Adult child educational attainment and older parents' psychosocial outcomes during the COVID-19 pandemic.

BACKGROUND: Older adults' psychosocial outcomes during the COVID-19 pandemic have been inequitable by socio-economic status (SES). However, studies have focused solely on own SES, ignoring emerging evidence of the relationship between adult child SES and late-life health. We evaluated whether adult child educational attainment - a core marker of SES - is associated with older parents' psychosocial outcomes during the pandemic. METHODS: We used data from the Survey of Health, Aging, and Retirement in Europe (SHARE) 2004-2018 and the SHARE Corona Surveys (SCS) 2020 and 2021. We included 40,392 respondents ≥ 65 years who had pre-pandemic information on adult child educational attainment and self-reported psychosocial outcomes during the pandemic, including self-assessments of worsened psychosocial outcomes compared to the pre-pandemic period. We used generalized estimating equations with a Poisson distribution and a log link, adjusted for respondent and family-level characteristics, including respondents' own educational attainment. RESULTS: Older adults whose adult children averaged levels of educational attainment at or above (vs. below) their country-specific mean had a lower prevalence of feeling nervous (Prevalence Ratio [PR]: 0.94, 95% Confidence Interval [CI]: 0.90, 0.97), sad or depressed (PR: 0.94, 95% CI: 0.91, 0.98), and having sleep problems (PR: 0.94, 95% CI: 0.90, 0.97) during the pandemic. Additionally, higher adult child educational attainment was associated with a lower risk of perceiving worsened feelings of nervousness (PR: 0.95, 95% CI: 0.90, 1.01) and worsened sleep problems (PR: 0.91, 95% CI: 0.82, 1.01) as compared to the pre-pandemic. In stratified models, protective associations were observed only in countries experiencing "high" levels of COVID-19 intensity at the time of the survey. All of these results are derived from adjusted models. CONCLUSIONS: Adult child SES may have "upward" spillover effects on the psychosocial wellbeing of older parents during periods of societal duress like the pandemic.

School-based racial segregation, social support, and late-life cognitive function in the Study of Healthy Aging in African Americans (STAR).

INTRODUCTION: School-based social support for Black students may mediate or modify the association between school segregation and late-life cognition. METHODS: Study of Healthy Aging in African Americans participants (n = 574) reported segregated school attendance and school-based social support. Associations of segregated schooling with domain-specific cognitive outcomes and effect modification or mediation by school-based social support were evaluated with linear mixed models. RESULTS: Segregated school attendance was associated with increased likelihood of school-based social support. Segregated (vs. desegregated in 6th grade) school attendance was associated with lower executive function (ß = -0.18 [-0.34, -0.02]) and semantic memory z-scores (ß = -0.31 [-0.48, -0.13]). Social support did not mediate these associations. Estimates for segregated school attendance were attenuated among those who felt supported, although there was limited evidence of statistically significant effect modification. DISCUSSION: Early-childhood school segregation was associated with poorer cognitive function. Sources of resilience within racialized educational experiences should be further evaluated to bridge inequities. HIGHLIGHTS: School segregation is a form of structural racism that affected the educational experiences of Black youth with potentially lasting consequences for healthy brain aging. Black students who attended a segregated school experienced greater school-based social support, which may highlight a potential source of resilience and resistance against the effects of racism-related stressors on cognitive function. The estimated adverse association between attending a segregated school on cognition was larger for students without an adult at school who cared about them versus those with an adult at school who cared about them, but estimates were imprecise.

My parent, myself, or my child: whose education matters most for trajectories of cognitive aging in middle age?

The growing body of evidence linking intergenerational education and late-life cognitive decline is almost exclusively from high-income countries, despite rapid intergenerational changes in education in low- and middle-income countries (LMICs). We used data from the Mexican Health and Aging Study (n = 8,822), a cohort of Mexican adults aged > 50 years (2001- 2018) to evaluate whether parental (none vs. any formal schooling), own (< primary school vs. primary completion), or adult child (< high school vs. high school completion) education was associated with verbal memory z-scores. We used linear mixed models with inverse probability of attrition weights. Educational attainment in all three generations was associated with baseline verbal memory scores, independent of the prior generation's education. Lower parental (ß= -0.005; 95% CI: -0.009, -0.002) and respondents' education (ß= -0.013; 95% CI: -0.017, -0.010) were associated with faster decline in delayed (not immediate) verbal memory z-scores. Associations between adult child education and respondent's verbal memory decline varied by exposure specification. Educational attainment of parents and adult children may influence the cognitive aging of middle-aged and older adults in LMICs. These results have important implications given recent structural shifts in educational attainment in many LMICs.

Prenatal and postpartum care during the COVID-19 pandemic: An increase in barriers from early to mid-pandemic in the United States.

BACKGROUND: The COVID-19 pandemic led to changes in the provision of pregnancy and postpartum care. The purpose of this study was to describe changes in access to prenatal and postpartum care over time, from early in the pandemic (July 2020) to mid-pandemic (January 2021) and to explore socioeconomic and COVID-19-related economic factors associated with experiencing barriers to care. METHODS: We recruited two cross sections of women and birthing people in the US in July 2020 (N = 4645) and January 2021 (N = 3343) using Facebook and Instagram Ads. RESULTS: Three out of four women in the prenatal period and four out of five women in the postpartum period reported barriers to scheduling a visit. The likelihood of not having a visit (OR = 4.44, 95% CI 2.67-7.40), being unable to schedule a visit (OR = 2.73, 95% CI 1.71-4.35), and not being offered visits (OR = 4.26, 95% CI 2.32-7.81) increased over time. Participants were more likely to report barriers attending scheduled prenatal or postpartum appointments over time (OR = 2.72, 95% CI 2.14-3.45). Women who experienced more economic impacts from COVID-19 were older, less educated, and were Black, Indigenous, or a person of color, and were more likely to have barriers to attending appointments. CONCLUSIONS: Certain subgroups are more at risk during COVID-19, and around 9 months into the pandemic, women were not only still facing barriers to care, but these had been amplified. Additional research using other data sources is needed to identify and ameliorate barriers and inequalities in access to prenatal and postpartum care that appear to have persisted throughout the pandemic.

The pain and depressive symptoms cascade: A bidirectional analysis of the Mexican Health and Aging Study 2012-2015.

OBJECTIVES: The association of pain and depression has not been evaluated in low- and middle-income countries, which have a disproportionate burden of pain compared to high-income countries. METHODS: Using data from the Mexican Health and Aging Study (baseline, 2012; follow-up, 2015), we examined the bidirectional relationship between pain and depressive symptoms and identified shared predictors among community-dwelling participants ≥60 years (n = 7237). Multivariable logistic regressions models evaluated the association between (1) baseline pain and incident elevated depressive symptoms and (2) baseline depressive symptoms and incident pain, adjusting for demographic, socioeconomic, and health-related factors. Models included inverse probability weights and evaluated interactions by gender. RESULTS: Participants (55.0% women) were on average 69.1 years old. Over half reported no pain (60.7%) and low/no depressive symptoms (67.9%) in 2012, of which, 20.2% reported elevated depressive symptoms and 25.3% self-reported pain in 2015. Baseline pain was associated with higher odds of incident elevated depressive symptoms (aOR 1.65; 95% CI, 1.41-1.93). Baseline elevated depressive symptoms were associated with higher odds of developing pain (aOR 1.57; 95% CI, 1.32-1.87). Age, gender, self-rated health, and activity of daily living limitations were shared risk factors for pain and elevated depressive symptomatology onset. Although the incidence of elevated depressive symptoms and pain was higher in women, there were no statistically significant interactions. CONCLUSIONS: Older adults with pain or depression may be at risk for developing the other. These shared predictors could help identify patients in clinical settings, where pain and depression are often overlooked, reducing the cascading risk of this comorbidity.

Does schooling attained by adult children affect parents' psychosocial well-being in later life? Using Mexico's 1993 compulsory schooling law as a quasi-experiment.

Higher adult child educational attainment may benefit older parents' psychosocial well-being in later life. This may be particularly important in low- and middle-income countries, where recent generations have experienced comparatively large increases in educational attainment. We used data from the 2012 Mexican Health and Aging Study, a nationally representative study of adults aged ≥50 years and leveraged the exogenous variation in adult child education induced by Mexico's compulsory schooling law passed in 1993. We employed two-stage least squares (2SLS) regression to estimate the effects of increased schooling among adult children on parents' (respondents') depressive symptoms and life satisfaction scores, controlling for demographic and socioeconomic characteristics. We considered heterogeneity by parent and child gender and other sociodemographic characteristics. Our study included 7186 participants with an average age of 60.1 years; 54.9% were female. In the 2SLS analyses, increased schooling among oldest adult children was associated with fewer depressive symptoms (ß = -0.25; 95% CI: -0.51, 0.00) but no difference in life satisfaction (ß = 0.01; 95% CI: -0.22, 0.25). Stratified models indicated differences in the magnitude of association with depressive symptoms for mothers (ß = -0.27, 95% CI: -0.56, 0.01) and fathers (ß = -0.18, 95% CI: -0.63, 0.26) and when considering increased schooling of oldest sons (ß = -0.37; 95% CI: -0.73, -0.02) and daughters (ß = -0.05, 95% CI: -0.23, 0.13). No parent and child gender differences were found for life satisfaction. Power was limited to detect heterogeneity across other sociodemographic characteristics in the second stage although first-stage estimates were larger for urban (vs. rural) dwelling and more (vs. less) highly educated respondents. Results were similar when considering the highest educated child as well as increased schooling across all children. Our findings suggest that longer schooling among current generations of adult children, particularly sons, may benefit their older parents' psychosocial well-being.

Quality of prenatal and postpartum telehealth visits during COVID-19 and preferences for future care.

BACKGROUND: At the start of the COVID-19 pandemic, telehealth practices for pregnancy-related care were rapidly implemented. Telehealth for pregnancy-related care is likely to continue after the pandemic. In order for health systems and clinicians to provide person-centered pregnancy-related care via telehealth, it is critical to understand patients' telehealth experiences and their preferences regarding the use of telehealth moving forward. OBJECTIVE: This study aimed to describe perceived quality of prenatal and postpartum telehealth visits during COVID-19 and to examine the association between telehealth quality during the pandemic and future telehealth preferences. STUDY DESIGN: We used data from of an online sample of US women aged 18 to 45 years seeking reproductive health care during COVID-19. Two cross-sections of survey data were collected in July 2020 and January 2021. This analysis included those who sought prenatal (n=1496) or postpartum (n=482) care during the pandemic. Among those who had a prenatal or postpartum telehealth visit, we used multivariable logistic regression to examine the association between a measure of perceived telehealth quality and openness to future telehealth visits, adjusting for sociodemographic characteristics. RESULTS: A total of 57.5% of prenatal and 52.9% of postpartum respondents had a telehealth appointment. Respondents agreed with most statements about the quality of their telehealth appointments, with ≥80% reporting that they were convenient, easy, safe, and provided good information. Lower-ranked quality items were related to visits feeling personal and the patient feeling cared for. A total of 35.2% of prenatal (n=816) and 43.3% of postpartum (n=231) respondents expressed openness to telehealth visits in the future. Prenatal and postpartum respondents reporting higher telehealth quality had increased odds of being open to telehealth in the future (prenatal: adjusted odds ratio, 1.2; 95% confidence interval, 1.2-1.3; postpartum: adjusted odds ratio, 1.2; 95% confidence interval, 1.1-1.3). CONCLUSION: Prenatal and postpartum respondents with better telehealth experiences were more likely to express openness to telehealth in the future, although most preferred future in-person visits. As pregnancy-related telehealth continues, it is important to offer appointment options that match patient preferences, especially populations that face barriers in access to care, and to explore ways to personalize care and support positive patient-provider relationships.

Contraceptive care in the United States during the COVID-19 pandemic: A social media survey of contraceptive access, telehealth use and telehealth quality.

OBJECTIVES: To examine demographic, socioeconomic, and regional differences in contraceptive access, differences between telehealth and in-person contraception visits, and telehealth quality in the United States during the COVID-19 pandemic. STUDY DESIGN: We surveyed reproductive-age women about contraception visits during the COVID-19 pandemic via social media in July 2020 and January 2021. We used multivariable regression to examine relationships between age, racial/ethnic identity, educational attainment, income, insurance type, region, and COVID-19 related hardship, and ability to obtain a contraceptive appointment, telehealth vs in-person visits, and telehealth quality scores. RESULTS: Among 2031 respondents seeking a contraception visit, 1490 (73.4%) reported any visit, of which 530 (35.6%) were telehealth. In adjusted analyses, lower odds of any visit was associated with Hispanic/Latinx and Mixed race/Other identity (aOR 0.59 [0.37-0.94], aOR 0.36 [0.22-0.59], respectively), the South, Midwest, Northeast (aOR 0.63 [0.47-0.85], aOR 0.64 [0.46-0.90], aOR 0.52 [CI 0.36-0.75], respectively), no insurance (aOR 0.63 [0.43-0.91]), greater COVID-19 hardship (aOR 0.52 [0.31-0.87]), and earlier pandemic timing (January 2021 vs July 2020 aOR 2.14 [1.69-2.70]). Respondents from the Midwest and South had lower odds of telehealth vs in-person care (aOR 0.63 [0.44-0.88], aOR 0.54 [0.40-0.72], respectively). Hispanic/Latinx respondents and those in the Midwest had lower odds of high telehealth quality (aOR 0.37 [0.17-0.80], aOR 0.58 [0.35-0.95], respectively). CONCLUSIONS: We found inequities in contraceptive care access, less telehealth use for contraception visits in the South and Midwest, and lower telehealth quality among Hispanic/Latinx people during the COVID-19 pandemic. Future research should focus on telehealth access, quality, and patients' preferences. IMPLICATIONS: Historically marginalized groups have faced disproportionate barriers to contraceptive care, and telehealth for contraceptive care has not been employed equitably during the COVID-19 pandemic. Though telehealth has the potential to improve access to care, inequitable implementation could exacerbate existing disparities.

Adult child socio-economic status and older parents' psychosocial outcomes during the COVID-19 pandemic.

Purpose: Older adults' psychosocial outcomes during the COVID-19 pandemic have been inequitable by socio-economic status (SES). However, studies have focused solely on own SES, ignoring emerging evidence of the relationship between adult child SES and late-life health. We evaluated whether adult child educational attainment - a core marker of SES - is associated with older parents' psychosocial outcomes during the pandemic. Methods: We used data from the Survey of Health, Aging, and Retirement in Europe (SHARE; 2004-2018) and the SHARE Corona Surveys (2020 and 2021). We included 15,553 respondents > 65 years who had pre-pandemic information on adult child educational attainment, self-reported mental health, and worsened mental health compared to the pre-pandemic period. We used generalized estimating equations adjusted for respondent and family-level characteristics, including respondents' own SES. Results: Older adults whose adult children averaged levels of educational attainment at or above (vs. below) their country-specific mean had a lower prevalence of nervousness (Prevalence Ratio [PR]: 0.95, 95% Confidence Interval [CI]: 0.91, 0.99), depression (PR: 0.96, 95% CI: 0.92, 1.00), and trouble sleeping (PR: 0.96, 95% CI: 0.92, 1.00) during the pandemic; associations with loneliness were null. Overall associations with worsened mental health as compared to the pre-pandemic period were null. Protective associations were stronger in countries experiencing "high" levels of COVID-19 intensity. Conclusions: Adult child SES may be an important driver of inequities in older adults' mental health during the COVID-19 pandemic. Policies aimed at improving adult child SES may buffer the adverse psychosocial impacts of societal stressors.

Predictors of COVID-19 Vaccination Likelihood Among Reproductive-Aged Women in the United States.

OBJECTIVES: Vaccination for COVID-19 is an effective method of preventing complications; however, studies suggest that public attitudes toward the vaccine are heterogeneous. The objective of our study was to identify predictors for low likelihood of COVID-19 vaccination among women in the United States and determine whether reasons for low intention were modified by race, ethnicity, or other characteristics to better understand the factors that shape attitudes toward the COVID-19 vaccine and help inform multilevel interventions. METHODS: In January 2021, we used social media to recruit a cross-section of reproductive-aged women in the United States (N = 5269). Our primary outcome was self-reported low vaccination likelihood (responses of unlikely or very unlikely on a 5-item scale). Our secondary outcome was concerns influencing vaccination decision that participants selected from a list of 19 items. We estimated multivariable logistic regression models and controlled for respondents' sociodemographic characteristics. RESULTS: Overall, race and ethnicity, educational attainment, health insurance type, annual household income, partnership status, and US region were associated with low vaccine likelihood. The adjusted odds of reporting low likelihood were 1.83 (95% CI, 1.45-2.32) times greater among non-Hispanic Black than among non-Hispanic White participants. Among pregnant or postpartum participants, breastfeeding status was the strongest predictor (adjusted odds ratio = 2.77; 95% CI, 2.02-3.79). CONCLUSIONS: Vaccine hesitancy and concerns may exacerbate existing COVID-19 health disparities in racial and ethnic groups and highlight the need to target messaging to specific populations, including pregnant and breastfeeding women, because these populations are at high risk for COVID-19 complications.

Association of total and free testosterone with cardiovascular disease in a nationally representative sample of white, black, and Mexican American men.

Associations of total testosterone (T) and calculated free T with cardiovascular disease (CVD) remain poorly understood. Particularly how these associations vary according to race and ethnicity in a nationally representative sample of men. Data included 7058 men (≥20 years) from NHANES. CVD was defined as any reported diagnosis of heart failure (HF), coronary artery disease (CAD), myocardial infarction (MI), and stroke. Total T (ng/mL) was obtained among males who participated in the morning examination. Weighted multivariable-adjusted logistic regression models were conducted. We found associations of low T (OR = 1.57, 95% CI = 1.17-2.11), low calculated free T (OR = 1.53, 95% CI = 1.10-2.17), total T (Q1 vs Q5), and calculated free T (Q1 vs Q5) with CVD after adjusting for estradiol and SHBG. In disease specific analysis, low T increased prevalence of MI (OR = 1.72, 95% CI = 1.08-2.75) and HF (OR = 1.74, 95% CI = 1.08-2.82), but a continuous increment of total T reduced the prevalence of CAD. Similar inverse associations were identified among White and Mexican Americans, but not Blacks (OR = 0.93, 95% CI = 0.49-1.76). Low levels of T and calculated free T were associated with an increased prevalence of overall CVD and among White and Mexican Americans. Associations remained in the same direction with specific CVD outcomes in the overall population.

COVID-19's impact on contraception experiences: Exacerbation of structural inequities in women's health.

INTRODUCTION: Structural inequities may impact the relationship between COVID-19 and access to contraception. METHODS: In July 2020 and January 2021, we used social media to survey 2 samples of women of reproductive age who had not been surgically sterilized and were not currently pregnant about their experiences seeking contraception. We explore whether experiences differed for people experiencing social and/or economic disadvantage due to COVID-19, using multivariable logistic regression to control for age, education and income. RESULTS: In July 2020, 51.5% of respondents who sought contraception (total N = 3064) reported barriers to care compared to 55.3% in January 2021 (total N = 2276). A larger percent (14% in July 2020 and 22% in Jan 2021) reported not using their preferred method of contraception due to COVID-19. Individuals experiencing income loss (OR = 1.61, 95% CI 1.27-2.04 early in the COVID-19 pandemic and OR = 1.58, 1.21-2.06 mid COVID-19 pandemic) and hunger (OR = 1.73, 1.24-2.40 early and OR = 2.02, 1.55-2.64 mid-COVID-19 pandemic) were more likely to report they would be using a different method if not for COVID-19, compared to respondents without income loss or hunger. CONCLUSIONS: COVID-19 has complicated access to contraception, especially for disadvantaged populations. IMPLICATIONS: Efforts are needed to ensure access to contraception despite the COVID-19 epidemic, especially for disadvantaged populations.

Is "Busy" Always Better? Time-Use Activities and Depressive Symptoms Among Older Mexican Adults.

BACKGROUND AND OBJECTIVES: Depression among older Mexican adults is underrecognized and of increasing concern due to its association with comorbidities including cognitive and functional impairments. Prior studies have found an association between low involvement levels in social activities and depression. We aimed to examine the association of time-use activities and depressive symptomatology by sex. RESEARCH DESIGN AND METHODS: We used data from the 2012 and 2015 waves of the Mexican Health and Aging Study. Participants aged 60 and older who had low or no depressive symptoms in 2012 were included in these analyses (N = 4,309). Factor analysis was used to group activities and logistic regression models were used to assess the association of baseline time use with depressive symptomatology in 2015. RESULTS: Among those with low or no depressive symptomatology in 2012, 21.0% reported elevated symptoms (5+) in 2015. Those with elevated depressive symptoms were more likely to be women, older, lower educated, and with at least one activity of daily living limitation. Four time-use domains emerged from the factor analysis including hobbies and indoor activities, volunteering, caregiving, and working. The hobbies and indoor activities domain was associated with lower odds of elevated symptoms for men and women (odds ratio [OR]: 0.76, 95% confidence interval [CI]: 0.61-0.96; and OR: 0.75, 95% CI: 0.61-0.91, respectively). Additionally, the volunteer and community activities domain was associated with lower odds of depressive symptoms for women (OR: 0.72, 95% CI: 0.58-0.89) and men (OR: 0.77, 95% CI: 0.60-0.99). DISCUSSION AND IMPLICATIONS: Understanding how older Mexicans distribute their time among different activities and its associations with depressive symptoms can help guide policy and sex-specific interventions for psychological well-being. Certain domains had lower odds for elevated depressive symptomatology; future work should examine this association in other countries as well as the context of the built environment.