An Introduction to Social Environment and Biomarkers of Aging Study the SEBAS 2000 in Taiwan

1. An Introduction toSocial Environment and Biomarkers of Aging Studythe SEBAS 2000 in Taiwan Yi-Li Chuang Bureau of Health Promotion Department of Health, Taiwan

2. About the SEBAS 2000 • The Social Environment and Biomarkers of Aging Study • an extension of the Survey of Health and Living Status of the Near Elderly and Elderly in Taiwan • a collaborative project of the Bureau of Health Promotion, the Georgetown University and the Princeton University • a five year project from 1999 to 2004 • granted by NIA and additional budget form Taiwan Government • integrating biological measurements based on medical exams and assays of blood and urine specimens into questionnaire interview surveys of health and aging

3. Bureau of Health Promotion and Protection Institute of Public Health Institute of Family Planning Institute of Maternal and Child Health The Establishment of the BHP Department of Health 1971 1959 1964 1959 Bureau of Health Promotion Bureau of Health Promotion July, 2001

4. Baseline 1989 4049(60+) 2nd wave 1993 3155(64+) 3rd wave 1996 2669(67+) 2462(50-66) 4th wave 1999 2310(70+) 2130(53-69) 5th wave 2003-2004 (74+) (57-73) (50-56) A Brief to the Survey of Health and Living Status of the Near Elderly and Elderly in Taiwan • a longitudinal survey with a national representative sample of non-aboriginal townships • initiated in 1989 under the Institute of Family Planning* (*: merged into the BHP in 2001) • in collaboration with the Population Studies Center and the Institute of Gerontology, University of Michigan

5. SEBAS is an extension to the elderly survey series 2000 Pretest Pingtung city Sample size: 50 2000 SEBAS Sample size: 1497 (interviewed) 1023 (biomed. information) 1998 Pilot Study 4 townships in Taichung Sample size: 100 1st wave 1989 4049(60+) 2nd wave 1993 3155(64+) 3rd wave 1996 2669(67+) 2462(50-66) 4th wave 1999 2310(70+) 2130(53-69) 5th wave 2003-2004 (74+) (57-73) (50-56)

6. Social Environment Position in Social Hierarchies Social Connection and Networks Research Model Life Challenges Sources of Stress Physical & Mental Health & Illness

7. Some Limitations of Existing Research • Infrequent follow-up (if any) of sample • Select (non-representative) samples • Lack of detailed data on health status at baseline • Dubious quality of self-reported data • Lack of detailed information on social environment (e.g., networks vs. support; positive vs. negative support) • Little attention to physiological parameters that help to identify pathways of influence

8. Social Environment Position in Social Hierarchies Social Connection and Networks Adding Physiology Response to the Model Physiological Response Life Challenges Sources of Stress Physical & Mental Health & Illness

9. Goals of SEBAS • To elucidate pathways among challenges, social environment, and a range of mental and physical health outcomes • the relationship between life challenge and health? • how the social environment affects the relationship? • how incorporating biological markers of health and stress can enhance our understanding of the relationships?

10. The Strength of the Study • Use of large, non-clinical population-based sample • Add information to existing social science surveys • Consider a broad range of social factors together with biological information • Breadth of data (social ties, self-reported health) and available longitudinal survey data • Strong field team, continuity of personnel, high quality data and high response rates • Compare results from Western populations to cultural different Taiwan population

11. Sampling Design • sub-sample of respondents to the 1999 wave • three-stage equal probability sample • nationally representative for aged 54 and above • over‑sampling by urban residence and age group • sample size: • Sample selected: 1713 (in 27 townships) • interviewed:1497 • Response rate: 92% (among survivors) • Biomedical data collected: 1023 • Response rate 68% (among respondents)

12. Organizations involve in SEBAS • Organized by Taiwan Provincial Institute of Family Planning (now BHP) , Princeton University, Georgetown University • Technique supported by University of California-Los Angeles and University of Michigan • Assistant Units include: • County/City Health Bureau • Local health stations and public health nurses • Local reputable hospitals • Central Lab (contracted commercial lab).

13. Fieldwork Operation • July, 2000 ~ December, 2000 • 3 mission oriented working teams • 7 staffs and 2 drivers for each task • spending a couple of weeks in each PSU • working with public health nurses and people in hospitals • each team is responsible for fieldwork in 7-9 PSUs

14. Task involves Years ahead • Identification of central lab • Conduction of pilot study Months ahead • Finalize standard operation protocol • Pretest of final protocol • Sampling operation • Formal visit to County/City Health Bureau • Identification of hospitals • Training of local public health nurses • Individual interview by public health nurses

15. Packing ice for 12 hour urine collection set

16. Task involves (Cont.) Day before medical exam • Preparation and delivery of urine collection containers • Instruction on 12 hour urine collection • Obtain informed consent • Help on participant’s transportation arrangement to hospital Day of medical exam • Participants pick up and collection of urine containers • Hospital visit • Short questionnaire Interview • Collection of blood and random urine specimens • Measurement and physician check up • Pretreatment of blood and urine specimens • Delivery of specimens to central lab

17. Blood pressure station in Hospital

18. Blood-drawing station in hospital ▄

19. Measuring waist & hip circumference in hospital

20. Completing questionnaires & forms in hospital

21. Urine samples pretreatment in hospital

22. Task involves (Cont.) Weeks after the medical exam • Sending health examination results to participants • Data entry and file construction

23. Mission of Public Health Nurse • conduct questionnaire interview • explain study to the respondents and get their consent • evaluate R’s condition for specimen collection • schedule physical exam for participants Elements to achieve the mission • Structured form and questionnaire • Standardized procedure • Systematic training

24. Mission of Central Lab • Immediate shipment of the specimens to lab in Taipei • Follow standard laboratory protocols for assays • Provide results within two weeks • Quality assurance for assays • Keep daily report of quality control • Spot check for compliance • Blind duplicate samples for intra-lab and inter-lab control

25. Content of Questionnaire • chronic conditions • physical functioning • psychological well-being • cognitive capacity • health services utilization • social networks and support • stressful life events • socioeconomic status • demographic characteristics

26. Health Exam Items & Biomarkers • Measurements • Waist/hip ratio • blood pressure readings • Blood test items • HDL & total cholesterol • DHEA-S • Glycosylated hemoglobin • Other experimental items • 12 Hour Urine Collection • Cortisol • Epinephrine, norepinephrine • Physical exam & lab test • items similar to National Health Exam • abdominal ultrasound

27. Reasons for not participating in health exam and collection of biomarkers • Not eligible for health examination* 111 (7.4%) • Living in an institution 10 (0.7%) • Seriously ill 61 (4.1%) • Catheter or diaper 23 (1.5%) • On kidney dialysis 7 (0.5%) • Other health condition that precludes blood drawing 33 (2.2%) • Refused to participate ** 363 (24.2%) * Respondents may have more than one health condition that makes them ineligible for health examination **The 363 refusals may have provided multiple reasons for refusing to participate

28. Major reasons for non-participation in physical exam • Just received or has regular health exams • R or family thinks R is healthy/no need for exam • Too ill/frail • Will be out of town/no time within scheduled days • Too much trouble