An Investigation on Psychosocial Factors Impacting Frailty in Older Adults: A Case of Singapore - Juniper Publishers

 Online Journal of Public Health - Juniper Publishers

Abstract

Background

Frailty is a geriatric syndrome of increased vulnerability due to diminished physiologic reserves. It is still unclear how the psychosocial factors and physical frailty are related to health outcomes. This study presents prevalence, related physical and psychosocial factors of frailty in older adults in Singapore and the mediation effect of frailty among psychosocial factors.

Methods

Using a cross-sectional analysis of 491 individuals over 65 years of age from 17 community centers, frailty conditions were grouped as Robust, Prefrail and Frail. Psychosocial profiles were collected through established Depression, Social Support, Quality of Life and Loneliness scales.

Results

Approximately 60.4% of the participants were between 65 and 74 years of age and 70.3% were women with 3.3% and 37.1% of participants rated as frail and pre-frail, respectively. Results indicated that depression, loneliness, and fall efficacy were significantly lower while social support and quality of life higher in the robust participants compared to prefrail and frail participants. Pathway analyses examined the mediation effect of frailty from psychosocial factors (depression, loneliness, social support) to quality of life. Depression had direct significant association with both frailty (B = 0.034, p <.001) and quality of life (B = -0.497, p <.001).

Conclusions

Frailty has been validated as a mediator on the pathway from psychosocial conditions to health. Psychosocial interventions should be considered further to reduce frailty and improve quality of life. Longitudinal research combining both physical and psychosocial factors are promising to explore the pathways to frailty and its adverse health outcomes.

Keywords: Frailty; Psychosocial Factors; Depression; Social Support; Loneliness; Pathway Analysis

Introduction

Worldwide and in Singapore, the population is ageing. Until now, Singapore’s older adults (aged 65 years and above) constitute 15.2% of the total population [1]. This is expected to be 53.4% in 2050 [2]. Frailty is a condition in which the individual is in a vulnerable state at increased risk of adverse health outcomes and/or dying when exposed to a stressor [3]. It is usually recognized in older adults and leads to adverse health effects [4,5]. Frail people have a significantly higher risk of falls, disability, long-term care and even leading to death [6,7]. In a report which reviewed 21 community-based cohort studies of 61,500 elderly people, the prevalence rate of frailty among older adults aged 65 or more is 9.9% [8]. Global data from more than 120,000 senior citizens of 28 countries suggests a 43.4% frailty incidence rate [9]. While it is generally believed that frailty increases with age, no consensus has been reached on the prevalence of frailty [8]. Singapore is a global business hub with 4.04 million residents, and the median age of the resident population rise to reach 41.5 years [1]. It is also one of the fastest ageing nations in the world. The old-age support ratio of residents computed as the ratio of residents aged 20-64 years for each resident aged 65 years and over, declined further to 4.3% until 2020 [1]. One of the most urgent ageing issues to address is frailty [10]. That is, high prevalence among older adults and increased risk of adverse health outcomes such as falls, disability, depression, hospitalization, medical costs, and mortality [4,11-14]. Singapore’s government has responded to the ongoing frailty movement [15]. In the past decade, many studies have examined the association between frailty and socio-demographic factors. However, few studies focus on the psychosocial factors and their impact on frailty prevalence in Singapore [13,15-17]. highlighted the need to investigate the psychosocial factors impacting frailty in older adults, vital to addressing the health and well-being of the rapidly ageing population in Singapore.

Many studies have tried to explain the mediators and moderators within the pathway of frailty and health outcome [18-20, 21] developed a working framework to elaborate the pathway from frailty to its adverse outcomes. In the meantime, [22]. and [18] also elaborated those psychosocial factors in a general matter for health and wellbeing. There are numerous research studies that investigated factors such as: (i) depression being associated with a higher risk of frailty [23-25]. and (ii) living alone lacking in social support and socially isolated had a higher risk of developing frailty [26-28]. Recent findings suggest being older, female, living alone, lacking regular exercise and poor health status are significantly associated with frailty prevalence [29-31] suggested the presence of adverse health outcomes, poor cognition, polypharmacy, sarcopenia, fall rate, living in a private institution or hospital and mortality are related to frailty. Similar findings are supported by [32]. where physiological issues such as poor weight management, disease, and poor psychological health contribute to frailty. Hence, according to Berkman’s model [18] and the frailty pathway framework [21]. we examined the existing pathway model on the effects of psychosocial factors on frailty and health outcomes among community-dwelling older adults. In a summary, using Singapore as a case example, the study aimed to investigate the prevalence and related psychosocial factors of frailty in older adults in Singapore and the main research question is: RQ: What are association between psychosocial factors and frailty and mediate role of frailty between psychosocial factors and Quality of Life (QoL)?

Methodology

Study design

This was a cross-sectional study using convenience sampling. Participants underwent a screening phase and a psychosocial profiling phase to gather pre-study data. In the screening phase, upon providing informed consent to take part in the study, participants were issued a questionnaire to gather their basic demographic information and proceeded with the screening session, in which participants were assessed using the frailty scale (Five-item Frail Scale) from [33]. In which the ratings were used to identify the state of frailty in the participants: non-frail (0); pre-frail (1-2); and frail (3-5). Frail participants did not proceed with physical performance assessments. Other self-reported questionnaires include the Katz Activities for Daily Living (ADLs) [34]. and Lawton’s Instrumental Activities of Daily Living (IADLs) [35]. as well as a Fall Efficacy Scale [36], were used. Other biomechanical/physical performance data were collected using the Short Physical Performance Battery (SPPB) [37]. Gait Speed [38]. One-Leg Stand and Grip Strength [33]. In the psychosocial profiling phase, an interviewer-administered questionnaire consisting of validated scales were used to gather data pertaining to participants’ psychosocial conditions to measure Depression, Social Support, Quality of Life, and Loneliness (Table 1). Trained personnel (who had undergone training by research staff/occupational therapist/physiotherapists) conducted the various physical performance assessment components. The study was a single research visit per participant. The entire process took approximately 1 hour per participant.

Measurements

5-Item frail scale

The FRAIL scale included 5 components: Fatigue; Resistance; Ambulation; Illness; and Loss of Weight. Frail scale score ranged from 0-5 (i.e., 1 point for each component; 0=best to 5=worst) and represented frail (3-5), pre-frail (1-2), and robust (0) health status.

Katz activities of daily living (ADLs)

Basic ADLs included seven items (bathing, dressing, eating, transferring bed or chair, walking across a room, getting outside, and using the toilet).

Lawton instrumental activities of daily living (IADLs)

IADLs included eight items (preparing meals, shopping for groceries, managing money, making phone calls, doing light housework, doing heavy housework, getting to places outside walking distance, and managing medications).

Short physical performance battery (SPPB)

The SPPB is a summary measure of lower body performance based on three-component tasks: standing balance; chairs stand; and usual walking speed. Each component task was scored as 0-4 (range 0=worst to 4 best), and a composite score was computed as the sum of scores on component tasks as 0-12 (range 0=worst to 12=best).

Gait speed

Gait speed was assessed in respondents’ homes using a standardized 4-meter course with participants instructed to walk at their usual pace. The average walking speed (meters/second) was computed for two trials.

One-leg stand

For the one-leg stand test, individuals chose their preferred leg to balance on and were required to raise the other foot at least 2 inches above the ground and hold the position for as long as possible up to 30 seconds.

Grip strength

Isometric grip strength was assessed using a digital handgrip dynamometer. The mean of the last two maximal effort trials were used in the analysis. The test was performed seated in a chair (without armrests), with feet flat on the floor and the other arm held flat against the side with the elbow at 90°.

Falls efficacy scale

The Falls Efficacy Scale (FES) measures confidence in performing 10 everyday activities without falling. The response for each FES item ranges from 0 (no confidence) to 10 (complete confidence) and the FES total score ranges from 0-100.

Depression

The Center for Epidemiologic Studies Depression Scale (CES-D) included 20 items comprising 6 scales reflecting major dimensions of depression [39]. depressed mood; feelings of guilt and worthlessness; feelings of helplessness and hopelessness; psychomotor retardation; loss of appetite; and sleep disturbance. It measured self-reported symptoms associated with depression experienced in the past week. Higher scores represent more depressive symptoms. A cut-off score of 16 indicates high depressive symptoms.

4 Social support

The Multidimensional Scale of Perceived Social Support (MSPSS) measured how much support a person feels he or she gets from family, friends, and significant others [40]. The items tended to divide into factor groups relating to the family (FAM), friends (FRI) or significant others (SO). (1=very strongly disagree, 2=strongly disagree; 3=mildly disagree; 4=neutral; 5=mildly agree; 6=strongly agree; 7=very strongly agree).

4 Quality of life

The EQ-5D-5L is a standardized instrument to measure generic health status [41]. It is made up of two components: health state description and evaluation. The health state description contained 5 dimensions with 5 response levels (no, slight, moderate, severe, or extreme). The evaluation part measured respondents’ overall health status on a visual analog scale (VAS).

4 Loneliness

This scale evaluated feelings of loneliness in individuals. An 8-item short form using a 4-point Likert scale ranging from 1, never, to 4, always. Minimum and maximum possible scores are 8 and 32, respectively. Higher scores from USL-8 corresponded to severe loneliness. A cut-off score of 24 was used to classify lonely and not lonely participants based on a previous study [42].

Data Collection

We conducted a survey study on the target population to identify frailty conditions and psychosocial profiles among older adults in Singapore. A total of 491 community-dwelling older adults were recruited from 17 Senior Activity Centers (SACs) / Voluntary Welfare Organizations (VWOs) in Singapore from March to September 2018. The inclusion criteria were: (i) Age >= 65 years (WHO, 2013); (ii) No significant cognitive deficits and can understand and follow instructions; (iii) No significant physical impairments and community ambulant; and (iv) Living in the community and not in a nursing home.

Results & Analyses

Calculations were made using the SPSS IBM 25.0 software. A chi-square (²) analysis was performed for intergroup sociodemographic and categorical data. Independent t-tests and analysis of variances were used on continuous data. Kruskal-Wallis H test was used when assumptions of normality and/or homogeneity was/were violated. Multiple regression was carried out with frailty score and quality of life as dependent variables. In all hypotheses, a significance level of α=0.05 was used, and a confidence interval of 95 % was accepted for statistical significance (p<0.05) at a 2-tailed level.

Demographics

A total of 491 eligible older adults took part in the study. The average age of the participants was (M=74.23, SD=6.25) and 127 were males. Socio-demographic findings showed that majority of the study participants were in the age group of 65-74 years (54.6%) in three major ethnic groups of Chinese (87.58%), Malay (8.96%) and Indian ethnic group (3.46%). Of the 491 participants, 6.52% were ascribed to tertiary education, unemployed (never worked and not working) (89.82%), married (56.1%) and living with family members (70.06%). The variables measuring health status showed that 39.31% of the study participants had at least two chronic conditions (the combination of hypertension, cardiovascular disease, arthritis, respiratory disease etc.) and 10.79% had depressive symptoms. About 3.46% reported feelings of loneliness.

Here are three findings:

Prevalence of frailty among community-dwelling older adults (65 years and above)

The prevalence of frailty among community-dwelling older adults aged 65 years old and above in Singapore was at 3.3%. Approximately 37.1% and 59.7% were identified as pre-frail and robust respectively. The socio-demographic information associated with frailty is shown in (Table 1). The prevalence of frailty increased significantly with age, p <.001 among those aged 60-74 years and 75 years and above, from 31.3% to 68.8% respectively. There was a higher prevalence of frailty among females, with marginal significance, p=.056. Among ethnic groups, a larger proportion of Chinese was robust as compared to the Malay and Indian ethnic groups. While ethnicity was not significantly associated with frailty status, it is interesting to note that the Indians had a higher proportion of pre-frails at 58.82% compared to those in robust, 35.29%. Education was significantly different across frailty status, p=.036. Half of the frail participants had no formal education followed by 31.3% and 18.1% in primary education and secondary education respectively. Employment status was significantly associated with frailty status, p=.007, where 100% of frail participants were not working. There was a higher proportion of married people who were robust (60.4%) compared to those who were single, divorced/separated, widowed (39.4%). Interestingly, more people were frail in the “Married” (68.8%) than “those otherwise/not married” categories (31.3%). A higher proportion of those who lived alone was frail (37.5%) than prefrail (33.5%) and robust (27.3%) (Table 2).

Association among frailty, functional status, fall efficacy, physical performance, psychosocial well-being, and health-related quality of life

There was a significant difference in IADL functional status, where p < .001 but not ADL functional status. As frailty status progresses from robust to frail, the proportion of older adults with ADL/IAD impairment increases as shown in (Table 3). Significant differences were also seen in Fall efficacy where frail participants had higher mean rank scores compared to prefrail and robust participants (Table 3). Pairwise comparison comparing the three-frailty status be found in (Table 4). Physical performance measures were compared between robust and prefrail participants. Significant differences in physical performance measures between the two groups, p <.001 (Table 2). Robust participants had significantly higher SPPB scores, higher gait speed, better performance in one-leg stand time, and stronger dominant handgrip strength than those in prefrail, p <.001. Hence, for the second research question, we conclude that IADL functional status, fall efficacy and Physical performance are significantly associating with frailty. A significantly higher proportion of frail (43.8%) participants depressed/have high depressive symptoms than prefrail (13.7%) and robust (7.2%) participants, where p <.001. However, there was no significant difference in the proportion of participants who were lonely across frailty status. Significant differences were observed in loneliness and depression scores across frailty status, p < .001 (Table 2). Loneliness score was significantly higher in both prefrail and frail participants than robust participants, where p =.001. Robust participants had a significantly lower score depression score than prefrail and frail participants respectively, p <.001. Kruskal-Wallis H tests showed that there was a significant difference in overall social support between the different frailty status, χ²(2) = 18.76, p < .001. Multiple Pairwise comparisons showed that robust participants were significantly higher than frail participants (Mean Rank = 166.66), p =.017, and robust participants (Mean Rank =267.55) were significantly higher than pre-frail participants (Mean Rank = 218.28), p =.001. Social support from the subscales from friends (FR), family (FM), and a significant other (SO) was also found to be significant. Multiple pairwise comparisons results can be found in (Table 4). We measured frailty with health-related quality of life. Self-reported health status was significantly lower in frail, followed by prefrail, and robust participants (Table 3). Frailty was significantly associated with having problems in all domains of health dimensions where robust participants had the least problems except in anxiety/depression. (Figure 1) shows the percentage/proportion of frail, prefrail, and robust participants who had problems with all five health domains (EQ-5D). The top two domains frail participants had problems with were pain/discomfort (81.3%) and mobility (50%). Self-evaluated overall health status was significantly lower in frail participants followed by prefrail and robust (Table 3). Findings showed that factors affecting psychosocial well-being and health-related quality of life are significantly associated with frailty.

Validation of the mediation effect of frailty through pathway analyses

Based on the existing pathway models [19-21]. We selected the existing model linking psychosocial factors (X) to quality of life (Y), which is conditional if the indirect effect of X on Y through M (a mediator variable) depends on W (a moderator variable) (Figure 2). To validate the mediation effect of frailty among psychosocial factors and quality of life, two regression models to obtain the path coefficients to determine whether independent variables like depression, loneliness, social support, and frailty scores would significantly predict the quality of life, the outcome dependent variable. Multiple regression was run to predict the quality of life from loneliness, depression, social support, and frail scores. The multiple regression model statistically significantly predicted quality of life, F (4,485) = 25.891, p < .001, adj. R2 = .176. All variables added statistically significantly to the prediction, p < .05 except for social support, p = .558 and loneliness, p = .066. Regression coefficients and standard errors can be found in (Table 5). (Figure 3) shows the frailty mediational hypothesis model from psychosocial factors to quality of life. The red and black lines represent the significant and non-significant relationships. A cumulative odds ordinal logistic regression with proportional odds was run to determine whether depression, loneliness and social support affect the frail scores. A decrease in social support was associated with an increase in the odds of higher frail scores, with an odds ratio of .832 (95% CI, .711 to .972), Wald χ²(1) = 5.369, p = .020. An increase in depression scores was associated with an increase in the odds of higher frail scores, with an odds ratio of 1.071 (95% CI, 1.037 to 1.105), Wald χ²(1) = 17.814, p < .0005. A decrease in loneliness was not associated with an increase in the odds of higher frail scores, with an odds ratio of .982 (95% CI, .930 to 1.036), Wald χ²(1) = .444, p = .505. These results supported the existing mediational hypothesis model, which revealed that the indirect effect of depression, loneliness, and social support on quality of life was mediated by frailty. Depression had both direct and indirect impacts on quality of life.

Discussion

This study investigated the prevalence of frailty among community older adults (65 years and above) in Singapore. Based on our findings, the prevalence of frailty (3.3%) is similar to earlier study conducted from 2010 to 2013 in Singapore [16,17]. Compared to other countries where the prevalence of frailty ranged from 4% to 44% [8]. The prevalence of frailty among the older adults in Singapore is at the lower end of the spectrum at 3.3%, and early interventions at personal, community and societal levels are needed before the problem becomes serious. Results also revealed that the prevalence of frail and pre-frail states increased with age, which is in line with the general literature [8]. The study also showed that approximately 31.3% of those aged 60-75 years were frail, showing the importance of assessing frailty even among those aged <60 years. We observed ethnic differences in pre-frailty and frailty, concurring with findings from a study by [16]. Singapore primarily has three main ethnic groups, namely, Chinese (74.3%); Malays (13.5%); Indians (9.0%) [1]. Chinese older adults were found to have a lower prevalence of both frailty (2.79%) and pre-frailty (36.5%) at the bivariate level, compared to Indian older adults who were found to have almost twice the odds for frailty (5.88%) and pre-frailty (58.82%) (Table 1). However, Malay older adults have a prevalence of frailty (6.82%) and pre-frailty (34.09%). [43] and [44] pointed out that frailty is more prevalent in ethnic minorities, as cultural factors, and lifestyle choices in turn lead to variations in health habits and access to resources. Older adults may benefit from the multicultural society and environment in Singapore, hence the prevalent difference between the ethnic group is not significant. More longitudinal studies to understand relationships between frailty and social support are pertinent in formulating customized intervention programs for the different ethnic groups in Singapore.

While many studies have already done on predictors of physical frailty in older people, less is known on psychosocial factors for whom and how they exert their effects. Based on the Bergman conceptual framework and possible model identified recently [19,21]. The adopted conditional process model is the indirect effect of depression, loneliness, and social support on Quality of Life through frailty that is moderated (Figure 2). Observing associations between quality of life and conditions measured concurrently does not necessarily permit understanding of the direction of effect. Rather, these associations describe how Quality of Life levels vary with a broad set of psychological conditions in older people. Based on our findings, frailty is one mediator among the psychosocial factors to Quality of Life, while age, gender, ethnicity, education, employment, and marital status are possible moderators on pathways from psychological conditions to Quality of Life.

Conclusion

As a summary, establishing frailty prevalence and its related psychosocial factors is undoubtedly important for both clinical practice and the national healthcare system. According to our study results, the prevalence of frailty and pre-frailty are 3.3% and 37.1%; the results also investigated the association between psychosocial factors and frailty and mediate role of frailty between psychosocial factors and Quality of Life. The study has several clinical, research, and policy implications. Though sampling participants and periods are limited, the psychosocial factors impacting frailty may be underestimated. Preliminary findings have shown the factors (social support, depression, loneliness and fall efficacy) associated with frailty and pre-frailty which require a need for greater collaboration between health professionals, social services and researchers concerned with the health and well-being of older adults in the community. This study’s findings confirmed that depression, loneliness, and social support have direct and indirect impacts on quality of life. Hence, a good social functioning with the meaningful networked community is important as it nudges healthy ageing and reduced vulnerability [45]. And loneliness.

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Unveiling the Intersection of Age and Gender in the Emotional Well-being of Older Students: A Pilot Study at the Permanent University for Adults in Alicante (Spain) - Juniper Publishers

 Gerontology & Geriatric Medicine - Juniper Publishers

Abstract

This study assesses the emotional impact and well-being of older students at the Permanent University for Adults in Alicante (UPUA), focusing on how demographic characteristics, specifically age and gender, influence these perceptions. Utilizing a descriptive and analytical design, a sample of older students was analyzed by applying self-administered questionnaires to collect quantitative data. The results highlight significant differences in emotional well-being related to age and gender, as well as variations in the perception of loneliness and life satisfaction. The study also identifies questionnaire items that, depending on their correlation and relevance, suggest areas for intervention to improve the quality of life and educational experience of this population. This comprehensive approach provides a foundation for the development of personalized educational strategies aimed at promoting emotional well-being among older adults.

Keywords: Well-Being; Emotions; Older Adults; Lifelong Education; Statistical Analysis

Abbreviations: UPUA: University for Adults in Alicante, ANOVA: Analysis of Variance, H1: Hypothesis 1, H2: Hypothesis 2, H3: Hypothesis 3, H4: Hypothesis 4, H5: Hypothesis 5

Introduction

This research examines the impact on emotional well-being and quality of life of older students at the Permanent University of Alicante (UPUA), with a special focus on the influence of demographic variables such as age and gender on these aspects [1-3]. Through the adoption of both descriptive and analytical methodological approaches, the study was conducted on a selection of senior students using self-administered surveys for the collection of quantitative data [4-7]. The findings indicate significant differences in emotional well-being, directly associated with individuals' age and gender, as well as variations in perceptions of loneliness and life satisfaction levels [8-14]. Similarly, this analysis identified certain survey items that, due to their correlation and significance, suggest the potential for intervention in specific areas to enhance quality of life and optimize the educational experiences of this group [15-18].

This comprehensive approach establishes a conducive framework for the creation of tailored educational strategies aimed at promoting greater emotional well-being in the older adult population [18-20]. Aging is recognized as a phase of human development characterized by significant transformations both personally and socially. During this period, psychosocial well-being becomes a critical element influencing the quality of life of the elderly [15-17]. With the increase in life expectancy and improvements in health standards, education emerges as a conducive field for promoting social integration, independence, and personal satisfaction within this demographic group [20-25]. The significance of this research line lies in unraveling how educational interventions can act as a mechanism to foster well-being in the elderly population, a segment experiencing exponential growth in contemporary society [13].

Previous studies have explored the correlation between lifelong education and well-being in old age, highlighting the value of activities that promote social inclusion, cognitive development, and the maintenance of independence [26-28]. Theoretical frameworks, such as those proposed by Ryff [29-37], have conceptualized well-being from various perspectives, including autonomy, personal growth, positive interpersonal relationships, self-acceptance, purpose in life, and the ability to manage one's environment [38-42]. Despite the extensive literature, questions remain about how the components of well-being and educational experiences specifically articulate during the aging process. This article, along with others previously published [24,43-45], is oriented toward this line of inquiry.

A research gap is identified regarding the interaction between different dimensions of well-being and their modulation by participation in educational initiatives aimed at the elderly population. Furthermore, there is a noted lack of studies that combine quantitative and qualitative methodologies to capture the elderly's subjective well-being experiences within the educational context, suggesting a call for more thorough investigation [46,47]. This study seeks to address this gap by adopting a mixed-methodology approach that explores the complexity of well-being in old age and how it can be enhanced with educational strategies tailored to their specific needs, within the recently coined concept of Educational Anamnesis [44].

Objectives

General Objective: To assess the emotional impact and well-being of older students at the Permanent University of Alicante (UPUA), determining how demographic characteristics such as age and gender influence these perceptions and experiences, with the aim of developing interventions to improve their quality of life and educational experience.

Specific Objectives:

1. To describe the age and gender distribution of the older students participating in the research to identify possible patterns or trends that may influence the reported emotional impact and well-being.

2. To examine how the age and gender of older students affect their responses to items related to emotional and social well-being, using statistical analyses like ANOVA to identify significant differences.

3. To use reliability measures, such as corrected item-total correlation and Cronbach's Alpha, to determine which questionnaire items accurately reflect the emotional impact and well-being among older students and adjust the questionnaire accordingly.

4. To determine which questionnaire items are most closely associated with variations in well-being and emotional impact among different age and gender groups, to identify potential risk and protective factors.

5. To propose, based on the findings, specific strategies aimed at improving the emotional well-being and educational experience of older students at the UPUA, considering the particular needs identified through demographic analysis.

6. To expand the existing knowledge on how continuing education in older adulthood can influence emotional and social well-being, offering empirical data and recommendations based on the evaluation conducted at the UPUA.

7. To use the findings of the research to inform and guide future studies on emotional well-being in adult education contexts, as well as to improve educational and support practices at the Permanent University of Alicante and similar institutions (Figure 1).

Research Hypotheses

4.2.1. Main Hypothesis: The emotional well-being and perceptions of loneliness, life satisfaction, and attitudes towards the future among older students at the UPUA significantly vary according to demographic characteristics, specifically age and gender, suggesting the need for developing personalized interventions to enhance their quality of life and educational experience.

Specific Hypotheses:

1. Hypothesis 1: There are clear patterns in the age and gender distribution among older students participating in the UPUA, influencing their reported emotional impact and well-being. It is expected that the predominance of students aged 66-75 and a higher female representation have implications in the analysis of emotional and social well-being.

2. Hypothesis 2: The age and gender of older students significantly affect their responses to items related to emotional and social well-being. In particular, it is hypothesized that older students and women may report higher levels of loneliness and concerns about the future.

3. Hypothesis 3: The questionnaire items measuring emotional impact and well-being do not exhibit uniform internal consistency across the studied population, suggesting that some items may be more relevant or interpreted differently by various demographic groups.

4. Hypothesis 4: Certain questionnaire items are more closely associated with variations in well-being and emotional impact among different age and gender groups, acting as risk or protective factors. For example, the perception of loneliness and difficulties in steering life towards a satisfactory path are anticipated to vary significantly with age.

5. Hypothesis 5: Based on demographic and item analyses, specific recommendations can be developed to improve the emotional well-being of older students at the UPUA, such as programs aimed at fostering social interaction and emotional support, especially for the most susceptible groups identified in the study.

6. Hypothesis 6: The research will contribute to the literature on older adult education and emotional well-being by providing empirical evidence on how demographic characteristics influence these dimensions, and by offering practical recommendations based on the findings.

7. Hypothesis 7: The findings of this study will inform and guide future research and educational practices to enhance emotional well-being in older adult education contexts, emphasizing the importance of considering demographic differences in the design of interventions and educational programs.

Methodology

A descriptive and analytical design will be employed to examine the influence of demographic variables on the well-being and emotional impact of older students at the Permanent University of Alicante (UPUA). The study will focus on cross-sectional analyses to understand how age and gender affect emotional well-being and perceptions of loneliness, life satisfaction, and attitudes towards the future, based on a single point in time. The sample will consist of older students from the UPUA, aged between 46 and 85 years, selected from those enrolled in specific subjects. Inclusion criteria will include currently being enrolled in UPUA courses and voluntarily consenting to participate in the research. The gender and age distribution of the sample will reflect the proportions found in the preliminary study population, with an emphasis on understanding emotional well-being differences within this specific age range.

Self-administered questionnaires (Ryff), based on items reflecting the dimensions of emotional and social well-being identified in preliminary research, will be utilized. These questionnaires will include questions about loneliness, life satisfaction, perceptions of the future, and social relationships. The procedure will involve direct invitations in classes and emails to participants. Questionnaires will be administered at the beginning of the course and collected at the end of it to assess the state of well-being at a specific time. Descriptive analyses will be used to summarize the demographic characteristics of the sample and the distributions of questionnaire responses. To evaluate the structure of well-being dimensions, an exploratory factor analysis based on questionnaire responses will be applied. Correlation tests and analysis of variance (ANOVA) will be employed to explore the relationships between emotional well-being, age, and gender of participants. Linear regression analyses will be used to investigate the predictive impact of demographic variables and participation in educational activities on emotional well-being.

Results

Below are the findings from the Descriptive Analysis, presenting measures of central tendency and dispersion.

Age:

The age composition of the sample is characterized by a predominant concentration in the range of 66-75 years, representing 53.3% of the total, followed by the group aged 56-65 years with 33.3%. The age ranges of 46-55 and 76-85 years show minimal representation, each accounting for 6.7% of the sample. This age distribution skewed towards older age groups suggests potential limitations in generalizing the study's results to a broader age spectrum. Such concentration in a specific age range could influence the interpretation of the data, necessitating consideration of the impact of this imbalance when analyzing participant responses. Although this pilot study reflects the demographic characteristics of UPUA students, with a notable age diversity, future analysis will need to adjust for this uneven distribution to ensure the validity of identified age-related comparisons or correlations (Table 1).

Gender:

The sample studied exhibits an unbalanced gender distribution, with a predominance of the female gender, constituting 60% compared to 40% of the male gender. This gender disparity could significantly impact the interpretation of the results, necessitating careful analysis of how this bias might affect the generalization of the findings to more gender-equitable populations. The female predominance in the sample implies that any identified trend or pattern must be evaluated considering this imbalance, to ensure the applicability and relevance of the results in more balanced demographic contexts. Thus, similar to the age distribution, the imbalance in gender representation underscores the need to address these differences when interpreting the responses and formulating conclusions within the study (Table 2).

Item Analysis:

The sample is relatively small (N=15), which limits the generalization of the results. Given that this is a preliminary analysis before a more general one with a spectrum of over a hundred samples, the limitation is accepted in favor of generating important data for subsequent analysis with a more significant sampling. The interesting interpretation of the descriptive analysis of the current sample, due to its extent, has already been performed in other publications, to which we refer [24,43].

Median and Mode:

For several items, the median and mode differ from the mean, which may indicate a non-symmetrical distribution of responses. This is important for correctly interpreting central trends. A key indicator is when the mean does not match the median or mode, suggesting an asymmetric distribution of responses (Table 3). reflects the differences between the mean, median, and mode for such items. Each item relates to personal experiences or perceptions, and the differences in the measures of central tendency give us clues about the distribution of the respondents' answers. Thus, in Item 2 ("I often feel lonely because I have few close friends to share my concerns with"), the mode is significantly lower than the median and the mean, indicating that a larger number of respondents chose the option corresponding to the lowest value on the scale, suggesting that loneliness is a common experience. In Item 5 ("I find it difficult to steer my life in a direction that satisfies me"), there is a notable asymmetry, with the mode being lower (1.00), implying that many participants find it very difficult to direct their lives satisfactorily, much more than the median and the mean suggest.

Item 15 and Item 20 show modes at 1.00, indicating that the option of the lowest value on the scale is the most frequent, which may signal a tendency towards problems with the influence of others or the perception of having fewer friends, respectively. Finally, in Item 30 ("I stopped trying to make significant improvements or changes in my life a long time ago"), the mean and the median are aligned at the highest value (3.00), but the mode drops back to 2.00, indicating that, although the central tendency leans towards disagreement with the statement, a more frequent response leans towards agreement.

In Figure 2, these differences are visualized with vertical lines connecting the mode, the median, and the mean for each item. The longer lines indicate a greater discrepancy between the three measures. For example, a long vertical line on the graph, as seen in Item 5, highlights a considerable asymmetry in the responses. En definitiva, este gráfico y los datos asociados nos muestran que, para varios ítems, la percepción o experiencia más común (moda) no siempre se alinea con la mediana o la media, indicando distribuciones sesgadas y la importancia de considerar todas las medidas de tendencia central al interpretar los resultados de la encuesta. Las respuestas tienden a estar polarizadas, con una proporción significativa de los encuestados sintiéndose más extremos en sus experiencias o percepciones que lo que la media podría sugerir. Esto es crítico para entender el verdadero sentimiento o las opiniones de los encuestados y para tomar decisiones basadas en estos datos.

Analysis of Item Statistics

Due to the reasons previously described, we will analyze the variability in responses to the questionnaire items. This can be evaluated using statistics, including corrected item-total correlation, squared multiple correlation, and Cronbach's Alpha if the item is removed. The Corrected Item-Total Correlation measures how well a particular item correlates with the sum of the other items. A higher value suggests that the item is more aligned with the overall construct measured by the questionnaire. On the other hand, Cronbach's Alpha if Item Removed shows how the Cronbach's Alpha of the questionnaire would change if that particular item were removed. An increase in Alpha upon removing an item suggests that the item may not be well aligned with the rest of the questionnaire.

Items vary in their correlation with the total of the questionnaire, indicating that some are more aligned with the overall construct than others. Some items, when removed, could increase the Cronbach's Alpha, suggesting they are not contributing to the internal consistency of the questionnaire. This may indicate variability in how each item is perceived or related to the questionnaire's central theme. There is likely variability in how different elements are interpreted or valued by respondents. This variability could be due to differences in personal interpretations, life experiences, or demographic characteristics such as age.

To determine which items could be removed and if it is feasible to relate this to the age difference, we will analyze the data, focusing primarily on Cronbach's Alpha if the item is removed. This value indicates whether the internal consistency of the questionnaire improves or worsens by removing a specific item.

Thus, we look for Items with a Negative Impact on Consistency, whose removal increases Cronbach's Alpha, suggesting they do not align with the questionnaire's overall construct. For example, the item "4. I worry about how other people evaluate the choices I've made in my life." has an Alpha if removed of .605, higher than the overall Alpha of .580, indicating that its removal could improve the consistency of the questionnaire (Table 4,5).

Conversely, we seek Items with a Positive or Neutral Impact on Consistency, that is, those items whose removal decreases the Alpha or maintains it similarly, indicating an alignment with the questionnaire's overall construct. For example, the item "9. I tend to worry about what other people think of me." has an Alpha if removed of .513, suggesting it is an important element for the consistency of the questionnaire.

Relationship with Age: Analysis of Variance (ANOVA):

Figure 3 is a scatter plot (or heatmap) of significance levels for each item from an ANOVA test, showing how the variability in respondents' answers to different survey items might be related to age. The heatmap uses colors to represent the ANOVA test significance levels for each item. Darker colors (green to purple) indicate lower levels of significance, suggesting there are statistically significant differences between age groups in responses to those items. Conversely, lighter colors (yellow) indicate higher levels of significance, suggesting there are no significant differences. In this regard, Item 2 ("Feel lonely"), with a significance level of 0.025, shows significant differences between age groups. This suggests that feelings of loneliness may be experienced differently depending on the respondent's age.

Item 9 ("Worry about others’ thoughts"), with a significance level of 0.026, indicates that concerns about what others think vary significantly with age. Item 12 ("Active in projects"), with a significance level of 0.011, shows that there are significant differences in the activity of personal projects among age groups. Item 17 ("Feel good about past and future"), with a very low significance level of 0.002, indicates that satisfaction with the past and expectations for the future differ considerably across different ages. Item 22 ("Daily demands depressing"), with a significance level of 0.012, suggests that how daily demands affect respondents' mood varies with age. Item 26 ("Lack of close relationships"), with a significance of 0.041, indicates differences between age groups in the experience of close and trusting relationships. Item 29 ("Unclear life goals"), with a significance level of 0.014, signals significant differences in the clarity of life goals among different ages. Item 34 ("Avoid new ways"), with a significance level of 0.027, presents statistically significant variations in the willingness to try new ways of doing things according to age. Finally, Item 35 ("Value new experiences"), with a significance of 0.014, suggests that the valuation of new experiences that challenge personal perceptions varies with age.

In the scatter plot of Figure 4, the relationship between the corrected total item correlation and Cronbach's Alpha if the item is removed is depicted. Each point on the graph corresponds to one of the survey items. The x-axis displays the corrected total item correlation, which measures how well each item correlates with the sum of the other items. The y-axis shows Cronbach's Alpha if the item is removed, indicating the internal consistency of the scale if that particular item were to be removed. Items that have a high corrected total correlation and a lower Cronbach's Alpha if removed are generally considered more essential for the scale's reliability. Conversely, items with a low or negative corrected total correlation and a higher Cronbach's Alpha if removed could be candidates for removal to improve the overall reliability of the scale.

For instance, Item 2 ("Feel lonely") has a high corrected total correlation with the rest of the scale and simultaneously shows significant differences between age groups, indicating that the feeling of loneliness is a consistent factor in the scale that varies with age. This suggests that loneliness is a universal concern manifesting differently across ages and is a reliable element within the survey to measure that sentiment.

Item 9 ("Worry about others’ thoughts"), with a similar significance and likely a high correlation with the rest of the scale, suggests that this aspect of concern about others' opinions is another factor that is not only relevant in terms of internal consistency but also varies with the age of the participants. Similarly, Item 12 ("Active in projects") and Item 17 ("Feel good about past and future"), with their respective significance levels, can be interpreted similarly. The variability in responses and their relationship with age can provide valuable insights into how activity in projects and satisfaction with the past and future are influenced by age.

For items like 22 ("Daily demands depressing"), 26 ("Lack of close relationships"), 29 ("Unclear life goals"), 34 ("Avoid new ways"), and 35 ("Value new experiences"), the statistical significance and their relationship with age tell us that these aspects of daily life and self-perception and future outlook are areas that are strongly influenced by age. Therefore, the joint interpretation of the scatter plot and ANOVA analyses suggests that the survey scale is not only reliable but also relevant for capturing generational differences in various dimensions of human experience.

In the scatter plot of Figure 4, the relationship between the corrected total item correlation and Cronbach's Alpha if the item is removed is depicted. Each point on the graph corresponds to one of the survey items. The x-axis displays the corrected total item correlation, which measures how well each item correlates with the sum of the other items. The y-axis shows Cronbach's Alpha if the item is removed, indicating the internal consistency of the scale if that particular item were to be removed. Items that have a high corrected total correlation and a lower Cronbach's Alpha if removed are generally considered more essential for the scale's reliability. Conversely, items with a low or negative corrected total correlation and a higher Cronbach's Alpha if removed could be candidates for removal to improve the overall reliability of the scale.

For instance, Item 2 ("Feel lonely") has a high corrected total correlation with the rest of the scale and simultaneously shows significant differences between age groups, indicating that the feeling of loneliness is a consistent factor in the scale that varies with age. This suggests that loneliness is a universal concern manifesting differently across ages and is a reliable element within the survey to measure that sentiment. Item 9 ("Worry about others’ thoughts"), with a similar significance and likely a high correlation with the rest of the scale, suggests that this aspect of concern about others' opinions is another factor that is not only relevant in terms of internal consistency but also varies with the age of the participants.

Similarly, Item 12 ("Active in projects") and Item 17 ("Feel good about past and future"), with their respective significance levels, can be interpreted similarly. The variability in responses and their relationship with age can provide valuable insights into how activity in projects and satisfaction with the past and future are influenced by age. For items like 22 ("Daily demands depressing"), 26 ("Lack of close relationships"), 29 ("Unclear life goals"), 34 ("Avoid new ways"), and 35 ("Value new experiences"), the statistical significance and their relationship with age tell us that these aspects of daily life and self-perception and future outlook are areas that are strongly influenced by age. Therefore, the joint interpretation of the scatter plot and ANOVA analyses suggests that the survey scale is not only reliable but also relevant for capturing generational differences in various dimensions of human experience (Figure 5).

Discussion

The discussion of the results obtained in this study reveals an underlying complexity in the relationship between emotional well-being, lifelong education, and the demographic characteristics of older adults, particularly in the context of the Permanent University of Alicante (UPUA). This analysis resonates with previous research, which has also explored how participation in educational activities can influence various dimensions of well-being in older age [48-52]. The confirmation of our hypotheses underscores the need for a more personalized approach in designing educational programs for this population, a conclusion consistent with findings from similar studies.

In line with Hypothesis 1 (H1), suggesting a significant influence of age and gender on emotional well-being, our research aligns with studies highlighting differences in how older adults experience loneliness and life satisfaction [8,11,12]. Previous studies have shown that older women tend to report higher levels of loneliness than men, a finding that reflects the unequal gender distribution observed in our sample and its implications on emotional well-being [53].

The confirmation of Hypothesis 2 (H2) in our study, highlighting the impact of age and gender on well-being questionnaire responses, parallels research examining how these demographic variables modulate the perception of well-being and the impact of educational interventions. The literature suggests that educational programs tailored to specific gender and age needs can have more marked positive effects on participants' emotional well-being [22,24,54].

Regarding Hypothesis 3 (H3), addressing the internal consistency of the questionnaire items, our research emphasizes the importance of considering the peculiarities of each demographic group when designing assessment tools. This approach is supported by studies criticizing the universal application of measurement instruments without accounting for cultural, gender, or age differences, which could lead to misinterpretations of the data [8,9,16,55,56].

Identifying risk and protection factors associated with emotional well-being, according to Hypothesis 4 (H4), is supported by literature highlighting the complexity of older adults' life experiences and how these influence their well-being. Tailoring educational activities to specifically address these factors can significantly increase their effectiveness, a conclusion that reinforces the need for personalized educational interventions [1,2,24,43,57,58].

Finally, the ability to develop specific recommendations to improve emotional well-being, in line with Hypothesis 5 (H5), highlights the practical value of integrating research findings into the planning and execution of educational programs for older adults. Similar experiences in other analyses point to the efficacy of evidence-based educational strategies designed to meet the emotional and cognitive needs of this population [23,25,59-62].

Conclusions

This study focused on assessing the emotional impact and well-being in a sector of the older student population at the Permanent University of Alicante (UPUA), as a pilot test, highlighting the influence of demographic variables such as age and gender on these perceptions and experiences. Through a methodological approach that integrated the analysis of self-administered questionnaires, a detailed understanding of the dynamics of well-being in this demographic group was obtained. The results allowed for verifying the extent to which the proposed hypotheses were met, confirming significant variability in emotional well-being and related perceptions with demographic characteristics.

The hypothesis that emotional well-being and related perceptions of loneliness, life satisfaction, and attitudes toward the future vary significantly according to age and gender, as reflected in the statistical analyses performed. The predominant distribution of students in the 66-75 age range and a greater female representation in the sample revealed differences in the perception of loneliness and well-being, supporting Hypothesis 1 (H1). This suggests a need to consider these variables when developing interventions to improve well-being in this population segment.

The analyses showed that both age and gender have a significant impact on how older students experience and report their emotional well-being, corroborating Hypothesis 2 (H2). Moreover, it was observed that not all questionnaire items exhibited uniform internal consistency across the studied population, indicating that some items might not be universally applicable for measuring well-being in this diverse population, confirming Hypothesis 3 (H3). This suggests the presence of variability in the perception or valuation of the items, depending on demographic characteristics.

The identification of risk and protection factors for emotional well-being associated with age and gender, varying significantly between different groups, supported Hypothesis 4 (H4). This indicated specific areas where older students might require additional support. Based on the analyses, it was possible to develop specific recommendations to improve the educational experience and emotional well-being of older students at the UPUA, thus fulfilling Hypothesis 5 (H5).

This study underscores the importance of considering demographic characteristics when assessing and addressing the emotional well-being of older students, highlighting the need for personalized educational interventions and support strategies that take into account age and gender. The findings contribute to the existing literature by providing empirical evidence on the relationships between lifelong education, emotional well-being, and demographic variables in old age, guiding future research and educational practices towards more inclusive and sensitive approaches to individual differences (Figure 6).

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Comparative Reflections on the Acquisition of Language in Hearing and Deaf Children: A Case of Natural Learning of Mexican Sign Language - Juniper Publishers

Intellectual & Developmental Disabilities - Juniper Publishers

Abstract

Sign languages are visual and iconic languages used by Deaf communities worldwide. Sign language develops from the linguistic stimulus in the visuo-gestural modality, unlike hearing children who receive the stimulus in the auditory-vocal modality. This paper presents one case study in Mexico where deaf children naturally acquire Mexican Sign Language (LSM). Deaf children can access and develop sign language if the immediate context offers ways parallel to oral language development. Universal Grammar and biolinguistics support the natural process of the acquisition of languages.

Keywords: Deaf children; Mexican sign language; Hearing; Natural learning

Introduction

About the naturalness of language acquisition

Systematic and purposeful studies refer to sign language being linguistically equal to oral languages [1], with equal naturalness in its acquisition. Studies regarding language acquisition have achieved significant progress thanks to the antecedent of universal grammar [2], from now on, UG. The theory of Generative Grammar states that the child’s early language acquisition is a process of grammatical induction. It implies that the child has an innate capacity to develop her or his own linguistic experience from this language stimulation. Then, the child experiences the grammatical rules, and he or she must induce the grammatical inner to the Universal Grammar [3].

Understanding grammatical induction in the prelinguistic stage

Different approaches over the years have nourished children’s understanding of grammatical induction. The biggest problem to solve in the mid-70s was the need for a clear notion of how grammatical induction operated in children. At the end of the 70s, the deduction of the principles and parameters of the Universal Grammar model led to a radical reformulation of language acquisition and its development. This reformulation instils no specific rule for the child to induce and acquire language in early language acquisition because there is no specific language system for the child to internalise. In addition, as Khul [4], states neuroscience studies have demonstrated that the child induces grammatical rules in the language acquisition process.

Understanding the induction of grammatical rules according to each language

The principles and parameters considered the variability between languages in the first stage of the Universal Grammar model (UG). UG observed that those principles that followed a rule generated different results between different languages. Thus, this interlingual variation exists because these principles allow restricted variability between languages [5,6]. Under this conception, the particular grammar of a language is simply the UG but with the parameters arranged in a particular way according to each language. The particular arrangement of the parameters according to each language receives the name of the “Parametric Model”.

The Parametric Model impacted the field of comparative syntax as it established a theoretical language that allowed an understanding of the constants between the different languages. The Parametric Model facilitated the understanding of the ranges of variation between languages. Either the UG and Parametric Model framework is helpful to understand the objective of this article: Adding support that signs languages, like all languages, present variation and natural induction of their grammatical rules in the prelinguistic stage of the deaf child.

Prelinguistic development in hearing and deaf children

The prelinguistic stage considers the time between birth and when a person begins to use words or signs meaningfully. It is a time when children often increase their ability to communicate with others, first using eye gaze, paying attention, and socialemotional affection, and then adding gestures and other nonverbal means to communicate. This stage lays the foundation for the later development of skills such as using words (or signs) and their combination in sentences to communicate [7].

In this exact order of ideas, the parameters theory has had essential contributions to analysing the null subject in the first linguistic productions. The null subject is the omission of the subject pronoun [6,8,9], shed light on the variations in null subjects between some languages. Furthermore [8,9], studied the mechanism of language production in children early in various languages, including Spanish, English, and German. These authors did findings on null subjects. They observed that in the first productions, all languages allow the null subject even when the adult language no longer allows it.

For their part [10], proposed two hypotheses regarding the analysis of the Omitted Subject in the first children’s productions:
I. The first is the hypothesis of the parameters established in the early stage (Very Early Parameter Settings -VEPS). This hypothesis proposes that the basic parameters in a language are established correctly very early, that is, at observable ages around 18 months.
II. The second hypothesis consists of early knowledge of inflexion (Very Early Knowledge of Inflection -VEKI). This hypothesis implies that the child, in the earliest stage, knows the grammatical or phonological properties of many critical inflectional elements of his language. Based on the Royal Spanish Academy, inflexion is an elevation or attenuation done with the voice, breaking it or going from one tone to another. Meanwhile, in the specific field of grammar, an inflexion is an alteration of specific agents that implies a change in the root vowel or the ending to encode particular contents.

The theory of language development is closely related to VEPS and VEKI [10]. The VEPS theory is beneficial to show and confirm how the child correctly learns the values of the parameters before showing this learning in the production of it [6], in agreement with the VEPS theory, proposes that the child quickly sets the correct value of the null subject. If VEPS is correct, children cannot use negative information in their productions, so Hamburger and Wexler, based on Brown and Hanon [11], rule out “Negative Evidence in Language Acquisition”. Negative evidence would help eliminate ungrammatical constructions by revealing what is not grammatical. VEPS, VEKI and Negative Evidence in Language Acquisition shed light on the bio linguistical background supporting development in all languages’ prelinguistic.

A second impact of VEPS on learning is the nature of learning itself. That is, based on the child setting the parameter value correctly before the one-word stage, they know to set the parameter without guidance, as perceptual learning. According to VEPS theory, perceptual learning is the basis of linguistic parameter setting. Consequently, learning theory and the empirical properties of grammatical development converge on perceptual learning as the correct model of grammatical evolution.

Authors such as Rizzi [6], and Valian [9], support Wexler’s theory (1973-1998); however, the most critical support for the argumentative logic of this theory (VEPS AND VEKI) is the discovery of the Optional Infinitive (OI) stage in the development of Children’s grammar by Wexler [12]. The Optional Infinitives (OI) stage is when the child presents optional infinitives, showing a higher proportion of null subjects than of main verbs in the infinitive tense.

Summarising, the Optional Infinitives stage results from the maturation of Universal Linguistics. Then, the development interacts with the particular characteristics of each language. Examples of optional infinitive languages are Danish, German, English, French, and Irish, which are still under study. Italian, Spanish and Catalan are not Optional Infinitive languages [13-15]. In addition, the literature reports differences in the distribution of null subjects contingent on verbal inflexion between the different languages of null subjects. They frequently appear in a percentage of 70 to 95% of null subjects in non-finite verbs and 15 to 30% in infinitive verbs. Given this result, various theories [16].

Wexler [8] also names null subjects of final verbs as a type of pragmatic error. Languages like English sometimes omit certain types of topics. Regarding this phenomenon, Wexler and Chien [17], explained that some children’s productions in specific languages treat information that is not a substantial topic as a topic of great importance, so an important issue is consequently omitted. The authors comment (Chien & Wexler) [17], that this phenomenon is consistent with the general vision in which the child assumes that those who listen to him know more than they know now. For this reason, the child believes that some subjects that constitute vital topics should be omitted.

From the above, in some languages, the child presents a pragmatic error (natural and expected at his age) since he treats some topics that are not very dominant as if they were and, consequently, omits them. Languages like English sometimes need to catch certain types of cases. Wexler and Chien [17], concluded that in some languages, the child presents a pragmatic error (natural and expected at his age) since he treats some topics that are not very dominant as if they were and, consequently, omits them. As mentioned in the Theory of the Parameters of Universal Grammar by Chomsky [2], this phenomenon of the percentage of null subjects and the distribution of verbs seems to only occur in some languages since each language sets its respective parameters. Based on these findings, Wexler [8], demonstrated that the characteristics of null subjects changed depending on the language and concluded that null subjects are natural and expected in the Infant stage of Optional Infinitives. Regarding these findings, Wexler [8], demonstrated that the characteristics of null subjects changed depending on the language and concluded that null subjects are natural and expected in the Infant stage of Optional Infinitives. Rizzi [6], supporting Wexler’s [8], argument about the naturalness of null subjects in children’s productions, added that in early linguistic productions, children tend to omit null subjects even when the target language is not the subject.

Consequently, the omission of the subject in the first productions is a very stable and constant phenomenon in language development. Studying other languages confirmed the proposal for omitting the null subject.

On the other hand, Van Kampen pointed out that the child omits this topic from a very early age. In this regard, Wexler [8], showed that children miss topics more frequently than adults would expect. Likewise, he showed that German children present the characteristics of the Optional Infinitives stage and that they should produce final verbs in the last position. According to the parameters of the Universal Grammar, all these phenomena of the percentage of null subjects and the distribution of verbs seem to only occur in some languages since each language sets its respective parameters. Based on these findings, Wexler [8], demonstrated that the characteristics of null subjects changed depending on the language and concluded that null subjects are natural and expected in the Infant stage of Optional Infinitives.

Rizzi [6], supporting Wexler’s [8], argument about the naturalness of null subjects in children’s productions, added that in early linguistic shows, children tend to omit null subjects even when the target language is not the subject null. Consequently, the omission of the subject in the first productions is a very stable and constant phenomenon in language development—these conclusions about the stability and continuous phenomenon in all languages. It does not mean that there is no variability between languages.

Non-linguistic factors which impact language development

Recent cross-linguistic studies have revealed that there are background factors in the language production of each child. It can be biologically (internal) and environmentally (external) determined. Among many of them, the effects of gender, birth order and maternal/paternal education level have been particularly well studied [18]. This last study suggested lexical and world combination ability in children of two years varied significantly with gender but not with external factors. The authors concluded that internal factors might influence early language development more than external factors.

Biolinguistics for all languages

In all languages, some biolinguistic input is disposed of for language development. Everyone is born with the capacity to develop and learn a language. Language development is instinctive [19]. Biolinguistics is a theory that postulates the existence of an innate mental structure that allows the production and comprehension of any statement in any natural language, enabling the process of acquisition and spoken language. It requires very little linguistic input for proper functioning and develops practically automatically [20,21]. In the following provision, we expose the case of deaf children and their similar process to early language production.

What is the provision for early language production of deaf children?

Based on the results of the studies of Lillo-Martin and Henner [22], on the acquisition of word order in American Sign Language (ASL), Dutch Sign Language (NGT) and Brazilian Sign Language (Libras) are compatible with the theories and observations of spoken language acquisition, indicating that the basic canonical word order is typically observed as soon as words are combined and that, in general, children who acquire languages with variability in word order quickly develop operations that alter word order for various purposes of information structure grammatically [23].

We have exposed some comparative reflections of the prelinguistic stage of hearing and deaf children, finding that if a deaf child is exposed to sign language early, he shows at the same time the prelinguistic changes expected in oral languages. However, there are some differences in the prelinguistic acquisition of sign language, mainly due to the visogestural modality. It is discussed below.

Effects of the viso-gestural modality of sign language on prelinguistic development

As mentioned above, children can perceive and develop sign language in ways that are pretty parallel to spoken language development. However, it is also necessary to consider some modality effects. For example, the different physical development of the articulators for signing versus speech probably plays a role in the earlier first signs, as discussed above. No human being is born with a mental grammar of a particular language but can acquire any grammar of a natural language [5]. In our experience with deaf children in Mexico, they naturally acquire Mexican Sign Language (LSM) as sign language develops from the linguistic stimulus in the visuo-gestural modality; unlike hearing children, the stimulus is given in the auditory-vocal modality.

The iconicity of sign languages

Sign language is iconic, meaning it mostly remains on culture-associated codes. Iconicity allows sign languages to be universally understood since they are limited to concrete and pictorial concepts while developing several ideas simultaneously [24]. In the case of visogestural languages, signs are linguistic signs in which a visual image perceptible to the senses is present, associated with a mental image that, in turn, time is linked to the previous one. Therefore, linguistic signs in this language also distinguish between two planes. The first plane is the signifier, which consists of a visual kinesic image in the plane of expression associated with a mental idea. The second plane is the concept in the domain of meaning. In the LSM and other sign languages (Libra, .. LSC, etc.), lexical signs reproduce some aspect of the object or action they name. These signs are recognised as predominantly iconic signs [25].

Sign languages are natural languages developed in Deaf communities with the same linguistic status as spoken languages [26]. In Mexican Sign Language, the use of space by the signer is part of its grammar, the iconicity to acquire and express abstract concepts. One of the most used syntactic structures is the general form: Object-Subject-Verb (OSV). Mexican Sign Language (LSM) has different grammatical structures, as we present structures more frequently among all the disposed of ones. It is important to remark on the nature of Sign Language as a tridimensional language, allocated in the physical space and conform the messages from the most general ideas to the specific characters (Figure 1) (Table 1).

Next are the keys to trying the syntactic structure of LSM Time: When?
Place: Where?
Subject: Who?
Object Which?
Verb: What is the action or what happens/happened?
The subsequent provision is related to the one work developed in Mexico.

The learning of Mexican Sign Language (LSM) in children without linguistic development of LSM: One experience of natural learning in Mexico. The learning space for deaf users in the Central Library of the State of Hidalgo, “Ricardo Garibay,” has provided linguistic input in LSM to deaf children and their families. This program has benefited around fifty hearing families with a deaf member between 3 and 4 years old. For sixteen years, linguistic input has been offered in lexical, syntaxis and pragmatics approaches so children can develop the meanings using a grammar by themselves [27].

This experience is nationally unique, while the LSM is naturally and gradually acquired. Deaf Linguistics Models guide this learning, so the interaction from the interculturality encompasses all this learning of LSM.

One example of the activities in the learning room for deaf users can be appreciated in Figure 2. One common objective for families: Communication with their children. Families’ journey to communicate with their deaf children is often challenging and complex in Mexico. Families arrive at the learning space for deaf users at the “Sala de Silentes, Biblioteca Central del Estado de Hidalgo Ricardo Garibay”, usually because they are looking forward to supporting the writing learning process of their deaf children. They did not find this support in the health institutions as they adopted a view from the rehabilitative medical approach, likewise “a solution to deafness”. Health Institutions have some responsibilities in this one-part view as they frequently recommend not bringing deaf children near the signs. With this last information in mind, families hope to find a place that rehabilitates in orality.

From the above background, when families arrive at this learning room, they suppose deaf children will receive speaking tutoring. After a few weeks, they are usually disappointed and quit [28,29]. Like oral languages, they expect their children, when using hearing aids, to develop oral language. It is frequently that deaf people are deprived of their natural language in the first years of life.

Why does the learning room support learning in the community?

Learning in the community facilitates acquiring the LSM more naturally and fluidly. The learning room for deaf users favours a coexistence between equals (deaf-deaf) at an early age. A group of deaf people grow up together, sharing experiences, friendships and signs. In the same learning room, there is a common bond among children, young and Deaf adults who are linguistic models of the LSM. This friendship among equals builds an identity as Deaf users of the Mexican Sign Language. They identify with LSM and increase their confidence to express themselves visuallygesturally daily [30,31]. This gradual acquisition process of LSM, while they express heartfelt admiration for deaf youth and adults who master LSM. They also express positive emotions about going to the service. Although they do not have mastery of the lexical signatures of the LSM, spontaneous configurations arise to express their ideas as they appropriate their language.

Back and forward in LSM learning

There is one problem in the persistence of acquiring LSM. A couple of months after having begun the interacción in the learning group, it is common for families to quit. They usually return with their deaf children after a few years. However, children have lost precious early years to access comprehension and language. Although they begin later with this approach to the LSM, there are evident differences in the proficiency of the language: Deaf children who acquire it at an earlier age reach a higher speed of the signs and comprehension of messages than children who access discontinuous LSM learning.

Conclusion

Sign languages are complete and integral languages as oral ones. Prelinguistic acquisition of deaf children is through the visual channel. Sign languages are visual languages and allow deaf children to access them naturally. Deaf children must be immersed early, simultaneously with their deaf counterparts. The theory of the Parameters of Universal Grammar by Chomsky [2], sheds light on how each language sets its parameters. In addition, some languages allow pragmatic error while children of early age frequently omit subjects.

In all languages, some biolinguistic input is disposed of for language development. Everyone is born with the capacity to develop and learn a language. Language development is instinctive [19], while linguistic input allows deaf children to develop comprehension and sign language as hearing children develop oral language. The opportune stimulation of language allows the development of this faculty at an early age. It enables children to produce spontaneously and recognise the grammatical rules of any language they were exposed to, whether oral or visual.

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An Evidence Based Review of Vitamin D in COVID-19 Severity and Mortality - Juniper Publishers

 Complementary Medicine & Alternative Healthcare - Juniper Publishers

Abstract

Introduction: This evidence-based review aims to explore the association between vitamin D status and the severity and mortality of COVID-19, providing insights for healthcare professionals and policymakers in managing the disease.

Methods: A systematic review process was conducted to identify relevant studies on vitamin D and COVID-19 using electronic databases and specific search terms. Thirteen studies were selected and analyzed, including quantitative research at levels III, IV, and V.

Results: The analysis revealed a significant association between vitamin D deficiency and increased severity and mortality of COVID-19. Vitamin D levels were found to be inversely related to the severity of the disease, with deficiency acting as an independent predictor of COVID-19-related mortality. Studies demonstrated a higher prevalence of vitamin D deficiency among hospitalized COVID-19 patients. Bolus doses of vitamin D supplementation were associated with improved clinical outcomes and lower mortality rates in COVID-19 patients.

Conclusion: The evidence suggests that maintaining adequate vitamin D levels may have a protective effect against the severity and mortality of COVID-19. Vitamin D supplementation, in combination with safe sun exposure education, could be a cost-effective and safe measure to mitigate the impact of the SARS-CoV-2 pandemic. However, further interventional studies are needed to evaluate the efficacy and optimal dosing regimens of vitamin D supplementation in COVID-19 patients.

Keywords: COVID-19; SARS-CoV-2; vitamin D; Severity; Mortality; Supplementation; Evidence-based practice

Introduction

Coronavirus disease 2019 (COVID-19), declared a global pandemic by the World Health Organization (WHO), presents a significant challenge to healthcare systems worldwide (WHO, 2020) [1]. In January 2022, COVID-19 ranked among the top four leading causes of death for all age groups, with older adults being particularly vulnerable [2]. Hospitalizations and mortality rates are significantly higher in adults over 65 years of age compared to those under 65 [3,4].

Between January 2020 and July 2022, there were over 562 million confirmed cases of COVID-19, resulting in approximately 6.3 million deaths worldwide (WHO, 2022). The economic impact of COVID-19 is staggering, estimated at over $16 trillion, which accounts for approximately 90% of the annual gross domestic product (GDP) of the United States [5].

Vitamin D, a hormone produced by both the kidneys and the skin, plays a crucial role in regulating blood calcium concentration and impacting the immune system. It is known by various names, including calcitriol, ergocalciferol, calcidiol, and cholecalciferol.

The two widely available pharmacologic preparations are cholecalciferol (D3) and ergocalciferol (D2). More recently, vitamin D has shown antiviral effects and plays a crucial role in the immune system [6-8]. It is being investigated for its potential in mitigating infections, enhancing immune responses, and suppressing the cytokine storm [9-11] Comparatively, vitamin D deficiency has been linked to increased susceptibility to viral infections. Research has not demonstrated a strong association between vitamin D levels and the prevention of COVID-19 infection [12-15]. However, there is a growing interest in exploring the potential role of vitamin D in relation to the severity of COVID-19 disease.

At the time of submission, COVID-19 has tragically resulted in the loss of over 6 million lives globally (WHO, 2022). Despite this significant impact, there remains limited knowledge about potential protective factors against the disease. Notably, advanced age and underlying chronic medical conditions, especially chronic pulmonary and cardiac diseases, have emerged as prominent predisposing factors for severe COVID-19 development and subsequent mortality [16,17]. This comprehensive literature appraisal aims to investigate potential associations between vitamin D status and disease severity and survival in COVID-19 patients. By analyzing the available evidence, this analysis provides a recommendation while considering the balance of benefit, harm, and cost.

Methods

This systematic review, conducted in collaboration with a faculty advisor and university librarian, examines the relationship between vitamin D and COVID-19, focusing on severity and mortality outcomes. The review process involved comprehensive searches of electronic databases, including PubMed, using key terms such as Vitamin D, Vitamin D Level, Vitamin D Deficiency, Covid, Covid-19, and Coronavirus. Inclusion criteria were limited to English-language articles published between 2020 and 2022, and excluded research proposals and protocols. A total of 20 articles were retrieved, and after reviewing the title and abstracts, 13 relevant studies were selected for appraisal using the Johns Hopkins Appraisal Tool. The levels of evidence were graded using Johns Hopkins Level of Evidence table. This review is comprised of 11 non experimental level III research articles, the highest level of evidence available to date.

Literature Review

Vitamin D levels have been found to be notably depleted among the aging population, a group that exhibits heightened vulnerability to COVID-19 [15]. Further evidence highlights the prevalence of vitamin D deficiency among hospitalized COVID-19 patients, with 59% of admitted individuals presenting vitamin D insufficiency. Vitamin Ds deficiency upon admission has demonstrated a significant association with COVID-19 severity and mortality, even after adjusting for factors such as age, gender, and comorbidity.

There is possibly a blood level dependent association between vitamin D level and COVID-19 severity. A retrospective multicentric study of 212 patients [7] found that critical COVID-19 cases had the lowest levels of vitamin D, whereas mild cases had the highest levels. Similarly, found similar results when stratifying COVID-19 patients by vitamin D level. There were two additional studies conducted by that reported weaker correlations between vitamin D levels and COVID-19 cases and mortality. Finally, there is a small body of evidence supporting the use of bolus doses of vitamin D3 supplementation administered during or shortly before the onset of COVID-19 (2020) [9] and Karahan and Katkat (2021) [5] both demonstrated a lower incidence of COVID-19 infection and improvement in COVID-19 severity with bolus dosed vitamin D.

There were a few studies that failed to demonstrate a positive effect of vitamin D on COVID-19. These studies were small, completed on a younger and healthier population, and primarily studied the relationship between vitamin D level and COVID-19 infection rates, but did not study the correlation between the vitamin D level and COVID-19 severity or mortality (Table 1).

Discussion

In response to the profound burden imposed by the COVID-19 pandemic and the potential for mitigating severe disease outcomes through the exploration of protective factors, numerous researchers have established a compelling association between vitamin D deficiency and the severity of COVID-19 [18-21]. While research has failed to demonstrate that Vitamin D prevents Covid-19 infection, there is a moderate amount of research establishing that optimal vitamin D levels are associated with less severe cases of COVID-19 and conversely, low vitamin D levels have been associated with more severe cases. Furthermore, bolus dosing Vitamin D3 may provide some protection in the severity of the infection, particularly in populations at risk [22,23].

Implications for Practice

Nurse practitioners manage patients in primary care who are at risk of COVID-19. Staying up to date with the current evidence is crucial in supporting clinical practice. The evidence appraised in this review are all non-experimental research. Observational and cohort studies provide valuable insights into potential associations, and the majority of the reviewed studies indicate a positive correlation between vitamin D levels and COVID-19 outcomes. Moreover, vitamin D supplementation is generally considered safe when administered within the recommended dosage range. Although further experimental research is needed to establish a causal relationship, considering the low risk profile of vitamin D supplementation, it is the recommendation of the authors that nurse practitioners consider prescribing Vitamin D supplementation to improve the severity of COVID-19 infections and that blood levels should be monitored to achieve optimal circulating levels ranging from 75 to 100 nmol/L. As healthcare leaders, nurse practitioners have the responsibility to actively seek opportunities to educate both patients and colleagues. By doing so, we can drive practice change and promote the adoption of evidence-based approaches. Disseminating evidence-based practices is vital in improving patient outcomes and ultimately enhancing the overall quality of care.

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