Quality of ethnicity data within Scottish health records and implications of misclassification for ethnic inequalities in severe COVID-19: a national linked data study.

BACKGROUND: We compared the quality of ethnicity coding within the Public Health Scotland Ethnicity Look-up (PHS-EL) dataset, and other National Health Service datasets, with the 2011 Scottish Census. METHODS: Measures of quality included the level of missingness and misclassification. We examined the impact of misclassification using Cox proportional hazards to compare the risk of severe coronavirus disease (COVID-19) (hospitalization & death) by ethnic group. RESULTS: Misclassification within PHS-EL was higher for all minority ethnic groups [12.5 to 69.1%] compared with the White Scottish majority [5.1%] and highest in the White Gypsy/Traveller group [69.1%]. Missingness in PHS-EL was highest among the White Other British group [39%] and lowest among the Pakistani group [17%]. PHS-EL data often underestimated severe COVID-19 risk compared with Census data. e.g. in the White Gypsy/Traveller group the Hazard Ratio (HR) was 1.68 [95% Confidence Intervals (CI): 1.03, 2.74] compared with the White Scottish majority using Census ethnicity data and 0.73 [95% CI: 0.10, 5.15] using PHS-EL data; and HR was 2.03 [95% CI: 1.20, 3.44] in the Census for the Bangladeshi group versus 1.45 [95% CI: 0.75, 2.78] in PHS-EL. CONCLUSIONS: Poor quality ethnicity coding in health records can bias estimates, thereby threatening monitoring and understanding ethnic inequalities in health.

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.

Region of birth differences in healthcare navigation and optimisation: the interplay of racial discrimination and socioeconomic position.

BACKGROUND: While a large body of research has documented socioeconomic and migrant inequities in the effective use of healthcare services, the reasons underlying such inequities are yet to be fully understood. This study assesses the interplay between racial discrimination and socioeconomic position, as conceptualised by Bourdieu, and their contributions to healthcare navigation and optimisation. METHODS: Using a cross-sectional survey in Luxembourg we collected data from individuals with wide-ranging migration and socioeconomic profiles. We fitted sequential multiple linear and logistic regressions to investigate the relationships between healthcare service navigation and optimisation with perceived racial discrimination and socioeconomic position measured by economic, cultural and social capital. We also investigated whether the ownership of these capitals moderates the experience of racial discrimination in healthcare settings. RESULTS: We observed important disparities in healthcare navigation among different migrant communities. These differences were explained by accounting for the experience of racial discrimination. Racial discrimination was also negatively related with the extent of healthcare services optimisation. However, the impact of discrimination on both health service navigation and optimisation was reduced after accounting for social capital. Higher volumes of economic and social capital were associated with better healthcare experience, and with a lower probability of perceived racial discrimination. CONCLUSIONS: Racial discrimination plays a substantial role in accounting for inequality in healthcare service navigation by different migrant groups. This study highlights the need to consider the complex interplay between different forms of economic, cultural and social capital and racial discrimination when examining migrant, and racial/ethnic differences in healthcare. Healthcare inequalities arising from socioeconomic position and racism need to be addressed via multilevel policies and interventions that simultaneously tackle structural, interpersonal, and institutional dimensions of racism.

The practice of participatory action research: Complicity, power and prestige in dialogue with the 'racialised mad'.

Mental health service users in the UK have become increasingly involved in research over the last 2 decades partly as a consequence of research governance. Ethnic minority service users, however, point to power imbalances stemming from marginalisation and discrimination creating barriers to knowledge co-production (Kalathil, J. (2013). Hard to reach? Racialised groups and mental health service user involvement.). Heavily influenced by Freire's liberatory education, participatory action research (PAR) repoliticises participation where those most affected by injustice are central in both producing knowledge about injustice and implementing solutions. Ethnic minority people with lived experience of 'severe mental illness' ('the racialised mad') were appointed as coresearchers to work with academic researchers on a qualitative study exploring ethnic inequalities in 'severe mental illness'. Drawing on Foucault's notion of power as relational, we focus on three key aspects of productive power: (1) relational engagement and reciprocity, (2) positioning coresearchers as authentic researchers and (3) adopting an ethic of care, to explore complicity and resistance in reproducing hierarchies of knowledge and power when attempting to create and sustain a PAR process for collective analysis, action and solidarity. We utilise retrospective and recorded reflections over the course of the project. Finally, we discuss the ethical and methodological implications for contemporary sociological research into health and illness.

Identifying evidence of effectiveness in the co-creation of research: a systematic review and meta-analysis of the international healthcare literature.

BACKGROUND: To investigate and address the evidence gap on the effectiveness of co-creation/production in international health research. METHODS: An initial systematic search of previous reviews published by 22 July 2017 in Medline, Embase, PsycINFO, Scopus and Web of Science. We extracted reported aims, elements and outcomes of co-creation/production from 50 reviews; however, reviews rarely tested effectiveness against intended outcomes. We therefore checked the reference lists in 13 included systematic reviews that cited quantitative studies involving the public/patients in the design and/or implementation of research projects to conduct meta-analyses on their effectiveness using standardized mean difference (SMD). RESULTS: Twenty-six primary studies were included, showing moderate positive effects for community functions (SMD = 0.56, 95%CI = 0.29-0.84, n = 11) and small positive effects for physical health (SMD = 0.25, 95%CI = 0.07-0.42, n = 9), health-promoting behaviour (SMD = 0.14, 95%CI = 0.03-0.26, n = 11), self-efficacy (SMD = 0.34, 95%CI = 0.01-0.67, n = 3) and health service access/receipt (SMD = 0.36, 95%CI = 0.21-0.52, n = 12). Non-academic stakeholders that co-created more than one research stage showed significantly favourable mental health outcomes. However, co-creation was rarely extended to later stages (evaluation/dissemination), with few studies specifically with ethnic minority groups. CONCLUSIONS: The co-creation of research may improve several health-related outcomes and public health more broadly, but research is lacking on its longer term effects.

Healthcare system performance and socioeconomic inequalities in hearing and visual impairments in 17 European countries.

BACKGROUND: Socioeconomic status is associated with health status among older adults, including hearing and vision impairments, and healthcare system performance is an important consideration in examining that association. We explored the link between a country's healthcare system performance and the hearing and visual impairments of its people in Europe. METHODS: This study enrolled 65 332 individuals aged 50+ from 17 countries participating in the Survey of Health, Ageing and Retirement in Europe Wave 6. We used latent class analysis to identify groups of countries based on six domains of healthcare system performance. We then performed multiple logistic regressions to quantify the association between socioeconomic status and hearing and visual impairments adjusted for demographic and other co-variates; finally, we compared the patterns of observed associations in each of the country groups. RESULTS: The latent class analysis separated countries into three groups based on the performance of their healthcare systems: poor, moderate and high. Respondents in countries with moderate and poor healthcare performance were more likely to experience hearing and visual impairment than those in countries with high healthcare performance. With respect to hearing and visual impairments, wealth gradients at the individual level varied among countries in different healthcare performance groups, with less wealth associated with worse hearing and seeing only in the countries with moderate and poor healthcare performance. CONCLUSION: The relationships between wealth and hearing and visual impairments differ among countries with different healthcare performance.

A Bourdieusian approach to class-related inequalities: the role of capitals and capital structure in the utilisation of healthcare services in later life.

This paper draws on Bourdieu's theory of economic, social and cultural capital to understand the relative effect of the volume and the composition of these capitals on healthcare service use in later life. Based on data from the fifth wave of the Survey of Health, Aging, and Retirement in Europe (n = 64,840), we first look at the contribution of each capital in the use of three healthcare services (general practitioner, dentist and hospital). Using cluster analysis, we then mobilise Bourdieu's concept of habitus to explain how the unequal distribution of material and non-material capitals acquired in childhood lead to different levels of health and hospital care utilisation in later life. After controlling for demographic and health insurance variables, our results show that economic capital has the strongest individual association among the three capitals. However, the results of a cluster analysis used to distinguish between capital structures show that those with high non-material capital and low material capital have higher levels of primary healthcare utilisation, and in turn lower levels of hospital use. Bourdieu's approach sheds light on the importance of capitals in all forms and structures to understand the class-related mechanisms that contribute to different levels of healthcare use.

Where next for understanding race/ethnic inequalities in severe mental illness? Structural, interpersonal and institutional racism.

In this article we use the example of race/ethnic inequalities in severe mental illness to demonstrate the utility of a novel integrative approach to theorising the role of racism in generating inequality. Ethnic minority people in the UK are at much greater risk than White British people of being diagnosed with a severe - psychosis related - mental illness, and this is particularly the case for those with Black Caribbean or Black African origins. There is entrenched dispute about how we might understand the drivers of this inequality. To address this dispute we build on, and to a certain extent refine, established approaches to theorising structural and institutional racism, and integrate this within a theoretical framework that also incorporates racist/discriminatory interactions (interpersonal racism). We argue that this provides a conceptually robust and thorough analysis of the role of inter-related dimensions of racism in shaping risks of severe mental illness, access to care, and policy and practice responses. This analysis carries implications for a broader, but integrated, understanding of the fundamental drives of race/ethnic inequalities in health and for an anti-racism public health agenda.

Ethnic inequalities in the incidence of diagnosis of severe mental illness in England: a systematic review and new meta-analyses for non-affective and affective psychoses.

PURPOSE: Although excess risks particularly for a diagnosis of schizophrenia have been identified for ethnic minority people in England and other contexts, we sought to identify and synthesise up-to-date evidence (2018) for affective in addition to non-affective psychoses by specific ethnic groups in England. METHODS: Systematic review and meta-analysis of ethnic differences in diagnosed incidence of psychoses in England, searching nine databases for reviews (citing relevant studies up to 2009) and an updated search in three databases for studies between 2010 and 2018. Studies from both searches were combined in meta-analyses allowing coverage of more specific ethnic groups than previously. RESULTS: We included 28 primary studies. Relative to the majority population, significantly higher risks of diagnosed schizophrenia were found in Black African (Relative risk, RR 5.72, 95% CI 3.87-8.46, n = 9); Black Caribbean (RR 5.20, 95% CI 4.33-6.24, n = 21); South Asian (RR 2.27, 95% CI 1.63-3.16, n = 14); White Other (RR 2.24, 95% CI 1.59-3.14, n = 9); and Mixed Ethnicity people (RR 2.24, 95% CI 1.32-3.80, n = 4). Significantly higher risks for diagnosed affective psychoses were also revealed: Black African (RR 4.07, 95% CI 2.27-7.28, n = 5); Black Caribbean (RR 2.91, 95% CI 1.78-4.74, n = 16); South Asian (RR 1.71, 95% CI 1.07-2.72, n = 8); White Other (RR 1.55, 95% CI 1.32-1.83, n = 5); Mixed Ethnicity (RR 6.16, 95% CI 3.99-9.52, n = 4). CONCLUSIONS: The risk for a diagnosis of non-affective and affective psychoses is particularly elevated for Black ethnic groups, but is higher for all ethnic minority groups including those previously not assessed through meta-analyses (White Other, Mixed Ethnicity). This calls for further research on broader disadvantages affecting ethnic minority people.

Ethnic inequalities and pathways to care in psychosis in England: a systematic review and meta-analysis.

BACKGROUND: As part of a national programme to tackle ethnic inequalities, we conducted a systematic review and meta-analysis of research on ethnic inequalities in pathways to care for adults with psychosis living in England and/or Wales. METHODS: Nine databases were searched from inception to 03.07.17 for previous systematic reviews, including forward and backward citation tracking and a PROSPERO search to identify ongoing reviews. We then carried forward relevant primary studies from included reviews (with the latest meta-analyses reporting on research up to 2012), supplemented by a search on 18.10.17 in MEDLINE, Embase, PsycINFO and CINAHL for primary studies between 2012 and 2017 that had not been covered by previous meta-analyses. RESULTS: Forty studies, all conducted in England, were included for our updated meta-analyses on pathways to care. Relative to the White reference group, elevated rates of civil detentions were found for Black Caribbean (OR = 3.43, 95% CI = 2.68 to 4.40, n = 18), Black African (OR = 3.11, 95% CI = 2.40 to 4.02, n = 6), and South Asian patients (OR = 1.50, 95% CI 1.07 to 2.12, n = 10). Analyses of each Mental Health Act section revealed significantly higher rates for Black people under (civil) Section 2 (OR = 1.53, 95% CI = 1.11 to 2.11, n = 3). Rates in repeat admissions were significantly higher than in first admission for South Asian patients (between-group difference p < 0.01). Some ethnic groups had more police contact (Black African OR = 3.60, 95% CI = 2.15 to 6.05, n = 2; Black Caribbean OR = 2.64, 95% CI = 1.88 to 3.72, n = 8) and criminal justice system involvement (Black Caribbean OR = 2.76, 95% CI = 2.02 to 3.78, n = 5; Black African OR = 1.92, 95% CI = 1.32 to 2.78, n = 3). The White Other patients also showed greater police and criminal justice system involvement than White British patients (OR = 1.49, 95% CI = 1.03 to 2.15, n = 4). General practitioner involvement was less likely for Black than the White reference group. No significant variations over time were found across all the main outcomes. CONCLUSIONS: Our updated meta-analyses reveal persisting but not significantly worsening patterns of ethnic inequalities in pathways to psychiatric care, particularly affecting Black groups. This provides a comprehensive evidence base from which to inform policy and practice amidst a prospective Mental Health Act reform. TRIAL REGISTRATION: CRD42017071663.

Making a difference: ethnic inequality and severe mental illness.

In this paper, we explore ethnic inequalities in severe mental illness and care experiences. We consider the barriers to progressive and cohesive action and propose ways of overcoming these. Clinical and policy leadership must bring together hidden patient voices, divergent professional narratives and quality research.Declaration of interestK.B. is Editor of the British Journal of Psychiatry, but has not played any role in the decision-making for this paper. K.B. leads and J.N. is a partner and K.H. a researcher in the Synergi Collaborative Centre.

Investigating ethnic variations in reporting of psychotic symptoms: a multiple-group confirmatory factor analysis of the Psychosis Screening Questionnaire.

BACKGROUND: Epidemiological evidence suggests risk for psychosis varies with ethnicity in Western countries. However, there is little evidence to date on the cross-cultural validity of screening instruments used for such comparisons. METHODS: Combining two existing UK population-based cohorts, we examined risk for reporting psychotic symptoms across White British (n = 3467), White Irish (n = 851), Caribbean (n = 1899), Indian (n = 2590), Pakistani (n = 1956) and Bangladeshi groups (n = 1248). We assessed the psychometric properties of the Psychosis Screening Questionnaire (PSQ) with a multiple-group confirmatory factor analysis, assessing the equivalence of factor loadings, response thresholds and residual variances in an analysis of measurement non-invariance. RESULTS: Compared with prevalence among British Whites (5.4%), the prevalence of self-reported psychotic symptoms was greater in the Caribbean group (12.7%, adjusted OR = 2.38 [95% CI 1.84-3.07]). Prevalence was also increased among Pakistani individuals (8.3%, adjusted OR = 1.36 [1.01-1.84]) although this difference was driven by a greater likelihood of reporting paranoid symptoms. PSQ items for thought interference, strange experience and hallucination were measured in equivalent ways across ethnic groups. However, our measurement models suggested that paranoid symptoms were measured less reliably among ethnic minorities than among British Whites and appeared to exaggerate latent differences between Pakistani and White British groups when measurement non-invariance was not accounted for. CONCLUSIONS: Notwithstanding evidence for measurement non-invariance, the greater risk for reporting psychotic symptoms among Caribbean individuals is unlikely to be an artefact of measurement. Greater residual variance in the recording of paranoid symptoms among ethnic minority respondents warrants caution in using this item to investigate ethnic variation in psychosis risk.

Dementia across local districts in England 2014 to 2015.

BACKGROUND: The number of older people needing dementia care is projected to rise rapidly, and local districts are now charged with responding to this need. But evidence on local area factors of dementia is scarce. We studied the odds of dementia prevalence and its individual risk factors enriched with area factors. MATERIALS AND METHODS: This study analysed objectively assigned dementia prevalence in people aged 60 and over living in community in England, drawing data from the English Longitudinal Study of Ageing 2014 to 2015 and local districts statistics using multilevel logistic models. Dementia status is ascertained using a modified version of the Telephone Interview for Cognitive Status. A number of individual risk factors were considered including social determinants, internet use, social connections, and health behaviours; 2 contextual factors were included: the index of multiple deprivation and land use mix. RESULTS: The prevalence of dementia by this method is 8.8% (95% confidence interval 7.7%-9.2%) in older adults in England. Maps of dementia prevalence across districts showed prevalent areas. In the full model, no area characteristics were significant in predicting dementia prevalence. Education, social connections, internet use, and moderate to vigorous physical activity showed protective associations. CONCLUSION: Dementia in older adults in England is largely predicted by individual characteristics, although some districts have a large share of their population with dementia. Given the health and social care costs associated with dementia, differential interventions and support to districts and to groups of individuals defined by these characteristics seem warranted.

Visual and hearing impairments are associated with cognitive decline in older people.

INTRODUCTION: highly prevalagent hearing and vision sensory impairments among older people may contribute to the risk of cognitive decline and pathological impairments including dementia.This study aims to determine whether single and dual sensory impairment (hearing and/or vision) are independently associated with cognitive decline among older adults and to describe cognitive trajectories according to their impairment pattern. MATERIAL AND METHODS: we used data from totals of 13,123, 11,417 and 21,265 respondents aged 50+ at baseline from the Health and Retirement Study (HRS), the English Longitudinal Study of Ageing (ELSA) and the Survey of Health, Ageing and Retirement in Europe (SHARE), respectively. We performed growth curve analysis to identify cognitive trajectories, and a joint model was used to deal with attrition problems in longitudinal ageing surveys. RESULTS: respondents with a single sensory impairment had lower episodic memory score than those without sensory impairment in HRS (ß = -0.15, P < 0.001), ELSA (ß = -0.14, P < 0.001) and SHARE (ß = -0.26, P < 0.001). The analysis further shows that older adults with dual sensory impairment in HRS (ß = -0.25, P < 0.001), ELSA (ß = -0.35, P < 0.001) and SHARE (ß = -0.68, P < 0.001) remembered fewer words compared with those with no sensory impairment. The stronger associations between sensory impairment and lower episodic memory levels were found in the joint model which accounted for attrition. CONCLUSIONS: hearing and/or vision impairments are a marker for the risk of cognitive decline that could inform preventative interventions to maximise cognitive health and longevity. Further studies are needed to investigate how sensory markers could inform strategies to improve cognitive ageing.

Ethnic differences in women's use of mental health services: do social networks play a role? Findings from a national survey.

OBJECTIVES: The reasons for ethnic differences in women's mental health service use in England remain unclear. The aims of this study were to ascertain: ethnic differences in women's usage of mental health services, if social networks are independently associated with service use, and if the association between women's social networks and service use varies between ethnic groups. DESIGN: Logistic regression modelling of nationally representative data from the Ethnic Minority Psychiatric Illness Rates in the Community (EMPIRIC) survey conducted in England. The analytic sample (2260 women, aged 16-74 years) was drawn from the representative subsample of 2340 women in EMPIRIC for whom data on mental health services, and social networks were available. RESULTS: Pakistani and Bangladeshi women were less likely than White women to have used mental health services (Pakistani OR = 0.23, CI = 0.08-0.65, p = .005; Bangladeshi OR = 0.25, CI = 0.07-0.86, p = .027). Frequent contact with relatives reduced mental health service use (OR = 0.45, CI = 0.23-0.89, p = .023). An increase in perceived inadequate support in women's close networks was associated with increased odds of using mental health services (OR = 1.91, CI = 1.11-3.27, p = .019). The influence of social networks on mental health service use did not differ between ethnic groups. CONCLUSIONS: The differential treatment of women from Pakistani and Bangladeshi ethnic groups in primary care settings could be a possible reason for the observed differences in mental health service use.

Optimal Network for Patients with Severe Mental Illness: A Social Network Analysis.

It is still unclear what the optimal structure of mental health care networks should be. We examine whether certain types of network structure have been associated with improved continuity of care and greater social integration. A social network survey was carried out, covering 954 patients across 19 mental health networks in Belgium in 2014. We found continuity of care to be associated with large, centralized, and homophilous networks, whereas social integration was associated with smaller, centralized, and heterophilous networks. Two important goals of mental health service provision, continuity of care and social integration, are associated with different types of network. Further research is needed to ascertain the direction of this association.

Reviving the 'double jeopardy' hypothesis: physical health inequalities, ethnicity and severe mental illness.

People with severe mental illness (SMI) experience a reduction in life expectancy of 15-20 years. Physical health and mortality experience may be even worse for ethnic minority groups with SMI, but evidence is limited. We suggest clinical, policy and research recommendations to address this inequality.

Cumulative Effect of Racial Discrimination on the Mental Health of Ethnic Minorities in the United Kingdom.

OBJECTIVES: To examine the longitudinal association between cumulative exposure to racial discrimination and changes in the mental health of ethnic minority people. METHODS: We used data from 4 waves (2009-2013) of the UK Household Longitudinal Study, a longitudinal household panel survey of approximately 40 000 households, including an ethnic minority boost sample of approximately 4000 households. RESULTS: Ethnic minority people who reported exposure to racial discrimination at 1 time point had 12-Item Short Form Health Survey (SF-12) mental component scores 1.93 (95% confidence interval [CI] = -3.31, -0.56) points lower than did those who reported no exposure to racial discrimination, whereas those who had been exposed to 2 or more domains of racial discrimination, at 2 different time points, had SF-12 mental component scores 8.26 (95% CI = -13.33, -3.18) points lower than did those who reported no experiences of racial discrimination. Controlling for racial discrimination and other socioeconomic factors reduced ethnic inequalities in mental health. CONCLUSIONS: Cumulative exposure to racial discrimination has incremental negative long-term effects on the mental health of ethnic minority people in the United Kingdom. Studies that examine exposure to racial discrimination at 1 point in time may underestimate the contribution of racism to poor health.

Physical activity in older age: perspectives for healthy ageing and frailty.

Regular physical activity helps to improve physical and mental functions as well as reverse some effects of chronic disease to keep older people mobile and independent. Despite the highly publicised benefits of physical activity, the overwhelming majority of older people in the United Kingdom do not meet the minimum physical activity levels needed to maintain health. The sedentary lifestyles that predominate in older age results in premature onset of ill health, disease and frailty. Local authorities have a responsibility to promote physical activity amongst older people, but knowing how to stimulate regular activity at the population-level is challenging. The physiological rationale for physical activity, risks of adverse events, societal and psychological factors are discussed with a view to inform public health initiatives for the relatively healthy older person as well as those with physical frailty. The evidence shows that regular physical activity is safe for healthy and for frail older people and the risks of developing major cardiovascular and metabolic diseases, obesity, falls, cognitive impairments, osteoporosis and muscular weakness are decreased by regularly completing activities ranging from low intensity walking through to more vigorous sports and resistance exercises. Yet, participation in physical activities remains low amongst older adults, particularly those living in less affluent areas. Older people may be encouraged to increase their activities if influenced by clinicians, family or friends, keeping costs low and enjoyment high, facilitating group-based activities and raising self-efficacy for exercise.

Sexual Health and Well-being Among Older Men and Women in England: Findings from the English Longitudinal Study of Ageing.

We describe levels of sexual activity, problems with sexual functioning, and concerns about sexual health among older adults in the English Longitudinal Study of Ageing (ELSA), and associations with age, health, and partnership factors. Specifically, a total of 6,201 core ELSA participants (56 % women) aged 50 to >90 completed a comprehensive Sexual Relationships and Activities questionnaire (SRA-Q) included in ELSA Wave 6 (2012/13). The prevalence of reporting any sexual activity in the last year declined with age, with women less likely than men at all ages to report being sexually active. Poorer health was associated with lower levels of sexual activity and a higher prevalence of problems with sexual functioning, particularly among men. Difficulties most frequently reported by sexually active women related to becoming sexually aroused (32 %) and achieving orgasm (27 %), while for men it was erectile function (39 %). Sexual health concerns most commonly reported by women related to their level of sexual desire (11 %) and frequency of sexual activities (8 %). Among men it was level of sexual desire (15 %) and erectile difficulties (14 %). While the likelihood of reporting sexual health concerns tended to decrease with age in women, the opposite was seen in men. Poor sexual functioning and disagreements with a partner about initiating and/or feeling obligated to have sex were associated with greater concerns about and dissatisfaction with overall sex life. Levels of sexual activity decline with increasing age, although a sizable minority of men and women remain sexually active until the eighth and ninth decades of life. Problems with sexual functioning were relatively common, but overall levels of sexual health concerns were much lower. Sexually active men reported higher levels of concern with their sexual health and sexual dissatisfaction than women at all ages. Older peoples' sexual health should be managed, not just in the context of their age, gender, and general health, but also within their existing sexual relationship.