Successful Aging in Individuals From Less Advantaged, Marginalized, and Stigmatized Backgrounds Scientific Update and Overview Successful Aging in Individuals From Less Advantaged, Marginalized, and Stigmatized Backgrounds Myriam V. Thoma ab, Shauna L. Mc Gee ab [a] Psychopathology and Clinical Intervention, Institute of Psychology, University of Zurich, Zurich, Switzerland. [b] University Research Priority Program “Dynamics of Healthy Aging”, University of Zurich, Zurich, Switzerland. Clinical Psychology in Europe, 2019, Vol. 1(3), Article 32578, https://doi.org/10.32872/cpe.v1i3.32578 Received: 2018-12-20 • Accepted: 2019-03-27 • Published (VoR): 2019-09-20 Handling Editor: Cornelia Weise, Philipps-University of Marburg, Marburg, Germany Corresponding Author: Myriam V. Thoma, Department of Psychology, University of Zurich, Binzmühlestrasse 14/17, 8050 Zurich, Switzerland. Tel.: +41 635 73 06. E-mail: m.thoma@psychologie.uzh.ch Abstract Background: Health and well-being in later life are heavily influenced by behaviors across the life course, which in turn are influenced by a variety of wider contextual, social, economic, and organizational factors. There is considerable potential for inequalities in health-promoting behaviors and health outcomes, arising from poverty, social, and environmental factors. This suggests that individuals from disadvantaged backgrounds and circumstances may have more exposure to (chronic) stressors, coupled with reduced access to resources, and increased susceptibility to risk factors for ill-health and mental disorders in later life. This drastically decreases the likelihood for successful aging in individuals from less advantaged backgrounds. Nevertheless, despite these adverse circumstances, some high-risk, disadvantaged individuals have been shown to achieve and maintain good health and well-being into later life. Method: This scientific update provides an overview of recently published research with samples that, against expectations, demonstrate successful aging. Results: Favorable personality traits, cognitive strategies, and a high-level of intrinsic motivation, paired with a supportive social environment, have been found to build a prosperous basis for successful aging and positive health outcomes in later life for individuals living in aversive environmental circumstances. Conclusion: For clinical psychologists, the movement towards the investigation of underlying mechanisms of successful aging from a psychological perspective, particularly in disadvantaged individuals, may be a critical step towards understanding the vast heterogeneity in aging. Keywords successful aging, disadvantaged backgrounds, marginalization and stigmatization, LGBT, disparities in racial and ethnic minorities This is an open access article distributed under the terms of the Creative Commons Attribution 4.0 International License, CC BY 4.0, which permits unrestricted use, distribution, and reproduction, provided the original work is properly cited. https://crossmark.crossref.org/dialog/?doi=10.32872/cpe.v1i3.32578&domain=pdf&date_stamp=2019-09-20 https://cpe.psychopen.eu/ https://www.psychopen.eu/ https://creativecommons.org/licenses/by/4.0/ https://creativecommons.org/licenses/by/4.0/ https://creativecommons.org/licenses/by/4.0/ Highlights • Successful aging is possible in disadvantaged individuals. • Psychological and social resilience resources may compensate for the impact of disadvantage. • The application of multi-level resilience models can aid future research on successful aging. Old age is a life stage characterized by a high degree of diversity between individuals. A growing body of literature has been dedicated to understanding this heterogeneity in ag‐ ing. Special focus has been placed on the positive end of the aging spectrum. At the mo‐ ment, there exists no universally-accepted definition for what constitutes this “positive end of the aging spectrum”. The “successful aging” (SA) construct, which is often used in research to examine positive aging research questions, is currently defined and opera‐ tionalized in more than 100 different ways (Cosco, Prina, Perales, Stephan, & Brayne, 2014). However, despite the current lack of a commonly-accepted definition, experts in the field generally agree that the SA construct should consist of several different dimen‐ sions, including a (mental and physiological) health facet, a (subjective) well-being facet, as well as a social (engagement) facet (Kleineidam et al., 2018). Nevertheless, despite its broad variety of operationalizations, the SA construct as a whole constitutes a meaning‐ ful and useful construct that can be applied to examine why some individuals are more likely than others to remain predominantly healthy and maintain a high level of physical functionality and social activity even into older age (Kleineidam et al., 2018). In this regard, it is particularly useful to examine what factors can be identified in connection with more favorable aging processes and outcomes. Previous research on SA has uncovered a range of predictors, including socio-demographic factors and specific be‐ haviors linked to SA. Socio-economic status (SES; including income and wealth), educa‐ tion, and health-promoting behaviors (e.g., non-smoking, healthy diet, physical activity), are among the frequently identified predictors for SA (e.g., Daskalopoulou et al., 2018; Gopinath, Kifley, Flood, & Mitchell, 2018; Kok, Aartsen, Deeg, & Huisman, 2016; Vauzour et al., 2017; Whitley, Benzeval, & Popham, 2018). Other branches of health-related re‐ search can also provide additional evidence for potential risk and protective factors that are essential in predicting SA. For instance, an important line of research on the (long- term) impact of early-life stress suggests that childhood neglect and abuse can increase the risk of future ill health and mental disorders, and may thus diminish the probability of SA (Jones, Nurius, Song, & Fleming, 2018; Nurius, Fleming, & Brindle, 2017). In fact, supporting this, a recently published large-scale longitudinal study found a meaningful link between early-life stress and SA trajectories (Kok, Aartsen, Deeg, & Huisman, 2017). Upon closer examination of the factors that may promote or hinder SA, it appears as if SA may be a rather elitist paradigm, seemingly reserved for more advantaged and al‐ Successful Aging in Disadvantaged Individuals 2 Clinical Psychology in Europe 2019, Vol.1(3), Article 32578 https://doi.org/10.32872/cpe.v1i3.32578 https://www.psychopen.eu/ ready healthy individuals. That is, those who grow up in more functional families, who were provided with the opportunity for a good education, and the necessary access to health-literacy and services, coupled with the essential assets and time required to imple‐ ment health-promoting behaviors. This leaves a rather pessimistic prospect for individu‐ als who grew up and lived in poverty or come from underprivileged educational back‐ grounds; as well as for those who experienced early misfortune in the form of childhood stressful life events, abuse and neglect, or those living with chronic health conditions (e.g., Bøe, Serlachius, Sivertsen, Petrie, & Hysing, 2018; Kok et al., 2017; Lê-Scherban et al., 2018). Are these individuals deprived of the opportunity to age successfully? This scientific update aims to answer this question by providing an overview of the latest research dedicated to the investigation of SA in individuals from less advantaged backgrounds. For this, a list of 'disadvantaged' groups was first compiled and the search was then limited to articles on older adults. A search of the databases was conducted for articles published since 2017. Given the wide diversity in how the SA construct is cur‐ rently defined in the scientific literature, the search was not restricted by applying a par‐ ticular SA definition or operationalization. S u c c e s s f u l A g i n g W i t h i n t h e C o n t e x t o f S o c i o - E c o n o m i c D i s a d v a n t a g e a n d C h i l d h o o d A d v e r s i t y The research group of Kok and colleagues (Kok, van Nes, Deeg, Widdershoven, & Huisman, 2018) qualitatively examined SA in Dutch individuals (N = 11; Agerange = 78-93 years) who had a low lifetime socio-economic position (SEP). More specifically, the au‐ thors were interested in the identification of resilience factors that protected those indi‐ viduals from the potentially negative impact of chronic socio-economic adversity. Several resilience-enhancing factors were identified, including ‘social support’, ‘generativity’, ‘pro-active management’, ‘cognitive restructuring’, ‘enduring’, and ‘surrendering’. Con‐ firming, but also expanding the resilience conceptualization for low SEP individuals pre‐ viously proposed by Chen and Miller (2012), the authors concluded that in addition to mental re-evaluation of the disadvantaged background, it also appears to be necessary to have a supportive social environment (which also requires pro-social behaviors) and the will to actively confront the external circumstances in question, i.e., by changing the ad‐ verse environment with one’s own actions (Kok et al., 2018). Another recent study (Scelzo et al., 2018) examined a sample of very old individuals living in rural villages in the southern part of Italy (N = 29; Agerange = 90-101 years). Ru‐ ral areas tend to show health-disparities due to a disproportionate lack of services in medically underserved areas, issues of access to existing services, differences in patient expectations and health-seeking behaviors, as well as the delivery of health care (Douthit, Kiv, Dwolatzky, & Biswas, 2015). While not directly assessing SA in this study, Thoma & Mc Gee 3 Clinical Psychology in Europe 2019, Vol.1(3), Article 32578 https://doi.org/10.32872/cpe.v1i3.32578 https://www.psychopen.eu/ (extreme) longevity can be regarded (and has previously been used) as a proxy to assess (the consequences of) SA (see Cosco et al., 2014). The qualitative part of this mixed-meth‐ od study examined themes related to (extreme) longevity. Common themes associated with SA were identified, including ‘positivity’, i.e., resilience and an optimistic outlook on life (also including self-efficacy and perseverance); being a ‘controlling’ or ‘strong’ per‐ sonality; being socially active and engaged, i.e., having tight bonds with family members; religious beliefs; as well as being hard working; and having a “love of the land” (p. 33). Altogether, the above findings show some parallels to those reported by Kok et al. (2018): In addition to the importance of having mental resources, such as the capacity for accept‐ ance/perseverance (facilitated by religious beliefs or particular personality traits), there is also the necessity of actively engaging with or changing the external environment (e.g., by being hard working), which is framed within the context of a functional and close so‐ cial network. Another example of SA despite adverse life circumstances can be seen in the case of Swiss former indentured child laborers (i.e., former Verdingkinder). Due to extreme pov‐ erty, death of a parent, divorce, or single motherhood, children were taken away from their parents and placed in foster families (mostly farmers), where they had to work for their living (Leuenberger & Seglias, 2008). Given that, in those times, the foster-care sys‐ tem was still poorly controlled, these children (in most cases forcefully separated from their families of origin) often experienced little to no protection. Documented by individ‐ uals who came forward publicly with their experiences, and corroborated by contempo‐ rary witnesses, these biographies are filled with reports of (extreme levels of) childhood abuse and neglect. A qualitative study (Höltge, Mc Gee, Maercker, & Thoma, 2018a) in‐ vestigated SA in former Verdingkinder (N = 12; Mage = 71 years; Agerange = 59-88). SA was defined as (self-rated) good health, feelings of happiness, balance and/or calmness most of the time, and a high level of satisfaction with (social) life. The factors ‘light-hearted‐ ness’, ‘social-purpose’, and ‘self-enhancement’ were identified as predictors for SA. These individuals, after what they had endured in early-life, took on a positive perspective fol‐ lowing conscious reflection (i.e., a proxy for a resilience resource). While striving to ex‐ perience positive feelings, they nevertheless kept a realistic perspective on life by ac‐ knowledging that negative experiences are part of a normal existence (i.e., cognitive re- evaluation). In general, participants could be classified as stress-resilient, a resource that was described to be developed through active coping and by coming to terms with their difficult past. They strongly valued (harmonic) social relationships and had the altruistic desire to help others (i.e., social component). Furthermore, they developed a strong moti‐ vation for self-improvement that pushed them to work hard and to continuously engage in further education (i.e., active engagement with external environment). Successful Aging in Disadvantaged Individuals 4 Clinical Psychology in Europe 2019, Vol.1(3), Article 32578 https://doi.org/10.32872/cpe.v1i3.32578 https://www.psychopen.eu/ S u c c e s s f u l A g i n g i n R a c i a l a n d E t h n i c M i n o r i t i e s Similar to individuals from disadvantaged backgrounds or adverse childhood circumstan‐ ces, individuals from minority groups often face issues of marginalization and stigma, which can influence their health and well-being into later life. One such example can be seen in racial and ethnic minorities, who, in addition to potentially higher levels of disad‐ vantages and inequalities (Zubair & Norris, 2015), can also face problems with exclusion and discrimination, which may compound health issues and ultimately hinder SA (Ferraro, Kemp, & Williams, 2017). However, despite these additional stressors, evidence is emerging that some individuals can experience good health into older age. For exam‐ ple, a study of perceived discrimination and psychological well-being in African Ameri‐ can older adults (N = 397; Agerange = 65-89) found that the characteristic of ‘self-accept‐ ance’, an awareness and acceptance of personal strengths and weaknesses, was shown to buffer the negative effect of discrimination on depressive symptomology, an indicator of psychological well-being (Yoon, Coburn, & Spence, 2019). Another study (Klokgieters, van Tilburg, Deeg, & Huisman, 2018a) examined the potential buffering effect of various religious activities against the negative impact of disadvantage (e.g., no/low resources) in older Turkish and Moroccan immigrants (N = 455; Agerange = 55-66 years). While a posi‐ tive relationship was found between well-being and private religious activities, there was no indication of a buffering effect for any of the religious activities against the experi‐ enced disadvantage. S u c c e s s f u l A g i n g i n I n d i v i d u a l s L i v i n g W i t h H I V Another minority group that has experienced much stigma and discrimination is that of individuals living with the human immunodeficiency virus (HIV). HIV is a chronic ill‐ ness, associated with a higher risk of experiencing psychosocial challenges and physio‐ logical issues. However, with advances in medicine, individuals with HIV are living longer, better lives and research has started focusing on SA and SA-related factors in this population. A qualitative study in individuals with HIV (N = 30; Agerange = 50-73) as‐ sessed barriers to and strategies for SA (Emlet, Harris, Furlotte, Brennan, & Pierpaoli, 2017). Results showed that while stigma, prejudice, and discrimination were identified as potential SA barriers, a number of SA-related themes emerged, including resilience com‐ ponents, such as self-care, mastery, and spirituality; social support; and the importance of the environmental context, such as structural support, social networks, and communities. Another qualitative study on SA in individuals with HIV (N = 24; Agerange = 50-73) identi‐ fied similar themes, emphasizing components over which persons had individual control (Solomon et al., 2018). These included staying positive, maintaining social support and connectedness with others, taking responsibility and being self-reliant for one’s well-be‐ ing, and engaging in meaningful activities. These findings indicate that a combination of Thoma & Mc Gee 5 Clinical Psychology in Europe 2019, Vol.1(3), Article 32578 https://doi.org/10.32872/cpe.v1i3.32578 https://www.psychopen.eu/ individual characteristics, such as control and mastery, and external influences, such as social and structural support, are important in fostering SA in this marginalized popula‐ tion. S u c c e s s f u l A g i n g i n L G B T O l d e r A d u l t s A population that also faces additional barriers to SA, are lesbian, gay, bisexual, and transgender (LGBT) older adults. Despite the risks of ill-health and social isolation for LGBT older adults (Wright et al., 2017), discrimination is often reported as a barrier to the utilization of health and community services (Alencar Albuquerque et al., 2016). A large-scale study of N = 2,415 LGBT older adults identified risk and resilience pathways to positive health outcomes in later life (Fredriksen-Goldsen, Kim, Bryan, Shiu, & Emlet, 2017). Results showed that marginalization was a risk factor associated with fewer social resources and poorer mental health outcomes. However, resilient pathways were identi‐ fied in which psychological (e.g., positive identity appraisal) and social (e.g., social con‐ nectedness) resources were associated with health-promoting behaviors, which in turn facilitated good physical health into older age. These findings suggest that the interaction of social and psychological factors can help LGBT older adults to maintain good health and foster SA, even within an environmental context of marginalization. The above research suggests that SA is possible for individuals from less advantaged, marginalized, and stigmatized backgrounds. However, as this is a relatively new and emerging topic, the exact mechanisms through which SA is fostered in these disadvan‐ taged populations are not yet known. Some theories and models are presented in the next section, which may be applied to help explain the underlying mechanisms of this process of SA. U n d e r l y i n g M e c h a n i s m s o f S u c c e s s f u l A g i n g The ‘steeling effect’ is one theory that may explain positive health in the face of adversi‐ ty (Liu, 2015; Rutter, 2006, 2012). This theory proposes that previous exposure to adversi‐ ty (e.g., disadvantaged circumstances, discrimination) may have a ‘steeling’ or strength‐ ening effect on individuals, which can increase their resistance to later stress or adversi‐ ty. It further suggests that moderate adversity may be more beneficial than no or high adversity, as it is adequately challenging to facilitate the development of coping skills and the utilization of resources (for a review see Höltge, Mc Gee, Maercker, & Thoma, 2018b). However, there is a lack of research applying this model in human studies (for one such study see Höltge, Mc Gee, & Thoma, 2018), particularly with older adults, and the role of steeling for SA remains poorly understood. Furthermore, while some studies have exam‐ ined aspects of adverse circumstances as part of a larger assessment, such as exposure to Successful Aging in Disadvantaged Individuals 6 Clinical Psychology in Europe 2019, Vol.1(3), Article 32578 https://doi.org/10.32872/cpe.v1i3.32578 https://www.psychopen.eu/ social and environmental stress (Seery, Holman, & Silver, 2010), future research is needed to apply this steeling model specifically to individuals from disadvantaged populations. The above literature suggests that a combination of psychological and individual fac‐ tors (e.g., mastery and control, self-efficacy) and external social factors (e.g., social en‐ gagement, connectedness with others) can contribute to resilience and SA in disadvan‐ taged populations. However, it is also important to consider the enabling environmental and context factors, which are particularly important in this specific population due to their adverse backgrounds and circumstances. Supporting this is the social ecological model of resilience, which emphasizes the role of environmental factors in health and well-being, and suggests that resilience is facilitated by the interaction between the indi‐ vidual and their environment (Ungar, 2012). Specifically, this model suggests that the en‐ vironment can facilitate access to resilience-promoting resources; that resilience may dif‐ fer as a result of the complex and changing nature of an individual’s circumstances and the interaction with their personal traits; and that the resilience process is culturally and temporally embedded and is therefore influenced by the cultural norms of the time, which is particularly important for specific cultural groups such as minorities (Ungar, 2011). The importance of the individual-environment interaction for the well-being of disadvantaged populations can be seen in the reoccurring finding that environmental and contextual factors, such as social support and social engagement, were significant in sup‐ porting individual resilience and SA (e.g., Emlet et al., 2017; Kok et al., 2018; Scelzo et al., 2018). Further support comes from a resilience conceptualization in the field of sociology (Schafer, Shippee, & Ferraro, 2009). Schafer and colleagues (2009) argue that in order to actively buffer or overcome disadvantage, several processes must take place: First, an in‐ dividual must become aware (i.e., recognition/subjective evaluation) of one’s undesirable position, adversity, or misfortune. Second, the individual must take action (i.e., construc‐ tive adaptation) to counteract or amend the adverse situation and/or to avoid negative consequences. Third, to efficaciously face disadvantage, one must activate and apply ade‐ quate and effective resources. These resources may be located within oneself (e.g., IQ, re‐ siliency traits) and/or within the socio-economic system, in the form of social relation‐ ships, SES, and economic resources (Schafer et al., 2009). As in the social ecological model of resilience, this conceptualization highlights the importance of both individual and so‐ cial-context factors in overcoming disadvantage. The interaction between individual and environment is also reflected in and suppor‐ ted by another model of resilience by Liu, Reed, and Girard (2017). This model proposes that resilience is dynamic and is formed through the interaction of factors across multi‐ ple, interconnected levels. These levels include core resilience, which are inherent, stable characteristics and traits, such as gender, race, and ethnicity; internal resilience, which are learnable and changeable factors, such as active coping, mastery, and self-acceptance; and external resilience, which are contextual and environmental factors, such as social Thoma & Mc Gee 7 Clinical Psychology in Europe 2019, Vol.1(3), Article 32578 https://doi.org/10.32872/cpe.v1i3.32578 https://www.psychopen.eu/ resources and support. This model could be applied in future research to better under‐ stand the multi-level mechanisms underpinning the processes of resilience and SA. In addition, the construct ‘Sense of Coherence-Revised’ (SOC-R) could be examined in conjunction with Liu et al.’s (2017) model. This construct may help explain how individu‐ als can utilize these multi-level factors to facilitate resilience and SA, as it is the ability to integrate and balance positive and negative experiences in order to maintain and develop health and well-being following stress or adversity (Bachem & Maercker, 2016; Mc Gee, Höltge, Maercker, & Thoma, 2018a, 2018b). It is based on the salutogenic theory, which views health as a continuum, and proposes that SOC-R can help individuals to utilize re‐ sources (e.g., personality traits, mastery, social support) appropriate for their current cir‐ cumstances and move them towards good health on this continuum (Antonovsky, 1987). In this way, SOC-R can positively influence the aging process and foster SA (Bachem & Maercker, 2016). The above theories and models provide a theoretical basis for future re‐ search to examine the mechanisms and factors associated with resilience and SA, particu‐ larly in populations with disadvantaged backgrounds. It should be emphasized that this article constitutes a short, current update and over‐ view of the latest developments and publications in this particular field. As such, a sys‐ tematic review of the literature was not conducted. This may have resulted in a non-com‐ prehensive or even biased delineation of existing literature and the deduction of over- simplified conclusions. It is possible that additional mechanisms and factors exist, which were not discussed in this short update that links SA to adverse experiences and disad‐ vantaged backgrounds. The association between SA and disadvantage is complex and un‐ derlying mechanisms are still poorly understood. Disadvantage can have multiple forms and can also hide behind alleged “advantaged” circumstances. For instance, a large-scale longitudinal study on SA (Kok et al., 2017) showed that not only low, but also high SEP, was linked to stressful life events (e.g., higher divorce rate). It is also important to note that the potential buffering impact of psychological resources may depend on the partic‐ ular context, such as the cultural background (Klokgieters, van Tilburg, Deeg, & Huisman, 2018b). C o n c l u s i o n Research on SA is continuously uncovering predictors for more favorable aging process‐ es and outcomes. This scientific update and overview focused on very recent develop‐ ments and trends in this area, examining SA in less advantaged populations. Findings from these studies highlight the importance of considering a combination of psychologi‐ cal and individual resilience factors, as well as external social and environmental compo‐ nents. Individual, psychological, and social factors can play a compensatory role for indi‐ viduals living with negative environmental influences. For clinical psychologists, the movement towards the investigation of underlying mechanisms of SA from a psychologi‐ Successful Aging in Disadvantaged Individuals 8 Clinical Psychology in Europe 2019, Vol.1(3), Article 32578 https://doi.org/10.32872/cpe.v1i3.32578 https://www.psychopen.eu/ cal perspective, particularly in disadvantaged individuals, may be a critical step towards understanding the vast heterogeneity in aging. Funding: This work was supported by the Swiss Government Excellence Scholarship (ESKAS-Nr. 2016.0109) which funded SLMG’s position. Competing Interests: The authors have declared that no competing interests exist. Acknowledgments: During the work on her dissertation, Shauna L. Mc Gee was a pre-doctoral fellow of LIFE (International Max Planck Research School on the Life Course; participating institutions: MPI for Human Development, Humboldt-Universität zu Berlin, Freie Universität Berlin, University of Michigan, University of Virginia, University of Zurich). 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Ageing & Society, 35(5), 897-916. https://doi.org/10.1017/S0144686X14001536 Clinical Psychology in Europe (CPE) is the official journal of the European Association of Clinical Psychology and Psychological Treatment (EACLIPT). PsychOpen GOLD is a publishing service by Leibniz Institute for Psychology Information (ZPID), Germany. Successful Aging in Disadvantaged Individuals 12 Clinical Psychology in Europe 2019, Vol.1(3), Article 32578 https://doi.org/10.32872/cpe.v1i3.32578 https://doi.org/10.1037/a0021344 https://doi.org/10.1177/0956462417721439 https://doi.org/10.1111/j.1939-0025.2010.01067.x https://doi.org/10.1016/j.ypmed.2012.07.021 https://doi.org/10.1016/j.arr.2016.09.010 https://doi.org/10.1177/0898264316665208 https://doi.org/10.1093/fampra/cmx005 https://doi.org/10.1080/13607863.2017.1423034 https://doi.org/10.1017/S0144686X14001536 https://www.psychopen.eu/ Successful Aging in Disadvantaged Individuals (Introduction) Successful Aging Within the Context of Socio-Economic Disadvantage and Childhood Adversity Successful Aging in Racial and Ethnic Minorities Successful Aging in Individuals Living With HIV Successful Aging in LGBT Older Adults Underlying Mechanisms of Successful Aging Conclusion (Additional Information) Funding Competing Interests Acknowledgments Author Contributions References