The intersection of social determinants of health and family care of people living with Alzheimer's disease and related dementias: A public health opportunity.

In this Perspective article, we highlight current research to illustrate the intersection of social determinants of health (SDOHs) and Alzheimer's disease and related dementia (ADRD) caregiving. We then outline how public health can support ADRD family caregivers in the United States. Emerging research suggests that family care for persons with ADRD is influenced by SDOHs. Public health actions that address these intersections such as improved surveillance and identification of ADRD caregivers; building and enhancing community partnerships; advancing dementia-capable health care and related payment incentives; and reducing the stigma of dementia and ADRD caregiving can potentially enhance the health and well-being of dementia caregivers. By engaging in one or all of these actions, public health practitioners could more effectively address the myriad of challenges facing ADRD caregivers most at risk for emotional, social, financial, psychological, and health disruption.

Paid Help and Caregiving Experiences of Black Caregivers of Community-Dwelling Older Adults.

OBJECTIVES: We examine associations between use of paid help and caregiving-related experiences (emotional, financial, and physical difficulty) of Black family and unpaid caregivers of older adults. METHODS: We examine a sample of N = 572 non-Hispanic Black caregivers of community-dwelling older adults receiving help with daily activities from the 2015 National Health and Aging Trends Study (NHATS) and National Study of Caregiving (NSOC). Guided by Pearlin's Stress Process Model, logistic regression models examine associations between assisting with finding paid help and caregiver experiences. RESULTS: Black caregivers who helped care recipients find paid help more often had a college degree or higher, were helping older adults who received assistance with three or more self-care/mobility activities or who were living in poverty and were not receiving help with caregiving from family and friends. In fully-adjusted models, assisting with finding paid help was associated with emotional (AOR 1.92, 95% CI 1.27, 2.92 p < .01) and physical (AOR 2.16, 95% CI 1.04, 4.51; p = .04) difficulty. CONCLUSIONS: Greater efforts are needed to support Black family and unpaid caregivers who are caring for older adults using paid help. CLINICAL IMPLICATIONS: Future interventions that target Black caregivers of older adults using paid help could be useful for improving caregiving experiences.

HIV and employment among Black men who have sex with men in Baltimore.

Employment status is a key social determinant of health, and many populations in the United States that are impacted by HIV have unequal access to education and employment opportunities which contributes to HIV-related disparities. Black men who have sex with men (BMSM) are one of the groups most heavily burdened by HIV. With improved health outcomes associated with advancements in HIV treatment, research suggests that more people living with HIV want to work. This study describes employment among BMSM living in Baltimore, assesses differences in employment by HIV status and assesses predictors of full-time employment among BMSM. The study found that BMSM have limited access to full-time employment and that this disparity is even more pronounced among BMSM living with HIV. Men living with HIV were less likely to be employed full-time compared to men not living with HIV controlling for education and social contextual factors (OR 0.40 95% CI (0.22-0.73)). HIV will most likely have important implications for employment patterns and trajectories of BMSM over the life course. Additional research is needed among BMSM living with HIV to understand work histories and experiences, facilitating factors, and the impact of various work experiences on the health and wellbeing.

Socioeconomic disparities in six-year incident dementia in a nationally representative cohort of U.S. older adults: an examination of financial resources.

BACKGROUND: Less educational training is consistently associated with incident dementia among older adults, but associations between income and financial strain with incident dementia have not been well tested in national samples. This is an important gap because, like education, financial resources are potentially modifiable by policy change and strengthening the social safety net. This study tested whether financial resources (income and financial strain) predict six-year incident dementia independent of education and occupation. METHODS: The National Health and Aging Trends Study is a prospective cohort study that recruited a nationally representative sample of U.S. Medicare beneficiaries aged ≥65 years. Incident dementia (2013 to 2018) was classified based on diagnosis, cognitive test scores or proxy-reported changes among participants dementia-free in 2012 (n = 3785). Baseline socioeconomic measures included income to poverty ratio (analyzed separately for those < 500% vs. ≥500% poverty threshold), financial strain, education and history of professional occupation. Discrete time survival analysis applied survey weights to account for study design and nonresponse. Coefficients were standardized to compare the strength of associations across the four socioeconomic measures. RESULTS: Adjusting for socioeconomic measures, demographic characteristics, home ownership, retirement, chronic conditions, smoking, BMI and depressive symptoms, higher income (hazard OR = 0.84, 95% CI: 0.74, 0.95 among those < 500% poverty) and higher education (hOR = 0.73, 95% CI: 0.65, 0.83) were associated with lower odds, and financial strain with higher odds (hOR = 1.20, 95% CI: 1.09, 1.31), of incident dementia. CONCLUSION: Low income and greater financial strain predict incident dementia among older adults and associations are comparable to those of low education among U.S. older adults. Interventions to mitigate financial strain through improving access to economic opportunity and strengthening safety net programs and improving access to them in low income groups may complement other ongoing efforts to prevent dementia.

Promoting dementia awareness in African-American faith communities.

INTRODUCTION: Alzheimer's disease and other dementia-related disorders are affecting the African-American community at alarming rates. African-American churches have traditionally been places of refuge where families go for support. However, many churches lack programs or resources to support families affected by dementia. In response, a nurse-led interdisciplinary collaborative partnered with churches to promote dementia awareness through education. PURPOSE: The purpose of this analysis was to (a) describe the demographics of those seeking dementia education in African-American faith communities; (b) identify prior knowledge of dementia community resources; and (c) determine the preliminary usefulness of the education provided. METHODS: Over the course of 16 months, 202 individuals attended nine educational sessions hosted by five churches across metropolitan Atlanta. Quantitative surveys were used to collect demographics and evaluate the educational sessions. RESULTS: The majority of attendees were African-American adults (91%), women (75%), and unaware of dementia resources (66%). Several attendees identified themselves as church leaders, community/church members, caregivers, and/or healthcare professionals. Attendees expressed the educational content was applicable to themselves or their families. CONCLUSION: Results help identify ways to alter and/or strengthen the educational content and serve as a guide for developing culturally relevant, faith-based community programs.

The association of pain, race and slow gait speed in older adults.

Gait speed is an important indicator of mobility and quality of life in older adults. Pain is related to gait speed; however, it is unknown if this relationship varies by race in a population based national sample. The aim of this study was to examine if the association between slow gait speed and pain differed between 7,025 older African Americans and non Hispanic Whites in the National Health and Aging Trends Study. Those with pain in the last month had higher odds of slow gait speed (odds ratio = 1.38, 95% confidence interval = 1.10 - 1.73) than those without pain. The relationship between pain and slow gait speed did not vary by race (interaction p = 0.6). This is important because it points to the underlying racial disparities in pain and gait speed being factors such as disparate opportunities and living conditions, and healthcare rather than attributes intrinsic to race.

High Levels of Medical Mistrust Are Associated With Low Quality of Life Among Black and White Men With Prostate Cancer.

BACKGROUND: Medical mistrust is thought to affect health care-based decisions and has been linked to poor health outcomes. The effects of medical mistrust among men with prostate cancer are unknown. Thus, the goal of the current study is to examine the association between medical mistrust and quality of life (QOL) among black and white men with prostate cancer. METHODS: A total of 877 men (415 black, 462 white) with prostate cancer between the ages of 40 to 81 years who entered the North Carolina Central Cancer Registry during the years 2007 and 2008 were retrospectively recruited. The dependent variable was overall QOL measured by the Functional Assessment of Cancer Therapy-Prostate questionnaire. The primary independent variable was medical mistrust. Multivariate regression analysis was used to assess the association between medical mistrust and overall QOL. RESULTS: Compared with white men, black men reported a higher level of medical mistrust (black = 2.7, white = 2.4; P < .001) and lower QOL (black = 134.4, white = 139.5; P < 0.001). After controlling for demographical and clinical variables, higher levels of medical mistrust were associated with a reduction in overall QOL among men with prostate cancer (beta = -7.73; standard error = 1.54) CONCLUSIONS: Higher levels of medical mistrust are associated with reduced overall QOL among black and white men with prostate cancer. Interventions targeted to reduce medical mistrust may be effective in increasing the overall QOL of men with prostate cancer.

Prevalence and Correlates of Major Depressive Symptoms among Black Men with Prostate Cancer.

Objectives: The objectives of our study were to determine the prevalence of major depressive symptoms and identify factors that are associated with major depressive symptoms among Black men with prostate cancer (PCa). Design: This study consisted of 415 Black men aged 40-81 years that entered the North Carolina Central Cancer Registry during the years 2007-2008. The primary outcome variable was depressive symptoms (CES-D). Factors included age, income, education, insurance status, treatment received, time between diagnosis and treatment, Gleason score, medical mistrust and experience with racism/discrimination. Logistic regression models were used to assess factors associated with the odds of having major depressive symptoms. Results: The prevalence of major depressive symptoms (≥16 on CES-D) among our sample of Black men with PCa was approximately 33%. Approximately 15% of the study participants underwent radiation beam treatment. Age was significantly associated with the odds of reporting major depressive symptoms (OR= .95, CI .91-.99) among Black men. In addition, compared with all other forms of treatment, Black men who underwent radiation beam treatment had higher odds (OR=2.38, CI 1.02- 5.51) of reporting major depressive symptoms. Conclusion: Nearly one-third of Black men with PCa in this study reported major depressive symptoms. Clinicians should pay closer attention to the mental health status of Black men with PCa, especially those who are younger and those who have undergone radiation beam treatment. Cancer survivorship, particularly quality of life, may be enhanced by opportunities for assessment, evaluation and intervention of depressive symptoms among these men disproportionately affected by PCa.

The Effects of Discrimination Are Associated With Cigarette Smoking Among Black Males.

Previous research has demonstrated that experiencing interpersonal discrimination is associated with cigarette smoking. Few studies have examined the relationship between the effects of physical and emotional discrimination and cigarette usage, and none have examined this relationship among Black men. The aim of this study was to examine the association between the effects of physical and emotional discrimination and cigarette smoking. METHODS: Data from the Indiana Black Men's Health Study, a community-based sample of adult Black men, was used to conduct multivariate logistic regression to examine the relationship between the physical and emotional effects of discrimination and smoking, net of healthcare and workplace discrimination, age, education, household income, and being married. RESULTS: After adjusting for having an emotional response to discrimination, health care and workplace discrimination, age, education, household income, and being married, males who had a physical response to discrimination (e.g., upset stomach or headache) had higher odds of cigarette use (odds ratio (OR): 1.95, 95% confidence interval (CI): 1.15-3.30) than men who did not have a physical response to discrimination. CONCLUSION: Findings from the study suggest that Black males may use cigarette smoking as a means to mitigate the stress associated with experiences of discrimination. Future research is needed further to explore if and how Black males use cigarette smoking to cope with unfair treatment.

The Influence of Religious Attendance on Smoking Among Black Men.

BACKGROUND: Cigarette smoking poses a major public health problem that disproportionately affects Blacks and men. Religious attendance has been shown to be positively associated with health promotion and disease prevention among the Black population. In light of this evidence, this study examined if a similar relationship could be found for religious attendance and smoking in Black men. METHODS: The National Survey of American Life (NSAL) study sampled 1,271 African American men and 562 Black Caribbean men. Multivariate logistic regression was used to determine the association between religious attendance and cigarette smoking. RESULTS: After adjusting for age, marital status, household income, education, foreign born status, importance of prayer and major stress, men who reported attending religious services almost every day (odds ratio (OR) = 0.21, 95% confidence interval (CI) = 0.07, 0.62) and weekly (OR = 0.47, 95% CI = 0.29, 0.77) had lower odds of being a current smoker compared to men who reported never attending religious services. Conclusions/Importance: Findings suggest a health benefit in attending religious services on cigarette smoking among Black men in a nationally representative sample. In spite of lower church attendance in Black men in general, our results demonstrate that religious service attendance may still serve as a buffer against cigarette use. Given the emergent attention on faith-based health promotion among men, this conclusion is relevant and timely.

Factors Associated With Black Men's Preference for Health Information.

Black men are less likely to seek routine health care examinations or preventative care compared with their racial/ethnic and gender counterparts. Because of Black men's limited engagement with the health system, Black men's preference to receive health information is unclear. Guided by a revised version of the Andersen Healthcare Utilization Model, the aim of the study is to examine factors associated with Black men's preference for informal or formal health information. Findings from the study demonstrate that financial barriers to care (odds ratio [OR] = 0.65, 95% confidence interval [CI] = 0.43-0.98) and higher income (OR = 2.44, 95% CI = 1.49-4.00) were most predictive of using a formal source for health information. Furthermore, age (OR = 1.02, 95% CI = 1.01-1.03) and having a college education (OR = 0.44, 95% CI = 0.26-0.76) were associated with using a formal place for health information. Interestingly, health care discrimination was not associated with preferred source or place for health information. Results from the study suggest that predisposing and enabling factors are most salient to the use of formal sources of health information among Black men.

Association Between Any Major Discrimination and Current Cigarette Smoking Among Adult African American Men.

BACKGROUND: Findings from previous research has demonstrated a positive relationship between interpersonal discrimination and cigarette smoking. Cigarette smoking is proposed to be an externalizing coping mechanism used to alleviate discrimination. At the national level, it is unclear if discrimination is associated with cigarette smoking among African American men. OBJECTIVE: The aim of the study was to examine the association between discrimination and cigarette smoking among a national sample of African American men. METHODS: Using data from the National Survey of American Life (n = 1,271), multivariable logistic regression was used to examine the relationship between discrimination and cigarette smoking. RESULTS: Thirty-two percent of the men were current smokers. Controlling for everyday discrimination, major discrimination, major stress, depressive symptoms, age, being married, household income, and education, African American men who experienced major discrimination had a higher odd of being a current smoking (odds ratio: 1.11, 95% confidence interval: 1.02-1.21) than African American men who did not experience major discrimination. Conclusion/Importance: Findings suggest that African American men may use cigarette smoking as a mechanism to alleviate the experiences of discrimination. Future studies should continue to examine factors associated with African American men's smoking behavior in efforts to inform culturally relevant interventions.

Embedding Caregiver Support Within Adult Day Services: Outcomes of a Multisite Trial.

BACKGROUND AND OBJECTIVES: Adult day services (ADS) provide quality-of-life benefits to people with dementia, but few provide systematic caregiver support. We report outcomes of a multisite, national trial testing a staff-delivered caregiver program, ADS Plus. RESEARCH DESIGN AND METHODS: Cluster-randomized trial involving 34 ADS: 18 sites provided ADS (controls) and 16 provided ADS and ADS Plus (intervention). Trained staff met with caregivers to provide dementia education, support/validation, referrals/linkages, and strategies for care challenges and self-care over 12 months. Main outcomes included depressive symptoms (Center for Epidemiological Studies Depression Scale [CES-D]) and well-being at 6 and 12 months, and client attendance over 12 months. RESULTS: Of 203 caregivers (Intervention = 102; Control = 101), 5.9% at 3 months, 12.8% at 6 months, and 22.7% at 12 months were lost to follow-up. Caregivers were predominantly female (80.3%), with 76.4% identifying as White/Caucasian, 14.8% Black/African American, and 12.3% Hispanic/Latino. Most (88.2%) had ≥college education and were 65.0 years old (SD = 13.46). For those with 6-month data, 40.4% control and 40.2% ADS Plus caregivers had depressed symptoms (≥16 CES-D) at baseline. By 6 months, 43.6% control versus 34.2% ADS Plus caregivers had ≥16 scores (odds ratio = 0.38, p = .072). By 12 months, after covariate adjustments, ADS Plus caregivers reported reduced total depression scores versus controls (p = .013) and lower depressed affect scores (p = .015). Of 18 sites providing 12-month client attendance data, 9 intervention sites reported 126.05 days attended versus 78.49 days for 9 control sites (p = .079). DISCUSSION AND IMPLICATIONS: Compared with ADS alone, by 12 months, ADS Plus improved caregiver mood and increased ADS utilization by 60.6%. Results support ADS staff delivering evidence-based caregiver support to enhance ADS benefits. CLINICAL TRIAL REGISTRATION: NCT02927821.

Using Hybrid Effectiveness Studies to Facilitate Implementation in Community-Based Settings: Three Case Studies in Dementia Care Research.

The pipeline from discovery to testing and then implementing evidence-based innovations in real-world contexts may take 2 decades or more to achieve. Implementation science innovations, such as hybrid studies that combine effectiveness and implementation research questions, may help to bridge the chasm between intervention testing and implementation in dementia care. This paper describes hybrid effectiveness studies and presents 3 examples of dementia care interventions conducted in various community-based settings. Studies that focus on outcomes and implementation processes simultaneously may result in a truncated and more efficient implementation pipeline, thereby providing older persons, their families, health care providers, and communities with the best evidence to improve quality of life and care more rapidly. We offer post-acute and long-term care researchers considerations related to study design, sampling, data collection, and analysis that they can apply to their own dementia and other chronic disease care investigations.

Examining the relationship between the endorsement of racial/ethnic stereotypes and excess body fat composition in a national sample of African Americans and black Caribbeans.

Using the National Survey of American Life, a nationally representative household survey of non-institutionalized US Blacks, our study examined whether the endorsement of racial/ ethnic stereotypes was associated with excess body fat composition among African Americans (n = 3,265) and Black Caribbeans (n = 1,332) living in the United States. We used ordinary least squares and multinomial logistic regression analyses controlling for potential confounders. Results from the linear regression suggested that the endorsement of racial/ethnic stereotypes was associated with increased body mass index and weight among African American males (b = .57, P < .05) and females (b = .50 P < .05). Further, results from the adjusted multinomial logistic regression suggested that African American males who endorsed racial/ethnic stereotypes were more likely to be obese (odds ratio = 1.33, P < .05), than African American males who did not endorse racial/ethnic stereotypes. Surprising, a positive relationship was not found among Black Caribbeans. Future studies should examine the relationship between internalized discrimination and endorsements of negative racial/ethnic stereotypes and excess fat accumulation among ethnically heterogeneous samples of Blacks.

It's More Than Language: Cultural Adaptation of a Proven Dementia Care Intervention for Hispanic/Latino Caregivers.

Although Hispanic/Latino older adults are at disproportionate and increased risk for Alzheimer's disease and related dementias, few evidence-based supportive care interventions are specifically developed for or adapted for this population. Adapting a supportive care intervention requires more than Spanish language translation; it necessitates an understanding of cultural nuances and care preferences of Hispanic/Latino families and staff who implement the intervention. This article describes the cultural adaptation of the Adult Day Service Plus intervention for delivery by staff to Hispanic/Latino caregivers, which was guided by the cultural adaptation process model. Also, using the Framework for Reporting Adaptations and Modifications-Enhanced, we discuss (a) when modifications were made, (b) who determined the modifications needed, (c) what aspects of the intervention were modified, (d) the relationship to fidelity and how fidelity was maintained, and (e) reasons for modifications. Modifications to the delivery and content were changed to reflect the values and norms of both the Hispanic/Latino staff and the caregivers they serve. As supportive interventions for caregivers are developed and implemented into real-world settings, inclusion of cultural elements may enhance research participation among Hispanic/Latino provider sites, people living with dementia, and their caregivers. Cultural adaptation is an essential consideration when developing, adapting, and implementing previously tested evidence-based interventions. Cultural adaptation offers an important lens by which to identify contextual factors that influence successful adoption to assure equity in the reach of evidence-based programs.

Who's Helping Whom? Examination of Care Arrangements for Racially and Ethnically Diverse People Living With Dementia in the Community.

Objective: To address notions around care arrangements for Black and Hispanic people living with dementia (PLwD), the study examined if racial and ethnic differences exist for community-dwelling PLwD. Methods: Using cross-sectional data from the 2015 National Health and Aging Trends Study, we used Pearson's chi-square and mean comparison to examine differences among a sample of n = 863 community-dwelling White, Black, and Hispanic older PLwD. Results: Black PLwD were less likely than White PLwD to use paid help (26.8% vs. 32.6%), but Hispanic PLwD were most likely to use paid help (46.2%, p < 0.05). Black and Hispanic older adults were more often receiving help from a child (65.8% and 72.2%, respectively; p = 0.01) or other family member (40.3% and 31.0%, respectively; p < 0.01). Discussion: Our findings highlight the important role of familial support in care provision for Black and Hispanic communities. Caregiving supports should be intentional in centering services on the family, not a sole caregiver.

Use of Critical Race Theory to Inform the Recruitment of Black/African American Alzheimer's Disease Caregivers into Community-Based Research.

Nearly 30 years after the 1993 National Institute of Health (NIH) Revitalization Act, which required the inclusion of women and racial/ethnic minority groups into government-funded clinical trials, minority groups remain underrepresented in research, and disparities in health outcomes and longevity remain. These problematic trends are particularly evident when considering Black and community-based research in Alzheimer's disease and related dementia (ADRD). Deeply rooted historical race-based mistreatment in research and in the health care system at large along with ineffective recruitment approaches persists as barriers to the low participation of Black participants in dementia care studies. In this article, we explore Critical Race Theory, its tenets, and applicability to inform national strategies to encourage participation of Black participants in ADRD research. We describe how Critical Race Theory constructs (e.g., race consciousness, storytelling, and praxis) can be used to inform recruitment strategies of Black caregivers for people living with dementia into community-based research. We provide a case example that draws upon our NIH-funded Adult Day Service Plus randomized trial and its engagement of Black caregivers into a community-based biomarker research arm of the main trial. Although the contribution of this article is primarily theoretical, in the spirit of Critical Race Theory it is also a call for action to transform dementia care research by offering a conceptual tool to assure inclusivity of Black participants, who are disproportionately affected by dementia when compared to other racial groups.

The Influence of Race and Gender on Receiving Assistance With Daily Activities Among Older Americans.

BACKGROUND AND OBJECTIVES: Nearly 8.2 million community-dwelling, older Medicare beneficiaries receive support from long-term services and supports (LTSS) with routine daily activities. Prior work demonstrates disability-related disparities; however, it is unclear whether these patterns persist among LTSS recipients and across specific sets of activities. We examine race and gender differences in receiving help with self-care (e.g., eating), mobility (e.g., getting around the house), and household (e.g., shopping) activities in a nationally representative sample of community-dwelling Medicare beneficiaries receiving LTSS. RESEARCH DESIGN AND METHODS: Cross-sectional analysis of 1,808 White and Black older adults receiving assistance with routine daily activities in the 2015 National Health and Aging Trends Study. Bivariate statistics were used to describe the sample and provide comparisons of characteristics by race and gender. Logistic regression models examined race and gender differences in receiving assistance with self-care, mobility, and household activities after adjusting for sociodemographic and health characteristics. RESULTS: Race and gender differences were observed across all sociodemographic and health characteristics, as well as for all forms of assistance. Relative to White men, Black men had lower odds of receiving help with self-care activities. White and black women had higher odds and Black men had lower odds of getting help with mobility activities than White men. Black men and White and Black women all had higher odds of receiving assistance with household tasks compared to White men. DISCUSSION AND IMPLICATIONS: Our findings indicate that, despite prior evidence of disability-related disparities, the receipt of help with self-care, mobility, and household activities varies by race and gender. Findings reveal several target areas for future research. Future work should examine the role of cultural and social preferences for care, as well as the appropriateness of help, as evidenced by health service use and changes in quality of life.

Is Dementia-Specific Caregiving Compared With Non-Dementia Caregiving Associated With Physical Difficulty Among Caregivers for Community-Dwelling Adults?

OBJECTIVE: The purpose of this study is to identify whether dementia caregiving is associated with physical difficulty among informal caregivers. METHODS: This cross-sectional retrospective cohort study design used data from the 2015 National Health and Aging Trends Study and the National Study of Caregiving. Binary logistic regression was used to examine the association between substantial physical difficulty and dementia caregiving among 1,871 caregivers. RESULTS: Nearly 14% of the caregivers reported substantial physical difficulty. Dementia caregivers were 1.5 times more likely to report caregiving-related substantial physical difficulty (adjusted odds ratio [AOR] = 1.58, p = .04) than non-dementia caregivers. Factors associated with substantial physical difficulty included caregiver gender, self-rated health, depressive symptoms, pain, and caring for someone receiving assistance with three or more self-care or mobility activities. DISCUSSION: Future studies should identify strategies to mitigate the physical demands on dementia caregivers. Early monitoring of caregivers' self-rated health, depressive symptoms, and pain may identify those more likely to experience physical difficulty.