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Yes / Objectives: To examine trends in opioid prescribing in primary care, identify patient and general practice characteristics associated with long-term and stronger opioid prescribing, and identify associations with changes in opioid prescribing. Design: Trend, cross-sectional and longitudinal analyses of routinely recorded patient data. Setting: 111 primary care practices in Leeds and Bradford, UK. Participants: We observed 471 828 patient-years in which all patients represented had at least 1 opioid prescription between April 2005 and March 2012. A cross-sectional analysis included 99 847 patients prescribed opioids between April 2011 and March 2012. A longitudinal analysis included 49 065 patient-years between April 2008 and March 2012. We excluded patients with cancer or treated for substance misuse. Main outcome measures: Long-term opioid prescribing (4 or more prescriptions within 12 months), stronger opioid prescribing and stepping up to or down from stronger opioids. Results: Opioid prescribing in the adult population almost doubled for weaker opioids over 2005–2012 and rose over sixfold for stronger opioids. There was marked variation among general practices in the odds of patients stepping up to stronger opioids compared with those not stepping up (range 0.31–3.36), unexplained by practice-level variables. Stepping up to stronger opioids was most strongly associated with being underweight (adjusted OR 3.26, 1.49 to 7.17), increasing polypharmacy (4.15, 3.26 to 5.29 for 10 or more repeat prescriptions), increasing numbers of primary care appointments (3.04, 2.48 to 3.73 for over 12 appointments in the year) and referrals to specialist pain services (5.17, 4.37 to 6.12). Compared with women under 50 years, men under 50 were less likely to step down once prescribed stronger opioids (0.53, 0.37 to 0.75). Conclusions: While clinicians should be alert to patients at risk of escalated opioid prescribing, much prescribing variation may be attributable to clinical behaviour. Effective strategies targeting clinicians and patients are needed to curb rising prescribing, especially of stronger opioids. / e National Institute for Health Research (NIHR) under its Research for Patient Benefit Programme (Grant Reference Number PB-PG- 1010-23041).

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Climate change mitigation requires changes in greenhouse gas emitting behaviours. This dissertation aims to provide insights into the influences of behaviour change for two high-impact pro-environmental behaviours: climate policy support and consumption of animal products. It does so by using quasi- and randomized experiments and by monitoring changes in behaviour over time. Study 1 examined changes in climate policy support and climate change risk perception over the course of a naturally occurring event: seasonal forest fires. It employed growth curve modeling techniques in a structural equation modeling framework to analyze longitudinal relations between these two constructs over time, and to examine growth in climate change risk perception while controlling for the effect of exposure to forest fires and other extreme weather. Indirect exposure to forest fires (e.g., media) had a modest effect on climate change risk perception. Climate change risk perception for individuals with above-mean perceptions of scientific agreement tended to increase faster than for those with below-mean perceptions. Individuals whose climate change risk perception grew at a faster-than-average rate tended to also grow at a faster-than-average rate for climate policy support. Study 2 provided insight into the psychological influences on consumption of animal products and on willingness to reduce. Following a comprehensive literature review, known influences were examined using Latent Profile Analysis to identify groups of individuals with similar perceptions of facilitators of meat consumption and obstacles to reducing it. Three groups were identified: strong-hindrance meat eaters, moderate-hindrance meat eaters, and reducers. Validation variables confirmed the practicality of the three profiles: groups differed in their current consumption of animal products and in their willingness to reduce. Using these findings, three group-matched interventions were designed in Study 3. Intervention design was informed by four behaviour-change frameworks. Participants were randomly assigned to one of four conditions: control condition, implementation-intention condition, information-and-healthy-recipe condition, and information-and-substitution condition. Then, they completed up to 28 days of food diaries. Multilevel model analyses were employed to examine changes in the consumption of animal products over time. Participants reduced their consumption by 20 grams of CO2 per day on average. Individuals that were randomly assigned to an intervention condition that matched their meat-eater profile reduced their consumption of animal products by 40 grams CO2 per day on average. Taken together, these studies highlight the importance of considering individual differences (i.e., tailoring) when designing pro-environmental behaviour interventions. / Graduate

Contexte : Les différences de fonctionnement physique entre les hommes et les femmes ne sont pas bien comprises. Les chercheurs ont porté attention aux différences biologiques entre les hommes et les femmes mais ne se sont pas concentrés sur les différences de fonctionnement physique et de mobilité qui pourraient être reliées au sexe et au genre. En particulier, les effets de la masculinité et de la féminité sur le fonctionnement physique des personnes âgées n’ont pas été examinés. Objectifs : L’objectif principal de cette recherche est d’évaluer l’association entre fonctionnement physique et rôles de genre. Pour atteindre cet objectif, nous avons examiné : 1) la validité de la version courte (12 items) de l’Inventaire des rôles sexués de Bem (IRSB) ; 2) les associations transversales et longitudinales entre l’IRSB et des indicateurs de mobilité et de performance physique, et finalement 3) les variables jouant un rôle de médiation entre l’IRSB et la performance physique. Méthodes : Les données de l’étude internationale sur la mobilité au cours du vieillissement (IMIAS) recueillies en 2012 et 2014 ont été utilisées dans cette recherche. Cette étude s’est déroulée dans 5 villes : Saint-Hyacinthe (Québec) and Kingston (Ontario) au Canada, Tirana (Albanie), Manizales (Colombie) et Natal (Brésil), avec un échantillon approximatif à chaque site de 200 hommes et 200 femmes âgés de 65 à 74 ans vivant dans la communauté (N=2004). Deux aspects du fonctionnement physique ont été examinés dans cette thèse : la mobilité et la performance physique. La mobilité a été mesurée par deux questions sur la difficulté à marcher un Km et à monter un étage d’escaliers. La performance physique a été objectivée par le Short Physical Performance Battery (SPPB). Cette batterie inclut des mesures de la marche, de l’équilibre et de la force musculaire et elle mesure le temps requis pour exécuter trois tests : marcher quatre mètres, se tenir début en position de tandem et se lever d’une chaise cinq fois. Pour la validation psychométrique de l’instrument IRSB, des analyses factorielles exploratoires et confirmatoires ont été réalisées. Pour les études d’associations transversales, des analyses de régression de Poisson ont permis l’estimation des ratios de prévalence pour les incapacités de mobilité et la mauvaise performance physique, comparant les rôles masculins, féminins et indifférenciés. Pour l’étude de l’incidence de la mauvaise performance physique, les estimations de risque relatif ont été obtenues à l’aide de la régression de Poisson. L’étude des variables de médiation entre les rôles de genre et la performance physique a inclus le tabagisme, l’inactivité physique, la consommation d’alcool, l’index de masse corporelle élevé, le nombre de maladies chroniques et la dépression. Finalement, une méta-analyse a été effectuée pour examiner l’homogénéité des associations entre les rôles de genre et la performance physique dans les cinq sites de recherche. Résultats : Les résultats des analyses factorielles pour l’instrument de mesure IRSB ont révélé qu’une solution à deux facteurs (instrumentalité-expression) donne une validité conceptuelle satisfaisante, ainsi qu’un ajustement aux données supérieur par rapport à une solution à trois facteurs. La solution à deux facteurs permet d’assigner un score de masculinité et un score de féminité à chaque participant et de classifier les personnes âgées dans quatre catégories selon leur typologie de rôle de genre : masculin, féminin, androgyne et indifférencié. En ce qui concerne les associations avec les indicateurs de mobilité et de fonctionnement physique, les rôles féminins et indifférenciés sont des facteurs indépendants associés à la prévalence des incapacités dans la mobilité et à la mauvaise performance après ajustement avec des variables de confusion potentielle. Les rôles féminins et indifférenciés sont des facteurs de risque associés à une détérioration plus rapide du fonctionnement des extrémités inferieures. Nous avons rapporté une incidence de mauvaise performance physique plus élevée pour ceux qui adoptent un rôle féminin (IRR ajusté=2.36, intervalle de confiance de 95% 1.55-3.60) ou le rôle indifférencié (IRR ajusté=2.19, 95% Intervalle de confiance de 95% 1.45-3.30) comparé au rôle androgyne. Le score de masculinité est associé à la performance physique, alors que le score de féminité ne l’est pas. Une augmentation d’une unité sur le score de masculinité est associée à une incidence de mauvais fonctionnement physique plus faible (IRR ajusté=0.76, 95% intervalle de confiance de 95% 0.67-0.87). Les rôles de genre agissent sur les comportements de santé (tabagisme et inactivité physique), sur l’index de masse corporelle et sur les maladies chroniques et la dépression, tous des facteurs de risque pour la performance physique. Les effets des rôles de genre ne sont que partiellement expliqués par ces facteurs de médiation et un effet direct des rôles de genre sur le fonctionnement physique reste toujours significatif. Conclusion : Les rôles de genre sont présents dans tous les cinq sites de recherche. La mobilité et la performance physique des personnes âgées sont associées au type de rôle de genre avec un possible effet protecteur pour les personnes androgynes, indépendamment du fait qu’ils soient un homme ou une femme. Les rôles de genre semblent influencer les comportements de santé et les risques de développer une maladie chronique et de souffrir de dépression, ce qui peut avoir des effets sur la fonction physique au cours du vieillissement. Cette étude est la première sur le sujet et nos résultats devraient être confirmés par des études futures avant d’être traduits en interventions concrètes de santé publique. / Background: Gender differences in mobility disability among older adults are not well understood. Studies have focused on the biological differences between men and women, but not on the mobility differences due to interrelationships of sex and gender. The associations between masculinity, and femininity on physical function in old age have never been examined. Objective: The main objective of this dissertation is to study the relationships between physical function and gender roles in old age. To accomplish this objective, I have: 1) assessed the psychometric properties and construct validity of the 12-items short form Bem Sex Roles Inventory (BSRI), 2) examined the cross-sectional associations between BSRI and mobility and physical performance, and 3) examined mediating pathways between BSRI and physical performance. Methods: A total of 2004 community-dwelling older adults from the International Mobility in Aging Study (IMIAS) aged 65 to 74 years were recruited in Natal (Brazil), Manizales (Colombia), Tirana (Albania), Kingston (Ontario, Canada), and Saint-Hyacinthe (Quebec, Canada). Two aspects of mobility loss will be assessed in this dissertation: first, Mobility disability is a self-reported measure of the difficulty to walk half a mile or climb one flight of stairs without assistance. Second, poor physical function or performance of the lower extremities which is assessed by an objective tool and defined as inability to perform physical action in the manner considered normal in the short physical performance battery (SPPB). This battery includes three timed tests of lower extremity function: a hierarchical test of standing balance, a four-meter walk, and five repetitive chair stands. To assess the validity of BSRI in old age as a measure of gender roles. The psychometric properties of the 12- items short form BSRI were assessed by means of exploratory (EFA) and confirmatory factor analysis (CFA). To assess the cross-sectional associations between gender roles and both measures of mobility loss, I used Poisson regression analysis to estimate prevalence rate ratios of gender role types using the androgynous type as reference category. To calculate the incidence of poor physical performance after two years of follow up, Poisson regression was conducted for the estimation of relative risks. Body mass index, smoking, alcohol consumption, physical activity, chronic diseases, and depression were tested as potential mediators in the pathway between gender roles and physical performance in old age. Finally, taking account the possible differences in associations between countries, I have conducted a meta-analysis to estimate overall effects of masculinity and femininity scores on physical performance based on five distinct studies representing each research site of IMIAS. Results: The results of Exploratory Factor Analysis revealed a three-factor model. This model was further confirmed by CFA and compared with the original two-factor structure model. CFA results revealed that a two-factor solution (instrumentality-expressiveness) has satisfactory construct validity and superior fit to data compared to the three-factor solution. These factor analysis findings allowed to calculate scores of masculinity and femininity and classify participants into four categories according to gender roles: Masculine, feminine, androgynous and undifferentiated. Feminine and undifferentiated gender roles are independent risk factors associated with the prevalence of mobility disability and low physical performance in older adults. Consistent with cross sectional analysis, higher incidence of poor physical performance was observed among participants endorsing the feminine role or the undifferentiated role compared to the androgynous role. Higher masculinity but not femininity scores predicted good physical performance two years later. Gender roles predicted poor physical performance through statistically significant direct and indirect pathways. Cumulative smoking, BMI, physical activity, multimorbidity, and depression were serial mediators explaining the indirect effect of gender roles on physical performance. These intermediate behavioral and pathological pathways only partially mediated the observed associations. None of the potential serial mediators in the present study could completely account for the association between gender roles and physical performance. Conclusions: Traditional gender roles are existent in the five research sites of IMIAS. Gender roles influence physical function in old age with a possible protective effect of androgyny in old age independent of biological sex. Gender roles influence health behaviors which in turn contribute to chronic conditions and faster decline of lower extremities physical function. This study adds to the scant literature on this topic and the findings obtained from this dissertation need to be confirmed by future longitudinal studies for the appropriate translation into public health actions.

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No description available.

<p>  </p> <p>The overarching goal of this dissertation was to understand how between-partner feedback loops facilitate adjustment in the year following a military deployment (i.e., reintegration). Reintegration encompasses a period of family transitions and can be a challenging and turbulent time for couples as they attempt to reconnect and reorganize household dynamics. Couples may experience changes in how they interact, and partners may be able to act as a catalyst for promoting positive change in each other. Guided by Family Systems and Interdependence Theories, this study tested a specific feedback loop of a between-partner mechanism across a period of family stress and transitions. Whereas the demand/withdraw dynamic is one example of a feedback loop that is consequential for relationship well-being, the present study examined an alternative feedback loop where partners may respond to individuals’ withdrawal with a type of constructive partner support that encourages discussions and facilitates effective collaboration (i.e., active engagement). Relationship happiness, an indicator for relationship climate, was considered as a moderator in this proposed feedback loop as it intersects with individuals’ tendencies to withdraw, partners’ attempts at support provision, and global relationship functioning during periods of stress and transition. </p> <p>This study utilized longitudinal dyadic data from 124 couples at three time points in the year following service members’ return from deployment to examine the 1) longitudinal interpersonal dynamics of individuals’ tendencies to withdraw, 2) mediating role of partners’ active engagement in the change in individuals’ withdrawal, and 3) moderating role of relationship happiness in the interpersonal dynamics. Study aims were evaluated with a series of actor-partner interdependence models and path models in a structural equation modeling framework. Results suggest three interpretations. First, whereas this study sought to examine change in individuals’ tendencies to withdraw, the data indicate high levels of within-person stability. Second, this study modeled a possible feedback loop where partners’ attempts at active engagement would result in less individual withdrawal. While I did not find evidence of this feedback loop as proposed, it appeared that (female) significant others’ withdrawal was salient for reductions in (male) service members’ active engagement. Finally, I sought to understand how relationship climate (operationalized by a dyad-level indicator of relationship happiness) was associated with the interpersonal dynamics. Couples defined by a happier relationship climate had a stronger negative association between significant others’ withdrawal and service members’ active engagement. This finding may be evidence of happier couples being more apt to shift between levels of independence and interdependence, which may be especially useful for postdeployment transitions. Taken together, findings from this study suggest that individuals’ tendencies to withdraw are relatively robust to the perturbations of deployment and the utility of flexibility and adaptability in couples’ patterns across reintegration. This dissertation concludes with a discussion of the theoretical implications, avenues for future research, and potential applications of these findings.  </p>

Die Psychologie der Lebensspanne und die Soziologie des Lebensverlaufs betonen die Bedeutung von Kontexten für den Erwerb individueller Fähigkeiten und die Entwicklung im Leben. In Übereinstimmung mit diesen konzeptionellen Annahmen zeigen Studien, dass verschiedene Kontexte die Entwicklung individueller Bereiche beeinflussen. Jedoch ist wenig darüber bekannt, wie kontextuelle Faktoren in der zweiten Lebenshälfte Wohlbefinden formen und wie Wohlbefinden in diesen Lebensphasen von sich schnell verändernden Kontexten beeinflusst wird. In dieser Dissertation werden unter Anwendung des Ökosystemischen Ansatzes von Bronfenbrenner drei Kontexte unterschiedlicher Proximität untersucht, in die die Entwicklung des individuellen Wohlbefindens eingebettet ist. Als erster Kontext wird die vielfältige Ökologie des Lebens und Sterbens in den ehemaligen Regionen Ost- und Westdeutschland herangezogen, um herauszufinden wie dieses Makrosystem Wohlbefinden in den letzten Lebensjahren gestaltet. Als zweiter Kontext wird die Bedeutung des Exosystems von Gesundheitseinrichtungen in Landkreisen (z.B. Anzahl stationärer Pflegereinrichtungen) auf Wohlbefindensverläufe am Lebensende beleuchtet. Als dritten Kontext untersuchen wir, wie das Mikrosystem sozialer Ökologien und Situationen momentanes, affektives Wohlbefinden gestaltet, sowie Altersunterschiede in diesen Assoziationen. Gemeinsam zeigen die drei Studien dieser Dissertation, dass Ökologien auf regionaler, dienstleistender und sozialer Kontextebene Entwicklung von Wohlbefinden in der zweiten Lebenshälfte beeinflussen. Diese Arbeit zeigt, dass Kontexte sowohl kognitives als auch affektives Wohlbefinden und innerhalb des letzteren sowohl Valenz und Aktivierung beeinflussen, und untersucht länger- und kurzfristige Kontext-Wohlbefindens-Assoziationen in späteren Lebensphasen. Die Ergebnisse liefern erste Vorschläge für Interventionen und veränderbare regionale Faktoren für die Erhaltung oder Verbesserung von Wohlbefinden. / Lifespan psychology and life course sociology have long acknowledged the role of context for individual functioning and development throughout life. Consistent with these conceptual notions, empirical studies show that various contextual factors influence development of individual-level outcomes. However, we know little about how contextual factors shape individual-level well-being and how well-being is influenced by fast changing contexts in the second half of life. Applying Bronfenbrenner’s model of human ecology as the overarching theoretical frame, this dissertation examines three sets of contexts that differ in the degree of proximity in which individual well-being and its development is embedded in. As a first context, the multifaceted ecology of living and dying in former regions of East and West Germany is used to investigate how the macrosystem shapes individual well-being in the last years of life. For a second context, the role of the exosystem of county-level health care features (e.g., number of inpatient care facilities) on late-life trajectories in well-being is examined. As a third context, we examine how the microsystem of social ecologies and situations influences momentary affective well-being and how these associations differ across age. Jointly, the three studies in this dissertation show that regional, service, and social ecologies profoundly shape development in well-being during the second half of life. To conclude, this dissertation shows that these contexts influence both cognitive and affective components of well-being, among the affective domain two facets (valence and arousal), and investigates long-term and short-term contextwell- being associations in later life phases. Results provide initial suggestions for interventions and malleable regional factors to maintain or improve well-being.