Impact of a COVID-19-Related Lockdown on the Experience of Informal Caregiving in Singapore.

INTRODUCTION: Lockdowns, while limiting COVID-19 transmission, can affect provision of care by informal caregivers and their caregiving experience. We assessed, among informal caregivers in Singapore, (a) the perceived impact of a 2-month (April to May 2020) nationwide lockdown on their care provision, (b) correlates of different perceptions of the impact of the lockdown on care provision, and (c) association of different perceptions of the impact with negative and positive experiences of caregiving. METHODS: In the August 2020 wave of the Singapore Life Panel (SLP; nationally representative, longitudinal monthly survey of Singapore citizens and permanent residents aged 50-70 years at baseline), 1,094 participants identified as informal caregivers reported whether their care provision became easier, remained the same, or became harder during the lockdown, compared to before the lockdown. We used multinomial logistic regression to assess the association of caregiver, care recipient, and caregiving context characteristics with their perceptions. Linear regression models examined the association of their perceptions with negative and positive experience domains of the modified Caregiver Reaction Assessment. RESULTS: Just over one-third (36.1%) of the informal caregivers reported that their care provision became harder during the lockdown compared to before the lockdown. However, nearly one-fifth (18.0%) said that it became easier, and the rest (45.9%) said that it remained the same. Care provision was more likely to be perceived as having become harder among caregivers who were male, of Chinese ethnicity, in worse health, whose care recipients had functional limitations, who did not have caregiving support from cohabiting family members before the lockdown, and who had caregiving support from non-cohabiting family members before the lockdown. The perception that care provision became easier was less likely among caregivers who were of higher age, were unemployed, were socially isolated, and whose care recipients had functional limitations. Caregivers who perceived that care provision became harder during the lockdown were worse-off in negative experiences of caregiving. CONCLUSION: A nationwide lockdown did not make care provision harder for all informal caregivers. However, informal caregivers for whom it did were more likely to have greater negative experiences of caregiving. The heterogeneity of the impact of lockdowns and the possibility of offering flexibility to non-cohabiting family members who support caregiving should be important considerations when planning for such disruptions.

Child marriage as a risk factor for non-communicable diseases among women in India.

BACKGROUND: Child marriage, defined as marriage under the age of 18 years, remains pervasive in India. Global evidence documents a negative association between child marriage and women's reproductive and sexual health outcomes; however, its relationship with non-communicable diseases (NCDs) remains underexplored. METHODS: We utilize biomarkers and self-reported data from the nationally representative National Family and Health Survey 4 (2015-2016) to examine the associations between child marriage and hypertension, diabetes, heart disease, asthma and thyroid disorder among currently married women (N = 421 107). We use regression models adjusted for a range of demographic and socio-economic controls to assess the association between child marriage and NCDs among women in India. We further assess whether and to what extent these relationships are mediated by early motherhood using the Karlson, Holm and Breen method of decomposition. RESULTS: Child marriage was associated with hypertension [adjusted odds ratio 1.20 (95% CI: 1.17-1.24)], diabetes [1.29 (1.22-1.37)], heart disease [1.27 (1.18-1.36)], asthma [1.19 (1.11-1.28)] and thyroid disorder [1.10 (1.02-1.18)]. Early motherhood also increased the risk of NCDs among women. Furthermore, it emerged as a pathway linking child marriage with hypertension, diabetes and heart disease; however, it provided a partial explanation for the disadvantage associated with child marriages. CONCLUSIONS: Child marriage emerges as a risk factor for NCDs among women in India. Health systems need to recognize the enduring influence of child marriages on women's health and ensure early detection and effective treatment of NCDs for this vulnerable group.

Impact of COVID-19 on perceived wellbeing, self-management and views of novel modalities of care among medically vulnerable patients in Singapore.

OBJECTIVES: This study aims to examine the impact of COVID-19 measures on wellbeing and self-management in medically vulnerable non-COVID patients and their views of novel modalities of care in Singapore. METHODS: Patients with cardiovascular disease (CVD), respiratory disease, chronic kidney disease, diabetes and cancer were recruited from the SingHealth cluster and national cohort of older adults. Data on demographics, chronic conditions and perceived wellbeing were collected using questionnaire. We performed multivariable regression to examine factors associated with perceived wellbeing. Qualitative interviews were conducted to elicit patient's experience and thematically analyzed. RESULTS: A total of 91 patients participated. Male patients compared with female patients perceived a lower impact of the pandemic on subjective wellbeing. Patients with CVD compared to those having conditions other than CVD perceived a lower impact. Impacts of the pandemic were primarily described in relation to emotional distress and interference in maintaining self-care. Hampering of physical activity featured prominently, but most did not seek alternative ways to maintain activity. Despite general willingness to try novel care modalities, lack of physical interaction and communication difficulties were perceived as main barriers. DISCUSSION: Findings underline the need to alleviate emotional distress and develop adaptive strategies to empower patients to maintain wellbeing and self-care.

Prevalence and correlates of use of digital technology for managing hypertension among older adults.

Hypertension is prevalent among older adults (60 years and above), but control of blood pressure (BP) remains suboptimal. While there is increasing interest in using digital technology for managing hypertension, information about the extent and potential correlates of such use among older adults remains scant. We assessed the prevalence and correlates of the use of digital technology for managing hypertension among older adults with hypertension. We also investigated if the use of digital technology was associated with BP or hypertension control. The use of digital technology (internet or digital apps) for information about or managing BP or hypertension was assessed among 1729 older adults diagnosed with hypertension participating in a national survey in Singapore. Regression analysis was used to assess the correlates (based on the Unified Theory of Use and Acceptance of Technology), and whether such use was associated with hypertension control or BP values. Digital technology for managing hypertension was used by 7.1% of older adults with hypertension. Those of higher age and with limitations in one or more activities or instrumental activities of daily living were less likely, while those with secondary education and above, and with stronger social network were more likely to use digital technology. There was no association between the use of digital technology and hypertension control. While users of digital technology had lower systolic (by 2.1 mmHg, adjusted p value = 0.12) and diastolic (by 1.6 mmHg, adjusted p value = 0.13) BP than non-users, the differences were not statistically significant. Given its low prevalence, there is potential for increased use of digital technology for managing hypertension among older adults with hypertension in Singapore. Initiatives to increase digital health use should target specific older adult subgroups.

Derivation, and establishment of the validity and reliability, of the CASP-11-SG quality of life scale among community-dwelling older adults.

PURPOSE: The number and proportion of older adults, aged ≥ 60 years, in Singapore is rapidly increasing. A valid and reliable quality of life (QoL) measure will enable assessment of their situation and help evaluate social and clinical interventions, potentially improving care. This study aims to evaluate the validity and reliability of the control, autonomy, self-realization, and pleasure (CASP)-12v.3 QoL scale and establish a scale suitable for use among older adults in Singapore. METHODS: Data from 3526 community-dwelling older adults from a national survey was used. Measurement properties of the CASP-12v.3 scale were evaluated. Confirmatory factor analysis (CFA; testing single- and two-factor models with residual covariances for negatively worded items and a bifactor model) was performed in half of the sample and exploratory factor analysis (EFA) was performed in the other half. The results led to revised CFA models and the CASP-11-SG scale. The CASP-11-SG scale's measurement properties, convergent, and known-groups validity, and measurement equivalence/invariance (ME/I) across English and Chinese languages were evaluated. RESULTS: Item 3 'I feel free to plan for the future' of the CASP-12v.3 scale had low correlation with other items of the control/autonomy subscale, low item-total correlation and high item-scale correlation. While CFA and EFA supported the two-factor model, removing item 3 improved model fit. The resulting CASP-11-SG scale (Cronbach's alpha: 0.81) demonstrated convergent and known-groups validity and partial ME/I across English and Chinese languages. CONCLUSION: The CASP-11-SG scale, with satisfactory psychometric properties, can be used for assessing QoL among older adults in Singapore.

Prevalence and correlates of medication reminder app 'use and use intention' among older adults.

Background: Medication adherence is relatively poor among older adults. Although there exist medication reminder apps, data on the prevalence and correlates of their 'use and use intention' by older adults are limited. Objective: To examine the prevalence, and socio-demographic and health correlates of medication reminder app use and use intention among older adults in Singapore. Methods: Data from a nationally representative survey of 2228 adults aged 62 years and above, who were taking at least one prescription medication, were analysed. Medication reminder app use (in the past one month) and use intention (in the next one month) were self-reported. Bivariate and multivariable logistic regression models were used to identify the correlates of medication reminder app use and use intention. Results: The prevalence of medication reminder app use and use intention was low at 2.6% (comprising 0.5% for use and 2.1% for use intention). Age, ethnicity, education level, previous participation in information technology/computer-related courses, comorbidity, health literacy, medication adherence and polypharmacy were correlated with app use and use intention in multivariable analyses. Conclusion: The very low prevalence of medication reminder app use and use intention among older adults in Singapore and identified correlates point to opportunities to increase the use of such apps.

Prevalence, Sociodemographic, and Health Correlates of Insufficient Physical Activity and High Sedentary Behavior Among Older Adults in Singapore.

We determined the prevalence and correlates of insufficient physical activity and high sedentary behavior among a nationally representative sample of 2,240 older adults (≥60 years) in Singapore. The Global Physical Activity Questionnaire, administered through face-to-face interviews, assessed physical activity and sedentary behavior. Logistic regression identified the correlates of insufficient physical activity (<600 metabolic equivalent of task minutes/week) and high sedentary behavior (>7 hr/day). The prevalence of insufficient physical activity and high sedentary behavior was 33.7% and 17.3%, respectively. Those older, females, Malays, residing in smaller housing, living with child but no spouse, with functional limitations and sensory impairments (vision/hearing) were more likely to have insufficient physical activity whereas those with tertiary education had lower odds. High sedentary behavior was more likely among those older, with secondary education, preobesity/obesity, and with functional limitations. While policies should encourage all older adults to be physically active, at-risk subgroups identified in our study merit greater attention.

Spillover Effects of COVID-19 on Essential Chronic Care and Ways to Foster Health System Resilience to Support Vulnerable Non-COVID Patients: A Multistakeholder Study.

OBJECTIVES: Little empirical research exists on how key stakeholders involved in the provision of care for chronic conditions and policy planning perceive the indirect or "spillover" effects of the COVID-19 on non-COVID patients. This study aims to explore stakeholder experiences and perspectives of the impact of COVID-19 on the provision of care for chronic conditions, evolving modalities of care, and stakeholder suggestions for improving health system resilience to prepare for future pandemics. DESIGN: Qualitative study design. SETTING AND PARTICIPANTS: This study was conducted during and after the COVID-19 lockdown period in Singapore. We recruited a purposive sample of 51 stakeholders involved in care of non-COVID patients and/or policy planning for chronic disease management. They included health care professionals (micro-level), hospital management officers (meso-level), and government officials (macro-level). METHODS: In-depth semi-structured interviews were conducted. All interviews were digitally recorded, transcribed verbatim, and thematically analyzed. RESULTS: Optimal provision of care for chronic diseases may be compromised through the following processes: lack of "direct" communication between colleagues on clinical cases resulting in rescheduling of patient visits; uncertainty in diagnostic decisions due to protocol revision and lab closure; and limited preparedness to handle non-COVID patients' emotional reactions. Although various digital innovations enhanced access to care, a digital divide exists due to uneven digital literacy and perceived data security risks, thereby hampering wider implementation. To build health system resilience, stakeholders suggested the need to integrate digital care into the information technology ecosystem, develop strategic public-private partnerships for chronic disease management, and give equal attention to the provision of holistic psychosocial and community support for vulnerable non-COVID patients. CONCLUSIONS AND IMPLICATIONS: Findings highlight that strategies to deliver quality chronic care for non-COVID patients in times of public health crisis should include innovative care practices and institutional reconfiguration within the broader health system context.

Association of vision and hearing impairments with quality of life among older adults: Mediation by psychosocial factors.

AIM: Vision impairment (VI) and hearing impairment (HI), alone or in combination (dual sensory impairment [DSI]), are common in older adults. We determined (i) the association of vision and hearing, and of VI only, HI only and DSI, with three psychosocial variables (social network, loneliness, depressive symptoms) and with quality of life (QoL), and (ii) whether the considered psychosocial variables mediate the association of VI only, HI only and DSI with QoL among older adults. METHODS: Cross-sectional survey data for 4077 older adults (≥60 years) from Singapore were analyzed. Those with self-reported fair or poor vision and hearing were considered to have an impairment in that sense. Standard scales were used to assess the psychosocial variables and QoL. Regression and mediation models were used. RESULTS: Those with fair and poor vs. good, vision and hearing generally had poorer psychosocial outcomes and lower QoL. VI only, HI only and DSI were all associated with lower social network, more depressive symptoms and lower QoL. VI only and DSI were associated with more loneliness. Social network, loneliness and depressive symptoms partially mediated the association of VI only, HI only and DSI with QoL, with depressive symptoms being the strongest mediator. CONCLUSIONS: VI and HI, particularly in combination, are associated with poorer psychosocial status and QoL among older adults. Older adults with VI or HI should be screened for depressive symptoms and social risks. Improving social network, loneliness and depressive symptoms among older adults with sensory impairments may enhance their QoL. Geriatr Gerontol Int 2022; 22: 56-62.

Types of Caregiving Experience and Their Association With Caregiver Depressive Symptoms and Quality of Life.

ObjectiveThis study examines distinct types of caregiving experience, each formed by varied combinations of caregiving burden and benefits, and their association with caregiver depressive symptoms and quality of life. Methods: We apply latent profile analysis and multivariable regression to data on 278 caregivers participating in the Caregiving Transitions among Family Caregivers of Elderly Singaporeans (TraCE) study in 2019-2020. Results: We identify four caregiving experience types: (1) balanced (low burden and moderate benefits, 40% of caregivers), (2) satisfied (low burden and high benefits, 33%), (3) intensive (high burden and high benefits, 17%), and (4) dissatisfied (moderate burden and low benefits, 10%). Caregivers with dissatisfied and intensive caregiving experience tend to report higher depressive symptoms and lower quality of life compared to those with satisfied caregiving experience. Discussion: A person-centered approach helps capture the heterogeneity in caregiving experience. Policymakers should develop tailored interventions by caregiving experience types for promoting caregiver well-being.

Gender differences in years of remaining life by living arrangement among older Singaporeans.

Living arrangements of older adults have often been studied as a measure of the support available to them. Given the rapidly ageing and low fertility context of Singapore where the prevalence of older adults living alone and without children is expected to increase, we construct multistate life tables to estimate the number of years that older persons can expect to live in different living arrangements at a population level (population-based) as well as based on their initial living arrangement (status-based). We focus particularly on whether there are gender differences in the expected years of life in different living arrangement states. We use the Panel on Health and Ageing of Singaporean Elderly, a 2009 nationally representative survey of 4990 Singaporeans aged 60 years and older, with follow-up surveys in 2011 and 2015. In calculating the probabilities of transition between different states, we control for number of children, housing type, and time-varying ADL limitations. We find that at age 60, women can expect to spend more than twice the proportion (18%) of their remaining lives living alone compared to men (7%). Status-based estimates indicate that the proportion of remaining years living with a child is higher for women initially living alone, with a spouse only or already with a child, compared to males. Our results indicate that while older women are more likely to live alone compared to their male counterparts, older women living alone are also more likely to transition to living with children. Our research sheds light on the importance of expanding research on life expectancy beyond health, to consider analysis using other forms of social stratification, particularly gender differences in states of living arrangement. SUPPLEMENTARY INFORMATION: The online version of this article contains supplementary material available at 10.1007/s10433-020-00594-3.

Validation and application of a needs-based segmentation tool for cross-country comparisons.

OBJECTIVE: To compare countries' health care needs by segmenting populations into a set of needs-based health states. DATA SOURCES: We used seven waves of the Survey of Health, Aging and Retirement in Europe (SHARE) panel survey data. STUDY DESIGN: We developed the Cross-Country Simple Segmentation Tool (CCSST), a validated clinician-administered instrument for categorizing older individuals by distinct, homogeneous health and related social service needs. Using clinical indicators, self-reported physician diagnosis of chronic disease, and performance-based tests conducted during the survey interview, individuals were assigned to 1-5 global impressions (GI) segments and assessed for having any of the four identifiable complicating factors (CFs). We used Cox proportional hazard models to estimate the risk of mortality by segment. First, we show the segmentation cross-sectionally to assess cross-country differences in the fraction of individuals with different levels of medical needs. Second, we compare the differences in the rate at which individuals transition between those levels and death. DATA COLLECTION/EXTRACTION METHODS: We segmented 270,208 observations (from Austria, Belgium, Czech Republic, Denmark, France, Germany, Greece, Israel, Italy, the Netherlands, Poland, Spain, Sweden, and Switzerland) from 96,396 individuals into GI and CF categories. PRINCIPAL FINDINGS: The CCSST is a valid tool for segmenting populations into needs-based states, showing Switzerland with the lowest fraction of individuals in high medical needs segments, followed by Denmark and Sweden, and Poland with the highest fraction, followed by Italy and Israel. Comparing hazard ratios of transitioning between health states may help identify country-specific areas for analysis of ecological and cultural risk factors. CONCLUSIONS: The CCSST is an innovative tool for aggregate cross-country comparisons of both health needs and transitions between them. A cross-country comparison gives policy makers an effective means of comparing national health system performance and provides targeted guidance on how to identify strategies for curbing the rise of high-need, high-cost patients.

Years of life with and without limitation in physical function and in activities of daily living by body mass index among older adults.

BACKGROUND: While older adults with pre-obesity and Class I obesity have similar or lower mortality risk versus those with normal weight, a heavier body mass index (BMI) may not translate into more healthy life years. Utilizing longitudinal data on 3452 older (≥60 years) Singaporeans, we assessed the association between BMI and years of remaining life overall with and without limitation in physical function and in activities of daily living (ADLs). METHODS: Difficulty in any of nine tasks involving upper or lower extremities was considered as limitation in physical function, and health-related difficulty in any basic ADL or instrumental ADL as limitation in ADLs. We utilized multistate life tables, including BMI as a time-varying covariate. RESULTS: At age 60, life expectancy (LE) was similar for those with normal weight, pre-obesity and obesity. However, those with obesity, versus normal weight, had 6.3 [95% confidence interval: 3.4-9.2] more years with limitation in physical function and 4.9 [3.4-6.5] less years without limitation in physical function. Those with pre-obesity, versus normal weight, also had 3.7 [1.9-5.3] more years with limitation in physical function. The same pattern across BMI categories was observed for years of life with and without limitation in ADLs. In stratified analyses, similar associations of BMI with years of life with and without limitation in physical function and in ADLs were observed across gender, ethnicity, and educational status. CONCLUSIONS: The increasing global prevalence of obesity may result in an increase in years of life with limitation in physical function and in ADLs at older ages. Older adults, their families and healthcare systems should be cognizant of this issue.

Productive aging in India.

With its sociocultural, institutional, and demographic contexts, India offers a unique opportunity to study the dynamics and experiences of aging, especially as it is poised to have a large increase in the number of persons aged 60 and above in the next half a century. In this paper, we focus on the concept of productive aging that emphasizes the active participation of older persons in society. We examine the correlates of productive aging in India, drawing on data from the Building Knowledge Base on Population Aging (BKPAI) survey of 9852 men and women aged 60 years and above in seven states of India in 2011. The productive activities that we examine pertain to four domains: work, contribution to household financial matters, grandparenting, and social engagement. The findings highlight the importance of gender, family structure, and socio-economic status in these different aspects of productive aging. Importantly, the findings show that the effect of the correlates is not the same across the different measures of productive aging. We find that women are less likely than men to engage in all productive activities except for grandparenting, and that living with children and adverse health reduce the likelihood of current employment or financial contributions, but not of social engagement or grandparenting. Greater wealth at older ages reduces the likelihood of employment but increases the likelihood of social engagement and ties. The study contributes to the understanding of opportunities and constraints of productive aging in India and has implications for intergenerational relationships, support and dependencies in old age.