COVID-19 Vaccine Uptake Among Nursing Home Staff via Statewide Policy: The Mississippi Vaccinate or Test Out Policy.

Objectives. To examine whether COVID-19 vaccine mandates that allow a test-out exemption for nursing home staff are associated with increased staff vaccination rates in nursing homes. Methods. Using the National Healthcare Safety Network data, we conducted analyses to test trends over time in statewide staff vaccination rates between June 1, 2021, and August 29, 2021, in Mississippi, 4 adjacent states, and the United States overall. Results. COVID-19 staff vaccination rates increased slowly following Mississippi enacting a vaccinate-or-test-out policy, achieving small, but statistically greater gains than most comparator states. Yet, staff vaccination rates in Mississippi remained well below the national average and similar numerically to surrounding states without mandates. Conclusions. Mississippi's COVID-19 vaccinate-or-test policy was ineffective in meaningfully increasing staff vaccination rates. For COVID-19 nursing home mandates to be effective while still balancing the staff turnover risks, facilities might consider a more stringent or hybrid approach (e.g., test-out option not offered to new staff). Public Health Implications. Statewide COVID-19 vaccine mandates, when given a test-out option, do not appear to be an effective strategy to meaningfully increase nursing home staff COVID-19 vaccination. (Am J Public Health. 2022;112(5):762-765. https://doi.org/10.2105/AJPH.2022.306800).

Aging sexual stereotypes and sexual expression in mid- and later life: examining the stereotype matching effect.

OBJECTIVES: Ageist sexual stereotypes may prohibit midlife and older adults from achieving sexual wellness when stereotypical beliefs about aging, sex, and intimacy become internalized over the life course (i.e. stereotype embodiment). Though there are several studies examining the application of stereotype embodiment theory to various health behaviors, it has not been applied to sexual and intimate health across the life course. The current study examined sexual stereotype embodiment by assessing the impact of aging-sexual-stigma on sexual and intimate activity among midlife and older adults. METHOD: In this cross sectional study, a convenience sample of 972 adults aged 50 and older was recruited via a crowdsourcing platform. Participants completed an online survey assessing attitudes about aging sexuality and their participation in a spectrum of sexual and intimate behaviors. Hierarchical linear regression was used to examine the study hypotheses related to sexual and intimate behaviors among middle age and older adults. RESULTS: Results of this exploratory study suggest that embodiment of sexual stereotypes effects both midlife and older adults, with endorsement of aging sexual stigma predicting lower engagement in both sexual and intimate activities. Sexual embodiment had similar effects across age cohort and gender. CONCLUSION: In addition to pervasive societal impact, ageist sexual stereotypes appear to affect individual sexual health and wellness via internalized beliefs. This provides preliminary evidence for stereotype embodiment in a novel domain, sexual health. Future research should explore potential age and cohort effects across the life course in longitudinal studies with robust measures of aging sexual stigma.

Social Cognitive Theory as a Theoretical Framework to Predict Sexual Risk Behaviors among Older Adults.

OBJECTIVES: Older adults vary in their safe and unsafe sexual behaviors. While researchers are beginning to understand more about the sexual and intimate expression of older adults, only recently are they beginning to understand how older adults make decisions about sexual risk. Bandura's social cognitive theory offers a frame for understanding how self-efficacy, environmental factors, and goal motivation are related to sexual risk behaviors for older adults, including the interplay between these variables. METHODS: Using a diverse sample of older adults (n = 720) age 50+ years, social cognitive theory was modeled to determine the relationship between environment variables (age, gender, and sexual health conversations with practitioners), behavioral variables (self-efficacy), and cognitive variables (importance of sexual wellness goals) with the outcome variable of sexual risk behaviors. RESULTS: Self-efficacy had an indirect effect on sexual risk via sexual wellness goal motivation. Healthcare provider conversations had both direct and indirect effects on older adults' sexual risk through sexual wellness goal motivation. Models were similarly predictive for older men and women. CONCLUSIONS: Sexual risk behaviors among older adults are more influenced by environmental factors in their healthcare settings and their perception and prioritization of sexual wellness goals. CLINICAL IMPLICATIONS: Providers play a key role in initiating and maintaining sexual health discussions with older patients, potentially mitigating sexual risk and bolstering self-efficacy.

Elder sexual abuse and implicit agism: examining the warm-incompetent bias among mock jurors.

Implicit ageist beliefs about the warmth and incompetence of older adults may influence jurors' perceptions and judgments of an older adult's competence in legal cases hinging on capacity and consent, including elder sexual abuse. However, little is known about the nuances of implicit agism in elder sexual abuse cases, and if it can be attenuated. The current study proposed to address these gaps via a randomized vignette design administered to a community sample of 391 US adults. Mock juror participants evaluated an elder sexual abuse case involving an older married couple, in which the victim had dementia. Results suggest that implicit agism was present among mock jurors, consistent with a warm-incompetence bias, and was predictive of mock jurors' guilt ratings. Age- and dementia-relevant jury instructions and mock juror gender were not found to be predictive of guilt ratings. Implicit agism among jurors should be addressed to reduce the potential for implicit age bias to affect elder sexual abuse cases.

Initiating Aha moments when implementing person-centered care in nursing homes: a multi-arm, pre-post intervention.

BACKGROUND: Comprehensive adoption of culture change via person-centered care (PCC) practices in nursing homes has been slow. Change such as this, requires transformation of organizational culture, frequently generating resistance and slow moving change. This study examined how nursing homes perceive their adoption of PCC practices across seven domains and how these perceptions change in response to an educational intervention embedded in a statewide program, Promoting Excellent Alternatives in Kansas nursing homes (PEAK 2.0). Given perception is an important feature of the change process, it was hypothesized that pre-adopters engaging in PEAK 2.0's initial Foundation year (level 0) would have lower perceived PCC adoption following a year of education and exposure to PCC, whereas adopters (PEAK 2.0 level 1-5 homes) would have higher perceived PCC adoption following a year of participation in their respective level in the program. METHODS: A multi-arm, pre/post intervention study was conducted during the 2014 and 2015 years of the PEAK 2.0 program comparing pre-PCC adopters to adopters. Outcomes were self-ratings of perceived PCC implementation across seven domains of PCC at the beginning and end of the 2014-15 program year, after pre-adopters had received PCC education and adopters had implemented a year of PCC. Paired t-tests and mixed repeated-measures linear models, controlling for potential confounders, were employed to test the study hypotheses. RESULTS: Across all seven domains of PCC, pre-adopters rated their PCC implementation as significantly higher on pre-test (2014) than on post-test (2015). In contrast, adopters rated their PCC achievement as higher on post-test (2015) than on pre-test (2014). CONCLUSIONS: Pre-adopters' lower score following a year of education and exposure to PCC may reflect a shift in perceptions of PCC as a concept or a deeper conceptualization of PCC. Since perceptions or assumptions can serve as a source of resistance to change, redefinition or "unlearning" to make way for more accurate definitions of PCC could aid in reducing organizational resistance to implementation of PCC and thus improve the rate of adoption.

Engagement and Adoption of Person-Centered Care: Participant Experiences in the Kansas PEAK 2.0 Program.

The Promoting Excellent Alternatives in Kansas (PEAK) 2.0 program provides training, evaluation, and support in person-centered care (PCC) for nursing homes across Kansas. To represent the participant voice, nursing home employees (N = 141) provided feedback on their experiences and their home's level of engagement in PEAK 2.0 as well as achievement of PCC adoption. Analyses were conducted to capture the positive/negative valence and specificity of their comments and examine how engagement in PEAK 2.0 relates to the process and outcome of PEAK 2.0. Qualitatively, staff participants demonstrated that PEAK 2.0 is viewed positively overall, with approximately twice as many participants with more positive (e.g., community support, satisfaction with resources) than negative (e.g., over-regulation, too structured) comments. Employees reporting moderate engagement in PCC provided the majority of specific suggestions for improvement. In addition, higher levels of engagement were significantly associated with higher levels of PCC achievement. Based on these results, suggestions are offered to enhance nursing staff experiences and engagement that will help support PCC adoption. [Journal of Gerontological Nursing, 45(11), 5-10.].

Content analysis of public opinion on sexual expression and dementia: Implications for nursing home policy development.

PURPOSE: We examined public opinion of sexual expression and dementia to inform nursing home policy and practice. DESIGN AND METHODS: A content analysis was conducted on public comments (N=1194) posted in response to a New York Times article about a highly publicized legal case involving a husband engaging in sexual acts with his wife who had dementia, living in a nursing home. Researchers utilized constant comparative analysis to code the comments; reliability analysis showed moderately strong agreement at the subcategory level. Data were also coded to indicate whether the commenter thought the couple should or should not have been allowed to be sexual. RESULTS: One primary theme was identified: conditions necessary for someone to be sexual. Six categories were identified within this theme, with the public commentary considering factors such as marital relationships, intimacy needs and several sexual consent-related issues as key conditions necessary to be sexual in a nursing home setting. Overall, the majority of commenters were in support of sexual expression for an individual with dementia in the described situation. DISCUSSION: This study revealed sexual expression among individuals with dementia is a contentious issue with strong public opinions about how this should be managed in a nursing home setting. These opinions should be considered as policy related to sexual expression in nursing homes is developed.

Examining aging sexual stigma attitudes among adults by gender, age, and generational status.

OBJECTIVES: Stigma related to later life sexuality could produce detrimental effects for older adults, through individual concerns and limited sexual health care for older adults. Identifying groups at risk for aging sexual stigma will help to focus interventions to reduce it. Accordingly, the purpose of this study was to examine cross-sectional trends in aging sexual stigma attitudes by age group, generational status, and gender. METHOD: An online survey was administered to a national sample of adults via a crowdsourcing tool, in order to examine aging sexual stigma across age groups, generational status, and gender (N = 962; 47.0% male, 52.5% female, and .5% other; mean age = 45 years). An aging sexual stigma index was formulated from the attitudinal items of the Aging Sexual Knowledge and Attitudes Scale. RESULTS: This sample reported moderately permissive attitudes toward aging sexuality, indicating a low level of aging sexual stigma. Though descriptive data showed trends of stigma attitudes increasing with age and later generations, there were no significant differences between age groups or generations in terms of aging sexual stigma beliefs. Men, regardless of age and/or generation, were found to espouse significantly higher stigmatic beliefs than women or those reporting 'other' gender. CONCLUSIONS: Aging sexual stigma beliefs may not be prevalent among the general population as cohorts become more sexually liberal over time, though men appear more susceptible to these beliefs. However, in order to more comprehensively assess aging sexual stigma, future research may benefit from measuring explicit and implicit aging sexual stigma beliefs.

Recommendations for sexual expression management in long-term care: a qualitative needs assessment.

AIMS: To conduct a qualitative needs assessment of Directors of Nursing regarding challenges and recommendations for addressing sexual expression and consent. BACKGROUND: Sexual expression management among long-term care residents is a complex issue for nursing home staff. Little guidance is available for those wanting to follow a person-centred approach. Policies and procedures are needed, and must be usable across long-term care settings. DESIGN: Qualitative design for in-depth exploration. METHODS: Semi-structured interviews were conducted with 20 Directors of Nursing in the spring and summer of 2013, representing a range of regions, facility sizes and resident populations. Interview questions prompted them to identify recommendations that address challenges to improving sexual expression management in long-term care settings. RESULTS: Comparative thematic analysis resulted in several codes, which were grouped into eight overall categories. Recommendation categories that addressed key challenges included: address the issue, make environmental changes, identify staff expertise, provide education and training, assess sexuality initially and recurrently, establish policies/procedures for sexual expression management, develop assessment tools for sexual expression and consent, and clarify legal issues. The recommendation to develop national guidelines was observed across categories. DISCUSSION: Directors of Nursing report several challenges to sexual expression management in their facilities, and perceive their current methods to be ad hoc. A proactive approach to policy and procedure development is needed.

Sexual health discussions with older adult patients during periodic health exams.

INTRODUCTION: Sexual health is an integral part of overall health across the lifespan. In order to address sexual health issues, such as sexually transmitted infections (STIs) and sexual functioning, the sexual history of adult patients should be incorporated as a routine part of the medical history throughout life. Physicians and health-care professionals cite many barriers to attending to and assessing the sexual health needs of older adult patients, underscoring the importance of additional research to improve sexual history taking among older patients. AIM: The purpose of this article is to explore the content and context of physician-patient sexual health discussions during periodic health exams (PHEs) with adults aged 50-80 years. METHODS: Patients completed a pre-visit telephone survey and attended a scheduled PHE with their permission to audio-record the exam. Transcribed audio recordings of 483 PHEs were analyzed according to the principles of qualitative content analysis. MAIN OUTCOME MEASURES: Frequency of sexual history taking components as observed in transcripts of PHEs. Physician characteristics were obtained from health system records and patient characteristics were obtained from the pre-visit survey. RESULTS: Analyses revealed that approximately one-half of the PHEs included some discussion about sexual health, with the majority of those conversations initiated by physicians. A two-level logistic regression model revealed that patient-physician gender concordance, race discordance, and increasing physician age were significantly associated with sexual health discussions. CONCLUSION: Interventions should focus on increasing physician self-efficacy for assessing sexual health in gender discordant and race/ethnicity concordant patient interactions. Interventions for older adults should increase education about sexual health and sexual risk behaviors, as well as empower individuals to seek information from their health-care providers.

Sexual self-esteem and psychosocial functioning in military veterans after cancer.

Little is known about the sexual well-being of male Veteran cancer survivors, or the relationship of sexual concerns to psychosocial adaptation postcancer. This study examined the association between sexual self-esteem and psychosocial concerns in male Veteran cancer survivors. Forty-one male survivors were recruited from a Veterans Affairs (VA) hospital to participate in a pilot study addressing cancer survivorship care for Veterans. Sixty- to 90-minute interviews were conducted, assessing sociodemographic, medical, stress/burden (cancer-related posttraumatic stress disorder [PTSD], depression), and resource (social support, post-traumatic growth) variables. Twenty-one (51.2%) Veteran cancer survivors reported lowered sexual self-esteem as a result of cancer, which corresponded to significantly higher levels of depression and cancer-related PTSD. The lowered sexual self-esteem group also indicated significantly lower social support. Veteran cancer survivors with lowered sexual self-esteem tend to have higher levels of stress and lower levels of resources, putting them at risk for lowered quality of life. This increased risk highlights the importance of addressing sexual well-being in the survivorship care of Veterans.

Person-Centered Sexual Expression: Determining Preferences of Future Nursing Home Residents.

BACKGROUND AND OBJECTIVES: Approaches to sexual expression in nursing homes are often devoid of person-centered components, such as resident choice. Little is known about residents' preferences for sexual and intimate expression across different situations. To evaluate future resident preferences, a convenience sample of 389 midlife and older adults in the United States were assessed for their perceptions of appropriateness of sexual and intimate activity among couples in nursing homes, given certain situational factors (e.g., cognitive impairment, relationship status, assent behaviors). RESEARCH DESIGN AND METHODS: A randomized experimental vignette design was implemented to determine situational factors that influence future resident preferences for sexual expression in nursing homes. Data were analyzed via multilevel modeling, allowing for multiple vignette ratings to be nested among respondents. RESULTS: Behavioral indications of assent, level of intimacy between the couple, and age of respondent affected respondents' ratings of appropriateness of sexual and intimate activities. Also, cognition and relationship levels interacted for more nuanced effects on activity appropriateness. DISCUSSION AND IMPLICATIONS: Future resident preferences are often incongruent with attitudes and common practices for approaching sexual expression in nursing home settings. This marks a unique opportunity for person-centered policy development and implementation in the realm of sexual expression.

"At My Age ": Defining Sexual Wellness in Mid- and Later Life.

Sexual wellness is integral to quality of life across the life span, despite ageist stereotypes suggesting sexual expression ends at midlife. However, conceptualizing sexual wellness in mid- and later life is complicated by a dysfunction-based narrative, lack of a sex-positive aging framework, and existing measures that are age irrelevant and limited in scope. This study aimed to address these limitations by providing a conceptualization of sexual wellness grounded in definitions from midlife and older adults. A sample of 373 midlife and older adults (M = 60, SD = 5.84) in the United States provided a definition of sexual wellness. Using thematic analysis, multiple researchers coded qualitative responses, and results suggested a biopsychosocial-cultural framework. Findings reflect that midlife and older adults provide multifaceted definitions inclusive of various behavioral experiences, including disengaging from sex. They are also keenly aware of physical and psychological limitations and strengths, and emphasize mutual experiences and synchronicity. Midlife and older adults also reflect on age, drawing comparisons to different phases of life and often displaying adaptability in adjusting expectations. When conceptualizing sexual wellness in this population it is imperative to capture this multidimensionality, include those who are not actively engaging in sex, and be aware of the influence of ageist and dys/function narratives.

A Comparison of Actual and Perceived Sexual Risk Among Older Adults.

Sexual risk among older adults (OAs) is prevalent, though little is known about the accuracy of sexual risk perceptions. Thus, the aim was to determine the accuracy of sexual risk perceptions among OAs by examining concordance between self-reported sexual risk behaviors and perceived risk. Data on OAs aged 50 to 92 were collected via Amazon.com's Mechanical Turk. Frequency of sexual risk behaviors (past six months) were reported along with perceived risk, namely, sexually transmitted infection (STI) susceptibility. Accuracy categories (accurate, underestimated, overestimated) were established based on dis/concordance between risk levels (low, moderate, high) and perceived risk (not susceptible, somewhat susceptible, very susceptible). Approximately half of the sample reported engaging in vaginal (49%) and/or oral sex (43%) without a condom in the past six months. However, approximately two-thirds of the sample indicated they were "not susceptible" to STIs. No relationship was found between risk behaviors and risk perceptions, and approximately half (48.1%) of OAs in the sample underestimated their risk. Accuracy was found to decrease as sexual risk level increased, with 93.1% of high-risk OAs underestimating their risk. Several sexual risk behaviors are prevalent among OAs, particularly men. However, perception of risk is often inaccurate and warrants attention.

Actualizing culture change: The Promoting Excellent Alternatives in Kansas Nursing Homes (PEAK 2.0) program.

Nursing homes have been challenged in their attempts to achieve deep, organizational change (i.e., culture change) aimed at providing quality of care and quality of life for nursing home residents through person-centered care. To attain deep change, 2 well-defined components must be in place: a shared understanding of (a) the what, or content goals, and (b) the how, or process of change. However, there are few examples of this at a macro or micro level in long-term care. In an effort to enact true culture change in nursing homes statewide, the Kansas Department for Aging and Disability Services implemented the Promoting Excellent Alternatives in Kansas Nursing Homes program. This program is a Medicaid, pay-for-performance program that formalizes the content and process of achieving culture change through person-centered care principles. This article aims to detail the content (what) and process (how) of a model macro-level program of culture change throughout the State of Kansas. Applications to the micro level (individual homes) are presented, and implications for psychologists' roles in facilitating culture change are discussed. (PsycINFO Database Record

Sexual Consent Capacity Assessment with Older Adults.

Many healthcare providers have a limited knowledge of sexual and intimate expression in later life, often due to attitudinal and informational limitations. Further, the likelihood of an older adult experiencing cognitive decline increases in a long-term care (LTC) setting, complicating the ability of the providers to know if the older adult can make his or her own sexual decisions, or has sexual consent capacity. Thus, the team is left to question if and how to support intimacy and/or sexuality among residents with intimacy needs. Psychologists working with LTC need to be aware and knowledgeable about sexual consent capacity in older adulthood to be prepared to conduct evaluations and participate in planning care. Limited research is available to consult for best practices in sexual consent capacity assessment; however, models of assessment have been developed based on the best available evidence, clinical judgment, and practice. Existing models will be discussed and an integrated model will be illustrated via a case study.

Predicting sexual decline and dissatisfaction among older adults: the role of partnered and individual physical and mental health factors.

OBJECTIVES: To target improvement in older adult sexuality by understanding how a myriad of partnered and individual physical and mental health factors, often associated with aging, affect sexual unwellness. METHOD: Data from the Wisconsin Longitudinal Study were used to conduct a case-control study on the risk factors for sexual unwellness (i.e., lack of sexual satisfaction, inability to maintain the sexual relationship) in older adults aged 63-67. RESULTS: Higher risk for lack of sexual satisfaction was associated with poor spousal health, a history of diabetes, and fatigue symptoms. In addition, being of male gender, being satisfied with marital support, and having better spousal health reduced the risk of being unsatisfied sexually. Also, higher risk for being unable to maintain the sexual relationship was independently associated with a higher education level, poorer self-rated health, better spousal health, a history of diabetes, prostate cancer, fatigue, sexual pain, and a history of depression. DISCUSSION: Results show the impact of several physical and mental health risk factors on the development of sexual unwellness in older adults. A gendered pattern also emerged, suggesting that women tend to be less sexually satisfied, as compared to their male peers, who tend to report sexual unwellness that is associated with individual health.

Sexuality among wounded veterans of Operation Enduring Freedom (OEF), Operation Iraqi Freedom (OIF), and Operation New Dawn (OND): Implications for rehabilitation psychologists.

OBJECTIVE: The sexual lives of returning Operation Enduring Freedom (OEF), Operation Iraqi Freedom (OIF), and Operation New Dawn (OND) veterans have only been discussed minimally in the psychological literature. Given the nature of military social and cultural contexts, the potential for exposure to combat-related stressors that may lead to posttraumatic stress disorder (PTSD), and the risk of traumatic brain injury secondary to physical injury, the potential for significant psychological and relational ramifications exists. This article focuses on the intimate relationships and sexuality of returning OIF/OEF/OND veterans within the context of their personal cultural variables and the diverse experience of being a part of military life. CONCLUSIONS: Culturally competent assessment and evidenced-based treatment approaches are highlighted to offer clinicians initial strategies to begin treatment of sexuality issues within the returning Veteran population. These clinical tools are discussed within a positive psychology approach that emphasizes healthy sexuality as a part of overall satisfactory quality of life.