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Reginald D Tucker-Seeley1, 2Email author,
Yi Li3, 4,
Glorian Sorensen1, 2 and

SV Subramanian2
BMC Public Health201111:313
DOI: 10.1186/1471-2458-11-313
© Tucker-Seeley et al; licensee BioMed Central Ltd. 2011
Lifecourse socioeconomic circumstances and multimorbidity
among olde...
http://bmcpublichealth.biomedcentral.com/articles/10.1186/147
1-2458-1...
1 of 25 10/18/2016 12:28 AM
Received: 6 December 2010
Accepted: 14 May 2011
Published: 14 May 2011
Open Peer Review reports
Background
Many older adults manage multiple chronic conditions (i.e.
multimorbidity); and many of these chronic conditions
share common risk factors such as low socioeconomic status
(SES) in adulthood and low SES across the lifecourse.
To better capture socioeconomic condition in childhood, recent
research in lifecourse epidemiology has broadened
the notion of SES to include the experience of specific
hardships. In this study we investigate the association among
childhood financial hardship, lifetime earnings, and

multimorbidity.
Methods
Cross-sectional analysis of 7,305 participants age 50 and older
from the 2004 Health and Retirement Study (HRS)
who also gave permission for their HRS records to be linked to
their Social Security Records in the United States.
Zero-inflated Poisson regression models were used to
simultaneously model the likelihood of the absence of
morbidity and the expected number of chronic conditions.
Results
Childhood financial hardship and lifetime earnings were not
associated with the absence of morbidity. However,
childhood financial hardship was associated with an 8% higher
number of chronic conditions; and, an increase in
lifetime earnings, operationalized as average annual earnings
during young and middle adulthood, was associated
with a 5% lower number of chronic conditions reported. We
also found a significant interaction between childhood
financial hardship and lifetime earnings on multimorbidity.
Conclusions
This study shows that childhood financial hardship and lifetime
earnings are associated with multimorbidity, but not
associated with the absence of morbidity. Lifetime earnings
modified the association between childhood financial
hardship and multimorbidity suggesting that this association is
differentially influential depending on earnings
across young and middle adulthood. Further research is needed
to elucidate lifecourse socioeconomic pathways
associated with the absence of morbidity and the presence of
multimorbidity among older adults.

Chronic conditions generally cluster and individuals with one
chronic condition are likely to have other conditions
as well. As such, many older adults now manage two or more
chronic conditions at the same time (i.e.
multimorbidity)[1, 2]; and evidence suggests that the presence
of multimorbidity is expected to continue to rise [3,
4, 5]. The influence of childhood material conditions and
lifetime earnings on multimorbidity has yet to be
investigated. Considering the impending shift in the US
population demographic as the baby-boomers reach age 65,
among olde...
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which will yield an elderly population characterized by
declining death rates, increasing life expectancy, and
increasing health care costs,[6, 7] an understanding of the
correlates of multimorbidity in older adults is a crucial
issue for population health research [8, 9].
Lifecourse financial/economic conditions
A substantial literature exists documenting the positive
association between childhood SES and adult health[10];
specifically, low childhood socioeconomic status (e.g. parental
occupation, parental educational attainment) has
been linked to heart disease,[11] stroke [12], diabetes [13], and
some cancers [14] among adults. A few lifecourse
epidemiology studies have broadened the notion of childhood

socioeconomic status (SES) to include specific
financial hardships present in the socioeconomic environment
during childhood [15, 16, 17]. For example,
Lundberg (1997) found that respondents growing up in a family
that experienced economic difficulties had an
increased risk for circulatory illness in adulthood, even after
controlling for demographic and socioeconomic
characteristics and baseline health [17]. Additionally, Moody-
Ayers, et al (2007) showed an independent effect of
childhood financial hardship on functional limitations among
older adults over and above the influence of adult
SES and demographic characteristics [18].
Financial hardships in childhood can greatly influence
subsequent access to financial/economic resources,[19, 20]
which in turn affects the trajectory of health outcomes
throughout the lifecourse [21]. As such, SES over the
lifecourse has been shown to be more strongly associated with
adult disease outcomes than an assessment of SES
for a particular point in time [22, 23]. In particular, cumulative
disadvantage or low lifecourse SES has been shown
to be positively associated with morbidity and mortality [24, 25,
26, 27]. However, the relationship among
childhood financial hardship, earnings across adulthood, and
multimorbidity remains to be investigated; in
particular, to our knowledge no study has been conducted to
determine the association of these factors among older
adults.
The aims for the present study were threefold. The first aim was
to determine the association between childhood
financial hardship and multimorbidity adjusting for
demographic and socioeconomic characteristics. The second
aim was to determine the association between lifetime earnings
and multimorbidity; and the third aim was to
determine if lifetime earnings act as an effect modifier in the

association between childhood financial hardship and
adult multimorbidity.
Data source
The Health and Retirement Study (HRS) is a national
longitudinal study of the economic, health, marital, family
status, and public/private support systems of older Americans
funded by the National Institute on Aging and the
Social Security Administration and conducted by the Institute
for Social Research Survey Research Center at the
University of Michigan [28]. The HRS uses a national
multistage area probability sample of households in the U.S.,
with oversamples of Blacks, Hispanics, and residents from the
state of Florida. Details of the HRS data collection
methods are described elsewhere [29]. We used respondents
from the 2004 wave of the HRS who signed consent
forms for their social security earnings records to be linked to
their HRS records (N = 7,792). To determine lifetime
earnings of the respondents, we linked the 2004 HRS public use
dataset to the 2004 Permissions: Summary
Earnings Information Restricted data set provided by the HRS.
The 2004 Permissions data set includes earnings
data for HRS respondents from 1951 to 2003. Subjects were
dropped from analyses if they were under age 50 (N =
369), if they were missing data on the childhood financial
hardship variable (N = 37), and if they were missing data
on the multimorbidity variable (N = 61) or the socioeconomic
variables (N = 20). The final sample used for
analysis was N = 7,305. The Institutional Review Board (IRB)
at the University of Michigan approved the Health
among olde...
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and Retirement Study and the Office of Human Research
Administration at the Harvard School of Public Health
approved this study.
Outcome variable
Multimorbidity was operationalized as the count of six chronic
conditions reported in the 2004 HRS. The chronic
conditions of interest were cancer, heart disease, lung disease,
stroke, diabetes, and hypertension. Chronic
conditions were assessed in the HRS by a series of questions
where respondents were asked if a doctor had ever
told them if they had one of these diseases.
Primary predictor variables
We operationalized childhood financial hardship with the
dichotomous (yes/no) question from the HRS: 1) While
you were growing up, before age 16, did financial difficulties
ever cause you or your family to move to a different
place?
We used average annual lifetime earnings during young and
middle adulthood to operationalize lifetime earnings.
Average annual lifetime earnings were calculated as the mean
annual earnings of the respondent from age 20 to age
50. We selected up to age 50 because this is the age of
eligibility for the HRS, thus all respondents would
potentially have earnings up to age 50. Years with zero earnings
were excluded from the calculation of average
annual lifetime earnings to avoid misclassifying respondents

who may temporarily leave the labor market (e.g.
respondents with child-rearing responsibilities) [30]. Earnings
were inflation-adjusted to 2003 US dollars using the
consumer price index for urban consumers (CPI-U 1951-2003)
[31]. For ease of interpretation, we divided average
annual earnings by $10,000 so that changes in the outcome
would be associated with a $10,000 change in average
annual earnings.
Covariates
Educational attainment was used as an indicator of adult SES
[32]. It was grouped into three categories: less than
high school, high school diploma/GED, and some college or
more.
Demographic characteristics such as gender, race (white/non-
white), ethnicity (Hispanic/non-Hispanic), and age
were assessed by self-report in the HRS. Tertiles were created
for the age variable: 50-59, 60-69, and 70 and older
for univariate and bivariate analysis.
Statistical analysis
In order to test the association among childhood financial
hardship, average annual lifetime earnings, and
multimorbidity, bivariate and multivariable tests were
performed. Bivariate analyses using Wilcoxon-
Mann-Whitney tests were conducted to determine differences in
multimorbidity between demographic categories
and Kruskall-Wallis tests were conducted to determine
differences in multimorbidity across SES categories.
Additionally, unadjusted rate ratios were estimated with robust
standard errors to quantify differences across
demographic and SES categories in multimorbidity.

To take into consideration the count nature of the outcome
variable and the substantial number of respondents
reporting no chronic conditions (Y = 0), zero-inflated Poisson
(ZIP) regression was used [33] (30% of respondents
in this sample reported no chronic conditions). The ZIP model
assumes that the respondents potentially come from
two different distributions: one distribution that is indeed likely
to have a zero count (no disease), and another
distribution that follows the Poisson distribution (count of the
six chronic conditions measured in this study) [34].
among olde...
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The ZIP model is a two-part model represented as: 1) P (y i |x i
) = p i + (1 - p i ) exp(-μ i ) when y i = 0 and; 2)
when y i ≥1 [35]. The first part represents a logistic model that
estimates the change in
the log-odds of reporting no chronic conditions (absence of
morbidity) for each one-unit change in the independent
variable, and the second part represents a Poisson model that
estimates the percentage change in the number of
chronic conditions for a one-unit change in the independent
variable. The justification for this approach is that the
factors associated with having one or more chronic conditions
might be differentially associated with the absence of
morbidity (reporting no chronic conditions).

SAS 9.2© was used for model building. Following bivariate
analysis, we developed unadjusted models to evaluate
the association between childhood financial hardship and
multimorbidity in 2004 (Model 1). Next, we adjusted for
demographic (Model 2) and socioeconomic characteristics
(Model 3). We then developed unadjusted models to
evaluate the association between lifetime earnings and
multimorbidity in 2004 (Model 4). Next, we adjusted this
model for demographic (Model 5) and socioeconomic
characteristics (Model 6). We then entered average annual
lifetime earnings into Model 3 to evaluate the influence of
lifetime earnings on the childhood financial hardship
adjusted model (Model 7). To determine if the association
between childhood financial hardship and multimorbidity
was modified by lifetime earnings, we entered an interaction
term (lifetime earnings × childhood financial hardship)
into the model (Model 8) [36].
Table 1 lists the descriptive statistics. The average age for the
full sample was 65 years old. Nineteen percent of the
sample reported childhood financial hardship. The mean number
of chronic conditions was 1.24, with 30% (N =
2,193) reporting no chronic conditions. The mean number of
chronic conditions for those reporting childhood
financial hardship was 1.35 and the mean number of chronic
conditions for those reporting no childhood financial
hardship was 1.20. The median average annual lifetime earnings
up to age 50 (CPI-U adjusted) was $19,410 with
an inter-quartile range of $20,235 (see Table 1).
Table 1
Frequency distributions for childhood financial hardship (CFH)
and chronic conditions and bivariate
associations between demographic and socioeconomic
characteristics and multimorbidity

Childhood
Financial
Hardship
Number of Chronic
Conditions (Multimorbidity)
N %
CFH =
0
CFH =
1
0 1 2 3
4 or
more
P-VALUE
Total 7,305 5,946 1,359 2,193 2,524 1,580 730 278
Gender p < .001
among olde...
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Childhood

Financial
Hardship
Number of Chronic
N %
CFH =
0
CFH =
1
0 1 2 3
4 or
more
P-VALUE
Female 3,916 53.61 3,244 672 1,238 1,382 769 374 153
Male 3,389 46.39 2,702 687 955 1,142 811 356 125
Race p < .001
White 5,907 80.87 4,827 1,080 1,861 2,053 1,241 550 202
Non-white 1,397 19.13 1,118 279 331 471 339 180 76
Hispanic Ethnicity p = .12
Hispanic 740 10.13 570 170 233 260 162 67 18
Non-Hispanic 6,565 89.87 5,376 1,189 1,960 2,264 1,418 663
260

Age
50-59 2,004 27.43 1,615 389 921 669 283 104 27 p < .001
60-69 3,218 44.05 2,661 557 866 1,169 707 338 138
≥ 70 2,083 28.51 1,670 413 406 686 590 288 113
Education p < .001
Less than High School 1,705 23.34 1,285 420 367 537 435 238
128
among olde...
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Childhood
Financial
Hardship
Number of Chronic
N %
CFH =
0
CFH =

1
0 1 2 3
4 or
more
P-VALUE
High School/GED 2,410 32.99 2,007 403 700 850 537 245 78
Some College or more 3,190 43.67 2,654 536 1,126 1,137 608
247 72
Median
AVGEARN_LIFETIME†
$19,410 $19,488 $19,138
Inter-quartile Range
AVGEARN_LIFETIME
$20,235
† AVGEARN_LIFETIME = Average annual lifetime earnings
(age 20-50) which are adjusted using the
CPI-U to account for inflation
Bivariate analysis suggests differences in multimorbidity across
all demographic and socioeconomic categories
except Hispanic ethnicity (see Table 1). Unadjusted rate ratios
showed that men reported slightly higher
multimorbidity than women. In particular, the expected number
of chronic conditions in men was 8% higher than in
women. For non-white respondents, the unadjusted expected
number of chronic conditions was 21% higher
compared to white respondents. The unadjusted expected

number of chronic conditions for those age 60-69 and 70
and older was 56% and 85%, respectively, greater than the
respondents age 50-59. The unadjusted expected number
of chronic conditions across education categories was 16%
higher for those with educational attainment of high
school/GED and 46% higher for those with less than high school
compared to the some college or more group of
respondents. No statistically significant differences in
multimorbidity were noted in Hispanic ethnicity; therefore,
ethnicity was not included in subsequent models (see Table 2).
Table 2
Unadjusted rate ratios of bivariate associations between the
demographic and socioeconomic variables
and multimorbidity
Multimorbidity
Gender
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Female 1.00
Male
1.08**
(1.03, 1.12)

Race
White 1.00
Non-white
1.21***
(1.15, 1.26)
Hispanic Ethnicity
Hispanic
.94
(.87, 1.00)
Non-Hispanic 1.00
Age
50-59 1.00
60-69
1.56***
(1.47, 1.65)
≥ 70
1.85***
(1.74, 1.96)
Education
Less than High School 1.46***

among olde...
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(1.39, 1.53)
High School/GED
1.16***
(1.11, 1.22)
Some College or more 1.00
p < .05; ** p < .01; *** p < .001
Multivariable analysis: childhood financial hardship and
multimorbidity
The logistic portion of the unadjusted and adjusted ZIP
regression models showed that childhood financial hardship
was not significantly associated with the absence of morbidity
(see Table 3, models 1-3, logistic portion). The
Poisson portion of the unadjusted ZIP model showed that the
expected number of chronic conditions for those
reporting childhood financial hardship was 1.11 (CI: 1.04, 1.19)
times that of those not reporting childhood
financial hardship. After adjusting for gender, age, and race, the
difference in expected number of chronic
conditions between those reporting childhood financial hardship
and those not reporting childhood financial

hardship did not change substantially (exp(β) = 1.10; CI: 1.04,
1.16). After adjusting for educational attainment, the
expected number of chronic conditions for those reporting
childhood financial hardship was reduced to 1.08 (CI:
1.02, 1.14) times greater than for those not reporting childhood
financial hardship (See Table 3, models 1-3, Poisson
portion).
Table 3
Unadjusted and adjusted exponentiated parameter estimates and
confidence intervals for the
zero-inflated Poisson regression models testing the association
between childhood financial hardship
and multimorbidity
Logistic portion of the ZIP model
Model 1 Model 2 Model 3
Childhood financial hardship†
.30
(.004, 46.63)
.39
(.10, 1.52)
.43
(.11, 1.60)
Gender
(female is reference)

.92
(.46, 1.87)
1.00
(.49, 2.04)
Age .77*** .78***
among olde...
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(.69, .82) (.68, .82)
Race
(white is reference)
4.03
(.74, 22.01)
.28

(.05, 1.22)
Educational Attainment
(less than high school)
High School/GED
1.79
(.74, 4.34)
Some College or more
.79
(.29, 2.16)
Poisson Portion of the ZIP model
1.11**
(1.04, 1.19)
1.10***
(1.04, 1.16)
1.08**
(1.02, 1.14)
Gender

.36
(.10, 1.39)
.41
(.11, 1.50)
Age
1.02***
(1.02, 1.03)
1.02***
(1.02, 1.03)
Race .73 1.14
among olde...
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(white is reference group) (.37, 1.45) (.56, 2.32)

(less than high school)
High School/GED
.21*
(.05, .93)
1.52
(.63, 3.67)
p < .05; ** p < .01; *** p < .001; † Childhood financial
hardship was measured by a question, "While
ever cause you or your family to move to
a different place?"
Multivariable analysis: lifetime earnings and multimorbidity
The logistic portion of the ZIP models showed that lifetime
earnings and the absence of morbidity were only
associated in the unadjusted model (exp(β) = .55; CI: .28, .91;
see Table 4, models 4-6, logistic portion). The
Poisson portion of the unadjusted ZIP model showed a 7%
decrease in the expected number of chronic conditions
for each $10,000 increase in average annual lifetime earnings
(see Table 4, model 4). After adjusting for gender,
age, and race the percent decrease was unchanged at 7%.
However, after adjusting for educational attainment the
percent decrease in the expected number of chronic conditions
was reduced to 5% for each $10,000 increase in
average annual earnings (see Table 4, model 6, Poisson
portion).

Table 4
Unadjusted and adjusted exponentiated parameter estimates and
confidence intervals for the
zero-inflated Poisson regression models testing the association
between lifetime earnings and
multimorbidity
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Lifetime Earnings§
.55*
(.28, .91)
1.08
(.81, 1.42)
1.10

(.80, 1.51)
Gender
1.15
(.50, 2.64)
1.16
(.50, 2.71)
Age
.77***
(.67, .83)
.76***
(.66, .82)
Race
.35
(.08, 1.45)
.32
(.08, 1.37)
(less than high school is reference)

High School/GED
2.03
(.73, 5.69)
.84
(.27, 2.55)
lifetime earnings§
.93***
(.91, .95)
.93***
(.91, .95)
.95***
(.93, .98)
among olde...
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Gender
1.14***
(1.08, 1.20)
1.11***
(1.05, 1.17)
Age
1.02***
(1.02, 1.03)
1.02***
(1.02, 1.03)
Race
1.22
(.54, 2.78)
1.23
(.53, 2.83)

(less than high school is reference)
High School/GED
.26
(.06, 1.06)
1.76
(.63, 4.89)
p < .05; ** p < .01; *** p < .001; § Lifetime earnings was
operationalized as average annual income
from 1951 up to age 50 of the respondent CPI-U adjusted
Multivariable analysis: childhood financial hardship and
lifetime earnings mutually adjusted
and interaction term added
Including childhood financial hardship and lifetime earnings
into the ZIP model (see Table 5, model 7) showed a
slight change in the childhood financial hardship rate ratio from
the fully adjusted model (see Table 3, model 3) of
1.08 to 1.07, but the rate ratio for lifetime earnings from the
fully adjusted model (see Table 4, model 6) was
unchanged (see Table 5, model 7). The childhood financial
hardship × average annual lifetime earnings interaction
term was statistically significant (exp(β) = .95; CI = .91, .99);
and with the inclusion of this interaction term the rate
ratio for childhood financial hardship increased (exp(β) = 1.19;
CI: 1.07, 1.32) and the rate ratio for lifetime
earnings changed by 2% (exp(β) = .97; CI = .94, .99; see Table
5, model 8).

among olde...
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Table 5
Fully adjusted exponentiated parameter estimates and
confidence intervals for zero-inflated Poisson
regression models testing the association among childhood
financial hardship, lifetime earnings, and
multimorbidity, and the interaction between childhood financial
hardship and lifetime earnings
Model 7 Model 8
.40
(.09, 1.71)
.27
(.04, 2.05)
Gender
1.16

(.50, 2.70)
1.05
(.47, 2.33)
Age
.76***
(.67, .82)
.75***
(.66, .81)
Race
.34
(.10, 1.23)
.34
(.10, 1.15)
Educational Attainment (less than high school reference)
High School/GED
1.91
(.71, 5.11)
1.49

(.61, 3.67)
.67
(.24, 1.89)
.62
(.22, 1.70)
Lifetime Earnings§
1.03
(.73, 1.42)
1.06
(.77, 1.44)
among olde...
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Model 7 Model 8
Childhood financial hardship X Lifetime earnings
1.35

(.35, 3.36)
Model 7 Model 8
1.07*
(1.01, 1.13)
1.19***
(1.07, 1.32)
Gender
.41
(.10, 1.74)
.25
(.03, 1.83)
Age
1.02***
(1.02, 1.03)
1.02***
(1.02, 1.03)

Race
(white is reference group)
1.23
(.53, 2.82)
1.12
(.51, 2.46)
Educational Attainment (less than high school is reference)
High School/GED
.27*
(.08, .95)
.27*
(.08, .89)
1.66
(.62, 4.41)
1.49
(.61, 3.67)
among olde...
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Model 7 Model 8
Lifetime Earnings§
.95***
(.93, .97)
.97*
(.94, .99)
Childhood financial hardship X Lifetime earnings
.95*
(.91, .99)
* p < .05; ** p < .01; *** p < .001; † Childhood financial
hardship was measured by a question, "While
ever cause you or your family to move to
a different place?" § Lifetime Earnings was operationalized as
average annual income from 1951 up to
age 50 of the respondent CPI-U adjusted
This study investigated the association among childhood
financial hardship, lifetime earnings, and multimorbidity
in a sample of older adults. Our findings revealed that after
controlling for socioeconomic and demographic

characteristics, childhood financial hardship was positively
associated with a higher number of the chronic
conditions. This suggests that over and above the influence of
age, race, and educational attainment, childhood
financial hardship exerts an influence on the multimorbidity of
the six chronic conditions measured in this study for
older adults. Our findings also indicate that lifetime earnings
was negatively associated with multimorbidity,
although the noted association was relatively small. In
particular, we showed that as the average annual income
during young and middle adulthood increases by $10,000 the
number of chronic conditions (as measured in this
study) decreases by 5%. Additionally, when we included both
childhood financial hardship and lifetime earnings in
our models, the association between lifetime earnings and
multimorbidity remained unchanged and the association
between childhood financial hardship and multimorbidity was
only slightly reduced. However, our tests of
interactions revealed that lifetime earnings significantly
modifies the relationship between childhood financial
hardship and multimorbidity. This suggests that the influence of
financial hardship in childhood on subsequent
multimorbidity may be altered by earnings occurring in young
and middle adulthood. More specifically, our
findings showed that for older adults experiencing childhood
financial hardship an increase by $10,000 in average
annual earnings reduces the expected number of chronic
conditions by 5%. Lastly, although we were primarily
interested in determining the association among childhood
financial hardship, lifetime earnings, and multimorbidity
over and above the influence of other socioeconomic indicators
such as educational attainment, it should be noted
that increasing education was not consistently associated with
an increase in the count of the six chronic conditions
in this study. In particular, educational attainment was not
associated with the absence of morbidity; and when

compared to the less than high school group, only the high
school/GED category showed a protective association
with multimorbidity.
We evaluated our hypotheses using ZIP regression; and, the
benefit of a ZIP modeling approach is the simultaneous
estimation of factors associated with multimorbidity and the
absence of morbidity. In fully adjusted models,
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childhood financial hardship was not associated with the
absence of morbidity and lifetime earnings was only
associated with the absence of morbidity in unadjusted models.
Consistent with the literature, the logistic portion of
our ZIP models showed that age was strongly negatively
associated with the absence of morbidity [37]. Lastly, the
widest confidence intervals were noted in the logistic portion of
the childhood financial hardship ZIP models. This
may indicate poor model fit and suggests that the potential
socioeconomic and demographic factors associated with
determining the number of diseases (of those measured in this
study) might be substantively different from the
factors associated with determining the absence of morbidity.
The lack of an association between the several indicators of
socioeconomic circumstances in this study (i.e.
childhood financial hardship, lifetime earnings, and educational
attainment) and demographic characteristics (i.e.

race and gender) and the absence of morbidity was unexpected.
Research has shown a negative association between
socioeconomic status and morbidity[38, 39] and
multimorbidity[40, 41]; and studies on successful aging (where
one component is the absence or low risk of morbidity[42])
have shown that childhood and mid-life socioeconomic
circumstances[43], and the stability of financial resources[44]
were positively associated with the absence of
morbidity in older adults. However, the evidence on the
association between socioeconomic factors and successful
aging is equivocal[45, 46, 47]. It has also been suggested that
age effects on self-reported morbidity may
overshadow socioeconomic effects[48]. Not surprising, our
results show an independent association between the
absence of morbidity and age, even when childhood financial
hardship and lifetime earnings are included in the
model. Demographic characteristics[48] and psychosocial and
behavioral factors[49] across the lifecourse may
prove more important than socioeconomic factors in
determining the absence of morbidity; however, the influence
of lifecourse socioeconomic factors on the absence of morbidity
requires further exploration to fully elucidate their
role in successful aging in general and the absence of morbidity
in particular among older adults.
Childhood socioeconomic condition and adult health
Financial and economic circumstances occurring in childhood
and throughout the lifecourse have been shown to
affect adult health outcomes [50]. Research shows that
antecedents to the socioeconomic gradient in adult health
can be seen in the socioeconomic environment in childhood
[51]. As such, the childhood environment can, 'cast
long shadows forward' on future health outcomes [52]; that is,
the financial and economic circumstances occurring
and accumulating throughout the lifecourse can determine and

influence the health trajectory of the individual [53,
54].
Additionally, it has been suggested that many chronic diseases
share common risk factors [55]. In particular, current
low socioeconomic status and disadvantage accumulated across
the lifecourse have been shown to be significant
pathways to many chronic conditions [25, 56]; and, socio-
environmental factors experienced at various stages
throughout the lifecourse can differentially impact disease
etiology [57]. So, even though chronic diseases have
long latency periods, research has consistently shown that for
many chronic conditions adult and childhood
socioeconomic factors can have a considerable impact on health
outcomes [58, 59]. Our results are consistent with
these findings. In particular, our results show that an expanded
notion of SES that includes hardships during
childhood and earnings throughout adulthood may also uncover
possible associations between socioeconomic
conditions and adult health. Our findings also show that a
possible modifier of the relationship between childhood
financial conditions and the number of adult chronic conditions
that deserves further attention is earnings during
young and middle adulthood.
There are limitations to the present study. First, respondents in
the HRS were asked to recall childhood financial
hardship experiences; as a result, the measures of childhood
financial hardship may be subject to recall bias.
Second, our sample only included those individuals who
provided permission for their social security records to be
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linked to their HRS records potentially introducing sample
selection bias. However, it has been shown that the HRS
respondents who grant permission for their social security were
not very much different from those who did not
[60]. In addition, the social security data linked to the HRS is
capped at the taxable maximum for a given year and
only includes earnings subject to Social Security deduction.
Next, the literature remains inconsistent in defining
multimorbidity [61, 62]; for example, some studies define
multimorbidity as the count of two or more chronic
conditions,[40] others use a combination of specific diseases,
and still others use a simple count of chronic
conditions reported or obtained from medical records [63, 64].
As a result, little guidance is provided in selecting a
measure for multimorbidity and the specific diseases such a
measure should contain. However, the chronic diseases
selected for the present study are consistent with those of other
studies of multimorbidity among older adults [21,
65]. Lastly, our study is cross-sectional so causal inferences
cannot be definitively made regarding the associations
noted.
Multimorbidity has considerable implications for health-related
research, health care, and many government
systems (e.g. Medicare, Medicaid, and Veterans
Administration). Due to the single disease focus in research and
health care[66, 67], we know relatively little about the
correlates of multimorbidity [68, 69]. Yet, health care models
on the delivery of clinical services for the elderly with multiple
chronic conditions have recently been introduced
highlighting the impact the growing problem of multimorbidity

has on health care delivery [70, 71]. However, we
know little about the factors that are associated with the various
combinations of morbidity experienced by older
adults, and such knowledge could potentially improve care and
delay mortality for many managing multiple chronic
conditions [72]. Additional research focused on the specific
socioeconomic factors associated with multimorbidity
across the lifecourse can also be used to inform the
development of appropriate interventions that target
socioeconomic groups at greatest risk for multimorbidity before
they enter the health care system. In particular,
interventions that target specific socioeconomic pathways might
prove useful in helping reduce the burden of
multimorbidity; more specifically, interventions that focus on
material resources such as reducing hardships during
childhood and increasing earnings throughout young and middle
adulthood may have a substantial impact on
prevention efforts[73] with those at risk for various
combinations of chronic disease multimorbidity.
Acknowledgements
None
Competing interests
The authors declare that they have no competing interests.
Authors' contributions
RDT-S, YL, GS, and SVS conceived of the study; RDT-S and
YL developed the analysis plan and performed the
statistical analysis; RDT-S, YL, GS, and SVS interpreted the
results; RDT-S wrote the first draft of the manuscript.
RDT-S, YL, GS, and SVS edited the manuscript. All authors
read and approved the final manuscript.

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(1)
Center for Community Based Research, Dana-Farber Cancer
Institute
(2)
Department of Society, Human Development, and Health,
Harvard School of Public Health
(3)
Department of Biostatistics and Computational Biology, Dana-
Farber Cancer Institute
(4)
Department of Biostatistics, Harvard School of Public Health
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MKTG 5001 – Peer Evaluation for Elevator Pitch
The evaluation of the elevator pitches will be done via
peermarking. You will each be responsible for marking three
pitches of other students. You must take this role seriously
since your classmate’s mark on their pitch will be largely
determined by these peer evaluations. Your job is to assess both
the content and the presentation using the criteria below. For
each of three evaluations you will answer each question and
write at least 50 words of comments (be specific and
constructive in your comments).
You will also be asked to invest you imaginary money
(Garbarino Gelt; GG). Imagine you are an investor (like Warren
Buffet) with $1,000,000 to invest. You are scheduled to hear
three short pitches. From this, you will decide how to invest
your funds. You may distribute the money anyway you wish;
for example, evenly among the pitches, more to some than
others, or allocate the entire sum to one of them depending on
your assessment. Since investors are primarily interested in
making return on their money, you should invest in the pitch or
pitches that you think have the best potential to succeed. Please
make sure that the sum of the total allocation is equal to
1,000,000 GG, you should make the allocation after watching
all the videos assigned to you. I recommend watching the
videos and entering your responses and comments, then saving
but not submitting them right away. Do this for all three
videos, until you are comfortable with your answers and
comments (and investment decisions) then submit all three.
The elevator pitches will be judged on the following criteria:
Group Name of Elevator Pitch 1: _______________
Content
Ex.
V.Good
Good

Fair
PoorClear what problem the product solves
Clear understanding of what the product is
Target market identification
Revenue model clear and valid
Competitors reasonably identified
Competitive advantage is clear and compelling
Delivery
Ex.
V. Good
Good
Fair
Poor
Clarity of verbal delivery

Confident and appropriately energetic delivery
Good and even pacing
Logic of pitch structure: logically flow through materials
Stimulating and catching investor interest
Time used wisely
Time limited observed

Amount of Garbarino Gelt assigned
Mark assigned
The Elevator Pitch
An elevator pitch is a very short summary of your product plan.
You will film your own elevator pitch based on the product your
team has done their plan on for the term. Each person will make
their own pitch video but you will be working from the
materials you have produced jointly with your group for the
term project. Your elevator pitch will be posted our blackboard
page and will be evaluated by three other students from the
class.
For this elevator pitch, your goals is to get your listener to want
to invest their “Garbarino Gelt” (see peer review mark for
elevator pitch for more details) in your product. The pitch
should cover the following aspects:
1) What problem does your product solve?
a. Describe what your product will do in one or two sentences.
Not just what it is (e.g., “this machine scans your pheromones
and those of all the people within ten feet of you) but what it
does (e.g. “a device that helps you scientifically find your
perfect match”)
2) What is your solution to that problem?
a. What is your product
3) Who is your target market?
a. Who will you be selling this to (hint: the answer is not
“everyone’)
b. How big is your market

4) What is your revenue model?
a. How will you make money from this idea
5) Who are your main competition?
a. The answer is not ‘we don’t have any’; who serves the same
need now?
6) What is your competitive advantage?
a. What makes your way of serving the need superior and how
will you hang on to this advantage.
The pitch should excite and inform the listener, make them want
to invest in your idea. The effectiveness at doing this will be a
function of both your content and your delivery. There is lots of
examples online (just search you tube) so you get a get a better
sense of what they look like.
The pitch should be no more than 2-3 minutes long. If it is over
3 minutes long you will be marked down. You will need to
practice it a number of times before it is smooth and clear and
tight enough to get all the key points across. It will likely take
you a few hours to decide what to say (based on your term
project) and at least ten run-throughs before you are ready to
say it on camera.
Once you have it on video, you will post it on the class
Blackboard to be peer evaluated by three of your classmates.
Their evaluation, in consultation with class instructor, will
determine your mark for this assessment. They will also decide
if they want to invest their Garbarino Gelt in your project.
Those who receive the most investment gelt will get their name
(and their project’s name) on Wall of Fame on Blackboard.
Your video pitch should be posted in the ‘assessment’ tab on
Blackboard under the ‘Elevator Pitch Video’ item with under
your name and your product’s name (under ‘submission title’).

C H A P T E R 16
Sociological Aspects of Later
Adulthood
On July 14, 2002, David Pearsall had his 70th birthday, and it
was a day to remem-
ber. It was not only his birthday but also his last day of work at
Quality Printers. That
evening, the owners of Quality Printers gave a retirement party
for Dave. He received
a gold watch, and the owners and many of his fellow printers
gave testimonial
speeches about how much Dave had contributed to the morale
and productivity of
the company. Dave was deeply honored, and tears occasionally
came to his eyes.
Dave felt strange waking up the next morning. He was used to
getting up early to
go to work. Work had become the center of his life. He even
socialized with his fellow
printers. Now he had nothing planned and nothing to do. He lay
in bed thinking
about what the future would hold for him. Dave had generally
muddled through
life. His father had helped him obtain a position as a printer,
and Dave seldom
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Copyright 2012 Cengage Learning. All Rights Reserved. May
not be copied, scanned, or duplicated, in whole or in part. Due
to electronic rights, some third party content may be suppressed
from the eBook and/or eChapter(s).
Editorial review has deemed that any suppressed content does
not materially affect the overall learning experience. Cengage
Learning reserves the right to remove additional content at any
time if subsequent rights restrictions require it.
gave much attention to planning for the future. For example,
while he thought it would
be nice to retire, he had given little consideration to it.
Dave got up, looked in a mirror, and noticed his thinning gray
hair, the wrinkles
on his face and hands, and the tire around his waist. In
concluding that the best part

of his life had passed by, he again wondered anxiously what the
future would hold for
him, and he contemplated what he should do with all of his
time. He had no idea.
For the next few weeks, he followed his wife, Jeanette, around
the house. Dave
began giving Jeanette suggestions on how she could be more
efficient and productive
around the house. After a few weeks of such advice, Jeanette
angrily told Dave to “get
off her back.” He visited the print shop where he used to work
but soon realized
everyone was too busy to spend time talking with him. He also
stopped socializing
with the printers, since they tended to talk about work. He felt
useless. As the months
went by, he spent most of his time sitting home and watching
TV. Occasionally, he
went to a neighborhood bar, where he drank to excess.
Dave and his wife had never given much attention to long-range
financial plan-
ning. They both had worked for many years and tended to spend
their paychecks
shortly after they received them. When they bought their house
in 1997, they gave
little thought to how they would make their mortgage payments
after retiring. Dave
had hoped the Social Security system would take care of his
bills.
Dave and Jeanette were in for a shock when they retired. The
monthly Social
Security checks were much less than they had anticipated. They
stopped going out

to eat, to movies, and to ball games. A few months after Dave
retired, they realized
they could no longer make the mortgage payments. They put the
house up for sale and
sold it four and a half months later, at a price lower than what
the house was worth.
Both were sad about leaving their home, but financially they
had no other choice.
They moved into a two-bedroom apartment. Both became even
more inactive, as they
no longer had yard work and now had fewer home maintenance
tasks. One neighbor
frequently played a stereo late into the night, and the Pearsalls
had trouble sleeping.
In February 2004, Jeanette had a major heart attack. She was in
the hospital for
nearly two weeks and then was placed in a nursing home. Dave
missed the companion-
ship of his wife and became deeply depressed. He wished she
could come home, but her
medical needs wouldn’t allow that, so he visited her every day.
Dave had never learned
to cook, and because he was depressed, his diet consisted
mainly of cheese sandwiches
and TV dinners. In November 2004, Jeanette suffered another
heart attack and died.
Dave now became even more depressed. He no longer shaved or
bathed. He no
longer cleaned his apartment, and neighbors began to complain
about the odor.
Dave gave up the will to live. He seldom heard from his son,
Donald, who was living
in a distant city. Dave sought to drown his unhappiness in
whiskey. One night in

January 2011, he passed out in his apartment with a lighted
cigarette in his hand,
which set his couch on fire. Dave died of smoke inhalation.
Dave’s later years raise some questions for our society. Have
we abandoned
elders to a meaningless existence? Is it a mistake for older
people to count on Social
Security to meet their financial needs when they retire? How
can our society provide a
more meaningful role for older people?
672 Understanding Human Behavior and the Social Environment
A Perspective
This chapter will focus on the social problems encountered by
older people. The plight
of older people has now become recognized as a major problem
in the United States.
Older people face a number of personal problems: high rates of
physical illness and
emotional difficulties, poverty, malnutrition, lack of access to
transportation, low status,
lack of a meaningful role in our society, elder abuse, and

inadequate housing. To a
large extent, older people are a minority group. Similar to other
minority groups, older
people are victims of job discrimination and are subjected to
prejudice that is based
on erroneous stereotypes.
Learning Objectives
This chapter will:
A. Summarizethespecificproblemsfacedbyolderpeopleand
the causes of these problems.
B. Describe the current services to meet these problems and
identify gaps in these services.
C. Discuss the emergence of older people as a significant po-
litical force in our society.
D. Present a proposal to provide older people with a
meaningful, productive
social role in our society.
Older People:
A Population-at-Risk
Human societies have different customs for dealing
with incapacitated older people. In the past, some
societies abandoned their enfeebled old. The Crow,
Creek, and Hopi tribes, for example, built special
huts away from the tribe where the old went to die.
The Eskimos left incapacitated older people in snow
banks, or sent them off in a kayak. The Siriono of
the Bolivian forest simply left them behind when
they moved on in search of food (Moss & Moss,
1975). Even today, the Ik of Uganda leave older
people and the disabled to starve to death (Korn-

blum & Julian, 2009). Generally, the primary reason
such societies have been forced to abandon older
people is scarce resources.
Although we might consider such customs to be
barbaric and shocking, have we not also abandoned
older people? We urge them to retire when many are
still productive. All too often, when a person is urged
to retire, his or her status, power, and self-esteem are
lost. Also, in a physical sense, we seldom have a
place for large numbers of older people. Community
facilities—parks, subways, libraries—are oriented to
serving children and young people. Most housing is
designed and priced for the young couple with one or
two children and an annual income over $50,000. If
older people are not able to care for themselves and
if their families are unable or unwilling to care for
them, we store them away from society in nursing
homes. About one out of 10 older people is living
in poverty (U.S. Census Bureau, 2010). (The poverty
rate for older adults is lower than that of the total
population.)
Older people are subjected to various forms of
discrimination—for example, job discrimination.
Older workers are erroneously believed to be less
productive. Unemployed workers in their 50s and
60s have greater difficulty finding new jobs and
remain unemployed much longer than younger un-
employed workers. Older people are given no
meaningful role in our society, which is youth-
oriented and deplores growing old (Santrock, 2009).
EP 2.1.7a,
2.1.7b

Sociological Aspects of Later Adulthood 673
Our society glorifies physical attractiveness and
thereby shortchanges older people. Older people are
viewed as out of touch with what’s happening, and
their knowledge is seldom valued or sought. Intellec-
tual ability is sometimes thought to decline with age,
even though research shows that intellectual capacity,
barring organic problems, remains essentially
unchanged until very late in life (Santrock, 2009).
Older people are erroneously thought to be senile,
resistant to change, inflexible, incompetent workers,
and a burden on the young. Given opportunities,
older individuals usually prove such prejudicial con-
cepts to be wrong. They generally react to prejudice
against them in the same way that racial and ethnic
minorities react—by displaying self-hatred and by
being self-conscious, sensitive, and defensive about
their social and cultural status (Santrock, 2009). As
we have mentioned previously, individuals who fre-
quently receive negative responses from others even-
tually tend to come to view themselves negatively.

Problems Faced by Older People
Individuals are dramatically affected by their inter-
actions with other micro, mezzo, and macro systems.
The following section will address a range of prob-
lems suffered by older people within the macro-
system context. This involves two dimensions. The
first concerns problems older people as individual
micro systems suffer within the macro environment.
These include poverty, malnutrition, health difficul-
ties, elder abuse, and lack of transportation. The
other dimension of problems affecting older people
focuses on the macro systems providing them with
support and services. Often, cost is of chief concern.
For example, the general population might experi-
ence rapidly rising taxes to cover a range of services
for older people, including medical care. Examining
both perspectives can enhance your understanding
of human behavior in preparation for assessment
and practice.
A point to remember is that unlike other minori-
ties, older people have problems that we all encoun-
ter eventually (assuming we do not die prematurely).
By the time most of today’s college students reach
middle age (presumably their peak earning years), a
larger proportion of the adult population will be re-
tired, because older people are the fastest-growing
segment of our population. Those who are retired
depend heavily on Social Security, Medicare, and
other government programs to assist in meeting their
financial and medical needs. If we do not face and
solve the financial problems of older people now, we
will be in dire straits in the future.

Emphasis on Youth: The Impact of Social
and Economic Forces
Our society fears aging more than most other socie-
ties do. Our emphasis on youth is illustrated by our
Older people may face many problems, such as severe financial
constraints, physical disabilities,
and perceptual limitations.
A
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K
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dread of getting gray hair and wrinkles or becoming
bald and by our being pleased when someone
guesses our age to be younger than it actually is.
We place a high value on youthful energy and ac-
tion. We like to think we are doers. But why is there
such an emphasis on youth in our society?
Industrialization resulted in a demand for la-
borers who are energetic, agile, and strong. Rapid
advances in technology and science have made ob-
solete past knowledge and certain specialized work
skills. Pioneer living and the gradual expansion of
our nation to the west required brute strength, en-
ergy, and stamina. Competition has always been em-
phasized and has been reinforced by a social
interpretation of Darwin’s theory of evolution,
which highlighted survival of the fittest, though Dar-
win meant those that “fit” their environment, not
those that were young and healthy. The cultural tra-
dition of overvaluing youth in our society has resulted
in our devaluation of older people. Spotlight 16.1
discusses the status of older people in China and
Japan and lists factors associated with high status
for older people.
The Increasing Older Population
There are now more than 10 times as many people
age 65 and older as there were in 1900. Table 16.1
shows that the percentage of older people has been
steadily increasing. As of 2010, there were about

38 million Americans age 65 and over. (U.S. Census
Bureau, 2010).
By 2030, the number is projected to be 72 million—
a 90 percent increase in 20 years, compared to a
30 percent growth in total population during the
same period (Hooyman, 2007).
Several reasons can be given for the phenomenal
growth of the older population. The improved care
of expectant mothers and newborn infants has re-
duced the infant mortality rate. New drugs, better
sanitation, and other medical advances have in-
creased the life expectancy of Americans from
49 years in 1900 to 78 years in 2010 (U.S. Census
Bureau, 2010).
Another reason for the increasing proportion of
older people is that the birth rate is declining—fewer
babies are being born, while more adults are reach-
ing later adulthood. After World War II, a baby
boom lasted from 1946 to 1964. Children born dur-
ing these years flooded schools in the 1950s and
1960s. Then they moved into the labor market.
Very soon, this generation will begin to reach retire-
ment. After 1964, there was a baby bust, a sharp
decline in birth rates. The average number of chil-
dren per woman went down from a high of 3.8 in
1957 to the current rate of about 2.0 (Mooney,
Knox, & Schacht, 2011).
The increased life expectancy, along with the
baby boom followed by the baby bust, will
SPOTLIGHT ON DIVERSITY 16.1

High Status for Older People in China, Japan,
and Other Countries
For many generations, older people in Japan and China have
experienced higher status than older people in the United
States. In both of these countries, older people are integrated
into their families much more than in the United States. In
Japan, more than 75 percent of older people live with their
children, whereas in the United States most older people live
separately from their children (Santrock, 2009). Older people
in Japan are accorded respect in a variety of ways. For exam-
ple, the best seats in a home are apt to be reserved for older
people, cooking tends to cater to the tastes of older people,
and individuals bow to older people.
However, Americans’ images of older people in Japan and
China are somewhat idealized. Japan is becoming more ur-
banized and Westernized. As a consequence, the proportion
of older people living with their children is decreasing, and
older people there are now often employed in lower-status
jobs (Santrock, 2008).
Five factors have been identified as predicting high status
for older people in a culture (Santrock, 2009):
1. Older persons are recognized as having valuable
knowledge.
2. Older persons control key family and community
resources.
3. The culture is more collectivistic than individualistic.
4. The extended family is a common family arrangement
in the culture, and older persons are integrated into the

extended family.
5. Older persons are permitted and encouraged to engage
in useful and valued functions as long as possible.
significantly increase the median age of Americans
in future years. The median age is indeed increasing
dramatically. The long-term implications are that
the United States will undergo a number of cultural,
social, and economic changes.
The Fastest—Growing Age Group: Old-Old
As our society is having more success in treating and
preventing heart disease, cancer, strokes, and other
killers, more and more older people are living into
their 80s and beyond. People 85 and over constitute
the fastest-growing age group in the United States
(Mooney et al., 2011). Older Americans are living
longer, due in part to betler medical care, sanitation,
and nutrition. The proportion of the old-old in our
society is projected to increase substantially in the
next few decades as the baby boomer generation

reaches age 75 and older. The number of people
age 85 and older, currently 15 percent of the total
older population, is the most rapidly growing seg-
ment of the U.S. population. The number of Amer-
icans over age 85 is projected to increase more than
500 percent by 2050, due largely to the aging of the
69 million baby boomers (Hooyman, 2007).
Those who are 75 and over are creating a number
of problems and difficult decisions for our society.
Many of the old-old suffer from multiple chronic ill-
nesses. Common medical problems of the old-old
include arthritis, heart conditions, hypertension, os-
teoporosis (brittleness of the bones), Alzheimer’s dis-
ease, incontinence, hearing and vision problems, and
depression. The old-old with major health problems
are putting strains on family resources. The old-old
need more of such community help as Meals on
Wheels, home health care, special busing, and home-
maker services. The older an older person becomes,
the higher the probability that he or she will become
a resident of a nursing home. The cost to society for
such care is high—more than $65,000 a year per
person to provide nursing home care (U.S. Census
Bureau, 2010). Despite the widespread image of
families dumping aged parents into nursing homes,
most frail older people still live outside institutional
walls, being cared for by a spouse, child, or other
relative. Some middle-aged people are now simulta-
neously encountering demands to put children
through college and to support an aging parent in
a nursing home.
“Can we afford the very old?” is a favorite con-
ference topic for doctors, bioethicists, and other spe-

cialists. Rising health-care costs and superlongevity
have ignited a controversy over whether to ration
health care to the very old. For example, should
people over age 75 be prohibited from receiving liver
transplants or kidney dialysis? Discussion of eutha-
nasia (the practice of killing individuals who are
hopelessly sick or injured) has also been increasing.
In 1984, Governor Richard Lamm of Colorado cre-
ated controversy when he asserted the terminally ill
have a duty to die. Dr. Eisdor Fer (quoted in Otten,
1984) stated: “The problem is age-old and across
cultures. Whenever society has had marginal eco-
nomic resources, the oldest went first, and the old
people bought that approach. The old Eskimo
wasn’t put on the ice flow; he just left of his own
accord and never came back” (p. 10).
Early Retirement: The Impact of Social
and Economic Forces
Maintaining a high rate of employment is a major
goal in our society. One instrument used in the past
to keep the workforce in line with demand was man-
datory retirement at a certain age, such as 65 or 70.
TABLE 16.1 COMPOSITION OF U.S. POPULATION AGE 65
AND OLDER
YEAR
1900 1950 1970 1980 1990 2000 2010
Number of older persons (in millions) 3 12 20 25 31 35 38
Percent of total population 4 8 9.5 11 12 12 12
SOURCE: U.S. Census Bureau, 2010, Statistical Abstract of the

United States: 2010. Washington, DC: U.S. Government
Printing Office.
Ethical Question 16.1
Do the terminally ill have a duty to
end their lives as soon as they can?
EP 2.1.2
In 1986, Congress (recognizing that mandatory re-
tirement was overtly discriminatory against older
adults) outlawed most mandatory retirement policies.
In many occupations, the supply of labor exceeds the
demand. An often used remedy for the oversupply of
available employees is the encouragement of ever ear-
lier retirement. Even though employers can no longer
force a worker to retire, many exert subtle pressures
on their older employees to retire.
Many workers who retire early supplement their
pension with another job, usually at a lower status.
About 85 percent of Americans 65 and older are

retired, even though many are intellectually and
physically capable of working (Papalia et al.,
2009). Our Social Security program supports early
retirement at the age of 62. Pension plans of some
companies and craft unions make it financially at-
tractive to retire as early as 55. Perhaps the extreme
case is the armed forces, which permit retirement on
full benefits after 20 years of service, or as early as
age 38.
Although early retirement has some advantages
to society, such as reducing the labor supply and
allowing younger employees to advance faster, there
are also some disadvantages. For society, the total
bill for retirement pensions is already huge and still
growing. For the retiree, it means facing a new life
and status without much preparation or assistance.
Although our society has developed education and
other institutions to prepare the young for the work
world, it has developed few comparable institutions
to prepare older people for retirement.
In our society, we still view people’s worth partly
in terms of their work. People often develop their
self-image in terms of their occupation. Because the
later years generally provide no exciting new roles to
replace the occupational roles lost on retirement, re-
tirees cannot proudly say, “I am a . . .” Instead, they
must say, “I was a . . .” The more a person’s life re-
volves around work, the more difficult retirement is
apt to be. Retirement often diminishes people’s so-
cial contacts and their status and places them in a
roleless role. People who were once valued as sales-
people, teachers, accountants, barbers, or secretaries
are now considered noncontributors in a roleless role
on the fringe of society.

Several myths about the older worker have been
widely believed by employers and the general public.
Older workers are thought to be less healthy, clum-
sier, more prone to absenteeism, more accident-
prone, more forgetful, and slower in task performance
(Papalia et al., 2009). Research has shown these be-
liefs to be erroneous. Older workers have lower turn-
over rates, produce at a steadier rate, make fewer
mistakes, have lower absenteeism rates, have a more
positive attitude toward their work, and exceed youn-
ger employees in health and low on-the-job injury
rates. However, when older workers do become ill,
they usually take a somewhat longer time to recover
(Papalia et al., 2009).
A key question about early retirement is the age
at which people want to retire. Gerontologists have
studied this question. Younger workers generally
state they prefer to retire before age 65. Older work-
ers indicate they desire to retire later than the con-
ventional age of 65 (Newman & Newman, 2009).
The explanation for this difference appears to be
partly economic. Because Social Security benefits
and pension plans are usually insufficient to provide
the same standard of living as when a person was
working, older people see an economic need to con-
tinue working beyond age 65. An additional expla-
nation is sociopsychological. With retirement often
being a roleless role in our society, older workers
may gradually identify more and more with their
work and prefer it over retirement.
Adjustment to retirement varies for different peo-
ple. Retirees who are not worried about money and

who are healthy are happier in retirement than those
who miss their income and do not feel well enough
to enjoy their leisure time. Many recent retirees rel-
ish the first long stretches of leisure time they have
had since childhood. After a while, however, they
may begin to feel restless, bored, and useless. The
most satisfied retirees tend to be physically fit people
who are using their skills in part-time volunteer or
paid work (Papalia et al., 2009).
Workers who are pressured to retire before they
want to may feel anger and resentment, and may feel
out of step with younger workers. Also, workers
who defer retirement as long as possible because
they enjoy their work may feel that no more work
is an immense loss when they are pressured to retire.
On the other hand, some people’s morale and life
satisfaction remain stable through both working
and retirement years.
Older adults who adjust best to retirement have
adequate income, are healthy, are active, are better
educated, have an extended social network that in-
cludes both family and friends, and usually were sat-
isfied with their lives prior to retiring. Those having
the most difficulty adjusting to retirement are those

with poor health, inadequate income, and who must
adjust to other stresses (such as the death of a
spouse) (Santrock, 2009, p. 573).
The two most common problems associated with
retirement are adjusting to a reduced income and
missing one’s former job. Those who have the
most difficulty in adjusting tend to be rigid or to
overly identify with their work by viewing their job
as their primary source of satisfaction and self-
image. Those who are happiest are able to replace
job prestige and financial status with values stress-
ing self-development, personal relationships, and
leisure activities.
Financial Problems of Older People
One out of 10 older people lives in poverty. Fair
numbers lack adequate food, essential clothes and
drugs, and perhaps a telephone in the house to
make emergency calls. Only small minorities of older
people have substantial savings or investments.
Poverty among older people varies dramatically
by race, sex, marital status, ethnicity, and age.
Women, the old-old, people of color, and those
who are widowed or single are most likely to be
poor (Mooney et al., 2009).
Older women are more likely to be poor than
older men. Nearly half of older Hispanic women,
and four out of 10 older African American women,

are living in poverty (Mooney et al., 2009). Women
of color were more likely to have been working in
low-paying jobs with no retirement plan.
The financial problems of older people are com-
pounded by other factors. One is the high cost of
health care, as previously discussed. A second factor
is inflation. Inflation is especially devastating to
those on fixed incomes. Most private pension bene-
fits do not increase after a worker retires. For exam-
ple, if living costs rise annually at 3.5 percent, after
20 years, a person on a fixed pension would be able
to buy only half as many goods and services as he or
she could at retirement (“Will Inflation Tarnish
Your Golden Years?” 1979). Fortunately, in 1974,
Congress enacted an automatic escalator clause in
Social Security benefits, providing a 3 percent in-
crease in payments when the consumer price index
increases a like amount. However, Social Security
benefits were never intended to make a person finan-
cially independent, and it is nearly impossible to live
comfortably on monthly Social Security checks.
The most important source of income for the vast
majority of older people is Social Security benefits,
primarily the Old-Age Survivors, Disability, and
Health Insurance (OASDHI) program. This pro-
gram is described later in this chapter. About
95 percent of older adults receive Social Security;
for 18 percent of them, Social Security is their only
income (Hooyman, 2007). About 14 percent of
Americans age 65 and older are in the paid labor
Retirees who have previously enjoyed social and economic
success and are in good physical health

are more likely to enjoy retirement.
A
ri
e
l
S
ke
ll
e
y/
G
e
tt
y
Im
a
g
e
s
force. This figure is substantially lower than in 1950,

but represents an increase since 1993 (Hooyman,
2007).
Sullivan and his associates (Sullivan, Thompson,
Wright, Gross, & Spady, 1980) emphasize the im-
portance of financial security for the elderly:
Financial security affects one’s entire life-style. It
determines one’s diet, ability to seek good health
care, to visit relatives and friends, to maintain a
suitable wardrobe, and to find or maintain ade-
quate housing. One’s financial resources, or lack
of them, play a great part in finding recreation
(going to movies, plays, playing bridge or bingo,
etc.) and maintaining morale, feelings of indepen-
dence, and a sense of self-esteem. In other words, if
an older person has the financial resources to re-
main socially independent (having her own house-
hold and access to transportation and medical
services), to continue contact with friends and rel-
atives, and to maintain her preferred forms of rec-
reation, she is going to feel a great deal better
about herself and others than if she is deprived of
her former style of life. (pp. 357–358)
The Social Security System
The Social Security system was not designed to be
the main source of income for older people. It was
originally intended as a form of insurance that
would supplement other assets when the retirement,
disability, or death of a wage-earning spouse oc-
curred. Yet many older people do not have invest-
ments, pensions, or savings to support them in
retirement, and therefore Social Security has become
their major source of income.

The Social Security system was instituted in the
United States in 1935. Money is paid into the system
from Social Security taxes on employers and em-
ployees. In 1935, life expectancy was only somewhat
over 60 years. Life expectancy, however, has in-
creased to 78 in 2010. Social Security taxes have
sharply increased in recent years, but the proportion
of older people is increasing even faster. Some pro-
jections have the Social Security fund being depleted
around 2030 (Santrock, 2009).
The dependency ratio is the number of societal
members who are under 18 or over 64 compared
with the number who are between 18 and 64. This
ratio is increasing. Currently, there are 63 “depen-
dents” for every 100 persons between 18 and 64.
By 2050, the estimated ratio will be 80 to 100
(Mooney, Knox, & Schacht, 2007, p. 427). Accord-
ing to Mooney et al.:
This dramatic increase, and the general movement
toward global aging, may lead to a shortage of
workers and military personnel, foundering pension
plans, and declining consumer markets. It may also
lead to increased taxes as governments struggle to
finance elder care programs and services, heighten-
ing intergenerational tensions as societal members
compete for scarce resources. (p. 427)
Some problems now exist with the system. First,
as mentioned, the benefits are too small to provide
the major source of income for older people. Even
with payments from Social Security included, an es-
timated 80 percent of retirees are now living on less
than half of their preretirement income. And the

monthly payments from Social Security are gener-
ally below the poverty line (Kornblum & Julian,
2009). Second, it is unlikely that the monthly bene-
fits will be raised much. Our society faces some hard
choices about keeping the Social Security system sol-
vent in future years. Benefits might be lowered, but
this would further impoverish the recipients. Social
Security taxes might be raised, but there is little pub-
lic support for this. The amount of salary that is
subject to Social Security taxes has been rising sig-
nificantly each year since 1970.
The future of the Social Security system is un-
clear. It is likely to continue to exist, but reduced
benefits are possible. Young people are well ad-
vised to plan for retirement through savings and
investments that will supplement Social Security
payments.
Death
Preoccupation with dying, particularly with the cir-
cumstances surrounding it, is an ongoing concern of
older people. For one reason, they see their friends
and relatives dying. For another, they realize they’ve
lived more years than they have left.
Ethical Question 16.2
Should Social Security benefits be
expanded, reduced, or kept at the
same level?
EP 2.1.2

The older person’s concern about dying is most
often focused on the disability, the pain, or the
long period of suffering that may precede death.
People generally would like a death with dignity.
They would prefer to die in their own homes, with
little suffering, with mental faculties intact, and with
family and friends nearby. Older people are also
concerned about the cost of their final illness, the
difficulties they may cause others by the manner of
their death, and whether their resources will permit a
dignified funeral.
In modern America, many people die in nursing
homes or hospitals surrounded by medical staff
(Papalia et al., 2009). Such deaths often occur with-
out dignity. Fortunately, the hospice movement has
been developing in recent years in an attempt to fos-
ter death with dignity. A hospice is a program that is
designed to allow the terminally ill to die with dig-
nity—to live their final weeks in a way they want.
Hospices originated in the Middle Ages among
European religious groups that welcomed travelers
who were sick, tired, or hungry (Sullivan et al., 1980).
Hospices serve patients in a variety of settings—

in hospitals, in nursing homes, in assisted-living fa-
cilities, and in the dying person’s home. Hospices
provide both medical and social services, and make
extensive efforts to allow the terminally ill to spend
their remaining days as they choose. Hospices some-
times have educational and entertainment programs,
and visitors are welcome. Pain relievers are exten-
sively used, so that the patient is able to live out
his or her final days in relative comfort.
Hospices view the disease, not the patient, as ter-
minal. Their emphasis is on helping people use the
time that is left, rather than on trying to keep people
alive as long as possible. Many hospice programs
are set up to assist people in living their remaining
days at home. In addition to medical and visiting
nurse services, hospices have volunteers to help the
patient and family members with such services as
counseling, transportation, filling out insurance
forms and other paperwork, and respite care (that
is, staying with the patient to provide temporary re-
lief for family members).
The Ethical Dilemma box raises a number of is-
sues, including refusal of treatment, termination of
treatment, and physician-assisted suicide.
Elder Abuse
A shocking way for older people to spend their final
years is as victims of elder abuse—neglect, physical
abuse, or psychological abuse of dependent older
persons. The perpetrator may be the son or daughter
of the older victim, a spouse, a caregiver, or some
other person. Although elder abuse can occur in
nursing homes and in other institutions, it is most

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