Advance care plans in UK care home residents: a service evaluation using a stepped wedge design.

INTRODUCTION: advance care planning (ACP) in care homes has high acceptance, increases the proportion of residents dying in place and reduces hospital admissions in research. We investigated whether ACP had similar outcomes when introduced during real-world service implementation. METHODS: a service undertaking ACP in Lincoln, UK care homes was evaluated using routine data. Outcomes were proportion of care homes and residents participating in ACP; characteristics of residents choosing/declining ACP and place of death for those with/without ACP. Hospital admissions were analysed using mixed-effects Poisson regression for number of admissions, and a mixed-effects negative binomial model for number of occupied hospital bed days. RESULTS: About 15/24 (63%) eligible homes supported the service, in which 404/508 (79.5%) participants chose ACP. Residents choosing ACP were older, frailer, more cognitively impaired and malnourished; 384/404 (95%) residents choosing ACP recorded their care home as their preferred place of death: 380/404 (94%) declined cardiopulmonary resuscitation. Among deceased residents, 219/248 (88%) and 33/49 (67%) with and without advance care plan respectively died in their care home (relative risk 1.35, 95% confidence interval [CI] 1.1-1.6, P < 0.001). Hospital admission rates and bed occupancy did not differ after implementation. DISCUSSION: About 79.5% participants chose ACP. Those doing so were more likely to die at home. Many homes were unwilling or unable to support the service. Hospital admissions were not reduced. Further research should consider how to enlist the support of all homes and to explore why hospital admissions were not reduced.

EDUCATIONAL OUTCOMES OF GENDER-DIVERSE YOUTH: A National Population-Based Study.

Despite the growing population of youth identifying with a transgender or nonbinary gender identity, research on gender-diverse individuals' educational outcomes is limited. This study takes advantage of the first nationally representative, population-based data set that includes measures of gender identity and educational outcomes: the High School Longitudinal study of 2009. Using minority stress and structural symbolic interactionist frameworks, we examine the association between gender identity and high school and college educational outcomes. We compare the educational outcomes of gender-diverse youth-binary transgender, nonbinary, and gender unsure-with those of cisgender youth, and also examine differences within the gender-diverse population. Given the strong link between minority stress and educational experiences among gender-diverse youth, we examine differences in outcomes before and after accounting for school belonging and emotional distress. We also account for individuals' social-structural location, arguing that social positionality shapes both gender identity and educational outcomes. Results indicate important differences in educational outcomes within the gender-diverse population: Whereas binary transgender and gender-unsure youth exhibit educational disadvantage, relative to cisgender youth, nonbinary youth do not. The gender-unsure disadvantage remains even after accounting for differences in social-structural location and social-psychological factors associated with minority stress.

Marital status differences in suicidality among transgender people.

The suicide rate for transgender people is among the highest of any group in the United States. Yet, we know little about disadvantages or resources available to transgender people to prevent suicide. The overall purpose of this study is to assess how marital status modifies the risk of suicide among transgender people. We analyzed data from the 2015 U.S. Transgender Survey to predict marital status differences in both suicide ideation and suicide attempt in the past year. The analytic sample for suicide ideation included 17,117 transgender respondents (9,182 transwomen and 7,935 transmen), and the analytic sample for suicide attempt was limited to 8,058 transgender respondents (4,342 transwomen and 3,716 transmen) who reported suicide ideation in the last 12 months. Results from binary logistic regression models suggested that never married and previously married transmen and transwomen, regardless of their partnership status, generally had higher risk of both suicide ideation and attempt than their married transgender counterparts with only one exception: never married transwomen had lower risk of suicide ideation (but not attempt) than their married transwomen counterpart after sociodemographic characteristics were accounted for. These findings draw attention to the heterogeneity of the transgender population, highlighting marital status as a key social factor in stratifying the life experiences of transgender people.

Tele-Rehabilitation for People with Dementia during the COVID-19 Pandemic: A Case-Study from England.

Introduction: The Promoting Activity, Independence and Stability in Early Dementia (PrAISED) is delivering an exercise programme for people with dementia. The Lincolnshire partnership National Health Service (NHS) foundation Trust successfully delivered PrAISED through a video-calling platform during the Coronavirus Disease 2019 (COVID-19) pandemic. METHODS: This qualitative case-study aimed to identify participants that video delivery worked for, to highlight its benefits and its challenges. Interviews were conducted between May and August 2020 with five participants with dementia and their caregivers (n = 10), as well as five therapists from the Lincolnshire partnership NHS foundation Trust. The interviews were analysed through thematic analysis. RESULTS: Video delivery worked best when participants had a supporting caregiver and when therapists showed enthusiasm and had an established rapport with the client. Benefits included time efficiency of sessions, enhancing participants' motivation, caregivers' dementia awareness, and therapists' creativity. Limitations included users' poor IT skills and resources. DISCUSSION: The COVID-19 pandemic required innovative ways of delivering rehabilitation. This study supports that people with dementia can use tele-rehabilitation, but success is reliant on having a caregiver and an enthusiastic and known therapist.

Investigating the prevalence of malnutrition, frailty and physical disability and the association between them amongst older care home residents.

BACKGROUND: Malnutrition, frailty and physical disability are inter-related, more prevalent in the older population and increase the risk of adverse health outcomes. Thus, screening is essential, especially in the understudied care home setting where the population is vulnerable and at higher risk of malnutrition. Furthermore, prevalence may vary depending upon screening tools used. The aims of this study were to: 1) investigate the prevalence of 1) malnutrition risk using Mini Nutritional Assessment - Short Form (MNA-SF) and Malnutrition Universal Screening Tool (MUST), 2) frailty using the Edmonton Frailty Scale (EFS), 3) physical disability using the Barthel Index (BI) and (4) examine the association between variables and coexistence of states. METHODS: Screening for malnutrition (MNA-SF and MUST) and frailty (EFS) was performed as part of a comprehensive geriatric assessment (CGA) in 527 residents from 17 care homes in Lincoln, UK. Mean age of the group was 85.6 ± 7.6 years and body mass index, BMI 23.0 ± 5.1 kg/m2. RESULTS: A high prevalence of malnutrition risk was detected: 41.4% by MNA-SF and 25.5% by MUST (high risk/malnourished). Furthermore, there was a clear discordance between MNA-SF and MUST scoring of malnutrition; for example, the percentage of those identified as being at low risk was 18.8% using the MNA-SF and 57.0% using the MUST. In addition, there was a high prevalence of severe frailty by EFS (69.6%) and functional impairment by BI (62.0%). There was good association between some variables (P < 0.001) and 33.4% of residents had coexistence of all three states of malnutrition, frailty and physical disability. CONCLUSIONS: Malnutrition risk, frailty and physical disability are highly prevalent in care home residents and interrelated. However, prevalence varies depending on the screening tool used. More research should be conducted in the care home setting to improve daily clinical practice as screening may impact upon subsequent treatment and care modalities and clinical outcomes.

Sexual Orientation and Diabetes During the Transition to Adulthood.

Purpose: The purpose of this study was to examine how sexual orientation in adolescence and young adulthood was linked to diabetes risk. Methods: Data were drawn from the 1994-2008 National Longitudinal Study of Adolescent to Adult Health. The baseline sample included 4330 girls and 3510 boys ages 12-18. Guided by the life course approach, we considered both the timing and continuity of sexual orientation-broadly defined by sexual identity, sexual attraction, sexual contact, and romantic/sexual relationships-by differentiating respondents into four categories: sexual minority in both adolescence and adulthood, sexual minority in adulthood only, sexual minority in adolescence only, and heterosexual in both adolescence and young adulthood. Diabetes was identified using A1c and glucose biomarkers and self-reports of diabetes diagnosis or medication use. Results: Results from logistic regression models indicated that in comparison with their continuously heterosexual counterparts, respondents reporting sexual minority status in adulthood only or continuously in both adolescence and adulthood had higher diabetes risk in adulthood. However, respondents reporting sexual minority status in adolescence only were not different in diabetes risk in adulthood. The association between diabetes risk and continuous sexual minority status was stronger among women than among men. Conclusions: Sexual minority health disparities emerge early in the life course during adolescence and young adulthood. These findings highlight the importance of designing and implementing policies and public programs to alleviate minority stress early in life to reduce health disparities.

Trajectories of Suicidal Ideation from Adolescence to Adulthood: Does the History of Same-Sex Experience Matter?

The fluidity of same-sex experience (SSE) can be conceptualized as both a risk and a resource that impacts suicidal ideation over time. Considering whether SSE occurs in adolescence, adulthood, or both, this study suggests that SSE in both adolescence and adulthood is associated with depression and low self-esteem throughout the life course, resulting in chronic susceptibility to suicidal ideation. Yet due to variation in both accumulation of risk and resources over time, trajectories of suicidal ideation during the transition to adulthood likely vary by timing of SSE. To test these hypotheses, we fit latent growth curve models to a gender-stratified sample taken from the National Longitudinal Study of Adolescent to Adult Health (7608 men, 8070 women). We created four groups of SSE: no SSE (6322 men, 5981 women), SSE in adolescence only (634 men, 480 women), SSE in adulthood only (372 men, 1081 women), and SSE in adolescence and adulthood (280 men, 528 women). Men and women with SSE in both life stages had the greatest risk of suicidal ideation in adolescence and in adulthood. Yet women with first SSE in adulthood had less of a decline in suicidal ideation over time, relative to those with no SSE and those with SSE in adolescence only, and this was partially due to higher depression and lower self-esteem. Results suggest greater support is needed for adolescents expressing non-normative sexualities and for those with first SSE in adulthood, a group that is more difficult to identify in schools.

Educational attainment of transgender adults: Does the timing of transgender identity milestones matter?

Adolescence is a difficult life stage in which to navigate a transgender identity, yet adolescence plays a key role in shaping educational trajectories. While transgender-related stigma and victimization within secondary schools persists, the social climate in which transgender adolescents navigate their identity has changed over time. Analyzing data from the National Transgender Discrimination Survey, a national, non-probability sample of U.S. transgender adults, we address the following research questions: 1) Is experiencing transgender identity milestones in adolescence associated with educational attainment?; 2) Does this association vary by birth cohort? We find that those who first experienced transgender identity milestones in adolescence attained less education than those who first experienced milestones in other life stages. This association is larger among younger birth cohorts, pointing to the adolescent years as a particularly difficult time to navigate a transgender identity, even in the midst of increased transgender awareness and resources within schools and society.

Marital Status and Perceived Discrimination among Transgender People.

Despite calls for increased attention to the experiences of transgender people, scientific understanding of the stigma and discrimination this population experiences is limited. We integrate minority stress and marital advantage perspectives to assess marital status differences in transgender-related perceived discrimination among transgender people in multiple life domains: the workplace, family, health care, and public accommodations. We analyze one of the first and most comprehensive large-scale samples of transgender people in the U.S. (N = 4,286), the National Transgender Discrimination Survey. We find that married transgender respondents tend to report lower levels of perceived discrimination than their cohabiting and previously married transgender counterparts. Married transgender respondents do not, however, report lower levels of perceived discrimination than their never married counterparts, once all covariates are accounted for. These marital status differences appear primarily among transwomen but not transmen. Economic resources account for some, but not all, of these differences.

Same-Sex Sexuality and Educational Attainment: The Pathway to College.

Research finds lower levels of academic performance among sexual minority high school students, but some studies suggest sexual minorities have higher levels of educational attainment in adulthood. To further our understanding of how and why sexual orientation is associated with educational success, this study turns attention to the pathways to college completion, examining points along educational trajectories in which sexual minorities fall behind or surpass their heterosexual peers. Using data from the National Longitudinal Study of Adolescent to Adult Health, we find that sexual minority women are less likely than women with no same-sex sexuality to complete college, in part due to their high school performance and transition into college. Men who experience same-sex sexuality only in adolescence struggle in high school, but men who experience same-sex sexuality for the first time in adulthood are more likely to earn a college degree than men who do not experience same-sex sexuality.

College-Going Benefits of High School Sports Participation: Race and Gender Differences over Three Decades.

The long touted athlete advantage in college enrollment has been tempered by assertions that this advantage is actually due to characteristics that precede participation. Moreover, it remains unclear whether the benefits of sports extend into contemporary times, and apply equally to female and racial minority athletes. This study uses three nationally representative longitudinal datasets of students who were 10th graders in 1980, 1990, and 2002. We find that high school sports participation was positively associated with college enrollment, even with the utilization of propensity score modeling, for white boys and girls, black boys, and Latino boys and girls during the 1980s, 1990s, and 2000s. The most important gender and race differences include black female athletes' college-going disadvantage in the 1980s and 1990s, and girls' persistently lower rates of high school sports participation than boys'.

Family relationships and adolescent well-being: are families equally protective for same-sex attracted youth?

Existing research suggests that sexual minority youth experience lower levels of well-being, in part because they perceive less social support than heterosexual youth. Sexual minority youth with strong family relationships may demonstrate resilience and increased well-being; however, it is also possible that the experience of sexual stigma may make these relationships less protective for sexual minority youth. Using two waves of data from the National Longitudinal Study of Adolescent Health, we explore the links between same-sex attraction, family relationships, and adolescent well-being in a sample of over 13,000 7th-12th grade adolescents (51 % female, 52 % non-Latino/a white, 17 % Latino, 21 % African American, and 7 % Asian). Specifically, we examine whether lower levels of parental closeness, parental involvement, and family support among same-sex attracted youth explain in part why these youth experience increased depressive symptoms and risk behaviors, including binge drinking, illegal drug use, and running away from home, relative to other-sex attracted youth. Second, we ask whether family relationships are equally protective against depressive symptoms and risk behaviors for same-sex attracted and other-sex attracted youth. We find that same-sex attracted youth, particularly girls, report higher levels of depressive symptoms, binge drinking, and drug use in part because they perceive less closeness with parents and less support from their families. Results also suggest that parental closeness and parental involvement may be less protective against risk behaviors for same-sex attracted boys than for their other-sex attracted peers. Findings thus suggest that interventions targeting the families of sexual minority youth should educate parents about the potentially negative effects of heteronormative assumptions and attitudes on positive adolescent development.

Race and Academic Achievement in Racially Diverse High Schools: Opportunity and Stratification.

BACKGROUND/CONTEXT: Brown v Board of Education fundamentally changed our nation's schools, yet we know surprisingly little about how and whether they provide equality of educational opportunity. Although substantial evidence suggests that African American and Latino students who attend these schools face fewer learning opportunities than their White counterparts, until now, it has been impossible to examine this using a representative sample because of lack of data. PURPOSE/OBJECTIVE/RESEARCH QUESTION/FOCUS OF STUDY: This study uses newly available data to investigate whether racially diverse high schools offer equality of educational opportunity to students from different racial and ethnic groups. This is examined by measuring the relative representation of minority students in advanced math classes at the beginning of high school and estimating whether and how this opportunity structure limits the level of achievement attained by African American and Latino students by the end of high school. SETTING: This study uses data from the Adolescent Health and Academic Achievement Study (AHAA) and its partner study, the National Longitudinal Study of Adolescent Health (Add Health), a stratified, nationally representative study of students in U.S. high schools first surveyed in 1994-1995. POPULATION/PARTICIPANTS/SUBJECTS: Two samples of racially diverse high schools were used in the analysis: one with African Americans, Whites, and Asians (26 schools with 3,149 students), and the other with Latinos, Whites, and Asians (22 schools with 2,775 students). RESEARCH DESIGN: Quantitative analyses first assess how high schools vary in the extent to which minority students are underrepresented in advanced sophomore math classes. Hierarchical multilevel modeling is then used to estimate whether racial-ethnic differences in representation in advanced math have an impact on African American and Latino students' achievement by the end of high school, relative to the Whites and Asians in the school. Specifically, we estimate the effects of Whites' and Asians' overrepresentation in sophomore-year math (or Latino or African American underrepresentation) within the school on students' senior-year grades and their postsecondary enrollment. FINDINGS/RESULTS: Findings show that schools vary in the extent to which African American and Latino students are underrepresented in advanced sophomore math classes. This pattern of racial inequality in schools is associated with lower minority senior-year grades and enrollment in 4-year postsecondary institutions, net of students' own background. CONCLUSIONS/RECOMMENDATIONS: Evidence consistently suggests that schools can play an active role in the provision of opportunities for social mobility or in the exacerbation of social inequality, depending on how they are structured. It is important to consider racial stratification within schools as a mechanism of inequality of educational opportunity.

Academic achievement and course taking among language minority youth in U.S. schools: Effects of ESL placement.

The 1974 Lau decision requires that U.S. public schools ensure a meaningful education for students learning English. English as a Second Language (ESL) placement is an institutional response to the linguistic needs of these students; however, its academic implications remain largely unexplored. Using nationally representative data from the Educational Longitudinal Study (ELS), the effects of ESL placement on college preparatory course enrollment and academic achievement of language minority students are estimated, first with fixed effects regression models and then with multi-level propensity score matching techniques. While numerous school and individual level factors beyond language proficiency predict ESL placement, a significant negative estimated effect of ESL placement on science enrollment and cumulative GPA is consistently found. Perhaps more important, however, no positive effects of ESL placement on the achievement of language minority youth are found when accounting for English proficiency and other potential covariates.

SCHOOL CULTURE AND THE WELL-BEING OF SAME-SEX-ATTRACTED YOUTH.

This study assesses how variations in heteronormative culture in high schools affect the well-being of same-sex-attracted youth. The authors focus on the stigmatization of same-sex attraction (rather than identity or behavior) to better understand how heteronormativity may marginalize a wide range of youth. Specifically, the authors use data from the National Longitudinal Study of Adolescent Health to examine how variation across schools in football participation, religious attendance, and urban locale affects same-sex-attracted adolescents' depressive symptoms, self-esteem, fighting, and academic failure. The results suggest that though same-sex-attracted youth are at greater risk for decreased well-being, these youth are at higher risk in nonurban schools and in schools where football and religion have a larger presence. Results vary for boys and girls: The urban locale of a school has a larger impact for boys, while school religiosity has a greater impact for girls.

ESL Placement and Schools: Effects on Immigrant Achievement.

In this study, the authors explore English as a Second Language (ESL) placement as a measure of how schools label and process immigrant students. Using propensity score matching and data from the Adolescent Health and Academic Achievement Study and the National Longitudinal Study of Adolescent Health, the authors estimate the effect of ESL placement on immigrant achievement. In schools with more immigrant students, the authors find that ESL placement results in higher levels of academic performance; in schools with few immigrant students, the effect reverses. This is not to suggest a one-size-fits-all policy; many immigrant students, regardless of school composition, generational status, or ESL placement, struggle to achieve at levels sufficient for acceptance to a 4-year university. This study offers several factors to be taken into consideration as schools develop policies and practices to provide immigrant students opportunities to learn.

School Context and the Effect ESL Placement on Mexican-Origin Adolescents' Achievement.

OBJECTIVES: Immigrant adolescents' academic achievement is crucial to our future economic stability, and Mexican-origin linguistic minority youth in U.S. schools generally demonstrate lower levels of achievement. English as a Second Language (ESL) programs provide an institutional response to these students' needs, the effect of which may vary by the proportion of immigrant students in the school. MEASURES: Using propensity score matching and data from the Adolescent Health and Academic Achievement Study (AHAA) and the National Longitudinal Study of Adolescent Health (Add Health), we estimate the effect of ESL placement on Mexican-origin achievement for first-, second-, and third-generation adolescents separately in schools with many and few immigrant students. RESULTS: The estimated effect of ESL placement varies by both immigrant concentration in the school and by students' generational status. CONCLUSIONS: We find that ESL enrollment may be protective for second-generation Mexican-origin adolescents in high immigrant concentration schools, and may prove detrimental for first-generation adolescents in contexts with few other immigrant students.

Adolescent Same-Sex Attraction and Academic Outcomes: The Role of School Attachment and Engagement.

Schools create environments in which some sexual feelings, behaviors, and relationships are stigmatized, and this may have negative consequences for adolescents with nonheterosexual romantic attractions. This stigma can lead them to withdraw and disengage from school at a critical time of preparation for adulthood, which can compromise opportunities for future success. Previous research has demonstrated that sexual minority youth report greater levels of school-related problems, including a weaker sense of attachment to school and more trouble with teachers and peers. This lack of social integration is likely to affect their educational success. Data from the National Longitudinal Study of Adolescent Health and the newly collected Adolescent Health and Academic Achievement study provide the first opportunity to fully explore whether and to what extent same-sex attracted youth enter adulthood with an educational disadvantage. In this study, we examine (1) whether same-sex attracted adolescents have lower levels of academic success, (2) if their lower academic success is explained by a lack of social integration at school, and (3) whether these relationships differ for boys and girls. Results suggest that same-sex attracted students, particularly boys, do suffer academically, and that this is in part a result of school-related problems and risk factors such as emotional distress and substance use; however, a great deal of the disadvantage fails to be explained by these factors. Additionally, while same-sex attracted boys show poorer academic performance, same-sex attracted girls do not, suggesting that gender may shape how sexual minority youth experience and respond to marginalizing school environments.