred, but being left behind appears to affect boys more than girls, needs further exploration.

Pilot study of a randomised trial of a guided e-learning health promotion intervention for managers based on management standards for the improvement of employee well-being and reduction of sickness absence: the GEM (Guided E-learning for Managers) study

Background

Psychosocial work environments influence employee well-being. There is a need for an evaluation of organisational-level interventions to modify psychosocial working conditions and hence employee well-being.

Objective

To test the acceptability of the trial and the intervention, the feasibility of recruitment and adherence to and likely effectiveness of the intervention within separate clusters of an organisation.

Design

Mixed methods: pilot cluster randomised controlled trial and qualitative study (in-depth interviews, focus group and observation).

Participants

Employees and managers of a NHS trust. Inclusion criteria were the availability of sickness absence data and work internet access. Employees on long-term sick leave and short-term contracts and those with a notified pregnancy were excluded.

Intervention

E-learning program for managers based on management standards over 10 weeks, guided by a facilitator and accompanied by face-to-face meetings. Three clusters were randomly allocated to receive the guided e-learning intervention; a fourth cluster acted as a control.

Main outcome measures

Recruitment and participation of employees and managers; acceptability of the intervention and trial; employee subjective well-being using the Warwick–Edinburgh Mental Wellbeing Scale (WEMWBS); and feasibility of collecting sickness absence data.

Results

In total, 424 employees out of 649 approached were recruited and 41 managers out of 49 were recruited from the three intervention clusters. Of those consenting, 350 [83%, 95% confidence interval (CI) 79% to 86%] employees completed the baseline assessment and 291 (69%, 95% CI 64% to 73%) completed the follow-up questionnaires. Sickness absence data were available from human resources for 393 (93%, 95% CI 90% to 95%) consenting employees. In total, 21 managers adhered to the intervention, completing at least three of the six modules. WEMWBS scores fell slightly in all groups, from 50.4 to 49.0 in the control group and from 51.0 to 49.9 in the intervention group. The overall intervention effect was 0.5 (95% CI –3.2 to 4.2). The fall in WEMWBS score was significantly less among employees whose managers adhered to the intervention than among those employees whose managers did not (–0.7 vs. 1.6, with an adjusted difference of 1.6, 95% CI 0.1 to 3.2). The intervention and trial were acceptable to managers, although our study raises questions about the widely used concept of ‘acceptability’. Managers reported insufficient time to engage with the intervention and lack of senior management ‘buy-in’. It was thought that the intervention needed better integration into organisational processes and practice.

Conclusions

The mixed-methods approach proved valuable in illuminating reasons for the trial findings, for unpacking processes of implementation and for understanding the influence of study context. We conclude from the results of our pilot study that further mixed-methods research evaluating the intervention and study design is needed. We found that it is feasible to carry out an economic evaluation of the intervention. We plan a further mixed-methods study to re-evaluate the intervention boosted with additional elements to encourage manager engagement and behaviour change in private and public sector organisations with greater organisational commitment.

Study registration

Current Controlled Trials ISRCTN58661009.

Funding

This project was funded by the NIHR Public Health Research programme and will be published in full inPublic Health Research; Vol. 3, No. 9. See the NIHR Journals Library website for further project information.

Is Social Capital a Determinant of Oral Health among Older Adults? Findings from the English Longitudinal Study of Ageing

There are a number of studies linking social capital to oral health among older adults, although the evidence base mainly relies on cross-sectional study designs. The possibility of reverse causality is seldom discussed, even though oral health problems could potentially lead to lower social participation. Furthermore, few studies clearly distinguish between the effects of different dimensions of social capital on oral health. The objective of the study was to examine the longitudinal associations between individual social capital and oral health among older adults. We analyzed longitudinal data from the 3rd and 5th waves of the English Longitudinal Study of Ageing (ELSA). Structural social capital was operationalized using measures of social participation, and volunteering. Number of close ties and perceived emotional support comprised the functional dimension of social capital. Oral health measures were having no natural teeth (edentate vs. dentate), self-rated oral health and oral health-related quality of life. Time-lag and autoregressive models were used to explore the longitudinal associations between social capital and oral health. We imputed all missing data, using multivariate imputation by chained equations. We found evidence of bi-directional longitudinal associations between self-rated oral health, volunteering and functional social capital. Functional social capital was a strong predictor of change in oral health-related quality of life - the adjusted odds ratio of reporting poor oral health-related quality of life was 1.75 (1.33-2.30) for older adults with low vs. high social support. However in the reverse direction, poor oral health-related quality of life was not associated with changes in social capital. This suggests that oral health may not be a determinant of social capital. In conclusion, social capital may be a determinant of subjective oral health among older adults rather than edentulousness, despite many cross-sectional studies on the latter.

Social relationships and health related behaviors among older US adults

BACKGROUND

Health behaviors are a key determinant of health and well-being that are influenced by the nature of the social environment. This study examined associations between social relationships and health-related behaviors among a nationally representative sample of older people.

METHODS

We analyzed data from three waves (1999-2004) of the US National Health and Nutrition Examination Survey (NHANES). Participants were 4,014 older Americans aged 60 and over. Log-binomial regression models estimated prevalence ratios (PR) for the associations between social relationships and each of the following health behaviors: alcohol use, smoking, physical activity and dental attendance.

RESULTS

Health-compromising behaviors (smoking, heavy drinking and less frequent dental visits) were related to marital status, while physical activity, a health-promoting behavior, was associated with the size of friendship networks. Smoking was more common among divorced/separated (PR = 2.1; 95% CI: 1.6, 2.7) and widowed (PR = 1.7; 95% CI: 1.3, 2.3) respondents than among those married or cohabiting, after adjusting for socio-demographic background. Heavy drinking was 2.6 times more common among divorced/separated and 1.7 times more common among widowed men compared to married/cohabiting men, while there was no such association among women. For women, heavy drinking was associated with being single (PR = 1.7; 95% CI: 1.0, 2.9). Being widowed was related to a lower prevalence of having visited a dentist compared to being married or living with a partner (PR = 0.92; 95% CI 0.86, 0.99). Those with a larger circle of friends were more likely to be physically active (PR = 1.17; 95% CI:1.06, 1.28 for 5-8 versus less than 5 friends).

CONCLUSIONS

Social relationships of older Americans were independently associated with different health-related behaviors, even after adjusting for demographic and socioeconomic determinants. Availability of emotional support did not however mediate these associations. More research is needed to assess if strengthening social relationships would have a significant impact on older people's health behaviors and ultimately improve their health.

Aging and subjective well-being in later life

OBJECTIVES

This paper examines age-related changes in subjective well-being (SWB) in later life using multiple measures that cover eudemonic, evaluative, and affective dimensions of well-being.

METHOD

Using data from 5 waves of respondents aged 50 and older from the English Longitudinal Study of Ageing (2002-11), we fit multilevel linear growth curve models to examine the cohort differences and individual aging effects on quality of life, depressive symptomatology, and life satisfaction.

RESULTS

Older cohorts are shown to have equivalent or better SWB than younger cohorts for each well-being measure. Nonetheless, individual aging effects for each well-being measure were observed with deterioration in well-being being greatest in older cohorts, even when adjusting for age-related changes in later life, including widowhood, retirement, and declining health.

DISCUSSION

The results suggest that although older cohorts enjoy higher levels of SWB than their younger counterparts when under similar circumstances, they experience sharper declines, especially in the very oldest cohorts. The findings demonstrate the importance of separating out cohort differences and aging effects and also of taking into account the multidimensionality of SWB to determine the point at which age deterioration begins to occur across different measures.