Women suffer but men die: survey data exploring whether this self-reported health paradox is real or an artefact of gender stereotypes.

BACKGROUND: Despite consistently reporting poorer health, women universally outlive men. We examine whether gender differences in lived circumstances considered, and meaning attributed to SRH by women and men might explain this paradox. METHODS: In an online survey 917 adults rated their health (SRH) and mental health (SRMH) and reflected upon what life experiences they considered in making their ratings. Descriptive findings were sex-disaggregated. The multiple experiences listed were then subject to factor analyses using principal components methods and orthogonal rotation. RESULTS: Women reported poorer SRH and SRMH. They considered a wider range of circumstances, weighing all but self-confidence and behaviors as more important to SRH than did men. Two underlying components, psychosocial context and clinical status were identified overall. Physical health and pain were more important elements of men's clinical status and behaviors. Comparisons with others of the same age played a larger role in male psycho-social context. Two components also underpinned SRMH. These were clinical problems and psycho-social circumstances for which self-confidence was only important among men. CONCLUSIONS: Women's and men's common interpretation of measures like SRH suggests that women's health disadvantage is neither artefactual nor determined by gendered meanings of measures and does not explain the paradox. SRH and SRMH captured social circumstances for all. Convergence of characteristics women and men consider as central to health is evidence of the dynamism of gender with evolving social norms. The remaining divergence speaks to persisting traditional male stereotypes.

Self-reported health and the well-being paradox among community-dwelling older adults: a cross-sectional study using baseline data from the Canadian Longitudinal Study on Aging (CLSA).

BACKGROUND: Self-reported health is a widely used epidemiologic measure, however, the factors that predict self-reported health among community-dwelling older adults (≥65 years), especially those with multimorbidity (≥2 chronic conditions), are poorly understood. Further, it is not known why some older adults self-report their health positively despite the presence of high levels of multimorbidity, a phenomenon known as the well-being paradox. The objectives of this study were to: 1) examine the factors that moderate or mediate the relationship between multimorbidity and self-reported health; 2) identify the factors that predict high self-reported health; and 3) determine whether these same factors predict high self-reported health among those with high levels of multimorbidity to better understand the well-being paradox. METHODS: A cross-sectional analysis of baseline data from the Canadian Longitudinal Study on Aging was completed (n = 21,503). Bivariate stratified analyses were used to explore whether each factor moderated or mediated the relationship between multimorbidity and self-reported health. Logistic regression was used to determine the factors that predict high self-reported health in the general population of community-dwelling older adults and those displaying the well-being paradox. RESULTS: None of the factors explored in this study moderated or mediated the relationship between multimorbidity and self-reported health, yet all were independently associated with self-reported health. The 'top five' factors predicting high self-reported health in the general older adult population were: lower level of multimorbidity (odds ratio [OR] 0.75, 95% confidence interval [CI] 0.74-0.76), female sex (OR 0.62, CI 0.57-0.68), higher Life Space Index score (OR 1.01, CI 1.01-1.01), higher functional resilience (OR 1.16, CI 1.14-1.19), and higher psychological resilience (OR 1.26, CI 1.23-1.29). These same 'top five' factors predicted high self-reported health among the subset of this population with the well-being paradox. CONCLUSIONS: The factors that predict high self-reported health in the general population of older adults are the same for the subset of this population with the well-being paradox. A number of these factors are potentially modifiable and can be the target of future interventions to improve the self-reported health of this population.

The intersectional impact of sex and social factors on subjective health: analysis of the Canadian longitudinal study on aging (CLSA).

BACKGROUND: Self-rated health (SRH) is a widely validated measure of the general health of older adults. Our aim was to understand what factors shape individual perceptions of health and, in particular, whether those perceptions vary for men and women and across social locations. METHODS: We used data from the Canadian Longitudinal Study on Aging (CLSA) of community-dwelling adults aged 45 to 85. SRH was measured via a standard single question. Multiple Poisson regression identified individual, behavioural, and social factors related to SRH. Intersections between sex, education, wealth, and rural/urban status, and individual and joint cluster effects on SRH were quantified using multilevel models. RESULTS: After adjustment for relevant confounders, women were 43% less likely to report poor SRH. The strongest cluster effect was for groupings by wealth (21%). When wealth clusters were subdivided by sex or education the overall effect on SRH reduced to 15%. The largest variation in SRH (13.6%) was observed for intersections of sex, wealth, and rural/urban status. In contrast, interactions between sex and social factors were not significant, demonstrating that the complex interplay of sex and social location was only revealed when intersectional methods were employed. CONCLUSIONS: Sex and social factors affected older adults' perceptions of health in complex ways that only became apparent when multilevel analyses were carried out. Utilizing intersectionality analysis is a novel and nuanced approach for disentangling explanations for subjective health outcomes.

A sex/gender perspective on interventions to promote children's and adolescents' overall physical activity: results from genEffects systematic review.

BACKGROUND: To evaluate the effects of interventions on children's and adolescents' overall physical activity (PA) for boys and girls separately and to appraise the extent to which the studies haven taken sex/gender into account. METHODS: Systematic review and semi-quantitative analysis. Eleven electronic databases were searched to identify all relevant randomized and non-randomized controlled trials. Studies had to report overall PA as the main outcome to be eligible for inclusion in the review. The main outcomes of the studies is a quantified measure of overall PA. Additionally, all studies had to report sex/gender disaggregated overall PA at baseline and/or follow up and/or explain how they dealt with sex/gender during outcome analysis (i.e., sex/gender adjusted analyses) and/or report that there were no differences in the outcome when looking at sex/gender. PRISMA guidelines were followed. Two authors independently screened studies for eligibility and assessed the risk of bias. Semi-quantitative analyses were conducted to evaluate intervention effects, taking into account the extent to which studies have considered sex/gender aspects. To evaluate sex/gender considerations in primary studies, a newly developed sex/gender checklist was used. The study was registered previously (registration number CRD42018109528). RESULTS: In total, 97 articles reporting 94 unique studies with 164 outcomes for overall PA were included in the present review. Average sample size was 829 participants, ranging from five to 9839. Participants' ages ranged from three to 19 years. Our review shows that overall 35% of PA outcomes had significant effects in increasing overall PA of children and adolescents. Not including single sex/gender studies, 105 out of 120 PA outcomes resulted in same intervention effects for boys and girls. The interventions reported to have similar effects on PA outcomes for boys and girls showed higher quality of reporting sex/gender aspects of measurement instruments, participant flow and intervention content and materials than PA outcomes with effects only in boys or only in girls. Overall, consideration of sex/gender aspects in intervention studies is low. CONCLUSIONS: There is still a need to address sufficient consideration of sex/gender aspects in developing and implementing interventions in the context of PA.

Sex, drugs, risk and resilience: analysis of data from the Canadian Health Behaviour in School-aged Children (HBSC) study.

Background: Risk-taking behaviour among adolescents, particularly those experiencing childhood adversities, can predispose to injury, unwanted pregnancy, long-term morbidity and death. Resilience, i.e. adapting to threats and thriving, has rarely been examined as a protective factor for adolescent risk-taking. We studied whether the malleable traits of empathy, confidence, self-control and optimism, all markers of resilience, align with decreased risk-taking despite adversity, among 11-15 year olds. Methods: From responses of 22 643 Canadian youth to the Health Behaviour in School-aged Children (2014) survey we validated a five-item resilience scale. Using regression analyses, this scale and a single measure of self-control were considered as potential protective factors for a composite measure of risk-taking behaviour and of initiation of sexual activity before age 14. Results: There was a dose-dependent association between greater resilience and diminished risk-taking for boys and, even more so, among girls. This relationship remained significant after controlling for family and social support, implying that greater resilience may override the detrimental impact of childhood adversity on risk-taking. The least resilient youth were most likely to report early sexual activity, although this relationship was not linear. Generally, the impact of self-control on risk-taking was not statistically significant, perhaps because of shortcomings of the self-control indicator. Conclusion: Brief screening protocols can identify assets that protect against risk-taking behaviours among adolescents. The malleable nature of these traits offers primary care providers and public health personnel a novel and effective route to decreasing adolescent risk-taking and fostering future health.

Bridging the gap in genetics: a progressive model for primary to specialist care.

BACKGROUND: The rapid expansion of genetic knowledge, and the implications for healthcare has resulted in an increased role for Primary Care Providers (PCPs) to incorporate genetics into their daily practice. The objective of this study was to explore the self-identified needs, including educational needs, of both urban and rural Primary Care Providers (PCPs) in order to provide genetic care to their patients. METHODS: Using a qualitative grounded theory approach, ten key informant interviews, and one urban and two rural PCP focus groups (FGs) (n = 19) were conducted. All PCPs practiced in Southeastern Ontario. Data was analyzed using a constant comparative method and thematic design. The data reported here represent a subset of a larger study. RESULTS: Participants reported that PCPs have a responsibility to ensure patients receive genetic care. However, specific roles and responsibilities for that care were poorly defined. PCPs identified a need for further education and resources to enable them to provide care for individuals with genetic conditions. Based on the findings, a progressive stepped model that bridges primary and specialty genetic care was developed; the model ranged from PCPs identifying patients with genetic conditions that they could manage alone, to patients who they could manage with informal or electronic consultation to those who clearly required specialist referral. CONCLUSIONS: PCPs identified a need to integrate genetics into primary care practice but they perceived barriers including a lack of knowledge and confidence, access to timely formal and informal consultation and clearly defined roles for themselves and specialists. To address gaps in PCP confidence in providing genetic care, interventions that are directed at accessible just-in-time support and consultation have the potential to empower PCPs to manage patients' genetic conditions. Specific attention to content, timing, and accessibility of educational interventions is critical to address the needs of both urban and rural PCPs. A progressive framework for bridging primary to specialty care through a 'stepped' model for providing continuing medical education, and genetic care can was developed and can be used to guide future design and delivery of educational interventions and resources.

Assessing wellness in the well-child check: What about social and emotional development?

OBJECTIVE: To determine whether Canadian children aged 4 to 6 received well-child checks; to explore the nature of these checkups in a large family practice; and to examine the merit of using parent questionnaires about child resilience as a means of introducing a discussion about social and emotional development into this checkup. DESIGN: Three-part mixed-methods study, using data derived from the Canadian Primary Care Sentinel Surveillance Network (CPCSSN), chart reviews of a family practice, and semistructured interviews with parents. SETTING: Primary care practices associated with CPCSSN, and a large primary care practice in Kingston, Ont. PARTICIPANTS: Patients who were born between 2008 and 2011, and a sample of parents whose children were between the ages of 6 and 9. METHODS: International Classification of Diseases, version 9, codes from CPCSSN records were used to identify the prevalence of well-child checks in the 4-to-6 age group. Then 110 randomly selected charts from a large family practice were audited for inclusion of behavioural and social assessments of those aged 4 to 6. Finally, randomly selected parents from the same practice were invited to pilot-test the PERIK (Positive development and resilience in kindergarten) resilience questionnaire, interviewed about its merit, and asked to recall whether the identified areas of child development had been included in previous well-child checkups. MAIN FINDINGS: Data from CPCSSN indicated that 11% of Canadian children aged 4 to 6 had had an explicit well-child check by their family physician. Among the reviewed charts from the one practice, social context was documented for 45% of them, but social and behavioural development was usually not recorded. The 42 parents interviewed found the PERIK questionnaire useful, but not perfect, for opening discussions about aspects of child development that they had not realized were central to the child's future health. CONCLUSION: This study offers an initial approach to exploring resilience in children and therefore addressing recognized and alterable predictors of adult well-being. Early social and emotional development predicts resilience that, in turn, foreshadows future health. The PERIK questionnaire facilitated discussions that could add tremendous value to the well-child checks of children aged 4 to 6.

Stresses, Strengths and Resilience in Adolescents: A Qualitative Study.

Resilience, or positive adaptation in the face of adversity, mitigates the negative effects of stress and promotes lifelong physical and mental wellbeing. Identifying adolescents who are struggling with stress could provide opportunities for individual clinical preventive interventions. However, resilience assessments are rarely performed in clinical settings and no clear, evidence-based protocols or language for such exploration exist. The aim of this qualitative study was to identify both clinically feasible methods for assessment, and actual findings, regarding stress, supports, attributes, and strategies youth consider most useful for building resilience. We recruited 59 urban and rural dwelling 13-16 year olds from two Canadian primary care practices. Interviewers asked five open-ended questions about sources of stress and resilience and wrote summaries of answers provided. These were then coded. Researchers independently identified conceptual themes, then reached consensus on these. Stress arose from schoolwork and conflicts with friends or family, rather than from socioeconomic adversities. A majority of participants felt able to manage stresses well, finding strength through (1) social connection with family or friends; (2) self-reliant activities including exercise, music or drawing; and (3) personal attributes such as optimism, calmness and competence. They used a variety of approaches to work through stress, many of which align with key domains of resilience, as well as the novel technique of distraction. Ruminating on stress-provoking events made youth feel they were coping poorly. Most participants experienced stress and drew strength from psychosocial and emotional assets, as well as external resources that fostered resilience. Direct, open conversation was particularly effective for building rapport, augmenting strengths by discussing them, and identifying those who were struggling. Similar questions asked in clinical practice may open doors to deep and, perhaps, transformative conversations and evidence-based preventive interventions.

Low Socioeconomic Status but Resilient: Panacea or Double Trouble? John Henryism in the International IMIAS Study of Older Adults.

John Henry (JH) theory provides a framework for understanding the physiological toll exerted on low socioeconomic status (SES) individuals as they overcome psychosocial stressors imposed by their environments. This theory suggests that resilience, a seemingly positive social adaptation, may in fact be physically deleterious. JH theory has been well-described in low-SES rural male African Americans, however it is currently unclear whether validity of this theory extends to women, other races and outside the rural US. We assessed whether, in individuals with low income, there is an association between self-mastery/resilience and either blood pressure or depressive symptoms that is different from the association seen in individuals with higher income. Data were obtained from 1353 older men and women participants of the International Mobility in Aging Study (IMIAS). Across 3 countries and 4 sites, higher self-mastery/resilience was associated with lower depressive symptoms in both low and high income groups. In low income individuals from Saint-Hyacinthe, Québec, higher self-mastery/resilience was associated with both higher mean systolic blood pressure (n = 240, ß = 0.135, p ≤ 0.05) and higher mean diastolic blood pressure (n = 240, ß = 0.241, p ≤ 0.0001). In the high income group of Saint-Hyacinthe, no such associations were observed. The findings in the Saint-Hyacinthe cohort (but not the other settings), are consistent with the John Henry hypothesis, and demonstrates this effect extends beyond a rural African American population. This finding indicates that in certain populations, the positive psychological effects of resilience come with a cost to physical health.

Professionalism, professionalization, expertise and compassion: a qualitative study of medical residents.

BACKGROUND: Formal and informal medical curricula convey expectations about professionalization, that is, the development of physician identity, and also about professionalism. This study examined whether, in general, junior residents experienced any dissonance between these roles and focused particularly on how they negotiated conflicts between compassion, self-care, duty and medical expertise. METHODS: In 2015, purposive sampling was used to select 21 first-year residents at a Canadian medical school. Participants listened to a 5-min audio-recording narrated in either male or female voice. Facing compassion fatigue after three obstetrical disasters over less than 2 days the resident narrator asks to go home. Participants reacted in writing to questions about this request and relevant teaching/modelling. Responses were analyzed using a qualitative, exploratory, thematic research design. RESULTS: Four themes were identified: i) empathy, self-doubt and fear of weakness, ii) the need for support from and communication with physicians and others, iii) education received, and iv) professionalization outranks professionalism. Participants agreed that under the circumstances the narrator's care, compassion and request were appropriate. Never the less, many grappled with feeling that asking to be relieved of work demonstrated weakness and a shirking of responsibility. Respondents had received no formal teaching about balancing compassion for patients or self with professional duty. Preceptors' informal teaching and modeling valorized scientific disengagement above all else. What emerged was participants' drive to become detached clinicians who set aside emotional responses and interactions that could impede and be incompatible with professionalization. However, participants also recognized and lamented what was lost in such a transformation. CONCLUSION: In the transition from student to practitioner, trainees' views and the modeling they receive shift emotion and compassion, whether for self or patients, from assets to liabilities as they aim to be invincible medical experts.

Association between C-reactive protein and physical performance in older populations: results from the International Mobility in Aging Study (IMIAS).

BACKGROUND AND OBJECTIVE: C-reactive protein (CRP) is a widely used cardiovascular risk marker, but questions remain about its role in the disability process in old age. This study examines the associations between CRP levels and physical performance in old age in different societies. METHODS: data were collected during the baseline survey of IMIAS in 2012 in Kingston (Canada), Saint-Hyacinthe (Canada), Manizales (Colombia) and Natal (Brazil). Approximately 200 men and 200 women aged 65-74 were recruited at each site. CRP was assessed using a high sensitivity assay and categorised as low (<1 mg/l), moderate (1-3 mg/l), high (3-10 mg/l) and very high (≥10 mg/l). Participants were interviewed at home; blood pressure, weight and height were measured. Physical function was assessed with the Short Physical Performance Battery (SPPB) and hand grip strength. Data were analysed using descriptive statistics, bivariate analysis (χ²) and linear or logistic regression. RESULTS: CRP was significantly associated with low hand grip strength and poor physical performance in bivariate analyses. Hand grip strength association with CRP disappeared after adjustment by socioeconomic factors and health behaviours. The odds of poor physical function was OR = 2.67 [95% CI 1.43-4.99] comparing the highest and lowest CRP categories after adjustment by relevant covariates. The three SPPB components were assessed separately. Graded associations between low CRP and faster gait speed and shorter time to rise from a chair were observed in adjusted models. Association between impaired balance and CRP was attenuated after adjustment by relevant covariates, OR = 1.15 [0.65-2.04]. CONCLUSIONS: CRP could be a possible pathway from inflammation to physical decline in older populations.

Extent, transparency and impact of industry funding for pelvic mesh research: a review of the literature.

BACKGROUND: Conflicts of interest inherent in industry funding can bias medical research methods, outcomes, reporting and clinical applications. This study explored the extent of funding provided to American physician researchers studying surgical mesh used to treat uterine prolapse or stress urinary incontinence, and whether that funding was declared by researchers or influenced the ethical integrity of resulting publications in peer reviewed journals. METHODS: Publications identified via a Pubmed search (2014-2021) of the terms mesh and pelvic organ prolapse or stress urinary incontinence and with at least one US physician author were reviewed. Using the CMS Open Payments database industry funding received by those MDs in the year before, of and after publication was recorded, as were each study's declarations of funding and 14 quality measures. RESULTS: Fifty-three of the 56 studies reviewed had at least one American MD author who received industry funding in the year of, or one year before or after publication. For 47 articles this funding was not declared. Of 247 physician authors, 60% received > $100 while 13% received $100,000-$1,000,000 of which approximately 60% was undeclared. While 57% of the studies reviewed explicitly concluded that mesh was safe, only 39% of outcomes supported this. Neither the quality indicator of follow-up duration nor overall statements as to mesh safety varied with declaration status. CONCLUSIONS: Journal editors' guidelines re declaring conflicts of interest are not being followed. Financial involvement of industry in mesh research is extensive, often undeclared, and may shape the quality of, and conclusions drawn, resulting in overstated benefit and overuse of pelvic mesh in clinical practice.

A novel online training program for sexual and gender minority health increases allyship in cisgender, heterosexual paramedics.

Introduction: Sexual and gender minorities (SGM) make up 4% of the Canadian population. Due to existing barriers to care in the community, SGM patients may seek more help and be sicker at presentation to hospital. Paramedics occupy a unique role and can remove or decrease these barriers. There are no existing evaluations of training programs in SGM health for prehospital providers. A training program to develop better allyship in paramedics toward SGM populations was developed and assessed. Methods: A 70- to 90-min mandatory, asynchronous, online training module in SGM health in the prehospital environment was developed and delivered via the emergency medical service (EMS) system's learning management system. A before-and-after study of cisgender, heterosexual, frontline paramedics was performed to measure the impact of the training module on the care of SGM patients. The validated Ally Identity Measure (AIM) tool was used to identify success of training and includes subscales of knowledge and skills, openness and support, and oppression awareness. Demographics and satisfaction scores were collected in the posttraining survey. Matched and unmatched pairs of surveys and demographic associations were analyzed using nonparametric statistics. Results: Of 609 paramedics, 571 completed the training, and 239 surveys were completed before and 105 (n = 344) surveys after the training; 60 surveys were paired. Overall AIM scores of matched pairs (n = 60) improved by 12% (p < 0.001), with knowledge and skills accounting for most of the increase (21%, p < 0.001). Unmatched pairs (n = 344) were similar in demographics and scores. Rural paramedics also had significantly lower pretraining oppression awareness scores and had lower posttraining AIM scores compared to suburban paramedics (6% difference). Satisfaction scores rated the training as relevant and applicable (87% and 82%, respectively). Conclusions: A novel prehospital training program in the care of SGM patients resulted in a statistically significant increase in allyship in cisgender, heterosexual-identified frontline paramedics.

Depends on whom you ask: Discordance in reporting spousal care between older women and men across European welfare states.

PURPOSE: We aim to investigate systematic differences in reporting spousal care between caregivers and cared-for persons and their possible effects for the analysis of care regimes and correlation of care with health. MATERIALS AND METHODS: Using information on care provided/received from the Survey on Health, Ageing and Retirement in Europe (SHARE), we estimate the prevalence of spousal care and discordance between caregivers and cared-for persons in the reporting of care among caregiving dyads. Multinomial regressions are used to estimate systematic differences in reporting spousal care. We then use multivariable logistic regressions to assess the association between discordance in reporting informal care and carer's self-rated health (SRH) and depression using the EURO-D scale. RESULTS: Only 53.9 % of dyads report care that is confirmed by both spouses. Multinomial regressions show that agreement on care being provided/received is more common when women are caregivers, while men are likely to underreport when providing or receiving personal care. Prevalence of spousal care across care regimes is sensitive to who reports care. There is no effect on the association of care with SRH regardless of who identifies the carer, while the magnitude and statistical significance of the association between depression symptoms and care varies according to the choice of respondent. CONCLUSIONS: Informal care may be understated across Europe when relying solely on carer self-identification through description of tasks in surveys. From a policy standpoint, relying on self-identification of carers to access support or social benefits may potentially reduce the take-up of such benefits or support.

Gender Disparities in End of Life Care: A Scoping Review.

Objective: Traditional gender norms and expectations may disproportionately constrain in-home palliative care received by women. This scoping review aims to canvass and evaluate the literature on gender disparities in end of life care and explore relevant themes that could inform future research and practice. Methods: A systematic search of MEDLINE, OVID, COCHRANE, and EMBASE was conducted using MeSH terms palliative care, palliative medicine, terminal care, or hospice care, combined with gender equity, sex factors, sexism, or gender disparities. Articles were limited to those in English (2010 to 2021), focusing on end of life care, gender roles, patients, and caregivers. Results: Of 624 articles identified, 15 met inclusion criteria for critical appraisal using the AMSTAR checklist for systematic reviews and NICE guidelines for quantitative and qualitative studies. Most studies were of poor to moderate quality. Thematic analyses identified 6 major themes related to gender disparities: living situation, symptom experience, care context, care preferences, caregiving, and coping strategies. Conclusion: Larger scale research of better quality is needed to fully characterize gender disparities in end of life care and understand how physicians might mitigate these disparities by building awareness of personal gender biases, providing support to families, educating them, and initiating care discussions that overturn traditional and stereotypic gendered expectations.