Tetyana Shippee

Aging and Cumulative Inequality: How Does Inequality Get Under the Skin?

PURPOSE This article draws from cumulative disadvantage and life course theories to develop a new theory for the social scientific study of aging. DESIGN AND METHODS Five axioms of cumulative inequality (CI) theory are articulated to identify how life course trajectories are influenced by early and accumulated inequalities but can be modified by available resources, perceived trajectories, and human agency. RESULTS Although the concept of CI has attracted considerable attention among social scientists, it holds promise for integrating additional disciplinary approaches to the study of aging including, but not limited to, biology, epidemiology, and immunology. The applicability of CI theory to gerontology is illustrated in research on the early origins of adult health. IMPLICATIONS Primary contributions of the theory to gerontology include greater attention to family lineage as a source of inequality; genes, gestation, and childhood as critical to early and enduring inequalities; the onset, duration, and magnitude of exposures to risk and opportunity; and constraints on generalizations arising from cohort-centric studies.

Age Identity, Gender, and Perceptions of Decline: Does Feeling Older Lead to Pessimistic Dispositions About Cognitive Aging?

OBJECTIVES Drawing on past studies of age identity, this article examined whether feeling older was associated with more pessimistic views about cognitive aging. METHODS Using respondents aged 55 years and older in the Midlife Development in the United States study, we estimated a series of linear regression models to predict peoples dispositions toward their cognitive aging. The main comparison is whether the effects of age identity on cognitive aging differ for men and women. RESULTS Beyond the effects of chronological age, older age identities were associated with more pessimistic dispositions about cognitive aging. This relationship, however, was found only among women. DISCUSSION Age identity shapes cognitive aging dispositions, though the gendered nature of this relationship remains somewhat unclear. The findings give further evidence about the far-reaching implications of age identity for successful aging and suggest that future work can explicate how subjective aging processes may differ by gender.

Age Identity in Context: Stress and the Subjective Side of Aging

The passage of time is fundamentally experienced through people’s interaction with their social worlds. Life-course scholars acknowledge the multiple aspects of time-based experience but have given little attention to age identity in a dynamic context. Drawing from a stress-process model, we expected that turbulence within people’s family relations and health declines would produce increases in subjective age. Family role transitions were also examined as potential factors that would hasten subjective aging, but only to the extent that they produced stress. We used the Midlife Development in the United States study, a nationally representative longitudinal survey. Regression results show that turbulence within one’s family accelerated age identity and that the effect of diminishing psychosocial resources explained this relationship. For the most part, however, changes within family roles did not affect age identity. On the other hand, the incidence of chronic health problems increased subjective ages, and this relationship too was mediated by the depletion of psychosocial resources. The findings demonstrate an interconnection between the stress process and age identity. Broadening our conception of time-based experience with attention to the stress process offers exciting directions for future theory and research in life course sociology.

Resident- and Facility-Level Predictors of Quality of Life in Long-Term Care

PURPOSE OF THE STUDY Although there is substantial research on quality of care in nursing homes (NH), less is known about what contributes to quality of life (QOL) for NH residents. This study assesses multiple domains of QOL and examines facility- and resident-level correlates for different domains. DESIGN AND METHODS Data come from (a) self-reported resident interviews using a multidimensional measure of QOL; (b) resident clinical data from the Minimum Data Set; and (c) facility-level characteristics from Minnesota Department of Human Services. We used factor analysis to confirm domains of QOL, and then employed cross-sectional hierarchical linear modeling to identify significant resident- and facility-level predictors of each domain. RESULTS We examined six unique domains of QOL: environment, personal attention, food, engagement, negative mood, and positive mood. In multilevel models, resident-level characteristics were more reliable correlates of QOL than facility characteristics. Among resident characteristics, gender, age, marital status, activities of daily living, mood disorders, cognitive limitations, and length of stay consistently predicted QOL domains. Among facility characteristics, size, staff hours, quality of care, and percent of residents on Medicaid predicted multiple QOL domains. IMPLICATIONS Examining separate domains rather than a single summary score makes associations with predictors more accurate. Resident characteristics account for the majority of variability in resident QOL. Helping residents maintain functional abilities, and providing an engaging social environment may be particularly important in improving QOL.

Barriers to care in an ethnically diverse publicly insured population: Is health care reform enough?

Background:The Affordable Care Act provides for the expansion of Medicaid, which may result in as many as 16 million people gaining health insurance coverage. Yet it is unclear to what extent this coverage expansion will meaningfully increase access to health care. Objective:The objective of the study was to identify barriers that may persist even after individuals are moved to insurance and to explore racial/ethnic variation in problems accessing health care services. Research Design:Data are from a 2008 cross-sectional mixed-mode survey (mail with telephone follow-up in 4 languages), which is unique in measuring a comprehensive set of barriers and in focusing on several select understudied ethnic groups. We examine racial/ethnic variation in cost and coverage, access, and provider-related barriers. The study adhered to a community-based participatory research process. Subjects:Surveys were obtained from a stratified random sample of adults enrolled in Minnesota Health Care Programs who self-report ethnicity as white, African American, American Indian, Hispanic, Hmong, or Somali (n=1731). Results:All enrollees reported barriers to getting needed care; enrollees from minority cultural groups (Hmong and American Indian in particular) were more likely to experience problems than whites. Barriers associated with cost and coverage were the most prevalent, with 72% of enrollees reporting 1 or more of these problems. Approximately 63% of enrollees reported 1 or more access barriers. Provider-related barriers were the least prevalent (about 29%) yet revealed the most pervasive disparities. Conclusions:Many challenges to care persist for publicly insured adults, particularly minority racial and ethnic groups. The ACA expansion of Medicaid, although necessary, is not sufficient for achieving improved and equitable access to care.

Accumulated Financial Strain and Women’s Health Over Three Decades

OBJECTIVE Drawing from cumulative inequality theory, this research examines how accumulated financial strain affects womens self-rated health in middle and later life. METHOD Using data from the National Longitudinal Survey of Mature Women (1967-2003), we employ random-coefficient growth curve models to examine whether recurring financial strain influences womens health, above and beyond several measures of objective social status. Predicted probabilities of poor health were estimated by the frequency of financial strain. RESULTS Financial strain is associated with rapid declines in womens health during middle and later life, especially for those women who reported recurrent strain. Changes in household income and household wealth were also associated with womens health but did not eliminate the effects due to accumulated financial strain. DISCUSSION Accumulated financial strain has long-term effects on womens health during middle and later life. The findings demonstrate the importance of measuring life course exposure to stressors in studies of health trajectories.

Care-Delivery Interventions to Manage Agitation and Aggression in Dementia Nursing Home and Assisted Living Residents: A Systematic Review and Meta-analysis

To evaluate the efficacy of nonpharmacological care‐delivery interventions (staff training, care‐delivery models, changes to the environment) to reduce and manage agitation and aggression in nursing home and assisted living residents.

Beyond the Barriers: Racial Discrimination and Use of Complementary and Alternative Medicine Among Black Americans

This article examines whether self-reported racial discrimination is associated with greater use of complementary and alternative medicine (CAM) and assesses whether the effects of reported racial discrimination are specific to the setting in which the unfair treatment occurred (i.e., medical or nonmedical settings). Data were drawn from the National Survey of Midlife Development in the United States (MIDUS) of Black adults aged 25 and older at baseline (N=201). Analyses account for multiple forms of discrimination: major lifetime discriminatory events and everyday discrimination (more commonplace negative occurrences). Using logistic and negative binomial regression, results reveal that racial discrimination was associated with a higher likelihood of using any type of CAM as well as using more modalities of CAM. Also, both discrimination in health care and discrimination in nonmedical contexts predicted greater use of CAM. The findings underscore the tenet that health care choices, while influenced by health status and availability of health care resources, are also shaped by perceived barriers. The experience of racial discrimination among Black people is associated with greater use of alternative means of health care, as a way to cope with the barriers they experience in institutional settings in the United States.

Health Insurance Coverage and Racial Disparities in Breast Reconstruction After Mastectomy

BACKGROUND Breast reconstruction after mastectomy offers clinical, cosmetic, and psychological benefits compared with mastectomy alone. Although reconstruction rates have increased, racial/ethnic disparities in breast reconstruction persist. Insurance coverage facilitates access to care, but few studies have examined whether health insurance ameliorates disparities. METHODS We used the Nationwide Inpatient Sample for 2002 through 2006 to examine the relationships between health insurance coverage, race/ethnicity, and breast reconstruction rates among women who underwent mastectomy for breast cancer. We examined reconstruction rates as a function of the interaction of race and the primary payer (self-pay, private health insurance, government) while controlling for patient comorbidity, and we used generalized estimating equations to account for clustering and hospital characteristics. FINDINGS Minority women had lower breast reconstruction rates than White women (adjusted odds ratio [AOR], 0.57 for African American; AOR, 0.70 for Hispanic; AOR, 0.45 for Asian; p < .001). Uninsured women (AOR, 0.33) and those with public coverage were less likely to undergo reconstruction (AOR, 0.35; p < .001) than privately insured women. Racial/ethnic disparities were less prominent within insurance types. Minority women, whether privately or publicly insured, had lower odds of undergoing reconstruction than White women. Among those without insurance, reconstruction rates did not differ by race/ethnicity. CONCLUSIONS Insurance facilitates access to care, but does not eliminate racial/ethnic disparities in reconstruction rates. Our findings-which reveal persistent health care disparities not explained by patient health status-should prompt efforts to promote both access to and use of beneficial covered services for women with breast cancer.

Delayed and unmet need for medical care among publicly insured adults with disabilities

Background:While Medicaid is an important source of insurance coverage for persons with disabilities, barriers remain to accessing care for this population. Objectives:This study addresses 3 research questions: (1) do adults with disabilities experience greater unmet need/delayed care?; (2) do barriers related to cost, providers, or structure vary by disability status?; and (3) do barriers mediate the relationship between disability and access to care? Research Design:Data were obtained from a 2008 stratified random sample of Minnesota Health Care Program’s nonelderly adult enrollees (n=1880). The survey was administered by mail, with a telephone follow-up for nonresponders. Measures:Disability is defined by self-report. Access to care is measured by reported delayed and unmet need for medical care within the past year. Respondents were asked about their experiences with a variety of cost-related, provider-related, and structural barriers to care. Results:Respondents with a disability were more likely to experience delayed (40%) and unmet need (23%) for medical care than persons without disabilities (24% and 10%, respectively). Persons with disabilities also reported multiple barriers to health care, especially structural barriers, such as making a timely appointment and accessing transportation (74% vs. 59%). The greater likelihood of facing a structural barrier partially explained increased risk of delayed or unmet care among adults with disabilities. Conclusions:Disparities in access to health care based on disability status remain even for persons who have insurance. These disparities deserve further research and policy attention to better address the particular needs of this population.