Leveraging community Wi-Fi and spaces for digital health use.

Digital health disparities continue to affect marginalized populations, especially older adults, individuals with low-income, and racial/ethnic minorities, intensifying the challenges these populations face in accessing healthcare. Bridging this digital divide is essential, as digital access and literacy are social determinants of health that can impact digital health use and access to care. This article discusses the potential of leveraging community Wi-Fi and spaces to improve digital access and digital health use, as well as the challenges and opportunities associated with this strategy. The existing limited evidence has shown the possibility of using community Wi-Fi and spaces, such as public libraries, to facilitate telehealth services. However, privacy and security issues from using public Wi-Fi and spaces remain a concern for librarians and healthcare professionals. To advance digital equity, efforts from multilevel stakeholders to improve users' digital access and literacy and offer tailored technology support in the community are required. Ultimately, leveraging community Wi-Fi and spaces offers a promising avenue to expand digital health accessibility and use, highlighting the critical role of collaborative efforts in overcoming digital health disparities.

Age Disparities in Access to First and Repeat Kidney Transplantation.

BACKGROUND: Evidence suggests that older patients are less frequently placed on the waiting list for kidney transplantation (KT) than their younger counterparts. The trends and magnitude of this age disparity in access to first KT and repeat KT (re-KT) remain unclear. METHODS: Using the US Renal Data System, we identified 2 496 743 adult transplant-naive dialysis patients and 110 338 adult recipients with graft failure between 1995 and 2018. We characterized the secular trends of age disparities and used Cox proportional hazard models to compare the chances of listing and receiving first KT versus re-KT by age (18-64 y versus ≥65 y). RESULTS: Older transplant-naive dialysis patients were less likely to be listed (adjusted hazard ratio [aHR] = 0.18; 95% confidence interval [CI], 0.17-0.18) and receive first KT (aHR = 0.88; 95% CI, 0.87-0.89) compared with their younger counterparts. Additionally, older patients with graft failure had a lower chance of being listed (aHR = 0.40; 95% CI, 0.38-0.41) and receiving re-KT (aHR = 0.76; 95% CI, 0.72-0.81). The magnitude of the age disparity in being listed for first KT was greater than that for re-KT ( Pinteraction < 0.001), and there were no differences in the age disparities in receiving first KT or re-KT ( Pinteraction = 0.13). Between 1995 and 2018, the age disparity in listing for first KT reduced significantly ( P < 0.001), but the age disparities in re-KT remained the same ( P = 0.16). CONCLUSIONS: Age disparities exist in access to both first KT and re-KT; however, some of this disparity is attenuated among older adults with graft failure. As the proportion of older patients with graft failure rises, a better understanding of factors that preclude their candidacy and identification of appropriate older patients are needed.

One Size Fits All-An Underappreciated Health Inequity.

This Viewpoint discusses why health priorities­tailored care, rather than the one-size-fits-all approach, is beneficial for marginalized individuals.

Acceptability and Feasibility of a Pain and Depressive Symptoms Management Intervention in Middle-Aged and Older African American Women.

Background and Objectives: The intersection of race, gender, and age puts older African American women at high risk of experiencing comorbid pain and depressive symptoms. The purpose of this study was to assess the feasibility and acceptability of a 12-week behavioral activation intervention to target self-selected goals related to pain and depressive symptoms in middle-aged and older African American women. Research Design and Methods: This randomized waitlist control study included 34 self-identified African American women, 50 years of age or older, with moderate-to-severe chronic pain and depressive symptoms. The intervention consisted of 8 in-person or virtual 1-hour visits with a nurse. Follow-up acceptability assessments were conducted with 10 participants. Results: The average age of the participants was 64.8 (standard deviation [SD] 10.5). They reported an average pain intensity score of 7.0 (SD 1.9) out of 10 and an average Patient Health Questionnaire-9 depressive symptoms score of 11.9 (SD 4.0) at baseline. Of the 34 participants who consented, 28 (82.4%) women started the intervention and 23 (82.1%) completed the intervention. Participants described the study as useful and beneficial. Participants recommended including a group component in future iterations. Effect sizes at 12 weeks were -0.95 for depressive symptoms indicating a substantial decrease in experienced depressive symptoms, but pain intensity was virtually unchanged (+0.09). Discussion and Implications: The findings of this study demonstrate that the intervention is acceptable among middle-aged and older African American women and their personal goals were met. Including a group component and identifying effective ways to decrease attrition rates will be key in the next steps of development for this intervention. It is crucial to provide tailored, nonpharmacological approaches to pain, and depression symptom management in older adult populations who experience inequities in pain and mental health outcomes. This study emphasizes the importance of participant-driven goal-setting interventions.

Life Space and Activity Space Measurement: Making 'Room' for Structural Racism.

As we age, the ability to move is foundational to health. Life space is one measure of a person's ability to move and engage in activity beyond the home. A separate but related concept is activity space, a measurement of a person's spatial behaviors and visited locations that include social networks, neighborhoods, and institutions. In this article, we integrate the literature on life space and activity space discussing how physical function is not only determined by individual capabilities, but also by the surrounding social and environmental factors which may limit their agency. We show how structural racism contributes to inequities within this paradigm linking related concepts of movement, agency, belonging, and timing. We also explore implications for research and theory for mobility, social connection, and activity.

Resilient Adaptation Strategies: Unveiling Older Adults' Coping Dynamics Amidst the COVID-19 Pandemic.

Older adults, who are particularly vulnerable to coronavirus disease 2019 (COVID-19), exhibit less stress and greater well-being than their younger peers. However, there have been no in-depth explorations of adaptive coping strategies among this population, nor has the role of frailty status been addressed. The current study examined stress and coping in 30 U.S. older adults (mean age = 81 years, range = 68 to 95 years) amidst the COVID-19 pandemic, uncovering themes of: (1) Pandemic Stresses: stresses experienced during the pandemic centered around social isolation and concern for others' well-being; (2) Resilience: older adults proved highly adaptable, with lifetime experience as a stress buffer; and (3) Silver Linings: older adults reported positive by-products, such as reconnecting with and a renewed appreciation for life and nature. Motivation for change and change itself centered around creating value and meaning in the present, especially around social isolation. Findings challenge existing ageist stereotypes, give insight into interventional design, and highlight the importance of ensuring infrastructural and societal support. [Journal of Gerontological Nursing, 49(12), 32-39.].

A Study of Physical Resilience and Aging (SPRING): Conceptual framework, rationale, and study design.

Understanding the physiological basis of physical resilience to clinical stressors is crucial for the well-being of older adults. This article presents a novel framework to discover the biological underpinnings of physical resilience in older adults as part of the "Characterizing Resiliencies to Physical Stressors in Older Adults: A Dynamical Physiological Systems Approach" study, also known as The Study of Physical Resilience and Aging (SPRING). Physical resilience, defined as the capacity of a person to withstand clinical stressors and quickly recover or improve upon a baseline functional level, is examined in adults aged 55 years and older by studying the dynamics of stress response systems. The hypothesis is that well-regulated stress response systems promote physical resilience. The study employs dynamic stimulation tests to assess energy metabolism, the hypothalamic-pituitary-adrenal axis, the autonomic nervous system, and the innate immune system. Baseline characteristics influencing resilience outcomes are identified through deep phenotyping of physical and cognitive function, as well as of biological, environmental, and psychosocial characteristics. SPRING aims to study participants undergoing knee replacement surgery (n = 100), bone and marrow transplantation (n = 100), or anticipating dialysis initiation (n = 60). Phenotypic and functional measures are collected pre-stressor and at multiple times after stressor for up to 12 months to examine resilience trajectories. By improving our understanding of physical resilience in older adults, SPRING has the potential to enhance resilient outcomes to major clinical stressors. The article provides an overview of the study's background, rationale, design, pilot phase, implementation, and implications for improving the health and well-being of older adults.

Clinical trial participation predicts improved survival in older adults receiving allogeneic blood and marrow transplant.

BACKGROUND: Older adults represent a large oncologic demographic and are under-represented within oncology research despite constituting nearly two-thirds of the oncologic population in the United States. Because many social factors influence research participation, those who enroll in research do not reflect the oncology population at large, introducing bias and creating issue with external validity of studies. The same factors that influence study enrollment may also impact cancer outcomes, meaning that those who enroll in studies may already have an improved chance of cancer survival, further skewing results of these studies. This study evaluates characteristics that influence study enrollment in older adults and explore to what degree these factors may influence survival after allogeneic blood or marrow transplantation. METHODS: This retrospective comparison study evaluates 63 adults aged 60 and above undergoing allogenic transplantation at one institution. Patients who elected and declined enrollment in a non-therapeutic observational study were evaluated. Demographic and clinical characteristics between groups were compared and assessed as predictors of transplant survival, including decision to enroll in the study. RESULTS: Participants who chose to enroll in the parent study were not different with regard to gender, race/ethnicity, age, insurance type, donor age, and neighborhood income/poverty level compared to patients who were invited to participate but declined enrollment. The research participant group had higher proportion assessed as being fully active (23.8% vs. 12.7%, p = 0.034) and lower mean comorbidity scores (1.0 vs 2.47, p = 0.008). Enrollment in an observational study independently predicted transplant survival (HR = 0.316, 95% CI 0.12-0.82, p = 0.017). When controlling for relevant confounders of disease severity, comorbidities, and transplant age, enrolling in the parent study was associated with a lower hazards of death following transplant (HR = 0.302, 95% CI 0.10-0.87, p = 0.027). CONCLUSIONS: Despite being demographically comparable, persons who enrolled in one non-therapeutic transplant study had significantly improved survivorship than those who did not participate in observational research. These findings suggest that there are unidentified factors that influence study involvement that may also impact disease survivorship, over-estimating outcomes from these studies. Results from prospective observational studies should be interpreted with the consideration that study participants have an improved chance of survival at baseline.

Context Matters: A Qualitative Synthesis of Adherence Literature for People on Hemodialysis.

BACKGROUND: Patients with ESKD treated with hemodialysis in the United States have persistently higher rates of nonadherence compared with patients in other developed countries. Nonadherence is associated with an increased risk of death and higher medical expenditure. There is an urgent need to address it with feasible, effective interventions as the prevalence of patients on hemodialysis in the United States continues to grow. However, published adherence interventions demonstrate limited long-term efficacy. METHODS: We conducted a synthesis of qualitative studies on adherence to hemodialysis treatment, medications, and fluid and dietary restrictions to identify gaps in published adherence interventions, searching PubMed, CINAHL, PsychInfo, Embase, and Web of Science databases. We analyzed qualitative data with a priori codes derived from the World Health Organization's adherence framework and subsequent codes from thematic analysis. RESULTS: We screened 1775 articles and extracted qualitative data from 12. The qualitative data revealed 20 factors unique to hemodialysis across the World Health Organization's five dimensions of adherence. In addition, two overarching themes emerged from the data: (1) adherence in the context of patients' whole lives and (2) dialysis treatment as a double-edged sword. Patient-level factors reflected in the qualitative data extended beyond knowledge about hemodialysis treatment or motivation to adhere to treatment. Patients described a profound grieving process over the loss of their "old self" that impacted adherence. They also navigated complex challenges that could be exacerbated by social determinants of health as they balanced treatment, life tasks, and social roles. CONCLUSIONS: This review adds to the growing evidence that one-size-fits-all approaches to improving adherence among patients on hemodialysis are inadequate. Adherence may improve when routine care incorporates patient context and provides ongoing support to patients and families as they navigate the logistical, physical, and psychological hardships of living with dialysis. New research is urgently needed to guide a change in course.

COVID-19: Implications for Nursing and Health Care in the United States.

PURPOSE: COVID-19 and other recent infectious disease outbreaks have highlighted the urgency of robust, resilient health systems. We may now have the opportunity to reform the flawed health care system that made COVID-19 far more damaging in the United States (U.S.) than necessary. DESIGN AND METHODS: Guided by the World Health Organization (WHO) Health System Building Blocks framework (WHO, 2007) and the socio-ecological model (e.g., McLeroy et al., 1988), we identified challenges in and strengths of the U.S.' handling of the pandemic, lessons learned, and policy implications for more resilient future health care delivery in the U.S. Using the aforementioned frameworks, we identified crucial, intertwined domains that have influenced and been influenced by health care delivery in the U.S. during the COVID-19 pandemic through a review and analysis of the COVID-19 literature and the collective expertise of a panel of research and clinical experts. An iterative process using a modified Delphi technique was used to reach consensus. FINDINGS: Four critically important, inter-related domains needing improvement individually, interpersonally, within communities, and for critical public policy reform were identified: Social determinants of health, mental health, communication, and the nursing workforce. CONCLUSIONS: The four domains identified in this analysis demonstrate the challenges generated or intensified by the COVID-19 pandemic, their dynamic interconnectedness, and the critical importance of health equity to resilient health systems, an effective pandemic response, and better health for all. CLINICAL RELEVANCE: The novel coronavirus is unlikely to be the last pandemic in the U.S. and globally. To control COVID-19 and prevent unnecessary suffering and social and economic damage from future pandemics, the U.S. will need to improve its capacity to protect the public's health. Complex problems require multi-level solutions across critical domains. The COVID-19 pandemic has underscored four interrelated domains that reveal and compound deep underlying problems in the socioeconomic structure and health care system of the U.S. In so doing, however, the pandemic illuminates the way toward reforms that could improve our ability not only to cope with likely future epidemics but also to better serve the health care needs of the entire population. This article highlights the pressing need for multi-level individual, interpersonal, community, and public policy reforms to improve clinical care and public health outcomes in the current COVID-19 pandemic and future pandemics, and offers recommendations to achieve these aims.

Associations of perceived stress, depressive symptoms, and caregiving with inflammation: a longitudinal study.

OBJECTIVES: Higher inflammation has been linked to poor physical and mental health outcomes, and mortality, but few studies have rigorously examined whether changes in perceived stress and depressive symptoms are associated with increased inflammation within family caregivers and non-caregivers in a longitudinal design. DESIGN: Longitudinal Study. SETTING: REasons for Geographic And Racial Differences in Stroke cohort study. PARTICIPANTS: Participants included 239 individuals who were not caregivers at baseline but transitioned to providing substantial and sustained caregiving over time. They were initially matched to 241 non-caregiver comparisons on age, sex, race, education, marital status, self-rated health, and history of cardiovascular disease. Blood was drawn at baseline and approximately 9.3 years at follow-up for both groups. MEASUREMENTS: Perceived Stress Scale, Center for Epidemiological Studies-Depression, inflammatory biomarkers, including high-sensitivity C-reactive protein, D dimer, tumor necrosis factor alpha receptor 1, interleukin (IL)-2, IL-6, and IL-10 taken at baseline and follow-up. RESULTS: Although at follow-up, caregivers showed significantly greater worsening in perceived stress and depressive symptoms compared to non-caregivers, there were few significant associations between depressive symptoms or perceived stress on inflammation for either group. Inflammation, however, was associated with multiple demographic and health variables, including age, race, obesity, and use of medications for hypertension and diabetes for caregivers and non-caregivers. CONCLUSIONS: These findings illustrate the complexity of studying the associations between stress, depressive symptoms, and inflammation in older adults, where these associations may depend on demographic, disease, and medication effects. Future studies should examine whether resilience factors may prevent increased inflammation in older caregivers.

Loneliness is Associated With Lower Coping Self-Efficacy Among Older Adults.

To address the gap of lacking research on the association between coping self-efficacy and loneliness, this study examined this relationship to inform future research and intervention on loneliness. Using data from 151 community-dwelling older adults ages 65 and older, we estimated multivariate logistic regression models with age, race/ethnicity, sex, body mass index, chronic disease composite score, social support, coping self-efficacy, and depression symptoms. Loneliness was reported in 32.1% of participants and negatively associated with coping self-efficacy (OR = 0.68, 95% CI: 0.50-0.93) while controlling for age, race, sex, chronic disease composite score, and body mass index. Our findings suggest that coping self-efficacy may be a target for intervention involving loneliness in future research; however, the causal relationship between coping self-efficacy and loneliness should be explored further.

Physical Resilience Phenotype Trajectories in Incident Hemodialysis: Characterization and Mortality Risk Assessment.

Introduction: Although life-saving, the physiologic stress of hemodialysis initiation contributes to physical impairment in some patients. Mortality risk assessment following hemodialysis initiation is underdeveloped and does not account for change over time. Measures of physical resilience, the ability of a physiologic state to overcome physiologic stressors, may help identify patients at higher mortality risk and inform clinical management. Methods: We created 3 resilience categories (improving, stable, and declining) for trajectories of 4 phenotypes (physical function [PF], mental health [MH], vitality [VT], and general health [GH]) using SF-36 data collected the first year after hemodialysis initiation in the Choices for Healthy Outcomes in Caring for ESKD (CHOICE) study on 394 adults aged more than 55 years. Using mixed effects and Cox proportional hazard modeling, we assessed mortality following the first year on dialysis by resilience categories for each phenotype, adjusting for baseline phenotype and other confounders defined a priori over 4 years average follow-up. Results: Based on global Wald tests, statistically significant associations of PF (P = 0.03) and VT (P = 0.0004) resilience categories with mortality were found independent of covariates. Declining PF trajectory was associated with higher mortality risk (hazard ratio [HR] = 1.32; 95% confidence interval [CI], 1.05-1.66), whereas improving VT trajectory was associated with lower mortality risk (HR= 0.73; 95% CI, 0.53 to 1.00), each as compared to stable trajectory. Conclusion: Decreased resilience in PF and VT was independently associated with mortality. Phenotypic trajectories provide added value to baseline markers and patient characteristics when evaluating mortality. Hence, resilience measures hold promise for targeting population health interventions to the highest risk patients.

Propensity score weighted associations between financial strain and subsequent inflammatory biomarkers of aging among a representative sample of U.S. older adults.

BACKGROUND: Despite known socioeconomic disparities in aging-related outcomes, the underlying physiologic mechanisms are understudied. This study applied propensity score weighting to estimate the effect of financial strain on inflammation-related aging biomarkers among a national sample of older adults. METHODS: Financial strain severe enough to lack money for housing, utilities, medical/prescription bills or food was measured among 4,593 community-dwelling National Health and Aging Trends Study participants aged ≥ 65 years in 2016. Inverse probability propensity score weights were generated based on 2015 background characteristics, including age, gender, race/ethnicity, income to poverty ratio, education, occupation, home ownership, retirement, Sect. 8 housing, Medicaid, food/energy assistance, childhood health, marital status, and U.S. region. Sampling weights additionally accounted for study design and non-response. RESULTS: In propensity score-weighted analyses adjusting for age, gender, race/ethnicity, 2017 income to poverty ratio and education, those with 2016 financial strain had 15% higher IL-6 (p = 0.026) and 20% higher CRP levels (p = 0.002) in 2017 than those who were not strained, but did not differ with regard to hemoglobin A1c or CMV. In weighted comparisons, those with financial strain did not differ from those without with regard any 2015 background characteristics. CONCLUSIONS: These results strengthen the etiologic evidence suggesting that financial strain increases inflammatory biomarkers among older adults. Importantly, inflammation is likely a key physiologic pathway contributing to socioeconomic disparities. Therefore, research is needed to address financial strain.

Strengths-building through life purpose, self-care goal setting and social support: Study protocol for Caregiver Support.

Background: For caregivers of people with heart failure, addressing a range of care recipient needs at home can potentially be burdensome, but caregivers may also gain meaning from caregiving. The Caregiver Support Program, a multicomponent strengths-based intervention, is designed to improve outcomes of heart failure caregivers. Objectives: 1) Test the feasibility and gauge an initial effect size of the Caregiver Support Program to improve caregiver quality of life (primary outcome), and fatigue and burden (secondary outcomes) from baseline to 16 weeks, 2) test whether fatigue and caregiver burden are associated with objective measures of resilience (sweat inflammatory cytokines (Il-6 and IL-10) and self-reported resilience, 3) evaluate changes in heart rate variability, IL-6 and IL-10, pre- and post-intervention. Methods: This is a single-blind, two group, waitlist control trial. Eligible caregivers are 1) ≥ 18 years, 2) English speaking, 3) live with the person with heart failure or visit them at least 3 days per week to provide care, 4) provide support for at least 1 instrumental activity of daily living (IADL), 5) live within a 1 h driving radius of the Johns Hopkins Hospital, and 6) the care-recipient has been hospitalized within the last 6 months. Trial participants are randomized into the immediate intervention (n = 24) or waitlist control group (n = 24). Data collection is at baseline, 16 weeks, and 32 weeks. Conclusion: The Caregiver Support program has the potential to increase quality of life and decrease fatigue and caregiver burden for caregivers of people with heart failure and multiple co-morbidities.

Home-based primary care visits by nurse practitioners.

BACKGROUND: With rapidly growing numbers of homebound older adults, the need for effective home-based health interventions is increasingly recognized. Advanced practice registered nurses (NPs) are one of the most common providers of home-based primary care. Limited information is available to address the scope and nature of NP-led home-based primary care and associated outcomes. OBJECTIVE: To synthesize research evidence of NP visits in home-based primary care. DATA SOURCES: Six electronic databases-PubMed, Cumulative Index to Nursing and Allied Health Literature, Embase, Cochrane, Web of Science, and Scopus-were searched to identify peer-reviewed research articles addressing home-based primary care interventions led by NPs. Independent screening resulted in 17 relevant articles from 14 unique studies to include in the review. CONCLUSIONS: Nurse practitioners provided health assessments, education, care planning and coordination primarily by face-to-face home visits. Despite a variability in terms of study design, setting, and sample, NP-led home-based primary care was in general associated with less hospitalization and fewer emergency department visits. Evidence was mixed in relation to patient-reported outcomes such as subjective health, functional status, and symptoms. Costs and patient or caregiver satisfaction were additional outcomes addressed, but the findings were inconsistent. IMPLICATIONS FOR PRACTICE: Recent policy changes to authorize NPs to independently assess, diagnose, and order home care services directly affect how NPs approach home-based primary care programs. Our findings support NP-led home-based primary care to decrease consequential health utilization and suggest the need for further evaluating the care models in diverse populations with more patient-reported and caregiver outcomes.

The effect of COVID-19 pandemic-related financial challenges on mental health and well-being among US older adults.

BACKGROUND: Despite profound financial challenges during the COVID-19 pandemic, there is a gap in estimating their effects on mental health and well-being among older adults. METHODS: The National Health and Aging Trends Study is an ongoing nationally representative cohort study of US older adults. Outcomes included mental health related to COVID-19 (scores averaged across eight items ranging from one to four), sleep quality during COVID-19, loneliness during COVID-19, having time to yourself during COVID-19, and hopefulness during COVID-19. Exposures included income decline during COVID-19 and financial difficulty due to COVID-19. Propensity score weighting produced covariate balance for demographic, socioeconomic, household, health, and well-being characteristics that preceded the pandemic to estimate the average treatment effect. Sampling weights accounted for study design and non-response. RESULTS: In weighted and adjusted analyses (n = 3257), both income decline during COVID-19 and financial difficulty due to COVID-19 were associated with poorer mental health related to COVID-19 (b = -0.159, p < 0.001 and b = -0.381, p < 0.001, respectively), poorer quality sleep (OR = 0.63, 95% CI: 0.46, 0.86 and OR = 0.42, 95% CI: 0.30, 0.58, respectively), more loneliness (OR = 1.53, 95% CI: 1.16, 2.02 and OR = 2.72, 95% CI: 1.96, 3.77, respectively), and less time to yourself (OR = 0.54, 95% CI: 0.40, 0.72 and OR = 0.37, 95% CI: 0.27, 0.51, respectively) during COVID-19. CONCLUSIONS: Pandemic-related financial challenges are associated with worse mental health and well-being regardless of pre-pandemic characteristics, suggesting that they are distinct social determinants of health for older adults. Timely intervention is needed to support older adults experiencing pandemic-related financial challenges.