Resilience and Hassles Trajectories Among Older Adults during the COVID-19 Pandemic.

OBJECTIVES: Despite higher physical vulnerability to COVID-19, older adults reported less psychological stress than younger and midlife adults during the pandemic. However, little is known about age differences in stress within later life, and most COVID-19 studies have been cross-sectional. We examined weekly hassles exposure and severity trajectories and whether these trajectories differed by age, resilience factors (higher trait resilience and education) and vulnerability factors (identifying as a woman, being a person of color, and having chronic health conditions). METHOD: Community-dwelling adults aged 50+ in Oregon (Mage = 71.1, SD = 7.3; 74% women, 89% non-Hispanic White) completed weekly online surveys across eight weeks (April 28 - June 22, 2020) during the COVID-19 stay-at-home mandate. A two-part model estimated how age, resilience, and vulnerability factors predicted weekly odds of any hassle exposure and level of severity. RESULTS: Across time, hassles exposure decreased and the rate of severity declined, but these patterns differed by age and other demographics. The old-old (estimated at age 78) remained stable in odds of any exposure, while the young-old (estimated at age 64) evidenced a J-shaped curve; age did not moderate the severity slopes. Further, both resilience factors were associated with exposure trajectories, whereas vulnerability factors (race/ethnicity and chronic illness) were associated with levels of hassles severity. DISCUSSION: There were age differences in patterns of hassles during the COVID pandemic. Further, resilience and vulnerability factors also showed complex patterns, underscoring the need for future studies to focus on age differences in well-being in later life.

'With or without you': associations between noteworthy events and cognitive complaints across 100 days.

OBJECTIVES: Daily noteworthy events have implications for physical and mental health, but less is known about the role daily events have for self-reported cognition and whether the involvement of close social partners differentiates these associations. The current study examined how daily positive and negative noteworthy events relate to subjective memory and attentional difficulties and whether close social partners moderated associations. METHOD: We used data from a 100-day microlongitudinal web-based study of 104 older adults (Nobservations=7,051; Mage=63.13 years, SDage=7.81, 88.46% Female). Participants reported on exposure to and valence of noteworthy events, involvement of close social partners, and subjective cognitive complaints at the end of each day. RESULTS: Logistic multilevel models revealed that days with a negative event were associated with increased odds of forgetting something and trouble concentrating whereas days with positive events were associated with decreased odds of trouble concentrating. Close social partner involvement did not moderate within-person associations. CONCLUSION: Our results suggest that day-to-day events are correlates of cognitive complaints regardless of close social partner involvement in the events. Research should clarify the role of daily positive and negative events in personalized interventions and determine whether this person-centered approach to self-reported cognitive health helps inform diagnostic practices.

Daily Caregiving Appraisals, Future Self-Views, and Physical Activity Goals Among Adult-Daughter Dementia Caregivers.

OBJECTIVES: Caregiving dynamics may shape caregivers' views on their own aging in ways that affect their (de)motivation to improve their current and future health and well-being. In this study, we investigated within-person associations of daily positive and negative caregiving appraisals, future self-views (physical functioning, cognitive, and overall health domains), and physical activity goal pursuit among adult-daughter dementia caregivers. METHODS: Data came from 33 middle-aged caregivers (M = 55.03) who participated in a 30-day microlongitudinal study of caregiving (N of occasions = 855). We used multilevel modeling to analyze within-person associations. RESULTS: Daily positive caregiving appraisals were not associated with daily future self-views. However, on days when caregivers reported higher negative caregiving appraisals, they thought more negatively about their future older selves in all domains. In turn, on days when caregivers thought more negatively about their future older selves in all domains, they reported lower physical activity goal pursuit. Future self-views in all domains mediated the association between negative caregiving appraisals and physical activity goal pursuit. Future self-views did not mediate the association between positive caregiving appraisals and physical activity goal pursuit. However, cognitive future self-views moderated the association between positive caregiving appraisals and physical activity goal pursuit. DISCUSSION: Results suggest that one pathway through which subjective caregiving experiences, especially negative caregiving appraisals, affect caregivers' physical activity goal pursuit is through future self-views. Thus, this study offers a deeper theoretical understanding of caregivers' self-regulatory health behavior and new empirical information on how caregiving might affect life-span developmental motivation.

Muscle power predicts frailty status over four years: A retrospective cohort study of the National Health and Aging Trends Study.

Objectives: Muscle power is a critical measure of physical capacity in older adults, however the association between muscle power and frailty is not well explored. The purpose of this study is to estimate the association between muscle power and frailty in community-dwelling older adults in the National Health and Aging Trends Study from 2011-2015. Methods: Cross-sectional and prospective analyses were performed on 4,803 community-dwelling older adults. Mean muscle power was calculated using the five-time sit-to-stand test, height, weight, and chair height and dichotomized into high-watt and low-watt groups. Frailty was defined using the five Fried criteria. Results: The low watt-group had higher odds of pre-frailty and frailty at baseline year 2011. In prospective analyses, the low-watt group that was pre-frail at baseline had increased hazards of frailty (AHR 1.62, 95% CI 1.31, 1.99) and decreased hazards of non-frailty (AHR 0.71, 95% CI 0.59, 0.86). The low-watt group that was non-frail at baseline had increased hazards of pre-frailty (1.24, 95% CI 1.04, 1.47) and frailty (1.70, 1.07, 2.70). Conclusions: Lower muscle power is associated with higher odds of pre-frailty and frailty and increased hazards of becoming frail or pre-frail over four years in those who are pre-frail or non-frail at baseline.

How Do Marital Transitions Affect Self-Perceptions of Aging?

OBJECTIVES: We analyzed whether marital status and experiences of marital loss or gain were associated with self-perceptions of aging (SPA), a major psychosocial mechanism of healthy aging. METHOD: We used data from 7028 participants of the Health and Retirement Study. Participants reported their marital status and their positive and negative SPA on two occasions 4 years apart. We ran general linear models to analyze differences in SPA between men and women who remained married, became divorced or widowed, or remarried following divorce or widowhood. RESULTS: Participants who experienced marital loss had lower positive SPA than participants who remained marred. Participants who experienced marital gain had lower negative SPA than participants who remained married. None of the associations differed between men and women. DISCUSSION: Results suggest that it may not be marital status itself, but rather the transition into or out of marriage, that impacts how people appraise their own aging.

Cardiovascular Disease and Health-Related Quality of Life Among Asian American, Native Hawaiian and Pacific Islander Older Adults.

Objectives: Assess the relationship between cardiovascular disease (CVD) and health-related quality of life (HRQOL) among Asian American, Native Hawaiian, and Pacific Islander (NH/PI) compared to white older adults. Methods: Data were from the 2011-2015 Health Outcomes Survey. HRQOL was assessed using the Veterans RAND 12-Item Survey, composed of physical (PCS) and mental component scores (MCS). Lower scores represent worse health. Multivariate regression was conducted to estimate PCS and MCS mean score differences related to self-reported CVD (coronary artery disease, congestive heart failure, myocardial infarction, other heart conditions, stroke) and race/ethnicity. Results: There were marked differences in PCS and MCS scores by disaggregated Asian American and NH/PI subgroups. After adjustment, Asian American and NH/PI older adults had better PCS but worse MCS than white older adults. Race/ethnicity moderated the relationship between CVD and HRQOL. Discussion: Asian American and NH/PI older adults with CVD had poorer mental health compared to their white counterparts.

Trends in Cardiovascular Disease by Asian American, Native Hawaiian, and Pacific Islander Ethnicity, Medicare Health Outcomes Survey 2011-2015.

BACKGROUND: The burden of cardiovascular disease (CVD) is increasing in the aging population. However, little is known about CVD risk factors and outcomes for Asian American, Native Hawaiian, and Other Pacific Islander (NH/PI) older adults by disaggregated subgroups. METHODS: Data were from the Centers for Medicare and Medicaid Services 2011-2015 Health Outcomes Survey, which started collecting expanded racial/ethnic data in 2011. Guided by Andersen and Newman's theoretical framework, multivariable logistic regression analyses were conducted to examine the prevalence and determinants of CVD risk factors (obesity, diabetes, smoking status, hypertension) and CVD conditions (coronary artery disease [CAD], congestive heart failure [CHF], myocardial infarction [MI], other heart conditions, stroke) for 10 Asian American and NH/PI subgroups and White adults. RESULTS: Among the 639 862 respondents, including 26 853 Asian American and 4 926 NH/PI adults, 13% reported CAD, 7% reported CHF, 10% reported MI, 22% reported other heart conditions, and 7% reported stroke. CVD risk factors varied by Asian American and NH/PI subgroup. The prevalence of overweight, obesity, diabetes, and hypertension was higher among most Asian American and NH/PI subgroups than White adults. After adjustment, Native Hawaiians had significantly greater odds of reporting stroke than White adults. CONCLUSIONS: More attention should focus on NH/PIs as a priority population based on the disproportionate burden of CVD risk factors compared with their White and Asian American counterparts. Future research should disaggregate racial/ethnic data to provide accurate depictions of CVD and investigate the development of CVD risk factors in Asian Americans and NH/PIs over the life course.

Are Thoughts About the Future Associated With Perceptions in the Present?: Optimism, Possible Selves, and Self-Perceptions of Aging.

Despite much literature pointing to the saliency of self-perceptions of aging (SPA) to aging processes, limited research offers empirical analysis on what shapes SPA. In order to identify possible antecedents to SPA, we conducted an exploratory analysis to analyze whether two future-oriented constructs-optimism and self-efficacy associated with possible selves-were associated with SPA. We ran hierarchical linear regressions, with optimism and self-efficacy of possible selves predicting SPA among 244 middle-aged and older adults. Higher optimism, higher self-efficacy to achieve hoped-for selves, and higher self-efficacy to avoid feared selves were associated with higher overall SPA. Results from our study suggest that how someone appraises their future older self impacts how they perceive their current older self.

Self-Perceptions of Aging Moderate Associations of Within- and Between-Persons Perceived Stress and Physical Health Symptoms.

OBJECTIVES: To examine how self-perceptions of aging (SPA) moderated within- and between-persons perceived stress associations with physical health symptoms. METHODS: A community-dwelling sample of 103 adults (Meanage = 63, range = 52-88) participated in an online microlongitudinal study for 100 days (Noccasions = 7,064). Participants completed baseline surveys consisting of SPA, social connections, and demographics followed by 100 daily surveys including information about daily stress perceptions and physical health. Utilizing generalized multilevel models, we examined whether daily fluctuations and average levels of perceived stress over 100 days affected physical health symptoms and whether these associations varied by SPA. RESULTS: Adults who had higher perceived stress, on average across 100 days, reported significantly more physical health symptoms compared to individuals with lower perceived stress on average (p < .05). On days when individuals reported higher perceived stress than their own average, they had a higher likelihood of reporting more physical health symptoms compared to days when their perceived stress was lower than their own average (p < .05). Further, SPA significantly moderated associations between both within- and between-persons perceived stress and physical health symptoms (ps < .05). Individuals with more positive SPA were less affected by high levels of perceived stress-both on average and on days when perceived stress was higher than their own average. DISCUSSION: More positive SPA significantly dampened the impact of perceived stress, suggesting the importance of SPA as an individual characteristic within stress processes. Future work should examine how daily changes in SPA may exacerbate or mitigate the impacts of daily stress processes and health outcomes.

Aging-Related Changes in the Association between Negative Affect and Response Time Inconsistency in Older Adulthood.

Negative affect (NA) and positive affect (PA) are established modifiable psychosocial correlates of cognitive health and have demonstrated capacity for meaningful within-person fluctuations based on person-environment interactions, age, and measurement approach. Previous research has shown NA is associated with increased response time inconsistency (RTI), an early performance-based indicator of cognitive health and aging. It is unclear, however, whether PA is associated with RTI, and whether affect-RTI associations exist within persons over time or change as individuals get older. We utilized data from a measurement burst study (Cognition, Health and Aging Project) to explore within- and between-person associations between affect and RTI in community-dwelling older adults (N=111, M=80.04 years, SD=6.30). Affect and RTI were assessed on six days over a two-week period, every six months for two years. Results revealed a significant association between NA-low arousal and RTI within persons over time. RTI was higher on sessions when NA-low arousal was higher than usual (b=0.21, 95%CI=0.08 to 0.35, p<.01). This association decreased in magnitude over time (b=-0.09, 95%CI=-0.14 to - 0.03, p<.001), ultimately resulting in increased NA-low arousal being associated with decreased RTI two years later (b=-.14, 95%CI=-0.27 to -0.01, p<.05). No PA-RTI associations emerged. The results suggest efforts focused on maximizing resource allocation and personalizing cognitive health efforts should consider for whom and when mitigating NA may be maximally beneficial to daily cognition, whereas additional work is needed to determine influences from PA.

Women's Self-Relevant Goal Pursuit in the Presence of Physical Pain: An Intraindividual Variability Approach.

OBJECTIVES: Pursuing personal goals that are relevant to one's sense of self is important for adjusting to age-related changes. Experiences of physical pain, however, are thought to threaten both people's sense of self and their pursuit of personal goals. Although a majority of older women experience physical pain, little is known about their day-to-day regulation of their self-relevant goals in the presence of physical pain. The objectives of this study were to explore associations between physical pain and health goal pursuit on a daily basis for women who identified health as a part of their possible selves. METHODS: We took an intraindividual variability approach to analyze whether there were within- and between-person differences in associations between daily pain and daily health goal progress among 62 women who provided data over the course of 100 days, yielding 4,150 occasions of data. RESULTS: At the between-person level, women with higher pain on average had lower health goal pursuit on average. At the within-person level, days of higher-than-average pain were associated with lower same-day health goal progress. DISCUSSION: Our results suggest that pain interrupts regulation of a self-relevant goal at a within-person-not just between-person-daily level. Future work should consider how these daily, within-person, disruptions affect broader identity processes and overall well-being.

Self-Perceptions of Aging: Factorial Structure and Invariance by Gender.

BACKGROUND AND OBJECTIVES: Self-perceptions of aging (SPA)-the appraisals people place on their own aging processes-predict well-being in later life. Researchers are increasingly hypothesizing that the overarching construct of SPA is comprised of two factors-positive SPA and negative SPA-and that SPA are gendered. The purpose of this study was to empirically test the hypothesized two-factor structure of SPA and to analyze how the two-factor structure varies between men and women. RESEARCH DESIGN AND METHODS: Data come from the 2012 wave of the Health and Retirement Study (N = 7,029; Mage = 68.08), which includes an 8-item SPA scale. We used confirmatory factor analysis (CFA) to assess (i) the positive SPA and negative SPA two-factor solution for the 8-item scale and (ii) whether the two-factor solution had configural, strong, or weak invariance across men and women. RESULTS: CFAs indicated a two-factor latent structure of the 8-item scale, with SPA being comprised of both a positive SPA factor and a negative SPA factor. The latent structure was the same for both men and women. DISCUSSION AND IMPLICATIONS: Results suggest that SPA is a broader construct made up of positive and negative latent factors. Researchers should consider separating the SPA by positive and negative factors to analyze how each factor uniquely shapes health. Moreover, the two-factor solution was equivalent across men and women, possibly because of the generalized nature of the 8-item scale. Researchers can use the 8-item scale similarly for men and women and should continue to elucidate possible gender differences in SPA.

Daily linkages among high and low arousal affect and subjective cognitive complaints.

Objectives: Subjective cognitive complaints may be an early indicator of Alzheimer's disease pathology and related dementias that can be detectable prior to objective, performance-based decline. Negative and positive affective states (NA and PA, respectively) are established psychosocial correlates of cognition in older adulthood and have demonstrated capacity for meaningful within-person fluctuations based on person-environment interactions, age, and measurement approach.Method: We utilized data from a 100-day, microlongitudinal study of 105 community-dwelling older adults (Mage = 63.19, SD = 7.80, Range = 52-88) to explore within- and between-person associations between high and low arousal NA and PA, and memory- and attention-related complaints.Results: For memory-related complaints, those who reported experiencing greater NA-high arousal had increased forgetfulness (OR = 2.23, 95%CI: 1.11-4.49, p < .05). Within persons, reporting more NA-high arousal than usual was associated with increased forgetfulness (OR = 1.01, 95%CI: 1.004-1.018, p < .01). For attention-related complaints, those who reported experiencing greater NA-low arousal had increased trouble staying focused (OR = 2.34, 95%CI: 1.17-4.66, p < .05). Within persons, reporting more NA-low arousal (OR = 1.02, 95%CI: 1.01-1.03, p < .001) and less PA-high arousal (OR = 0.96, 95%CI: 0.95-0.97, p < .001) than usual was associated with increased trouble staying focused. Additionally, reporting more PA-low arousal than usual was associated with decreased trouble staying focused among those with higher levels of conscientiousness (OR = 0.72, 95%CI: 0.57-0.92, p < .01).Conclusion: Results from this study offer a means to maximize resource allocation and personalized cognitive health efforts by pinpointing for whom and on which days boosting PA and/or reducing NA may both serve as pathways to benefit daily subjective cognition.

Personality Moderates Intervention Effects on Cognitive Function: A 6-Week Conversation-Based Intervention.

BACKGROUND AND OBJECTIVES: Social isolation is associated with a higher risk of dementia. We previously conducted and showed the efficacy of an intervention which uses conversation (the core component of social interactions) as a tool to enhance cognitive function. We now explore whether cognitive improvements through conversation-based intervention depend on an individual's personality. RESEARCH DESIGN AND METHODS: We reexamined data from a 6-week randomized controlled trial (ClinicalTrials.gov Number: NCT01571427) to determine whether conversation-based intervention effects were moderated by personality traits in 83 older adults (mean age = 80.51 years, 49 cognitively intact, 34 individuals with mild cognitive impairment). The intervention group participated in daily 30-min face-to-face semi-structured conversations with trained interviewers through a web-enabled system for 6 weeks. At baseline, psychosocial questionnaires and a neuropsychological battery were completed. RESULTS: Intervention group participants with high agreeableness, conscientiousness, and extraversion exhibited significant improvements in language-based executive function tasks beyond changes in the control group (ps < .05). An opposite pattern for delayed recall memory and working memory tasks emerged among highly extraverted participants (ps < .05). DISCUSSION AND IMPLICATIONS: Our exploratory findings suggest the adaptive role of personality traits in conversation-based cognitive interventions may be limited to tasks incorporating a language component, and offer initial evidence for personalized approaches to cognitive health in late life.

Effects of Age Discrimination on Self-perceptions of Aging and Cancer Risk Behaviors.

BACKGROUND AND OBJECTIVES: Almost one-third of older adults report experiencing age discrimination. We hypothesized sequential links between older adults' everyday experiences of age discrimination and future health behaviors related to cancer risk through self-perceptions of aging (SPA). RESEARCH DESIGN AND METHODS: Participants were community-dwelling respondents (age: 51-96 years) from the 2008, 2012, and 2014 waves of the Health and Retirement Study (N = 4,467). Generalized path models estimated the immediate and enduring effects of age discrimination in 2008 on proximal SPA in 2012 and distal health behaviors in 2014. RESULTS: Age discrimination was associated with lower positive SPA and higher negative SPA in 2012. The effect of age discrimination on physical activity, smoking, and drinking in 2014 was mediated by positive and negative SPA in 2012. Through subsequent SPA, those who experienced age discrimination in 2008 were less likely to engage in regular moderate physical activity, more likely to smoke, and less likely to drink more than 3 times per week in 2014. Analysis of change in positive and negative SPA showed the effect of age discrimination on physical activity to be mediated by change in positive, but not negative, SPA. DISCUSSION AND IMPLICATIONS: The enduring effects of age discrimination were found through a reduction in positive SPA. Elevating positive SPA could be as important as reducing negative SPA for future health behaviors related to cancer risk.

Depression Among Older Adults in the United States by Disaggregated Race and Ethnicity.

BACKGROUND AND OBJECTIVES: As the population becomes increasingly diverse, it is important to understand the prevalence of depression across a racially and ethnically diverse older population. The purpose of this study was to compare rates of depression by age and disaggregated racial and ethnic groups to inform practitioners and target resource allocation to high risk groups. RESEARCH DESIGN AND METHODS: Data were from the Centers for Medicare and Medicaid Services Health Outcomes Survey, Cohorts 15 and 16, a national and annual survey of a racially diverse group of adults aged 65 and older who participate in Medicare Advantage plans (N = 175,956). Depression was operationalized by the Patient Health Questionnaire-2 (PHQ-2); we estimated a logistic regression model and adjusted standard errors to account for 403 Medicare Advantage Organizations. RESULTS: Overall, 10.2% of the sample (n = 17,957) reported a PHQ-2 score of 3 or higher, indicative of a positive screen for depression. After adjusting for covariates, odds of screening positively for depression were higher among participants self-reporting as Mexican (odds ratio [OR] = 1.19), Puerto Rican (OR = 1.46), Cuban (OR = 1.57), another Hispanic/Latino (OR = 1.29), and multiple Hispanic/Latino (OR = 1.84) ethnicities, compared with non-Hispanic whites. Odds were also higher among participants reporting that their race was black/African American (OR = 1.20), Asian Indian (OR = 1.67), Filipino (OR = 1.30), Native Hawaiian/Pacific Islander (OR = 1.82), or two or more races (OR = 1.50), compared with non-Hispanic whites. DISCUSSION AND IMPLICATIONS: Prevalence varied greatly across segments of the population, suggesting that certain racial/ethnic groups are at higher risk than others. These disparities should inform distribution of health care resources; efforts to educate and ameliorate depression should be culturally targeted.

A New Brief Measure of Executive Function: Adapting the Head-Toes-Knees-Shoulders Task to Older Adults.

BACKGROUND AND OBJECTIVES: Executive function (EF) abilities are recognized as components of cognition most likely to show age-related declines. Measurement of EF in older adults is often computer-based, takes place in a laboratory setting, and thus lacks ecological validity. We sought to investigate a new way of measuring EF in older adults by adapting a brief, behavioral measure of EF in children, the Head-Toes-Knees-Shoulders task (HTKS). RESEARCH DESIGN AND METHODS: A sample of 150 community-dwelling older adults (Mean age = 68.55, SD = 6.34) completed the HTKS, NIH Toolbox: Cognition Battery (NIHTB-CB) and Positive and Negative Affect Schedule. RESULTS: The HTKS showed adequate internal consistency, α = .84. Significant associations between HTKS variables and measures of attention and inhibitory control were robust to the influences of age, processing speed, and subjective health ratings. HTKS completion time exhibited the strongest associations to NIHTB-CB measures, suggesting that the time it takes older adults to complete the HTKS may be a better measure of EF than the total score. Nonsignificant associations between HTKS variables and positive and negative affect demonstrated discriminant validity. DISCUSSION AND IMPLICATIONS: These results provide initial evidence for use of the HTKS as a brief, low-cost, easy to administer measure of EF in older adults. Further research is needed to determine its potential to identify individuals at risk for poor cognitive outcomes. A brief, valid measure may allow for wider screenings aimed at early intervention, when cognitive interventions are most effective.

An Exploration of Factors Associated With Ageist Stereotype Threat in a Medical Setting.

Objectives: Experiencing stereotype threat in a medical setting may be triggered by routine clinical activities, and may be detrimental to healthcare processes and outcomes. This study estimated the prevalence of, and identified factors associated with, reporting ageist stereotype threat in a medical setting using a nationally representative dataset. Methods: Participants were community-dwelling adults aged 50 and older who had visited the doctor at least once in the past 2 years (n = 1,662). We analyzed data from the Health and Retirement Study using multivariate logistic regression. Results: 8.31% of participants felt worry or fear that they were judged by medical staff because of their age. Previous experiences of age discrimination (adjusted odds ratio [AOR] = 2.47, p < .01), poorer self-perceptions of aging (AOR = 1.34, p < .05), and having greater control over one's health (AOR = 0.84, p < .05) were associated with reporting stereotype threat because of age. Discussion: Future research should investigate if measures to reduce age discrimination and to improve self-perceptions of aging and individual control over health protect against experiencing ageist stereotype threat in healthcare settings.

Mixed Emotions Within the Context of Goal Pursuit.

Development in adulthood occurs through the process of setting and working toward goals. Emotions link experiences to goals and action, and as such are integral to goal setting, evaluation of goal progress, and goal pursuit. When viewed in the context of goals, the simultaneous experience of positive and negative or "mixed" emotions coheres with the complexity of goal pursuit within the context of competing demands in daily life. Mixed emotions may be experienced as uncertainty in which goal to prioritize, ambiguity in whether an event served or impeded goal progress, or poignancy in a bittersweet moment of recognizing the losses that accompany gains. Mixed emotions therefore represent a problem that must be resolved-through either prioritization of conflicting goals, down-playing negative affective response, or goal disengagement-before goal pursuit can continue. Because mixed emotions must be resolved before they can be translated to action, the experience of mixed emotions may evoke a new awareness of priorities and available options that leads to better goal outcomes. Over time, openness to mixed emotions could result in outcomes such as better health and self-actualization.