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The COVID-19 pandemic has presented numerous challenges to older adults in Canada, including the ability to volunteer. The purpose of this study is to improve the understanding of the social context surrounding volunteering in Canada, by (a) determining changes in associations between human, social, and cultural capital and volunteering among older adults; and (b) examining the relationship between ethnic minority status and volunteering, using data from the Canadian Longitudinal Study on Aging (CLSA), collected prior to and during the pandemic. This study utilized data from 24,306 CLSA Baseline, Follow-up 1 (FUP1), and COVID-19 Baseline Survey participants (aged 55+). Results confirm a decrease in volunteering during the early stages of the pandemic. Compared to pre-pandemic associations, volunteers during the early stages of the pandemic were more likely to be young-old, male, employed, and not involved in religious activities. Findings provide evidence of pandemic effects on volunteering among older adults in Canada.

Ageism remains a key issue in gerontological literature and has long been recognized as a deeply harmful form of discrimination. Despite advances in ageism scholarship related to education, advocacy, and prevention, there are calls for ongoing intersectional examinations of ageism among minority groups and across older people facing multiple exclusions. In particular, very little ageism research has considered the experiences of age-based discrimination and prejudice among older people experiencing homelessness. We problematize this gap in knowledge and provide recommendations for policy, practice, and research to address ageist discrimination toward older people experiencing homelessness. Intersections of ageism and homelessness are summarized at four levels: intrapersonal, interpersonal, institutional/community, and societal/structural. Building upon the limited research, we recommend key strategies for supporting and protecting older people experiencing homelessness through the reduction of ageism at each level. We present these insights and recommendations as a call to action for those working in both the aging and housing/homelessness spheres., (© The Author(s) 2023. Published by Oxford University Press on behalf of The Gerontological Society of America. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.)

Background and Objectives: The concept of aging in place is acknowledged as the preference of older adults, yet without consideration of the intersections of diversity in later life, it is critiqued as unattainable, unrealistic, or even undesirable. This gave rise to the exploration of what is needed to age in the right place (AIRP). Building on existing research, we examined the meaning of AIRP to older adults (aged 55+ years) who have experienced homelessness., Research Design and Methods: We conducted photovoice interviews with 11 residents of a temporary housing program in Metro Vancouver (Canada)., Results: Using thematic analysis, we organized meanings of AIRP according to (1) Where one lives-the physical and social environment, (2) Where one goes and what one does, and (3) How one feels in "the right place.", Discussion and Implications: Participants meanings' of AIRP are applied to Maslow's hierarchy of needs. That is, when basic needs of shelter are met, participants' considerations of "the right place to age" extend beyond affordable housing to include feeling safe and comfortable in one's home and neighborhood and having access to meaningful engagement and activities-both in vibrant urban districts and naturescapes-enabled by affordable transportation. Our examination of what AIRP means to this group of older adults broadens current conceptualizations. Given the increase in homelessness among older adults, it is imperative that policymakers and practitioners are cognizant of meanings of AIRP so diverse older adults can not only age in place, but can thrive in the right place., (© The Author(s) 2023. Published by Oxford University Press on behalf of The Gerontological Society of America. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.)

The COVID-19 pandemic created a shift in interprofessional education (IPE) courses, causing programs to change pedagogical approaches. We sought to examine student preferences for taking IPE simulations. On post-simulation surveys from two courses (n=844 students, 2020-2022 academic years), we asked students if they preferred to take the simulation through a synchronous in-person or virtual format. More students preferred a virtual platform in academic year 2021-2022 than the previous year (p<0.001). Students who chose the virtual format believed it was more convenient, reduced COVID-19 transmission, and eased interprofessional collaboration. The downsides to in-person simulations included travel logistics and technical challenges in the simulation lab. Students suggested that in-person simulations more closely resembled 'real life' and that communication and body language are easier to convey in person.

Background and Objectives: Response to the coronavirus disease 2019 pandemic required rapid changes to physical, social, and technological environments. There is a need to understand how independent-living older adults are adapting to pandemic-borne transformations of place and how environmental factors may shape experiences of aging well in the context of a public health emergency response., Research Design and Methods: We conducted a photovoice study to examine the characteristics associated with aging in place. Our study investigated how independent-living older adults characterized aging in a "right" place approximately 1 year after the onset of the pandemic., Results: Six themes categorized into 2 groups capture how older adults describe a "right" place to age. The first category, "places as enactors of identity and belonging," describes the significance of places contributing to intimate relationships, social connections, and a sense of personal continuity. The second category, "places as facilitators of activities and values," recognizes environments that promote health, hobbies, goals, and belief systems. Participants reported modifying their daily living environments with increased use of technology and more time outdoors., Discussion and Implications: Our findings emphasize older adults' active engagement with place and strategies used to maintain healthy aging despite public health restrictions. The results also identify place-based characteristics that may help overcome stressful circumstances from older adults' perspectives. These findings inform pathways to pursue to facilitate resiliency for aging in place., (© The Author(s) 2023. Published by Oxford University Press on behalf of The Gerontological Society of America.)

The provision and siting of homeless emergency shelters have community-wide implications for addressing the needs of people experiencing homelessness (PEH). In Utah, Salt Lake County's transition from a large, centralized emergency shelter sited in a free transit zone to a decentralized scattered-site model outside of a no-cost transit zone provided the context to evaluate how transportation access and mobility patterns of PEH were affected as they were displaced from a centralized service network in a downtown core. We conducted 19 in-depth, semi-structured interviews with PEH aged 18 + who were staying in one of three distributed resource centers who had also previously stayed at the former centralized shelter. Thematic analysis of the interviews resulted in three categories, each with distinct sub-categories: 1) Pre-decentralization transportation and mobility, 2) Post-decentralization transportation and mobility, and 3) Recommendations to improve transportation access for PEH, including lowering or eliminating financial barriers to transportation and expanding transit and shuttle van frequency and route radius. Study findings demonstrate that there is a significant need for community planners to collaborate on the siting of homeless shelters to provide more affordable, flexible, and equitable access to transportation networks., Competing Interests: Conflict of interest None., (Copyright © 2023 The Authors. Published by Elsevier Ltd.. All rights reserved.)

Formal and informal networks of resources are critical to supporting the growing number of older adults aging in place (AIP). Data are needed from aging-service providers about assets and barriers that impact their abilities to support AIP during the pandemic, as well as emergent needs resulting from response measures. A series of World Café workshops were conducted with aging-service providers in Salt Lake City, Utah, to understand supportive factors, service gaps, and future needs. Novel domains to support AIP in the context of the pandemic were identified: digital access and literacy, social isolation and mental health, and emergency preparedness. Issues related to access, equity, and affordability were identified as overarching themes across domains. Issues reflect concern over how the pandemic exacerbated socioeconomic and cultural disparities impacting older adults who benefit from aging services. Networks of advocacy and support are needed to bolster resources for older adults, caregivers, and aging-service providers.

Background: To sufficiently house and support persons experiencing homelessness (PEH), deeper understandings of the cultural appropriateness and responsiveness of community resources and the service delivery system is essential. In the case of Metro Vancouver, Canada, the cultural appropriateness and responsiveness of Housing First as a service model for supporting PEH was explored., Methods: Local service providers and stakeholders (n = 52) participated in three full day service-mapping workshops to identify Housing First supports for older adults, youth, and women experiencing homelessness, as part of a municipal-wide participatory and action-oriented study. Data were analyzed using a structured framework thematic analysis approach and cultural safety and humility lenses., Results: We generated three key themes: (i) insufficient built environments create challenges across gender and age, (ii) cultural safety and humility concerns at the intersection of gender and age, and (iii) implications for a culturally-responsive Housing First implementation., Conclusions: Findings informed the development of a Culturally-Responsive Planning resource to support housing, health, and social service providers who are implementing Housing First initiatives., (© 2023. The Author(s).)

To address the numerous challenges associated with aging, increased attention has been given to the development of age-friendly cities and communities (AFCC) to promote healthy aging and social participation. However, limited evidence exists for addressing both health and social needs through the AFCC framework. We address this gap by conducting a scoping review of the interventions that target both health and social outcomes within the purview of the AFCC framework. The results showed that many of the successful interventions used a partnership model and behavioral change theories to inform the program design and implementation. The results also indicated that social participation and engagement played a key role in making the interventions successful. However, the results revealed that the literature is dominated by person-focused approaches. Future research should focus more on evaluating environmental-focused interventions and develop a holistic framework that combines both person- and environment-based approaches to healthy aging.

Older people with experiences of homelessness (OPEH) tend to experience more complex health, social, and psychological issues than people experiencing homelessness at younger ages. Simultaneously, many housing resources (e.g., shelters, temporary housing) are often ill equipped to meet the needs of OPEH. As such, OPEH are often unable to age in the right place (AIRP) - that is, in a place that supports unique needs and vulnerabilities. However, several promising practices exist that deliver housing and services tailored to OPEH. To investigate the aspects of housing and shelter that both promote and impede AIRP for OPEH, this study examines the delivery of services in three such promising practices from the perspective of service providers. Findings from fifteen qualitative interviews revealed three overarching themes: 1) barriers to providing individualized support (e.g., staff turnover); 2) shifting contexts and structures (e.g., housing market changes); and 3) mechanisms of success (e.g., facilitating smooth transitions into permanent housing). These findings provide evidence to support the refinement of service delivery to promote AIRP for OPEH. In doing so, these insights can help to elevate promising practices to the level of best practice.

Introduction: Given the increasing rates of homelessness in recent years, there is an urgent need to address the ongoing discrimination and societal disinterest in preventing, reducing and ending homelessness. There is no systematic review of experiences of stigma and discrimination among persons experiencing homelessness or interventions to combat this discrimination. The objective for the proposed study is to identify ways in which persons experiencing homelessness have been stigmatised and discriminated against, the results of these experiences, and interventions to reduce stigma and discrimination towards persons experiencing homelessness., Methods and Analysis: We are conducting a scoping review with guidance from the JBI Manual for Evidence Synthesis and Arksey and O'Malley's framework. From 15 to 19 July 2022, we searched the following databases from our institutional licensed years of coverage: Medline, Embase, CINAHL Complete, Academic Search Ultimate, APA PsycINFO, Science Citation Index Expanded, Social Sciences Citation Index, Arts & Humanities Citation Index, Emerging Sources Citation Index, Left, PAIS International, PILOTS, Psychology & Behavioral Sciences Collection, Sociological Abstracts, and Dissertations and Theses Global. Two independent reviewers are screening study titles/abstracts and will independently screen the full texts. Study inclusion criteria include any study type reporting primary findings of English-language research on non-refugee persons experiencing homelessness in any type of setting or service worldwide. Three reviewers will then chart data of our included studies. Data will be extracted and organised into categories and subthemes in tabular form. To understand the validity of the scoping review findings in the local context and to gather additional perspectives on the topic, we will conduct an 'expert consultation' workshop., Ethics and Dissemination: This study has ethics approval from the University of Utah Institutional Review Board. Review findings will be disseminated through a peer-reviewed journal and at conferences. We plan to preregister this protocol with Open Science Framework., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2022. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Research on programs offering senior-specific housing supports and enabling "aging in the right place" (AIRP) for "older persons with experiences of homelessness" (OPEH) is limited. This paper presents an environmental assessment of a "transitional housing program" (THP) in Metro Vancouver, Canada, for OPEH to AIRP. Data were collected using Aging in the Right Place Environmental (AIRP-ENV) and Secondary Observation (AIRP-ENV-SO) audit tools designed to evaluate multi-unit housing for OPEH. The 241-item AIRP-ENV tool was used to assess the built environmental features of four multi-unit buildings of the THP. The AIRP-ENV-SO tool was used to collect contextual data on the function, safety, and land use of the surrounding neighborhood. Findings identified built environment and urban design features that support THP residents' safety, security, accessibility, functionality, social activity, autonomy, and identity. The THP buildings were rated ' Good ' for accessibility, functionality, autonomy and identity, while ' Satisfactory ' or ' Poor ' for safety, security, and social activity. Findings point to the built environmental features (e.g., size and layout of spaces) required in the THP to create opportunities for increased social engagement among residents and enhanced safety and security. The AIRP-ENV and AIRP-ENV-SO audit tools can help inform programs across the housing continuum to develop supportive built environments that promote AIRP for OPEH.

Despite steady increases in homelessness in the U.S., only recently has research on transportation needs and use for persons experiencing homelessness (PEH) been the focus of research endeavours. Moreover, limited research has identified how the geographic relocation of homeless community services and resources impacts the transportation needs of PEH and how this process affects access to health and social services. To fill this gap in the literature, using a community-engaged research approach, we conducted a qualitative research study in which 24 professionals working in planning, transportation, local government, and the homelessness services sector were engaged in in-depth, semi-structured interviews. We examined participant perspectives on how PEH transportation needs and use changed after three new emergency shelters replaced a centralised one, and how access to health and social services was impacted. Data were organised into three overarching categories: (1) Changes in transportation need and use following decentralisation; (2) Impact of transportation changes on PEH access to services; and (3) Recommendations for improving transportation access. Findings suggest the need to offer PEH transportation on demand, provide education on transportation and system navigation, and increase transportation-related funding for homeless service providers and PEH to ensure transportation costs are not a barrier to healthcare and social services., (© 2022 John Wiley & Sons Ltd.)

While policies and practices that promote aging in place have risen in prominence over the last two decades, marginalised older adults have largely been overlooked. 'Aging in the right place' is a concept that recognises the importance of adequate and appropriate age-related health and psychosocial supports in shelter/housing settings and their impact on the ability of older people to age optimally. To understand the unique shelter/housing challenges and solutions that affect aging in the right place for older people experiencing homelessness (OPEH), we conducted three World Café workshops in three Canadian cities-Montreal, Calgary, and Vancouver. In total, 89 service providers and OPEH engaged in the workshops, which involved guided, small-table discussions with the goal of stimulating creative ideas and fostering a productive atmosphere. Findings revealed two overarching themes 1) Discrepancies, between the need and availability of housing options and community supports for OPEH, such as affordable transportation, case management, access to healthcare, and system navigation; and 2) Desires, for more peer support, participatory planning, service-enriched housing, social programming, and policies that promote agency, independence, and choice for OPEH. These findings provide evidence to inform the development or modification of housing and supports for OPEH that promote aging in the right place., (© 2022 John Wiley & Sons Ltd.)

Aging in place may not be a universally optimal goal nor accessible to all. Research has highlighted the significance of aging in the right place (AIRP) by recognizing that secure housing for older adults should support one's unique vulnerabilities and lifestyles. Despite the evolving conceptualization of AIRP for general populations of older adults, considerations of AIRP relevant for older people with previous or current experiences of homelessness are absent from the existing literature. Given this conceptual gap, we developed a framework of indicators relevant for older persons experiencing homelessness. We engaged community partners in the development of our framework and examined what had been described in prior research on aging in place and person-environment fit for older adults. The resulting conceptual framework is comprised of 6 subcategories of indicators: (a) built environment of the housing unit and surrounding neighborhood, (b) offsite and onsite health and social services and resources, (c) social integration, (d) stability and affordability of place, (e) emotional place attachment, and (f) broader political and economic contexts. This framework provides a practical and meaningful contribution to the literature which can be used to promote AIRP for individuals whose experiences are often not reflected in existing models., (© The Author(s) 2022. Published by Oxford University Press on behalf of The Gerontological Society of America. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.)

The purpose of this study was to update our understandings of older adults' experiences and perceptions of alcohol use. Taking a community-based research approach, three Knowledge Café workshops hosted 66 older adults and service providers in Vancouver, BC. Thematic analysis identified three overarching categories: (a) reasons older adults use alcohol, including out of habit, social expectations, or to self-medicate; (b) personal experiences of alcohol use, including reduced consumption over time as a result of the cost of alcohol, the physical effects, and increased knowledge about the effects of alcohol; and (c) older adults' perceptions of alcohol use outcomes, including positive outcomes from drinking in moderation and negative outcomes that can worsen one's health, lead to tolerance, and harm others. Developing and promoting healthy drinking behaviours in later life is needed as the general population continues to age.

Background: Older persons with lived or living experience of homelessness (PWLEs) often live with complex physical and/or mental health conditions which are challenged by poor access to health services, especially primary care. To fill the gap in the continuum of care following hospital discharge for PWLEs, medical respite provides health and shelter support for PWLEs who do not have acute care needs that qualify for a stay in a hospital bed, yet are too sick or frail to recover on the streets or in a traditional shelter., Objective: This study examines how a medical respite could be designed for older PWLEs in Metro Vancouver, BC., Research Design: Using a community-based participatory research approach, in-depth interviews and focus groups were conducted with PWLE (n=15) and service provider (n=11) participants., Results: Participants offered rich suggestions about (a) the culture of the medical respite, (b) the physical design of a medical respite, (c) individuals who should be involved in medical respite delivery, (d) services a medical respite should provide, and (e) who the medical respite should serve., Conclusions: When designing a medical respite for older PWLEs, considerations include providing an environment where patients can rest, but also feel safe and be surrounded by persons who they trust and who care for them. Developing a medical respite that adheres to the tenets of trauma-informed and patient-centered care acknowledges the mistrust and traumatization that often accompanies homeless patients presenting to health care., Competing Interests: The authors declare no conflict of interest., (Copyright © 2021 Wolters Kluwer Health, Inc. All rights reserved.)

Despite widespread use and acceptance of alcohol, discussions of age-related changes that impact alcohol consumption behaviors are rare. The objective of this community-engaged qualitative research study was to gain insight into how to promote knowledge dissemination regarding newly developed low-risk drinking guidelines for older adults. A convenience sample of 66 older adults and service providers participated in three Knowledge Café dialogue workshops and discussed their opinions about alcohol use in later life and ideas for sharing alcohol-related research evidence with the community. Participants discussed (a) low-risk drinking knowledge dissemination, (b) personal choice in drinking alcohol and adherence to low-risk drinking guidelines, and (c) preferences for engaging in discussions about alcohol use. Community dialogues fostered knowledge dissemination while participants engaged in rich conversations about a rarely discussed topic. Sharing evidence-based clinical advice with community stakeholders through dialogue events offers an innovative opportunity for health promotion efforts.

Introduction: Though hospitals are a common location where older adults experiencing homelessness receive health care, an understanding of the types of supports needed upon hospital discharge is limited. We examined the unique characteristics of older homeless adults and the health and psychosocial supports required upon hospital discharge., Design and Methods: Guided by principles of community-based participatory research (CBPR), we conducted 20 in-depth, semi-structured interviews with shelter/housing and health care providers in Metro Vancouver., Results: Thematic analyses revealed 6 themes: (a) older people experiencing homelessness have unique vulnerabilities upon hospital discharge; (b) following hospital discharge, general population shelters are inappropriate for older adults; (c) shelter/housing options for older adults who have complex health and social needs are limited; (d) shelter/housing for older adults who require medical stabilization and convalescence after hospital discharge is needed; (e) a range of senior-specific shelter/housing options are needed; and (f) unique community supports are needed for older adults upon hospital discharge., Discussion and Implications: As the population of older adults increases across North America, there is a parallel trend in the increased numbers of older adults who are experiencing homelessness. Not only is there often a need for ongoing medical care and respite, but there is a need for both shelter and housing options that can appropriately support individual needs., (© The Author(s) 2019. Published by Oxford University Press on behalf of The Gerontological Society of America. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.)

Using mechanisms of active learning, we developed a Persona project for our undergraduate Introduction to Gerontology course. We conceive of Personas as fictional characters that are created through the amalgamation of physical, social, and psychological traits and have unique lived experiences. This article details the development of this innovative pedagogical tool and describes how Personas are used as part of an experiential learning assignment over the course of a semester. Student-generated Personas act to contextualize the broad course material, ranging from physical and mental health to environments and financial well-being in later life. Student feedback of the Persona project highlights what they learned, how this project was helpful for them, and suggestions for enhancing the experience for students in subsequent semesters. We conclude by recommending that other gerontological and social science educators incorporate Personas into their coursework to provide students an interactive tool to apply information learned through class lectures and readings.

Objectives: To understand the experience of Metro Vancouver's Homelessness Partnering Strategy-funded Housing First program and how it is functioning from the perspective of a representative sample of providers and clients who deliver and receive HF services., Methods: Thirty-four clients and providers who currently or formerly delivered HF in Metro Vancouver participated in one-on-one interviews (n = 26) or focus groups (n = 8) between March and April 2017 and data were thematically analyzed., Results: Strengths of the HF program included: the ability to transition persons from the street into housing with individualized service supports and, in certain cases, with 12-month rent subsidies, household goods, and connection to community resources. Identified program weaknesses were: eligibility criteria, limited rent subsidy funds, limited provider capacity, and workload burden. Suggested opportunities to improve HF were: streamlining federal and provincial reporting and rent subsidy systems and building friendly landlord networks. Potential threats to HF described were: limited affordable housing, stigma and discrimination toward clients, inadequate income assistance, and limited opportunity for cross-sector collaboration., Conclusions: The delivery of HF in regions that have limited affordable housing presents unique challenges. Recommendations are provided to improve HF practice and policy in these contexts., (Copyright © 2019 Elsevier Ltd. All rights reserved.)

Being homeless has a negative effect on health and the health needs of individuals experiencing homelessness are complex and challenging to address. As a result of limited access to and use of primary healthcare, the main point of entry into the healthcare system for individuals experiencing homelessness is often hospitals and emergency departments. Persons experiencing homelessness are commonly discharged from hospital settings to locations that do not support recovery or access to follow-up care (e.g. shelters or the street). This can be costly to both the healthcare system and to individuals' health and quality of life. We conducted a scoping review of the literature published between 2007 and 2017 to identify the types of health supports needed for persons experiencing homelessness who are discharged from the hospital. Thirteen literature sources met inclusion criteria and thematic data analyses by two researchers resulted in the identification of six themes related to the types of health supports needed for persons experiencing homelessness who are transitioning (i.e. being discharged) from the hospital. Using a community consultation approach, the scoping review themes were validated with 23 health and shelter service providers and included in our integrated findings. Themes included: (a) a respectful and understanding approach to care, (b) housing assessments, (c) communication/coordination/navigation, (d) supports for after-care, (e) complex medical care and medication management, and (f) basic needs and transportation. These themes were found to resonate with participants of the community consultation workshop. Recommendations for trauma-informed care and patient- or client-centred care approaches are discussed., (© 2018 John Wiley & Sons Ltd.)

Objective: Research has repeatedly shown that reminiscence affects the mental health and well-being of older adults contemporaneously and over time. Cross-sectional research also points to a link between reminiscence and physical health. The direction of this relationship is unclear, however. Does physical health affect how and why older adults think of themselves in the past? Or conversely, do various functions of reminiscence affect both mental and physical health now, and in future?, Methods: Online responses were collected from a primarily Canadian sample of 411 older adults at three time points, separated by eight months on average. Participants responded to the Reminiscence Functions Scale at baseline and reported their health conditions, perceived state of health, life satisfaction, and psychological distress at subsequent points of measurement. A structural equation model was computed to identify direct and indirect associations between reminiscence functions and health over time., Results: Self-negative reminiscence functions at baseline (T1) predicted physical health 8 months later (T2), whereas self-positive reminiscence functions at T1 predicted both physical health and psychological distress at T2. The associations among self-positive functions and subsequent physical and mental health were maintained over time. Additionally, longitudinal crossover was observed in which psychological distress at T2 predicted physical health at T3, controlling for physical and mental health at T2., Conclusions: Findings confirm longitudinal associations among reminiscence functions and subsequent indicators of health. For older adults, this extends to both physical and mental health. Future research should examine the physiological mechanisms by which autobiographical memory affects health over time.

This article describes the experience and process of using community mapping as a tool for collecting data on the functioning of housing-related support services in Metro Vancouver. We outline our mapping methods and discuss strengths and challenges encountered during workshops aimed at understandings how the system of housing-related supports function. Strengths were that workshops provided a forum for social participation and engagement. In addition, mapping is a research tool that enables local knowledge of service functioning and service gaps to be accessed and exchanged. Challenges include ensuring diverse representation; reducing power imbalances; and having adequate space to accommodate interested participants., (Copyright © 2018 Elsevier Ltd. All rights reserved.)

Background and Objectives: The digital revolution has resulted in innovative solutions and technologies that can support the well-being, independence, and health of seniors. Yet, the notion of the "digital divide" presents significant inequities in terms of who accesses and benefits from the digital landscape. To better understand the social and structural inequities of the digital divide, a realist synthesis was conducted to inform theoretical understandings of information and communication technologies (ICTs); to understand the practicalities of access and use inequities; to uncover practices that facilitate digital literacy and participation; and to recommend policies to mitigate the digital divide., Research Design and Methods: A systematic search yielded 55 articles published between 2006 and 2016. Synthesis of existing knowledge, combined with user-experience elicited through a deliberative dialogue session with community stakeholders (n = 35), made visible a pattern of privilege that determined individual agency in ICT access and use., Results: Though age is consistently centralized as the key determinant of the digital divide, our analyses, which encompassed both van Dijk's resources and appropriation theory and intersectionality, appraised this notion and revealed that age is not the sole determinant. Findings highlight the role of other factors that contribute to digital inequity among community-dwelling middle-aged (45-64) and older (65+) adults, including education, income, gender, and generational status., Discussion and Implications: Informed by results of a realist synthesis that was guided by intersectional perspectives, a conceptual framework was developed outlining implications for theory, policy, and practice to address the wicked problem that is the digital divide.

Objectives: Across age groups, bipolar disorder (BD) carries the greatest risk of death by suicide of all psychiatric conditions; 25%-50% of those with BD will make one or more suicide attempt. Psychometrically sound instruments are required to reliably measure suicide ideation and risk of self-harm for older adults with BD. For this study, we validate the geriatric suicide ideation scale (GSIS) with adults 50+ years with BD., Methods: We recruited a global sample of 220 older adults with BD (M = 58.50 years of age) over 19 days using socio-demographically targeted, social media advertising and online data collection. To demonstrate the construct validation of GSIS responses by older adults with BD, we computed correlations and performed regression analyses to identify predictors of suicide ideation., Results: Our analyses support a four-factor model of responses to the GSIS (ideation, death ideation, loss of personal and social worth, and perceived meaning in life) measuring a higher order latent construct. Older adults with BD reporting low satisfaction with life and current depressive symptoms, and who misuse alcohol, report significantly higher levels of suicide ideation. Sleep quality and cognitive failures are also correlated with GSIS responses., Conclusions: Results support the factorial validity of the GSIS with older adults with BD. Similar to other populations, the GSIS measures a four-factor structure of suicide ideation. Across BD subtypes, the GSIS appears to reliably measure suicide ideation among older adults with BD.

Objectives: Most persons with bipolar disorder (BD) misuse alcohol and/or illicit drugs at some point, yet research specific to older adults with BD is nascent. The current study sought an in-depth understanding of the experiences and meanings of substance use in a sample of adults who self-reported substance misuse., Methods: Semi-structured interviews were conducted and thematically analyzed to understand the personal theories of substance use by 12 adults (9 women and 3 men; M = 49 years old) who self-reported diagnoses of BD and regular alcohol or illicit drug use., Results: Findings provide an in-depth picture of the theories middle-aged and older adults with BD have developed to explain their substance use. Participants' theories suggest multiple reasons for substance use, including self-medication; increased confidence with substance use; rejection of prescribed medications; easy access to alcohol; early social exposure/use as facilitator; and living in a culture of substance use., Conclusion: Findings suggest multiple theories for the comorbid link between BD and substance use, primarily that persons with BD use drugs and/or alcohol to relieve stress or manage symptoms. It is clinically relevant to incorporate personal reasons for actively and regularly using substances as part of personalized substance treatment and BD symptom management.

Instruments developed for mental health research are commonly devised and validated with young adults only. However, the measurement properties of these scales may differ over the lifespan. For this study, we set out to demonstrate the psychometric equivalence of the BDSx scale with an international sample of young and older adults with bipolar disorder (BD). We independently replicated the 4-factor model of BDSx responses with young and older participants (M = 45.63, range 19-87 years of age); we then compared the psychometric properties between models. This allowed us to compare responses to each BDSx item between groups, and the strength of association among depression and hypo/mania factors (cognitive depressive symptoms, somatic depressive symptoms, affrontive symptoms of hypo/mania, elation/loss of insight). Young and older adults responded to 19 of 20 BDSx items in similar ways. Only responses to the 'talkative' item were significantly higher for younger adults. Correlations between depression and mania factors are statistically indistinguishable between age groups. This suggests that symptoms cluster and present similarly for young and older adults with BD. The BDSx is currently being used for ecological momentary sampling of mood by the BADAS (Bipolar Affective Disorder and older Adults) Study app for iPhone., (Copyright © 2017 Elsevier B.V. All rights reserved.)

High prevalence rates of alcohol and substance use disorders have been reported among persons with bipolar disorder (BD). In the present study, we explored the daily experiences of middle-aged and older adults living with BD who reported regular substance use and the ways in which participants expressed 'control' in relation to their use of alcohol and other substances. Semistructured, in-depth interviews were conducted with 12 participants (nine women and three men), aged 36-57 years of age (mean = 49 years). Thematic analyses identified emergent themes and patterns in participants' life histories. The theme of 'control' emerged as central to participants' reports, and was organized into four categories: (i) substance use to control BD symptoms; (ii) substance use provides a sense of being in control; (iii) methods of controlled substance use; and (iv) not having control: overreliance on substances. Implications of the present study include the need for nurses to openly discuss the use of alcohol and other drugs with persons with BD, provide health information and screening, and determine whether persons with BD feel they have control over their substance use. Several lines of research with persons who have BD and use substances are suggested., (© 2017 Australian College of Mental Health Nurses Inc.)

Objectives: This study was undertaken to examine bidirectional effects of well-being over time in long-wed couples., Method: We recruited 125 couples 50+ years of age who had been married 20+ years. Both spouses reported life satisfaction and depressive symptoms independently at three annual points over 2 years. We computed actor-partner interdependence models (APIMs) to identify concomitant and longitudinal bidirectional effects between long-wed spouses. Where parallel associations were found between models of life satisfaction and depressive symptoms, we undertook invariance analyses to compare the relative strength of associations., Results: We observed a significant association between wives' and their husbands' life satisfaction at baseline; a concomitant crossover effect was also evident from wives to husbands at 1- and 2-year follow-up, such that wives' life satisfaction predicted changes in their husbands' life satisfaction beyond that previously and concomitantly reported., Discussion: Our findings suggest that older wives influence their husbands after decades of marriage; the relative effect of this crossover on older husbands is comparatively equivalent for life satisfaction and depressive symptoms. These findings stand in contrast to prior research with younger couples suggesting that long-wed couples may be a distinct subset of the population of all married couples (i.e., those who have not divorced).

Purpose of the Study: Home and community engagement are key contextual factors for aging well, particularly for older adults in vulnerable social positions. A community-based participatory action research project conducted in Western Canada examined how to best use the shared amenity spaces in a low-income seniors' apartment complex in order to connect services and programs with tenants and to provide opportunities for service providers and local stakeholders to build upon and create new relationships toward collaboration and service delivery., Design and Methods: Pre-move deliberative dialogue workshops (n = 4) were conducted with stakeholders (e.g., service providers, developers, and municipal government employees). Workshop participants (n = 24) generated ideas and plans on how physical and social environments can contribute to the social engagement of senior tenants., Results: Shared dialogue led to community investment and asset sharing by integrating the knowledge and experiences of multiple stakeholder groups into the planning process. This article highlights how collaborative planning approaches for the effective use of the social environment (e.g., social programming), within the physical environment (e.g., amenity and community spaces), can generate rich and illuminating data for informing enhancements in the social environment of apartment dwelling low-income seniors. Contextual challenges to service provision are discussed, including the need for communication about and coordination of on-site programming, culturally diverse and responsive programming, and long-term funding., Implications: Prolonging independent community living with the assistance of support services should be a goal to both delay premature relocation into institutional care and meet the preferences of older adults., (© The Author 2017. Published by Oxford University Press on behalf of The Gerontological Society of America. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.)

Housing First is a model and philosophy for housing homeless people in immediate and permanent housing. In order to implement and deliver Housing First, research is essential to understand the system of support services as they currently exist. Guided by principles of community-based participatory research, this paper presents the findings from a senior-focused deliberative dialogue workshop in Metro Vancouver, Canada. Participants (16 service providers and 1 service recipient) identified services and resources available to support seniors in maintaining housing and barriers and facilitators for accessing services. Broadly, data were organized into seven themes: (1) Housing; (2) Home support; (3) Transportation; (4) Information availability, accessibility, and navigation; (5) Cultural diversity; (6) Discrimination; and (7) Funding and financial support. Results found that affordable housing that adapts to changing health conditions, income supports, health services, homecare, transportation, and culturally appropriate and nondiscriminatory informational resources are among the supports most needed for persons as young as 50 years old to succeed under the Housing First model in Metro Vancouver. Barriers to Housing First service provision, including rigid eligibility criteria for chronically and episodically homeless, should be revised to better support the growing number of older adults who are newly entering homelessness in Metro Vancouver.

Objectives: Bipolar disorder (BD) carries the greatest risk of death by suicide of all psychiatric conditions as 25%-50% of those with BD will make one or more suicide attempt, and about 15% will intentionally end their lives. Among young adults with BD, substance misuse, medication non-adherence, age at onset, and comorbid psychiatric conditions each predict self-harm. It is currently unclear if these same factors or others predict suicide ideation among older adults with BD., Methods: We recruited a global sample of 220 older adults with BD over 19 days using socio-demographically targeted, social media advertising and online data collection (Mean = 58.50, SD = 5.42; range 50 to 81 years). Path analyses allowed us to identify direct and indirect predictors of suicide ideation among older adults with BD., Results: Cognitive failures (perception, memory, and motor function), depressive symptoms, alcohol misuse, and dissatisfaction with life as direct predictors of suicide ideation; duration of BD symptoms and medication non-adherence emerged as indirect predictors. Of note, the significant impact of sleep on suicide ideation is indirect via depressive symptoms, cognitive failures, medication non-adherence and life dissatisfaction., Conclusions: As with young adults with BD, alcohol misuse and medication non-adherence emerged as significant predictors of suicide ideation. In addition, cognitive failures directly and indirectly predict suicide ideation in this sample of older adults with BD. Population aging and treatment efficacy are leading to ever growing numbers of older adults with BD. Both direct and indirect predictors of suicide ideation need to be considered in future BD research and treatment planning.

Purpose of the Study: The ability to integrate traumatic memories into a coherent life narrative is one factor associated with the mental health and well-being of Holocaust survivors. In the present study, reminiscences reported by survivors in Israel were collected to identify themes arising in positive and negative memories and experience., Design and Methods: Participants (M = 80.4 years; SD = 6.87) were asked to describe memories that typify a reminiscence function in which they frequently or very frequently engage. Open-ended responses were collected from 269 Holocaust survivors and thematic analyses were conducted in English (translated) and Hebrew., Results: Thematic analyses of these data suggest three overarching themes related to bridging the past and present, rebuilding families and the Jewish state, and the duty to share. These suggest how integral endurance, survival, and resilience were to participants during the war and how these themes defined their choices and understanding of their lives., Implications: The results of this study demonstrate how reminiscence serves many functions. Participants appear to have integrated memories of horror and loss as part of coherent life narratives. Resilience and memory are ongoing and intertwined processes whereby survivors juxtapose their early lives to the present., (© The Author 2016. Published by Oxford University Press on behalf of The Gerontological Society of America. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.)

Objective: Long-term care (LTC) facilities are increasingly intent on creating a "homelike" atmosphere for residents. Although residential staff are integral to the construction of a home within LTC settings, their perceptions have been relatively absent from the literature., Method: Thirty-two LTC staff participants were interviewed about their experiences and perceptions of the physical environment and conceptualizations of home, and thematic analyses were conducted., Results: An overarching category-interpersonal relationships-emerged from our analyses emphasizing the importance of relationships in creating a homelike environment within institutional settings. Sub-themes that inform our understanding include the following: (a) Staff members' perceptions of home; (b) "Their second home": Adjustment to and familiarity in LTC; and (c) "We become family": Relationality makes a home., Discussion: The study provides evidence to inform current policies and practices in LTC. Specifically, enough time and space should be given to residents and staff to create and maintain personal relationships to make residential care homelike.

Objectives: Ecological momentary sampling in BD research requires brief symptom measures with low cognitive demands to maximize data collection across the range of BD symptomatology. We developed the BD Sx cognizant of the challenges inherent in scale development with low prevalence populations and the limitations of existing measures (e.g., over-reliance on patients in acute states recruited from psychiatric settings). In order to be generalizable across the full spectrum of the illness, we also included those currently euthymic and those who avoid clinical contact., Methods: We recruited a global sample of 1010 adults with BD over 19 days using socio-demographically targeted, social media advertising and online data collection. At follow-up, 428 participants provided responses 67 days later on average. This enabled us to develop the BD Sx and replicate initial findings across multiple samples over time., Results: Both exploratory and confirmatory factor analyses support a 4-factor BD Sx model. Goodness of fit indices indicate good model fit across samples and over time. We labeled these factors: elation/loss of insight, affrontive symptoms of mania, cognitive/depressive, and somatic/depressive symptoms. Affrontive symptoms correlate positively with cognitive and somatic depression factors, which may suggest mixed-state symptom clusters in accord with DSM 5., Conclusions: Responses to the BD Sx reliably measure both depressive and hypo/manic symptoms. Temporal invariance analyses indicate that the 4-factor structure is consistent over time. Future research  should compare BD Sx responses to clinical diagnoses of hypo/mania and major depressive episodes.

Social capital is a critical resource for physical and mental health among older adults, but few studies have investigated this relationship in Chinese populations, and specifically among those with low socioeconomic status. This study examined the association between depression and cognitive social capital (reciprocity and trust) and structural social capital (social participation) in a community sample of older adults living in public housing in Macau (SAR), China (N = 366). Multivariable linear regressions estimated the associations between dimensions of social capital and depression, while adjusting for potential confounders. Significant inverse associations were found between reciprocity and trust and depression. No association was found between social participation and depression. Poor self-reported health was a robust correlate of depression in all models tested. Future studies are needed to evaluate whether enhancing social capital may reduce depression among Chinese older adults living in poverty.

Objectives: Insomnia is reported to be more prevalent in minority racial/ethnic groups. Little is known, however, about racial/ethnic differences in changes in insomnia severity over time, particularly among older adults. We examined racial/ethnic differences in trajectories of insomnia severity among middle-aged and older adults., Design: Data were drawn from five waves of the Health and Retirement Study (2002-2010), a nationally representative longitudinal biennial survey of adults aged > 50 years., Setting: Population-based., Participants: 22,252 participants from non-Hispanic white, non-Hispanic black, Hispanic, and other racial/ethnic groups., Measurements: Participants reported the severity of four insomnia symptoms; summed scores ranged from 4 (no insomnia) to 12 (severe insomnia). We assessed change in insomnia across the five waves as a function of race/ethnicity., Results: Across all participants, insomnia severity scores increased 0.19 points (95% CI: 0.14-0.24; t = 7.52; design df = 56; p < 0.001) over time after adjustment for sex, race/ethnicity, education, and baseline age. After adjusting for the number of accumulated health conditions and body mass index, this trend decreased substantially and even changed direction (B = -0.24; 95% CI: -0.29 to -0.19; t = -9.22; design df = 56; p < 0.001). The increasing trajectory was significantly more pronounced in Hispanics compared with non-Hispanic whites, even after adjustment for number of accumulated health conditions, body mass index, and number of depressive symptoms., Conclusions: Although insomnia severity increases with age-largely due to the accumulation of health conditions-this trend appears more pronounced among Hispanic older adults than in non-Hispanic whites. Further research is needed to determine the reasons for a different insomnia trajectory among Hispanics., (Copyright © 2016 American Association for Geriatric Psychiatry. Published by Elsevier Inc. All rights reserved.)

Objectives: We examined the association between alcohol use, at-risk drinking, and binge drinking, and loneliness in a sample of middle-aged and older adults., Method: We studied participants aged 50+ years from the 2008 wave of the Health and Retirement Study who reported alcohol use. We ran separate multinomial logistic regressions to assess the association of three alcohol use outcomes (i.e., weekly alcohol consumption, at-risk drinking, and binge drinking) and loneliness., Results: After adjusting for covariates, being lonely was associated with reduced odds of weekly alcohol consumption 4 to 7 days per week, but not 1 to 3 days per week, compared with average alcohol consumption 0 days per week in the last 3 months. No association was found between at-risk drinking or binge drinking and loneliness., Discussion: Results suggest that among a sample of community-based adults aged 50+, loneliness was associated with reduced alcohol use frequency, but not with at-risk or binge drinking., (© The Author(s) 2015.)

Aim: We examined qualitative data from a larger study of benzodiazepine-using women older than 65 years, living in the United States, for subjective experiences of loneliness and social isolation., Method: Data from semistructured interviews with seven participants discussed aspects of social isolation or loneliness. Following a phenomenological design, data were coded and analysed for experiences., Results: Three themes emerged: 'Dislike being alone'; 'Loneliness and isolation'; and 'Social isolation causes negative feelings'., Conclusion: Social isolation and loneliness are negative aspects of the lived experience for older benzodiazepine-using women and the loss of companions and transportation is important to this experience. Being isolated can cause depression, fear and insecurity. Future research should consider the role psychotropic medications have in coping with social isolation and loneliness among older adults. Clinicians should be aware of social isolation and loneliness in late life and discuss non-pharmacologic treatment options with their ageing patients., (© 2014 ACOTA.)

The prevalence of alcohol, drug, and tobacco use among US middle-aged and older adults is increasing. A subset of this population uses substances to cope with stress, but the characteristics of these individuals, and the association between substance-use coping and health outcomes remain unclear. We identified correlates of substance-use coping and measured its association with self-rated health in a community-based sample of adults aged 54-99 in the Health and Retirement Study (HRS). In the 2008 HRS, 1351 participants reported their frequency of prescription/other drug-, alcohol-, and cigarette-use coping with stress and reported self-rated health (excellent/very good, good, or fair/poor); 1201 of these participants also reported self-rated health in 2010. One in six participants frequently used substances to cope. The oldest participants were least likely to engage in frequent alcohol-use coping. Those with elevated depressive symptoms were more likely to frequently engage in cigarette- and prescription/other drug-use coping. In multivariable-adjusted analyses, participants who frequently used cigarettes (compared to participants who infrequently used cigarettes) to cope had 2.7 times (95% CI=1.1-6.7) the odds of poor (vs. excellent) self-rated health. Relative to participants who infrequently used prescription/other drugs to cope, participants who frequently used prescription/other drugs to cope had 2.4 times (95% CI=1.1-5.1) the odds of reporting poor self-rated health. The association between prescription/other drug-use coping in 2008 and self-rated health in 2010 was statistically significant (relative OR=3.5, 95% CI=1.7-7.2). Participants engaging in substance-use coping likely have particular demographic and clinical characteristics. Interventions to reduce substance-use coping may prevent adverse health outcomes., (Copyright © 2014 Elsevier Ltd. All rights reserved.)

Objective: Alcohol use in later life has been linked to poor sleep. However, the association between binge drinking, which is common among middle-aged and older adults, and insomnia has not been previously assessed., Methods: We studied participants aged 50 years and older (n = 6027) from the 2004 Health and Retirement Study who reported the number of days they had ≥4 drinks on one occasion in the prior 3 months. Participants also reported the frequency of four insomnia symptoms. Logistic regression analyses assessed the association between binge drinking frequency and insomnia., Results: Overall, 32.5% of participants had >0 to ≤2 binge drinking days/week; and 3.6% had >2 binge drinking days/week. After adjusting for demographic variables, medical conditions, body mass index, and elevated depressive symptoms, participants who binged >2 days/week had a 64% greater odds of insomnia than non-binge drinkers (adjusted odds ratio [aOR] = 1.64, 95% confidence interval [CI] = 1.09-2.47, p = 0.017). Participants reporting >0 to ≤2 binge days/week also had a 35% greater odds of insomnia than non-binge drinkers (aOR = 1.35, 95% CI = 1.15-1.59, p = 0.001). When smoking was added to the regression model, these associations fell just below the level of significance., Conclusions: Results suggest that binge drinking is associated with a greater risk of insomnia among adults aged 50 years and older, although this relationship may be driven in part by current smoking behavior. The relatively high prevalence of both binge drinking and sleep complaints among middle-aged and older populations warrants further investigation into binge drinking as a potential cause of late-life insomnia., (Copyright © 2014 John Wiley & Sons, Ltd.)

Sleep disturbances are common among older women; however, little is known about sleep experiences among chronic benzodiazepine users. The experience of sleep, sleep troubles, and management of sleep problems were explored through semistructured interviews with 12 women aged 65-92 who had used a benzodiazepine for three months or longer to treat a sleep disturbance. Themes that emerged from an interpretive phenomenological analysis included multiple reasons for sleep disruptions (health problems, mental disturbances, and sleeping arrangements), opposing effects of benzodiazepines on sleep (helps or does not work), and several supplemental sleep strategies (modification of the environment, distraction, and consumption).

A phenomenological study explored whether older women who are chronic benzodiazepine users identified themselves as dependent, how dependence was perceived, and how meanings and understandings shaped experiences of benzodiazepine use. Self-reported benzodiazepine dependence was associated with being unable to reduce use or a desire to discontinue use and reliance on benzodiazepines to remain comfortable and able to handle daily life. Themes included: (a) benzodiazepine dependence is similar to dependence to diabetes or blood pressure medications; (b) dependence is distinctive from addiction/abuse; (c) addiction/abuse is perceived as worse than dependence; and (d) concerns of addiction/abuse result in low-dose benzodiazepine use.

Background: Complaints of poor sleep are common among older adults. We investigated the prospective association between insomnia symptoms and hospitalization, use of home health care services, use of nursing homes, and use of any of these services in a population-based study of middle-aged and older adults., Methods: We studied 14,355 adults aged 55 and older enrolled in the 2006 and 2008 waves of the Health and Retirement Study. Logistic regression was used to study the association between insomnia symptoms (0, 1, or ≥ 2) in 2006 and reports of health service utilization in 2008, after adjustment for demographic and clinical characteristics., Results: Compared with respondents reporting no insomnia symptoms, those reporting one symptom had a greater odds of hospitalization (adjusted odds ratio [AOR] = 1.28, 95% confidence interval [CI] = 1.15-1.43, p < .001), use of home health care services (AOR = 1.29, 95% CI = 1.09-1.52, p = .004), and any health service use (AOR = 1.28, 95% CI = 1.15-1.41, p < .001). Those reporting greater than or equal to two insomnia symptoms had a greater odds of hospitalization (AOR = 1.71, 95% CI = 1.50-1.96, p < .001), use of home health care services (AOR = 1.64, 95% CI = 1.32-2.04, p < .001), nursing home use (AOR = 1.45, 95% CI = 1.10-1.90, p = .009), and any health service use (AOR = 1.72, 95% CI = 1.51-1.95, p < .001) after controlling for demographics. These associations weakened, and in some cases were no longer statistically significant, after adjustment for clinical covariates., Conclusions: In this study, insomnia symptoms experienced by middle-aged and older adults were associated with greater future use of costly health services. Our findings raise the question of whether treating or preventing insomnia in older adults may reduce use of and spending on health services among this population.

As the world's population ages, the elevated prevalence of insomnia in older adults is a growing concern. Insomnia is characterized by difficulty falling or remaining asleep, or by non-restorative sleep, and resultant daytime dysfunction. In addition to being at elevated risk for primary insomnia, older adults are at greater risk for comorbid insomnia, which results from, or occurs in conjunction with another medical or psychiatric condition. In this review, we discuss normal changes in sleep that accompany aging, circadian rhythm changes and other factors that can contribute to late-life insomnia, useful tools for the assessment of insomnia and related problems in older people, and both non-pharmacological and pharmacological strategies for the management of insomnia and optimization of sleep in later life., (Copyright © 2013 Elsevier Ireland Ltd. All rights reserved.)

Although doctorally trained gerontologists have unique types of expertise as a result of their interdisciplinary training, research exploring perceptions of their hirability in faculty positions is lacking. This exploratory study examined the perceptions of administrators and faculty at institutions identified as having a doctoral program in gerontology or a doctoral program in another aging-related area. A short, semistructured 27 question survey was disseminated online. Twenty-five (N = 25) deans, associate deans, or other faculty participated in this study. Results indicate varying views of the attractiveness of hiring doctorally trained gerontologists, who or what is a gerontologist, and the value of having a doctorally trained gerontologist as a faculty member.

Previous work suggests that control and suffering are related to one another. Although it would be expected that within cultures which emphasize the importance of masculinity, as well as personal control, there would be greater suffering among individuals who lose their sense of masculinity or control, how these constructs relate to each other and are individually negotiated has been largely understudied. This paper takes a case study approach to further exploring how the constructs of control, masculinity, and suffering are related in the lived experience of an older European American man, Mr. Gregor. Analysis of this case shows that masculinity is related to control and that these constructs act as themes which interact over Mr. Gregor's lifetime in a variety of ways. The level of control maintained by Mr. Gregor in different aspects of his life affects his sense of suffering. In some instances his sense of masculinity helps to protect Mr. Gregor against suffering; in others, it contributes to his suffering. These findings support the notion that there are culturally dependent possibilities for how control and masculinity are related.