active aging - a policy framework
TRANSCRIPT
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ACTIVEAGEING:APOLICYFRAMEWORK
WHO/NMH/NPH/02.8
DISTR.:GENERALORIG.:ENGLISH
ActiveAgeingAPolicyFramework
WorldHealthOrganization
NoncommunicableDiseasesandMentalHealthCluster
NoncommunicableDiseasePreventionandHealthPromotionDepartment
AgeingandLifeCourse
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PAGE2
ThisPolicyFrameworkisintendedtoinform
discussionandtheformulationofactionplans
thatpromotehealthyandactiveageing.Itwas
developedbyWHOsAgeingandLifeCourse
ProgrammeasacontributiontotheSecond
UnitedNationsWorldAssemblyonAgeing,
heldinApril2002,inMadrid,Spain.The
preliminaryversion,publishedin2001entitled
HealthandAgeing:ADiscussionPaper,was
translatedintoFrenchandSpanishandwidely
circulatedforfeedbackthroughout2001
(includingatspecialworkshopsheldinBrazil,
Canada,theNetherlands,SpainandtheUnited
Kingdom).InJanuary2002,anexpertgroup
meetingwasconvenedattheWHOCentrefor
HealthDevelopment(WKC)inKobe ,Japan,
with29participantsfrom21countries.De-
tailedcommentsandrecommendationsfrom
thismeeting,aswellasthosereceivedthrough
thepreviousconsultationprocess,werecom-
piledtocompletethisfinalversion.
Acomplementarymonographentitled
ActiveAgeing:From EvidencetoActionis
beingpreparedincollaborationwiththeInter-
nationalAssociationofGerontology(IAG)and
willbeavailableathttp://www.who.int/hpr/
ageingwheremoreinformationaboutageing
fromalifecourseperspectiveisalsoprovided.
AcontributionoftheWorldHealthOrganizationtothe
SecondUnitedNationsWorldAssemblyonAgeing,
Madrid, Spain,April 2002.
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ACTIVEAGEING:APOLICYFRAMEWORK
Contents
Intro duction 5
1 . Global Ageing: A Tr iumph and a Challen ge 6
TheDemographicRevolution 6
RapidPopulationAgeinginDevelopingCountries 9
2. Active Ageing: The Con cept and Rationale 1 2
WhatisActiveAgeing? 12
ALifeCourseApproachtoActiveAgeing 14
ActiveAgeingPoliciesandProgrammes 16
3. The Deter min ants of Active Ageing: Under standing the Evidence 1 9
Cross-CuttingDeterminants:CultureandGender 20
DeterminantsRelatedtoHealthandSocialServiceSystems 21
BehaviouralDeterminants 22
DeterminantsRelatedtoPersonalFactors 26
DeterminantsRelatedtothePhysicalEnvironment 27
DeterminantsRelatedtotheSocialEnvironment 28
EconomicDeterminants 30
4. Challen ges of an Ageing Population 33
Challenge1:TheDoub leBurdenofDisease 33
Challenge2:IncreasedRiskofDisability 34
Challenge3:ProvidingCareforAgeingPopulations 37
Challenge4:TheFeminizationofAgeing 39
Challenge5:EthicsandInequities 40
Challenge6:TheEconomicsofanAgeingPopulation 42
Challenge7:ForgingaNewParadigm 43
5. The Policy Respon se 45IntersectoralAction 46
KeyPolicyProposals 46
1.Health 47
2.Participation 51
3.Security 52
WHOandAgeing 54
InternationalCollaboration 55
Conclusion 55
6. Referen ces 57
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PAGE4
Thisbooklet usestheUn itedNationsstandardofage 60todescribe olderpeop le.Thismayseemyounginthedevelopedworldand inthosedevelop ing countrieswheremajorgainsinlifeexpectancyhave alreadyoccurred .However,whateverage isused with indifferentcon-texts,itisimportant to acknowledgethatchronolog icalage isnotaprec isemarkerforthechangesthataccompanyage ing .Therearedramaticvariationsinhealth status,participation and levelsofindependenceamongolderpeopleofthesame age .Decision-makersneedto taketh isintoaccountwhendesign ing po liciesand programmesfortheirolderpopulations.Enact ing broadsocialpo liciesbased on chronolog icalage alonecanbe discriminatoryand counterproductive to we llbe ing inolderage .
HowOldisOlder?
Thehandsyouseeinthebackgrounddesignofthispaperarecelebratingtheworldwide
triumphofpopulationageing.Ifyoufanthepagesquickly,youwillseethemapplaudingthe
importantcontributionthatolderpeoplemaketooursocieties,aswellasthecriticalgainsin
publichealthandstandardsoflivingthathaveallowedpeopletolivelongerinalmostallparts
oftheworld.
ThistextandthepreliminaryversionofthepaperweredraftedbyPeggyEdwards,aHealth
CanadaconsultantbasedforsixmonthsatWHO,undertheguidanceofWHOsAgeingandLife
CourseProgramme.ThesupportfromHealthCanadaatallphasesoftheprojectisgratefully
acknowledged.
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ACTIVEAGEING:APOLICYFRAMEWORK
Introduction
Populationageingraisesmanyfundamental
questionsforpolicy-makers.Howdowehelp
peopleremainindependentandactiveasthey
age?Howcanwestrengthenhealthpromo-
tionandpreventionpolicies,especiallythose
directedtoolderpeople?Aspeopleareliving
longer,howcanthequalityoflifeinoldage
beimproved?Willlargenumbersofolder
peoplebankruptourhealthcareandsocial
securitysystems?Howdowebestbalancethe
roleofthefamilyandthestatewhenitcomes
tocaringforpeoplewhoneedassistance,as
theygrowolder?Howdoweacknowledge
andsupportthemajorrolethatpeopleplayas
theyageincaringforothers?
Thispaperisdesignedtoaddresstheseques-
tionsandotherconcernsaboutpopulation
ageing.Ittargetsgovernmentdecision-mak-
ersatalllevels,thenongovernmentalsec-
torandtheprivatesector,allofwhomare
responsiblefortheformulationofpoliciesand
programmesonageing.Itapproacheshealth
fromabroadperspectiveandacknowledges
thefactthathealthcanonlybecreatedand
sustainedthroughtheparticipationofmultiple
sectors.Itsuggeststhathealthprovidersand
professionalsmusttakealeadifweareto
achievethegoalthathealthyolderpersonsre-
mainaresourcetotheirfamilies, communities
andeconomies,asstatedintheWHOBrasilia
DeclarationonAgeingandHealthin1996.
Part1describestherapidworldwide
growthofthepopulationoverage60,espe-
ciallyindevelopingcountries.
Part2explorestheconceptandrationale
foractiveageingasagoalforpolicyand
programmeformulation.
Part3summarizestheevidenceabout
thefactorsthatdeterminewhetherornot
individualsandpopulationswillenjoya
positivequalityoflifeastheyage.
Part4discussessevenkeychallengesas-
sociatedwithanageingpopulationforgov-
ernments,thenongovernmental,academicandprivatesectors.
Part5providesapolicyframeworkfor
activeageingandconcretesuggestionsfor
keypolicyproposals.Theseareintended
toserveasabaselineforthedevelopment
ofmorespecificactionstepsatregional,
nationalandlocallevelsinkeepingwith
theactionplanadoptedbythe2002Second
UnitedNationsWorldAssemblyonAgeing.
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1.GlobalAgeing:ATriumphandaChallenge
Populationageingisoneofhumanitys
greatesttriumphs.Itisalsooneofourgreat-
estchallenges.Asweenterthe21stcentury,
globalageingwillputincreasedeconomic
andsocialdemandsonallcountries.Atthe
sametime,olderpeopleareaprecious,often-
ignoredresourcethatmakesanimportant
contributiontothefabricofoursocieties.
TheWorldHealthOrganizationarguesthat
countriescanaffordtogetoldifgovernments,
internationalorganizationsandcivilsociety
enactactiveageingpoliciesandprogrammes
thatenhancethehealth,participationand
securityofoldercitizens.Thetimetoplanand
toactisnow.
In all countries, and in developing
countries in particular, measures to
help older people remain healthy
and active are a necessity, not a
luxury.
Thesepoliciesandprogrammesshou ldbe
basedontherights,needs,preferencesand
capacitiesofolderpeople.Theyalsoneedto
embracealifecourseperspectivethatrecog-
nizestheimportantinfluenceofearlierlife
experiencesonthewayindividualsage.
The Demograph ic Revolution
Worldwide,theproportionofpeopleage
60andoverisgrowingfasterthananyother
agegroup.Between1970and2025,agrowth
inolderpersonsofsome694millionor
223percentisexpected.In2025,therewillbe
atotalofabout1.2billionpeopleovertheage
of60.By2050therewillbe2billionwith
80percentofthemlivingindeveloping
countries.
Agecompositionthatis,theproportionate
numbersofchildren,youngadults,middle-
agedadultsandolderadultsinanygiven
countryisanimportantelementforpolicy-
makerstotakeintoaccount.Population
ageingreferstoadeclineintheproportionof
childrenandyoungpeopleandanincrease
intheproportionofpeopleage60andover.
Aspopulationsage,thetriangularpopulation
pyramidof2002willbereplacedwithamore
cylinder-likestructurein2025(seeFigure1).
Populationageingisfirstandforemostasuccessstoryforpublichealthpolicies
aswellassocialandeconomicdevelopment.
GroHarlemBrundtland,Director-General,WorldHealthOrganization,1999
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ACTIVEAGEING:APOLICYFRAMEWORK
Decreasingfertilityratesandincreasing
longevitywillensurethecontinuedgreying
oftheworldspopulation,despitesetbacks
inlifeexpectancyinsomeAfricancountries
(duetoAIDS)andinsomenewlyindepen-
dentstates(duetoincreaseddeathscaused
bycardiovasculardiseaseandviolence).Sharp
decreasesinfertilityratesarebeingobserved
throughouttheworld.Itisestimatedthatby
2025,120countrieswillhavereachedtotal
fertilityratesbelowreplacementlevel(aver-
agefertilityrateof2.1childrenperwoman),a
substantialincreasecomparedto1975,when
just22countrieshadatotalfertilityratebelow
orequaltothereplacementlevel.Thecurrent
figureis70countries.
Untilnow,populationageinghasbeenmostly
associatedwiththemoredevelopedregions
oftheworld.Forexample,currentlynineof
thetencountrieswithmorethantenmillion
inhabitantsandthelargestproportionofolder
peopleareinEurope(seeTable1).Little
changeintherankingisexpectedby2025
whenpeopleage60andoverwillmakeup
aboutone-thirdofthepopulationincountries
likeJapan,GermanyandItaly,closelyfol-
lowedbyotherEuropeancountries
(seeTable1).
Astheproportionofchildrenandyoungpeopledeclinesandtheproportionofpeopleage60andoverincreases,thetriangularpopulationpyramidof2002willbereplacedwithamorecylinder-likestructurein2025.
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Table1.Countrieswithmorethan10millioninhabitants(in2002)withthehighestproportionofpersonsaboveage60
2002 2025
Ita ly 24 .5% Japan 35.1%
Japan 24.3% Ita ly 34 .0%
Germany 24.0% Germany 33.2%
Greece 23 .9% Greece 31 .6%
Be lg iu m 22.3% Spain 31 .4%
Spain 22 .1% Belg ium 31.2%
Portuga l 21 .1% Un ite dKing do m 29.4%
Un ite dKin gd om 20.8% Netherlands 29 .4%
Ukraine 20.7% France 28 .7%
France 20 .5% Canada 27.9%
Source:UN,2001
Whatislessknownisthespeedandsignifi-
canceofpopulationageinginlessdeveloped
regions.Already,mostolderpeoplearound
70percentliveindevelopingcountries(see
Table2).Thesenumberswillcontinuetorise
atarapidpace.
Table2.Absolutenumbersofpersons(inmillions)above60yearsofageincountrieswithatotalpopulationapproachingorabove100millioninhabitants(in2002)
2002 2025
Ch ina 134.2 China 287.5
Ind ia 81 .0 Ind ia 168.5
UnitedStatesofAmerica 46 .9 Un itedStatesofAmerica 86 .1
Japan 31.0 Japan 43.5
RussianFederat ion 26.2 Indonesia 35 .0
Indonesia 17 .1 Brazil 33 .4
Brazil 14 .1 RussianFederation 32.7
Pak istan 8.6 Pakistan 18.3
Mexico 7.3 Bang ladesh 17 .7
Bang lad esh 7.2 Mexico 17 .6
Niger ia 5.7 N iger ia 11 .4Source:UN,2001
Inallcountries,especiallyindevelopedones,
theolderpopulationitselfisalsoageing.
Peopleovertheageof80currentlynumber
some69million,themajorityofwhomlive
inmoredevelopedregions.Althoughpeople
overtheageof80makeupaboutonepercent
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ACTIVEAGEING:APOLICYFRAMEWORK
oftheworldspopulationandthreepercentof
thepopulationindevelopedregions,thisage
groupisthefastestgrowingsegmentofthe
olderpopulation.
Inbothdevelopedanddevelopingcountries,
theageingofthepopulationraisesconcerns
aboutwhetherornotashrinkinglabour
forcewillbeabletosupportthatpartofthe
populationwhoarecommonlybelievedtobe
dependentonothers(i.e.,childrenandolder
people).
Theold-agedependencyratio(i.e.,thetotal
populationage60andoverdividedbythe
populationage15to60seeTable3)ispri-
marilyusedbyeconomistsandactuarieswho
forecastthefinancialimplicationsofpension
policies.However,itisalsousefulforthose
concernedwiththemanagementandplanning
ofcaringservices.
Old-agedependencyratiosare
changingquicklythroughoutthe
world.InJapanforexample,there
are currently39peopleover
age 60forevery100intheage
group1560.In2025thisnumber
willincreaseto66.
However,mostoftheolderpeopleinall
countriescontinuetobeavitalresourceto
theirfamiliesandcommunities.Manycon-
tinuetoworkinboththeformalandinfor-
mallaboursectors.Thus,asanindicatorfor
forecastingpopulationneeds,thedependency
ratioisoflimiteduse.Moresophisticated
indicesareneededtomoreaccuratelyreflect
dependency,ratherthanfalselycategorizing
individualsthatcontinuetobefullyableand
independent.
Atthesametime,activeageingpoliciesand
programmesareneededtoenablepeopleto
continuetoworkaccordingtotheircapaci-
tiesandpreferencesastheygrowolder,and
topreventordelaydisabilitiesandchronic
diseasesthatarecostlytoindividuals,families
andthehealthcaresystem.Thisisdiscussed
furtherinthesectiononwork(page31)and
inChallenge2:IncreasedRiskofDisability
(page34)andChallenge6:theEconomicsof
anAgeingPopulation(page42).
Table3.Oldagedependencyratioforselectedcountries/regions
2002 2025
Japan 0.39 Japan 0.66
NorthAmerica 0.26 NorthAmerica 0.44
European
Un ion
0.36 Euro pea n
Un ion
0.56
Source:UN,2001
Rapid Population Ageing in
Develop ing Countries
In2002,almost400millionpeopleaged60
andoverlivedinthedevelopingworld.By
2025,thiswillhaveincreasedtoapproximately
840millionrepresenting70percentofallolder
peopleworldwide.(seeFigure2).Intermsof
regions,overhalfoftheworldsolderpeople
liveinAsia.Asiasshareoftheworldsold-
estpeoplewillcontinuetoincreasethemost
whileEuropesshareasaproportionofthe
globalolderpopulationwilldecreasethemost
overthenexttwodecades(seeFigure3).
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ACTIVEAGEING:APOLICYFRAMEWORK
Comparedtothedevelopedworld,socio-
economicdevelopmentindevelopingcoun-
trieshasoftennotkeptpacewiththerapid
speedofpopulationageing.Forexample,
whileittook115yearsfortheproportionof
olderpeopleinFrancetodoublefrom7to
14percent,itwilltakeChinaonly27years
toachievethesameincrease.Inmostofthe
developedworld,populationageingwasa
gradualprocessfollowingsteadysocio-eco-
nomicgrowthoverseveraldecadesandgener-
ations.Indevelopingcountries,theprocessis
beingcompressedintotwoorthreedecades.
Thus,whiledevelopedcountriesgrewaffluent
beforetheybecameold,developingcountries
aregettingoldbeforeasubstantialincreasein
wealthoccurs(KalacheandKeller,2000).
Rapidageingindevelopingcountriesis
accompaniedbydramaticchangesinfam-
ilystructuresandroles,aswellasinlabour
patternsandmigration.Urbanization,the
migrationofyoungpeopletocitiesinsearch
ofjobs,smallerfamiliesandmorewomen
enteringtheformalworkforcemeanthatfewer
peopleareavailabletocareforolderpeople
whentheyneedassistance.
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2.ActiveAgeing:TheConceptandRationale
Ifageingistobeapositiveexperience,
longerlifemustbeaccompaniedbycontinu-
ingopportunitiesforhealth,participationand
security.TheWorldHealthOrganizationhas
adoptedthetermactiveageingtoexpress
theprocessforachievingthisvision.
What is Active Agein g?
Activeageingistheprocessof
optimizingopportunitiesforhealth,
participationandsecurityinorder
toenhancequalityoflifeaspeople
age.
Activeageingappliestobothindividualsand
populationgroups.Itallowspeopletorealize
theirpotentialforphysical,social,andmental
wellbeingthroughoutthelifecourseandto
participateinsocietyaccordingtotheirneeds,
desiresandcapacities,whileprovidingthem
withadequateprotection,securityandcare
whentheyrequireassistance.
Thewordactivereferstocontinuingpartici-
pationinsocial,economic,cultural,spiritual
andcivicaffairs,notjusttheabilitytobe
physicallyactiveortoparticipateinthelabour
force.Olderpeoplewhoretirefromwork
andthosewhoareillorlivewithdisabilities
canremainactivecontributorstotheirfami-
lies,peers,communitiesandnations.Active
ageingaimstoextendhealthylifeexpectancy
andqualityoflifeforallpeopleastheyage,
includingthosewhoarefrail,disabledandin
needofcare.
Healthreferstophysical,mentalandsocial
wellbeingasexpressedintheWHOdefinition
ofhealth.Thus,inanactiveageingframe-
work,policiesandprogrammesthatpromote
mentalhealthandsocialconnectionsare
asimportantasthosethatimprovephysical
healthstatus.
Maintainingautonomyandindependenceas
onegrowsolderisakeygoalforbothindi-
vidualsandpolicymakers(seeboxondefini-
tions).Moreover,ageingtakesplacewithin
thecontextofothersfriends,workassoci-
ates,neighboursandfamilymembers.Thisis
whyinterdependenceaswellasintergenera-
tionalsolidarity(two-waygivingandreceiv-
ingbetweenindividualsaswellasolderand
youngergenerations)areimportanttenetsof
activeageing.Yesterdayschildistodaysadult
andtomorrowsgrandmotherorgrandfather.
Thequalityoflifetheywillenjoyasgrandpar-
entsdependsontherisksandopportunities
theyexperiencedthroughoutthelifecourse,
aswellasthemannerinwhichsucceeding
generationsprovidemutualaidandsupport
whenneeded.
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ACTIVEAGEING:APOLICYFRAMEWORK
Somekeydefinitions
Autonomyistheperceivedab il ityto contro l,
co p ew ithan dmakep ersonaldecisionsaboutho wonelivesonaday-to -day basis,accord ingto oneso wnru lesan dprefer-ences.
Independenceiscommon lyunderstoodastheab il ityto p er for mfunctionsre latedtodailylivingi.e.thecapacityoflivingindependentlyinthecommun ityw ithnoand/orli tt lehelpfro mothers.
Qualityoflifeis anind ivid ualsperceptionofh isorherpositioninlifeinthecontextofthecultureandva luesyste mwheretheylive ,an dinre lat ionto theirgoals,expecta -tions,standardsandconcerns. Itisabroadrangingconcept,incorporatin ginaco m-p lexway apersonsp hysicalhealth,psycho log icalstate,leve lofindependence,social
re lat ionsh ips,p ersonalb eliefsandre lat ionsh iptosalientfeaturesintheenvironment.(WH O,1994).Aspeop leage,theirquali tyoflifeislargelydeterm inedbytheirab il ity to mainta inautonomyan dindependence.
Healthylifeexpectancyiscommon lyusedasasynonymfor d isab ili ty-fre elifeexpec-ta ncy.Whilelifeexpecta ncyat b irt hremainsanimportantmeasureofp o p ulat ionageing,howlongpeop lecanexpecttolivew ithoutd isab il itiesisesp eciallyimportant toanageingp o p ulat ion.
Withtheexce ptionofautonomywh ichisnotoriouslyd ifficultto measure,alloftheaboveconce ptshavebeenelaboratedbyattemptstomeasurethedegreeofd if-ficu ltyano ld erp ersonhasinp er for m ingactivitiesre latedto dailyliving (ADLs) andinstrumentalactivitiesofdailyliving (IA DLs).ADLsinclude,forexample,bath ing,eat ing,usingtheto iletandwalkingacrosstheroom . IA DLsincludeactivitiessuchasshop-p in g,houseworkandmealpreparation.Recently,anumberofva lidated,moreho listicmeasuresofhealth-re latedqualityoflifehavebeendevelo p e d.Th eseind icesneedtobesharedandadaptedforuseinavarietyofculturesandsett ings.
Thetermactiveageingwasadoptedbythe
WorldHealthOrganizationinthelate1990s.It
ismeanttoconveyamoreinclusivemessage
thanhealthyageingandtorecognizethefac-
torsinadditiontohealthcarethataffecthow
individualsandpopulationsage(Kalacheand
Kickbusch,1997).
Theactiveageingapproachisbasedonthe
recognitionofthehumanrightsofolder
peopleandtheUnitedNationsPrinciplesof
independence,participation,dignity,careand
self-fulfillment.Itshiftsstrategicplanningaway
fromaneeds-basedapproach(whichas-
sumesthatolderpeoplearepassivetargets)to
arights-basedapproachthatrecognizesthe
rightsofpeopletoequalityofopportunityand
treatmentinallaspectsoflifeastheygrow
older.Itsupportstheirresponsibilitytoexer-
cisetheirparticipationinthepoliticalprocess
andotheraspectsofcommunitylife.
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A Life Course Appr oach to Active
Agein g
Alifecourseperspectiveonageingrecognizes
thatolderpeoplearenotonehomogeneous
groupandthatindividualdiversitytendsto
increasewithage.Interventionsthatcreate
supportiveenvironmentsandfosterhealthy
choicesareimportantatallstagesoflife(see
Figure4).
Asindividualsage,noncommunicablediseases
(NCDs)becometheleadingcausesofmorbid-
ity,disabilityandmortalityinallregionsof
theworld,includingindevelopingcountries,
asshowninFigures5and6.NCDs,which
areessentiallydiseasesoflaterlife,arecostly
toindividuals,familiesandthepublicpurse.
ButmanyNCDsarepreventableorcanbe
postponed.Failingtopreventormanagethe
growthofNCDsappropriatelywillresultin
enormoushumanandsocialcoststhatwillab-
sorbadisproportionateamountofresources,
whichcouldhavebeenusedtoaddressthe
healthproblemsofotheragegroups.
*Changesintheenvironmentcanlowerthedisabilitythreshold, thusdecreasingthenumberofdisabledpeopleinagivencom-munity.
Functionalcapacity(suchasventilatorycapacity,muscularstrength, andcardiovascularoutput)increasesinchildhoodandpeaksinearlyadulthood, eventuallyfollowedbyadecline.Therateofdecline,however, islargelydeterminedbyfactorsrelatedtoadultlifestylesuchassmoking, alcoholconsumption, levelsofphysicalactivityanddietaswellasexternalandenvironmen-talfactors.Thegradientofdeclinemaybecomesosteepastoresultinprematuredisability.However, theaccelerationindeclinecanbeinfluencedandmaybereversibleatanyagethroughindividualandpublicpolicymeasures.
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ACTIVEAGEING:APOLICYFRAMEWORK
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Majorchronicconditionsaffectingolderpeopleworldwide Cardiovascu lard iseases
(suchascoronaryheartd isease)
Hypertension
Stroke
D iabetes
Ca ncer
Chronicobstructivep ulmonaryd isease
Muscu loske leta lcond itions(suchasarthritisan dosteoporosis)
Mentalhealthcond itions(mostlydement iaan ddepression)
Blindnessandvisualim pairment
Note:Thecausesofdisabilityinolderagearesimilarforwomenandmenalthoughwomenaremorelikelytoreportmusculoskeletalproblems.
Source:WHO,1998a
Intheearlyyears,communicablediseases,
maternalandperinatalcond itionsandnu-
tritionaldeficienciesarethemajorcausesof
deathanddisease.Inlaterchildhood,ado-
lescenceandyoungadulthood,injuriesand
noncommunicablecond itionsbegintoassume
amuchgreaterrole.Bymidlife(age45)and
inthelateryears,NCDsareresponsiblefor
thevastmajorityofdeathsanddiseases(see
Figures5and6).Researchisincreasingly
showingthattheoriginsofriskforchronic
cond itions,suchasdiabetesandheartdisease,
begininearlychildhoodorevenearlier.This
riskissubsequentlyshapedandmodifiedby
factors,suchassocio-economicstatusand
experiencesacrossthewholelifespan.The
riskofdevelopingNCDscontinuestoincrease
asindividualsage.Butitistobaccouse,lack
ofphysicalactivity,inadequatedietandother
establishedadultriskfactorswhichwillput
individualsatrelativelygreaterriskofdevelop-
ingNCDsatolderages(seeFigure7).Thus,
itisimportanttoaddresstherisksofnoncom-
municablediseasefromearlylifetolatelife,
i.e.throughoutthelifecourse.
Activ e Agein g Policies an dProgrammes
Anactiveageingapproachtopolicyand
programmedevelopmenthasthepotentialto
addressmanyofthechallengesofbothindi-
vidualandpopulationageing.Whenhealth,
labourmarket,employment,educationand
socialpoliciessupportactiveageingtherewill
potentiallybe:
fewerprematuredeathsinthehighlypro-
ductivestagesoflife
fewerdisabilitiesassociatedwithchronic
diseasesinolderage
morepeopleenjoyingapositivequalityof
lifeastheygrowolder
morepeopleparticipatingactivelyasthey
ageinthesocial,cultural,economicand
politicalaspectsofsociety,inpaidand
unpaidrolesandindomestic,familyand
communitylife
lowercostsrelatedtomedicaltreatment
andcareservices.
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ACTIVEAGEING:APOLICYFRAMEWORK
Activeageingpoliciesandprogrammesrec-
ognizetheneedtoencourageandbalance
personalresponsibility(self-care),age-friendly
environmentsandintergenerationalsolidarity.
Individualsandfamiliesneedtoplanandpre-
pareforolderage,andmakepersonalefforts
toadoptpositivepersonalhealthpracticesat
allstagesoflife.Atthesametimesupport-
iveenvironmentsarerequiredtomakethe
healthychoicestheeasychoices.
Therearegoodeconomicreasonsforenacting
policiesandprogrammesthatpromoteactive
ageingintermsofincreasedparticipationand
reducedcostsincare.Peoplewhoremain
healthyastheyagefacefewerimpediments
tocontinuedwork.Thecurrenttrendtoward
earlyretirementinindustrialisedcountriesis
largelytheresultofpublicpoliciesthathave
encouragedearlywithdrawalfromthelabour
force.Aspopulationsage,therewillbe
increasingpressuresforsuchpoliciesto
changeparticularlyifmoreandmoreindi-
vidualsreacholdageingoodhealth,i.e.are
fitforwork.Thiswouldhelptooffsetthe
risingcostsinpensionsandincomesecurity
schemesaswellasthoserelatedtomedical
andsocialcarecosts.
Withregardtorisingpublicexpenditures
form
edica
lcar
e,a
va
ila
bledata
incr
ea
singlyindicatethatoldageitselfisnotassociated
withincreasedmedicalspending.Rather,itis
disabilityandpoorhealthoftenassociated
witholdagethatarecostly.Aspeopleage
inbetterhealth,medicalspendingmaynot
increaseasrapidly.
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Policymakersneedtolookatthefullpicture
andconsiderthesavingsachievedbydeclines
indisabilityrates.IntheUSAforexample,
suchdeclinesmightlowermedicalspend ing
byabout20percentoverthenext50years
(Cutler,2001).Between1982and1994,inthe
USA,thesavingsinnursinghomecostsalone
wereestimatedtoexceed$17billion(Singer
andManton,1998).Moreover,ifincreased
numbersofhealthyolderpeoplewereto
extendtheirparticipationintheworkforce
(througheitherfullorpart-timeemployment),
theircontributiontopublicrevenueswould
continuouslyincrease.Finally,itisoftenless
costlytopreventdiseasethantotreatit.For
example,ithasbeenestimatedthataone-dol-
larinvestmentinmeasurestoencouragemod-
eratephysicalactivityleadstoacostsavingof
$3.2inmedicalcosts(U.S.CentersforDisease
Control,1999).
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PAGE19
ACTIVEAGEING:APOLICYFRAMEWORK
Activeageingdependsonavarietyofinflu-
encesordeterminantsthatsurroundindivid-
uals,familiesandnations.Understandingthe
evidencewehaveaboutthesedeterminants
helpsusdesignpoliciesandprogrammesthat
work.
Thefollowingsectionsummarizeswhatwe
knowabouthowthebroaddeterminantsof
healthaffecttheprocessofageing.These
determinantsapplytothehealthofallage
groups,althoughtheemphasishereisonthe
healthandqualityoflifeofolderpersons.At
thispoint,itisnotpossibletoattributedirect
causationtoanyonedeterminant;however,
thesubstantialbodyofevidenceonwhat
determineshealthsuggeststhatallofthese
factors(andtheinterplaybetweenthem)are
goodpredictorsofhowwellbothindividuals
andpopulationsage.Moreresearchisneeded
toclarifyandspecifytheroleofeachdeter-
minant,aswellastheinteractionbetween
determinants,intheactiveageingprocess.We
alsoneedtobetterunderstandthepathways
thatexplainhowthesebroaddeterminants
actuallyaffecthealthandwellbeing.
Moreover,itishelpfultoconsidertheinflu-
enceofvariousdeterminantsoverthelife
coursesoastotakeadvantageoftransitions
andwindowsofopportunityforenhancing
health,participationandsecurityatdifferent
stages.Forexample,thereisevidencethat
stimulationandsecureattachmentsininfancy
influenceanindividualsabilitytolearnand
3.TheDeterminantsofActiveAgeing:UnderstandingtheEvidence
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PAGE20
getalongwithothersthroughoutallofthe
laterstagesoflife.Employment,whichisa
determinantthroughoutadultlifegreatlyinflu-
encesone sfinancialreadinessforoldage.Ac-cesstohighquality,dignifiedlong-termcareis
particularlyimportantinlaterlife.Often,asis
thecasewithexposuretopollution,theyoung
andtheoldarethemostvulnerablepopula-
tiongroups.
Cross-Cutting Determinants: Culture
and Gender
Cultureisacross-cuttingdeterminantwithinthe
frameworkforunderstandingactiveageing.
Culture, w hich surr ounds all indi-
viduals and p op ulation s, sh ap es th e
way in which we age because it in flu-
ences all of the other deter minants
of active ageing.
Culturalvaluesandtraditionsdeterminetoa
largeextenthowagivensocietyviewsolder
peopleandtheageingprocess.Whensocieties
aremorelikelytoattributesymptomsofdis-
easetotheageingprocess,theyarelesslikely
toprovideprevention,earlydetectionand
appropriatetreatmentservices.Cultureisa
keyfactorinwhetherornotco-residencywith
youngergenerationsisthepreferredwayof
living.Forexample,inmostAsiancountries,
theculturalnormistovalueextendedfami-
liesandtolivetogetherinmultigenerational
households.Culturalfactorsalsoinfluence
health-seekingbehaviours.Forexample,at-
titudestowardsmokingaregraduallychanging
inarangeofcountries.
Thereisenormousculturaldiversityandcom-
plexitywithincountriesandamongcountries
andregionsoftheworld.Forexample,diverse
ethnicitiesbringavarietyofvalues,attitudes
andtraditionstothemainstreamculturewithin
acountry.Policiesandprogrammesneedto
respectcurrentculturesandtraditionswhile
de-bunkingoutdatedstereotypesandmisinfor-
mation.Moreover,therearecriticaluniversal
valuesthattranscendculture,suchasethics
andhumanrights.
Gender is a lens thr ough wh ich to
consider the approp riateness of vari-
ous policy options and how they will
affect the well being of both men
and women.
Inmanysocieties,girlsandwomenhave
lowersocialstatusandlessaccesstonutri-
tiousfoods,education,meaningfulworkand
healthservices.Womenstraditionalroleas
familycaregiversmayalsocontributetotheir
increasedpovertyandillhealthinolderage.
Somewomenareforcedtogiveuppaidem-
ploymenttocarryouttheircaregivingrespon-
sibilities.Othersneverhaveaccesstopaid
employmentbecausetheyworkfull-timein
unpaidcaregivingroles,lookingafterchildren,
olderparents,spouseswhoareillandgrand-
children.Atthesametime,boysandmenare
morelikelytosufferdebilitatinginjuriesor
deathduetoviolence,occupationalhazards,
andsuicide.Theyalsoengageinmorerisk-
takingbehaviourssuchassmoking,alcoho l
anddrugconsumptionandunnecessaryexpo-
suretotheriskofinjury.
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PAGE21
ACTIVEAGEING:APOLICYFRAMEWORK
Determinants Related to Health and
Social Serv ice Systems
To p r omo te active ageing, healthsystems n eed to take a life course
per sp ectiv e th at fo cuses o n health
pr om otio n, disease pr ev en tio n an d
equitable access to quality pr imar y
health care an d long-term care.
Healthandsocialservicesneedtobeinte-
grat
ed,coor
dinat
eda
ndcost
-effect
ive.Ther
emustbenoagediscriminationintheprovision
ofservicesandserviceprovidersneedtotreat
peopleofallageswithdignityandrespect.
HealthPromotionandDiseasePrevention
Healthpromotionistheprocessofenabling
peopletotakecontroloverandtoimprove
theirhealth.Diseasepreventionincludesthe
preventionandmanagementofthecond itions
thatareparticularlycommonasindividuals
age:noncommunicablediseasesandinjuries.
Preventionrefersbothtoprimarypreven-
tion(e.g.avoidanceoftobaccouse)aswell
assecondaryprevention(e.g.screeningfor
theearlydetectionofchronicdiseases),or
tertiaryprevention,e.g.appropriateclini-
calmanagementofdiseases.Allcontributeto
r
educing
t
heri
skofdisa
biliti
es.Disea
sepr
e-
ventionstrategieswhichmayalsoaddress
infectiousdiseasessavemoneyatanyage.
Forexample,vaccinatingolderadultsagainst
influenzasavesanestimated$30to$60in
treatmentcostsper$1spentonvaccines(U.S.
DepartmentofHealthandHumanServices,
1999).
CurativeServices
Despitebesteffortsinhealthpromotionand
diseaseprevention,peopleareatincreasing
riskofdevelopingdiseasesastheyage.Thus
accesstocurativeservicesbecomesindispens-
able.Asthevastmajorityofolderpersons
inanygivencountryliveinthecommunity,
mostcurativeservicesmustbeofferedbythe
primaryhealthcaresector.Thissectorisbest
equ ippedto.makereferralstothesecondary
andtertiarylevelsofcarewheremostacute
andemergencycareisalsoprovided .
Ultimately,theworldwideshiftintheglobal
burdenofdiseasetowardchronicdiseases
requiresashiftfromafinditandfixitmodel
toacoordinatedandcomprehensivecontin-
uumofcare.Thiswillrequireareorientation
inhealthsystemsthatarecurrentlyorganized
aroundacute,episodicexperiencesofdis-
ease.Thepresentacutecaremode lsofhealth
servicedeliveryareinadequatetoaddressthehealthneedsofrapidlyageingpopulations
(WHO,2001).
Asthepopulationages,thedemandwillcon-
tinuetoriseformedicationsthatareusedto
delayandtreatchronicdiseases,alleviatepain
andimprovequalityoflife.Thiscallsfora
renewedefforttoincreaseaffordableaccessto
essentialsafemedicationsandtobetterensure
theappropriate,cost-effectiveuseofcurrent
andnewdrugs.Partnersinthiseffortneedto
includegovernments,healthprofessionals,the
pharmaceuticalindustry,traditionalhealers,
employersandorganizationsrepresenting
olderpeople.
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PAGE22
Long-termcare
Long-termcareisdefinedbyWHOasthe
systemofactivitiesundertakenbyinformal
caregivers(family,friendsand/orneighbours)
and/orprofessionals(healthandsocialser-
vices)toensurethatapersonwhoisnotfully
capableofself-carecanmaintainthehighest
possiblequalityoflife,accordingtohisor
herindividualpreferences,withthegreatest
possibledegreeofindependence,autonomy,
participation,personalfulfillmentandhuman
dignity(WHO,2000b).
Thus,long-termcareincludesbothinformal
andformalsupportsystems.Thelattermay
includeabroadrangeofcommunityservices
(e.g.,publichealth,primarycare,homecare,
rehabilitationservicesandpalliativecare)as
wellasinstitutionalcareinnursinghomesand
hospices.Italsoreferstotreatmentsthathalt
orreversethecourseofdiseaseanddisability.
MentalHealthServices
Mentalhealthservices,whichplayacrucial
roleinactiveageing,shou ldbeanintegral
partoflong-termcare.Particularattention
needstobepaidtotheunder-diagnosisof
mentalillness(especiallydepression)and
tosuicideratesamongolderpeople(WHO,
2001a).
Behavioural Determinants
The adoption of healthy lifestyles
and actively participating in ones
own care ar e impor tant at all stages
of the life course. One of the my ths
of ageing is that it is too late to adop t
such lifestyles in the later year s. On
the contrary , engaging in appr opr i-
ate physical activity, healthy eating,
not smokin g and using alcohol and
medications wisely in older age can
prev en t disease an d f un ctional de-
cline, extend longevity and en hance
on es quality of life.
TobaccoUse
Smokingisthemostimportantmodifiable
riskfactorforNCDsforyoungandoldalike
andamajorpreventablecauseofpremature
death.Smokingnotonlyincreasestherisk
fordiseasessuchaslungcancer,itisalso
negativelyrelatedtofactorsthatmaylead
toimportantlossesinfunctionalcapacity.
Forexample,smokingacceleratestherateof
declineofbonedensity,muscularstrengthand
respiratoryfunction.Researchontheeffects
ofsmokingrevealednotjustthatsmokingisa
riskfactorforalargeandincreasingnumber
ofdiseasesbutalsothatitsilleffectsarecu-
mulativeandlonglasting.Theriskofcontract-
ingatleastoneofthediseasesassociatedwith
smokingincreaseswiththedurationandthe
amountofexposure.
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PAGE24
activityandareorganizedandledbyolder
peoplethemselves.Professionaladvicetogo
fromdoingnothingtodoingsomethingand
physicalrehabilitationprogrammesthathelpolderpeoplerecoverfrommobilityproblems
arebotheffectiveandcost-efficient.
Intheleastdevelopedcountries,theoppo-
siteproblemmayoccur.Inthesecountries,
individualsareoftenengagedinstrenuous
physicalworkandchoresthatmayhasten
disabilities,causeinjuriesandaggravateprevi-
ouscond itions,especiallyastheyapproach
oldage.Thismayincludeheavycaregiving
responsibilitiesforillanddyingrelatives.
Healthpromotioneffortsintheseareasshou ld
bedirectedatprovidingrelieffromrepetitive,
strenuoustasksandmakingadjustmentsto
unsafephysicalmovementsatworkthatwill
decreaseinjuriesandpain.Olderpeoplewho
regularlyengageinvigorousphysicalwork
needopportunitiesforrestandrecreation.
HealthyEating
Eatingandfoodsecurityproblemsatallages
includebothunder-nutrition(mostly,butnot
exclusively,intheleastdevelopedcountries)
andexcessenergyintake.Inolderpeople,
malnutritioncanbecausedbylimitedaccess
tofood,socioeconomichardships,alackof
informationandknowledgeaboutnutrition,
poorfoodchoices(e.g.,eatinghighfatfoods),
diseaseandtheuseofmedications,toothloss,
socialisolation,cognitiveorphysicaldisabili-
tiesthatinhibitone sabilitytobuyfoodsand
preparethem,emergencysituationsandalack
ofphysicalactivity.
Excessenergyintakegreatlyincreasestherisk
forobesity,chronicdiseasesanddisabilitiesas
peoplegrowolder.
Diets high in (saturated) fat and
salt, low in fr uits and vegetables and
providing in suffi cient amoun ts offibr e and vitamins combined with
sedentarism, are m ajor r isks factors
for chr onic conditions like diabetes,
cardiovascular disease, high blood
pressure, obesity , ar th r itis an d some
cancers.
InsufficientcalciumandvitaminDisassoci-
atedwithalossofbonedensityinolderage
andconsequentlyanincreaseinpainful,costly
anddeb ilitatingbonefractures,especiallyin
olderwomen.Inpopulationswithhighfrac-
tureincidence,riskcanbedecreasedthrough
ensuringadequatecalciumandvitaminD
intake.
OralHealth
Poororalhealthprimarilydentalcaries,
periodontaldiseases,toothlossandoralcan-
cercauseothersystemichealthproblems.
Theycreateafinancialburdenforindividuals
andsocietyandcanreduceself-confidence
andqualityoflife.Studiesshowthatpoor
oralhealthisassociatedwithmalnutritionand
thereforeincreasedrisksforvariousnoncom-
municablediseases.Oralhealthpromotion
andcavitypreventionprogrammesdesigned
toencouragepeopletokeeptheirnatural
teethneedtobeginearlyinlifeandcontinue
overthelifecourse.Becauseofthepainand
reducedqualityoflifeassociatedwithoral
healthproblems,basicdentaltreatmentservic-
esandaccessibilitytodenturesarerequired.
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PAGE25
ACTIVEAGEING:APOLICYFRAMEWORK
Alcohol
Whileolderpeopletendtodrinklessthan
youngerpeople,metabolismchangesthat
accompanyageingincreasetheirsuscepti-
bilitytoalcohol-relateddiseases,including
malnutritionandliver,gastricandpancreatic
diseases.Olderpeoplealsohavegreaterrisks
foralcoho l-relatedfallsandinjuries,aswellas
thepotentialhazardsassociatedwithmixing
alcoho landmedications.Treatmentservices
foralcoho lproblemsshouldbeavailableto
olderpeopleaswellasyoungerpeople.
AccordingtoarecentWHOreviewofthe
literature,thereisevidencethatalcoho luseat
verylowlevels(uptoonedrinkaday)may
offersomeformofprotectionagainstcoronary
heartdiseaseandstrokeforpeopleage45and
over.However,intermsofoverallexcessmor-
tality,theadverseeffectsofdrinkingoutweigh
anyprotectionagainstcoronaryheartdisease,
eveninhighriskpopulations(Jerniganetal.,2000).
Medications
Becauseolderpeopleoftenhavechronic
healthproblems,theyaremorelikelythan
youngerpeopletoneedandusemedications
traditional,over-the-counterandprescribed.
Inmostcountries,olderpeoplewithlow
incomeshavelittleornoaccesstoinsuranceformedications.Asaresult,manygowithout
orspendaninappropriatelylargepartoftheir
meagerincomesondrugs.
Incontrast,medicationsaresometimesover-
prescribedtoolderpeople(especiallytoolder
women)whohaveinsuranceorthemeans
topayforthesedrugs.Adversedrug-related
reactionsandfallsassociatedwithmedication
use(especiallysleepingpillsandtranqu ilizers)
aresignificantcausesofpersonalsufferingand
costlypreventablehospitaladmissions(Gur-
witzandAvorn,1991).
Iatrogenesishealthproblemsthatare
inducedbydiagnosesortreatmentscaused
bytheuseofdrugsiscommoninoldage,
duetotheinteractionofdrugs,inadequate
dosagesandahigherfrequencyofunpredict-
ablereactionsthroughunknownmechanisms.
Withtheadventofmanynewtherapies,there
isanincreasingneedtoestablishsystemsfor
preventingadversedrugreactionsandfor
informingbothhealthprofessionalsandthe
ageingpublicabouttherisksandbenefitsof
moderntherapies.
Adherence
Accesstoneededmedicationsisinsufficientin
itselfunlessadherencetolong-termtherapy
forageing-relatedchronicillnessesishigh.
Adherenceincludestheadoptionandmain-
tenanceofawiderangeofbehaviours(e.g.,
healthydiet,physicalactivity,notsmoking),
aswellastakingmedicationsasdirectedby
ahealthprofessional.Itisestimatedthatin
developedcountriesadherencetolong-term
therapyaveragesonly50percent.Indevelop-
ingcountriestheratesareevenlower.Such
pooradherenceseverelycompromisesthe
effectivenessoftreatmentsandhasdramatic
qualityoflifeandeconomicimplicationsfor
publichealth.Populationhealthoutcomespre-
dictedbytreatmentefficacydatacanonlybe
achievedifadherenceinformationisprovided
toallhealthprofessionalsandplanners.With-
outasystemthataddressestheinfluenceson
adherence,advancesinbiomedicaltechno l-
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PAGE26
ogywillfailtorealizetheirpotentialtoreduce
theburdenofchronicdisease(Dipollinaand
Sabate,2002).
Determ inan ts Related to Person al
Factors
BiologyandGenetics
Biologyandgeneticsgreatlyinfluencehowa
personages.Ageingisasetofbiologicalpro-
cessesthataregeneticallydetermined.Ageing
canbedefinedasaprogressive,generalized
impairmentoffunctionresultinginalossof
adaptativeresponsetoastressandinagrow-
ingriskofage-associateddisease(Kirkwood ,
1996).Inotherwords,themainreasonwhy
olderpersonsgetsickmorefrequentlythan
youngerpersonsisthat,duetotheirlonger
lives,theyhavebeenexposedtoexternal,
behavioural,andenvironmentalfactorsthat
causediseaseforalongertimethantheir
youngercounterparts(Gray,1996).
While genesmaybeinvolvedinthe
causationofdisease,formany
diseasesthe causeisenvironmental
andexternaltoagreaterdegree
thanitisgeneticandinternal.
Itshouldalsobenotedthatthereisevidence
inhumanpopulationsthatlongevitytends
toruninfamilies.But,allthingsconsidered,
thereisgeneralagreementthatthelifelong
trajectoryofhealthanddiseaseforanindi-
vidualistheresultofacombinationofgenet-
ics,environment,lifestyle,nutrition,andtoan
importantextent,chance(Kirkwood,1996).
Therefore,theinfluenceofgeneticsonthe
developmentofchroniccond itionssuchas
diabetes,heartdisease,AlzheimersDisease
andcertaincancersvariesgreatlyamongindi-viduals.Formanypeople,lifestylebehaviours
suchasnotsmoking,personalcopingskills
andanetworkofclosekinandfriendscan
effectivelymodifytheinfluenceofheredityon
functionaldeclineandtheonsetofdisease.
PsychologicalFactors
Psychologicalfactorsincludingintelligence
andcognitivecapacity(forexample,theabilitytosolveproblemsandadapttochangeand
loss)arestrongpredictorsofactiveageingand
longevity(Smitsetal.,1999).Duringnormal
ageing,somecognitivecapacities(including
learningspeedandmemory)naturallyde-
clinewithage.However,theselossescanbe
compensatedbygainsinwisdom,knowledge
andexperience.Often,declinesincognitive
functioningaretriggeredbydisuse(lackofpractice),illness(suchasdepression),behav-
iouralfactors(suchastheuseofalcoho land
medications),psychologicalfactors(suchas
lackofmotivation,lowexpectationsandlack
ofconfidence),andsocialfactors(suchas
lonelinessandisolation),ratherthanageing
perse.
Otherpsychologicalfactorsthatareacquired
acrossthelifecoursegreatlyinfluencethe
wayinwhichpeopleage.Self-efficacy(the
beliefpeoplehaveintheircapacitytoexert
controlovertheirlives)islinkedtopersonal
behaviourchoicesasoneagesandtoprepara-
tionforretirement.Copingstylesdetermine
howwellpeopleadapttothetransitions(such
asretirement)andcrisesofageing(suchas
bereavementandtheonsetofillness).
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PAGE27
ACTIVEAGEING:APOLICYFRAMEWORK
Menandwomenwhoprepareforoldageand
areadaptabletochangemakeabetteradjust-
menttolifeafterage60.Mostpeopleremain
resilientastheyageand,onthewhole,older
peopledonotvarysignificantlyfromyounger
peopleintheirabilitytocope.
Determ inan ts Related to the Phy sical
Environment
PhysicalEnvironments
Physicalenvironmentsthatareagefriendly
canmakethedifferencebetweenindepen-
denceanddependenceforallindividualsbut
areofparticularimportanceforthosegrow-
ingolder.Forexample,olderpeoplewho
liveinanunsafeenvironmentorareaswith
multiplephysicalbarriersarelesslikelytoget
outandthereforemorepronetoisolation,
depression,reducedfitnessandincreased
mobilityproblems.
Specificattentionmustbegiventoolderpeo-plewholiveinruralareas(some60percent
worldwide)wherediseasepatternsmaybe
differentduetoenvironmentalcond itionsand
alackofavailablesupportservices.Urbaniza-
tionandthemigrationofyoungerpeoplein
searchofjobsmayleaveolderpeopleisolated
inruralareaswithlittlemeansofsupportand
littleornoaccesstohealthandsocialservices.
Accessibleandaffordablepublictransporta-
tionservicesareneededinbothruraland
urbanareassothatpeopleofallagescanfully
participateinfamilyandcommunitylife.This
isespeciallyimportantforolderpersonswho
havemobilityproblems.
Hazardsinthephysicalenvironmentcanlead
todebilitatingandpainfulinjuriesamong
olderpeople.Injuriesfromfalls,firesandtraf-
ficcollisionsarethemostcommon.
Safe Housing
Safe,adequatehousingandneighbourhoods
areessentialtothewellbeingofyoungand
old.Forolderpeople,location,including
proximitytofamilymembers,servicesand
transportationcanmeanthedifferencebe-
tweenpositivesocialinteractionandisolation.
Buildingcodesneedtotakethehealthand
safetyneedsofolderpeopleintoaccount.
Householdhazardsthatincreasetheriskof
fallingneedtoberemediedorremoved.
Worldwide,thereisanincreasingtrendforolderpeopletolivealoneespeciallyunat-
tachedolderwomenwhoaremainlywidows
andareoftenpoor,evenindevelopedcoun-
tries.Othersmaybeforcedtoliveinarrange-
mentsthatarenotoftheirchoice,suchaswith
relativesinalreadycrowdedhouseholds.In
manydevelopingcountries,theproportionof
olderpeoplelivinginslumsandshantytowns
isrisingquicklyasmany,whomovedtothecitieslongago,havebecomelong-termslum-
dwellers,whileotherolderpeoplemigrateto
citiestojoinyoungerfamilymemberswho
havealreadymovedthere.Olderpeopleliving
inthesesettlementsareathighriskforsocial
isolationandpoorhealth.
Intimesofcrisisandconflict,displacedolder
peopleareparticularlyvulnerable.Oftenthey
areunabletowalktorefugeecamps.Even
iftheymakeittocamps,itmaybehardto
obtainshelterandfood,especiallyforolder
womenandolderpersonswithdisabilities
whoexperiencelowsocialstatusandmultiple
otherbarriers.
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PAGE28
Falls
Fallsamongolderpeoplearealargeand
increasingcauseofinjury,treatmentcostsand
death.Environmentalhazardsthatincrease
therisksoffallingincludepoorlighting,slip-
peryorirregularwalkingsurfacesandalack
ofsupportivehandrails.Mostoften,these
fallsoccurinthehomeenvironmentandare
preventable.
Theconsequencesofinjuriessustainedinold-
eragearemoreseverethanamongyounger
people.Forinjuriesofthesameseverity,olderpeopleexperiencemoredisability,longerhos-
pitalstays,extendedperiodsofrehabilitation,
ahigherriskofsubsequentdependencyanda
higherriskofdying.
The greatmajorityofinjuriesare
preventable;however,thetraditional
viewofinjuriesasaccidentshas
resultedinhistoricalneglectofthis
areainpublichealth.
CleanWater,CleanAirandSafeFoods
Cleanwater,cleanairandaccesstosafefoods
areparticularlyimportantforthemostvulner-
ablepopulationgroups,i.e.childrenandolder
persons,andforthosewhohavechronicill-
nessesandcompromisedimmunesystems.
Determ inan ts Related to the Social
Environment
Socialsupport,opportunitiesforeducation
andlifelonglearning,peace,andprotection
fromviolenceandabusearekeyfactorsin
thesocialenvironmentthatenhancehealth,
participationandsecurityaspeopleage.Lone-
liness,socialisolation,illiteracyandalack
ofeducation,abuseandexposuretoconflict
situationsgreatlyincreaseolderpeoplesrisks
fordisabilitiesandearlydeath.
SocialSupport
Inadequatesocialsupportisassociatednot
onlywithanincreaseinmortality,morbidity
andpsychologicaldistressbutadecreasein
overallgeneralhealthandwellbeing.Disrup-
tionofpersonalties,lone linessandconflictual
interactionsaremajorsourcesofstress,while
supportivesocialconnectionsandintimatere-
lationsarevitalsourcesofemotionalstrength(GirondaandLubben,inpress).InJapan,for
example,olderpeoplewhoreportedalack
ofsocialcontactwere1.5timesmorelikely
todieinthenextthreeyearsthanwerethose
withhighersocialsupport(Sugiswawaetal,
1994).
Olderpeoplearemorelikelytolosefamily
membersandfriendsandtobemorevulner-
abletolone liness,socialisolationandthe
availabilityofasmallersocialpool.Social
isolationandlone linessinoldagearelinked
toadeclineinbothphysicalandmental
wellbeing.Inmostsocieties,menareless
likelythanwomentohavesupportivesocial
networks.However,insomecultures,older
womenwhoarewidowedaresystematically
excludedfrommainstreamsocietyoreven
rejectedbytheircommunity.
Decision-makers,nongovernmentalorganiza-
tions,privateindustryandhealthandsocial
serviceprofessionalscanhelpfostersocial
networksforageingpeoplebysupportingtra-
ditionalsocietiesandcommunitygroupsrun
byolderpeople,voluntarism,neighbourhood
helping,peermentoringandvisiting,family
caregivers,intergenerationalprogrammesand
outreachservices.
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PAGE29
ACTIVEAGEING:APOLICYFRAMEWORK
ViolenceandAbuse
Olderpeoplewhoarefrailorlivealonemay
feelparticularlyvulnerabletocrimessuchas
theftandassault.Acommonformofviolence
againstolderpeople(especiallyagainstolder
women)iselderabusecommittedbyfamily
membersandinstitutionalcaregiverswho
arewellknowntothevictims.Elderabuse
occursinfamiliesatalleconomiclevels.It
islikelytoescalateinsocietiesexperiencing
economicupheavalandsocialdisorganization
whenoverallcrimeandexploitationtendsto
increase.
AccordingtotheInternational
NetworkforthePreventionofElder
Abuse,elderabuseisasingleor
repeatedact,orlackofappropriate
actionoccurring withinanyrela-
tionshipwherethereisanexpecta-
tionoftrustwhichcausesharmor
distresstoanolderperson(Action
onElderAbuse 1995).
Elderabuseincludesphysical,sexual,psycho-
logicalandfinancialabuseaswellasneglect.
Olderpeoplethemselvesperceiveabuseas
includingthefollowingsocietalfactors:neglect
(socialexclusionandabandonment),violation
(human,legalandmedicalrights)anddepriva-
tion(choices,decisions,status,financesand
respect)(WHO/INPEA2002).Elderabuseis
aviolationofhumanrightsandasignificant
causeofinjury,illness,lostproductivity,isola-
tionanddespair.Typically,itisunderreported
inallcultures.
Confrontingandreducingelderabuserequires
amultisectoral,multidisciplinaryapproachin-
volvingjusticeofficials,lawenforcementoffi-
cers,healthandsocialserviceworkers,labour
leaders,spiritualleaders,faithinstitutions,
advocacyorganizationsandolderpeople
themselves.Sustainedeffortstoincreasepublic
awarenessoftheproblemandtoshiftvalues
thatperpetuategenderinequitiesandageist
attitudesarealsorequired.
EducationandLiteracy
Lowlevelsofeducationandilliteracyareas-sociatedwithincreasedrisksfordisabilityand
deathamongpeopleastheyage,aswellas
withhigherratesofunemployment.Education
inearlylifecombinedwithopportunitiesfor
lifelonglearningcanhelppeopledevelopthe
skillsandconfidencetheyneedtoadaptand
stayindependent,astheygrowolder.
Studieshaveshownthatemploymentprob-
lemsofolderworkersareoftenrootedintheir
relativelylowliteracyskills,notinageingper
se.Ifpeoplearetoremainengagedinmean-
ingfulandproductiveactivitiesastheygrow
older,thereisaneedforcontinuoustraining
intheworkplaceandlifelonglearningoppor-
tunitiesinthecommunity(OECD,1998).
Likeyoungerpeople,oldercitizensneedtrain-
inginnewtechno logies,especiallyinagricul-
tureandelectroniccommunication.Self-direct-
edlearning,increasedpracticeandphysical
adjustments(suchastheuseoflargeprint)
cancompensateforreductionsinvisualacuity,
hearingandshort-termmemory.Olderpeople
cananddoremaincreativeandflexible.Inter-
generationallearningbridgesagedifferences,
enhancesthetransmissionofculturalvalues
andpromotestheworthofallages.Studies
haveshownthatyoungpeoplewholearnwith
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PAGE30
olderpeoplehavemorepositiveandrealistic
attitudesabouttheoldergeneration.
Unfortunately,therecontinuetobestriking
disparitiesinliteracyratesbetweenmenand
women.In1995intheleastdevelopedcoun-
tries,31percentofadultwomenwereilliterate
comparedto20percentofadultmen(WHO,
1998a).
Econo mic Determ inan ts
Threeaspectsoftheeconomicenvironment
ha
veapart
icular
lysignifica
nteffec
ton
a
ct
iveageing:income,workandsocialprotection.
Income
Activeageingpoliciesneedtointersectwith
broaderschemestoreducepovertyatallages.
Whilepoorpeopleofallagesfaceanin-
creasedriskofillhealthanddisabilities,older
peopleareparticularlyvulnerable.Manyolder
people espec
ially
t
hosewhoar
efemal
e,live
aloneorinruralareas donothavereliableor
sufficientincomes.Thisseriouslyaffectstheir
accesstonutritiousfoods,adequatehousing
andhealthcare.Infact,studieshaveshown
thatolderpeoplewithlowincomesareone-
thirdaslikelytohavehighlevelsoffunction-
ingasthosewithhighincomes(Guralnickand
Kaplan,1989).
Themostvulnerableareolderwomenand
menwhohavenoassets,littleornosavings,
nopensionsorsocialsecuritypaymentsor
whoarepartoffamilieswithloworuncertain
incomes.Particularly,thosewithoutchildren
orfamilymembersoftenfaceanuncertain
futureandareathighriskforhomelessness
anddestitution.
SocialProtection
Inallcountriesoftheworld,familiesprovide
themajorityofsupportforolderpeoplewho
requirehelp.However,associetiesdevelop
andthetraditionofgenerationslivingtogether
beginstodecline,countriesareincreasingly
calledontodevelopmechanismsthatpro-
videsocialprotectionforolderpeoplewho
areunabletoearnalivingandarealoneand
vulnerable.Indevelopingcountries,older
peoplewhoneedassistancetendtorelyon
familysupport,informalservicetransfersand
personalsavings.Socialinsuranceprogrammes
inthesesettingsareminimalandinsome
casesredistributeincometominoritiesinthe
populationwhoarelessinneed.However,in
countriessuchasSouthAfricaandNamibia,
whichhaveanationaloldagepension,these
benefitsareamajorsourceofincomefor
manypoorfamiliesaswellastheolderadults
wholiveinthesefamilies.Themoneyfrom
thesesmallpensionsisusedtopurchasefood
forthehousehold,tosendchildrentoschoo l,
toinvestinfarmingtechno logiesandtoen-
suresurvivalformanyurbanpoorfamilies.
Indevelopedcountries,socialsecurity
measurescanincludeold-agepensions,
occupationalpensionschemes,voluntary
savingsincentives,compulsorysavingsfunds
andinsuranceprogrammesfordisability,
sickness,long-termcareandunemployment.
Inrecentyears,policyreformshavefavoured
amulti-pillaredapproachthatmixesstate
andprivatesupportforoldagesecurityand
encouragesworkinglongerandgradual
retirement(OECD,1998).
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PAGE31
ACTIVEAGEING:APOLICYFRAMEWORK
Work
Throughouttheworld,ifmorepeople
wouldenjoyopportunitiesfordignified
work(properlyremunerated,inadequate
environments,protectedagainstthehazards)
earlierinlife,peoplewouldreacholdage
abletoparticipateintheworkforce.Thus,the
wholesocietywouldbenefit.Inallpartsofthe
world,thereisanincreasingrecognitionof
theneedtosupporttheactiveandproductive
contributionthatolderpeoplecananddo
makeinformalwork,informalwork,unpaid
activitiesinthehomeandinvoluntary
occupations.
Indevelopedcountries,thepotentialgain
ofencouragingolderpeopletowork
longerisnotbeingfullyrealized.Butwhen
unemploymentishigh,thereisoftena
tendencytoseereducingthenumberofolder
workersasawaytocreatejobsforyounger
people.However,experiencehasshownthat
theuseofearlyretirementtofreeupnewjobs
fortheunemployedhasnotbeenaneffective
solution(OECD,1998).
Inlessdevelopedcountries,olderpeopleare
bynecessitymorelikelytoremaineconomically
activeintooldage(seeFigure9).However,
industrialization,adoptionofnewtechnologies
andlabourmarketmobilityisthreatening
muchofthetraditionalworkofolderpeople,
particularlyinruralareas.Developmentprojects
needtoensurethatolderpeopleareeligiblefor
creditschemesandfullparticipationinincome-
generatingopportunities.
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PAGE32
Concentratingonlyon workinthe
formallabourmarkettendstoig-
norethevaluable contributionthatolderpeoplemakein workinthe
informalsector(e.g.,smallscale,
self-employedactivitiesanddomes-
tic work)andunpaidworkinthe
home.
Inbo thdevelopinganddevelopedcou n-
tries,olderpeopleoftentakeprimerespon -
sibili tyforho useholdmanagemen tand
childcaresothatyoungeradu ltscanwork
ou tside thehome.
Inallcountries,skilledandexperiencedolder
peopleactasvolunteersinschoo ls,commu-
nities,religiousinstitutions,businessesand
healthandpoliticalorganizations.Voluntary
workbenefitsolderpeoplebyincreasing
socialcontactsandpsychologicalwellbeing
whilemakingasignificantcontributiontotheir
communitiesandnations.
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PAGE33
ACTIVEAGEING:APOLICYFRAMEWORK
Thechallengesofpopulationageingare
global,nationalandlocal.Meetingthesechal-
lengeswillrequireinnovativeplanningand
substantivepolicyreformsindevelopedcoun-
triesandincountriesintransition.Develop-
ingcountries,mostofwhomdonotyethave
comprehensivepoliciesonageing,facethe
biggestchallenges.
Challenge 1: The Double Burden
of Disease
Asnationsindustrialize,changingpatternsof
livingandworkingareinevitablyaccompanied
byashiftindiseasepatterns.Thesechanges
impactdevelopingcountriesmost.Evenas
thesecountriescontinuetostrugglewithinfec-
tiousdiseases,malnutritionandcomplications
fromchildbirth,theyarefacedwiththerapid
growthofnoncommunicablediseases(NCDs).
Thisdoubleburdenofdiseasestrainsalready
scarceresourcestothelimit.
TheshiftfromcommunicabletoNCDsisfast
occurringinmostofthedevelopingworld,
wherechronicillnessessuchasheartdisease,
canceranddepressionarequicklybecomingtheleadingcausesofmorbidityanddisabil-
ity.Thistrendwillescalateoverthenextfew
decades.In1990,51percentoftheglobal
burdenofdiseaseindevelopingandnewly
industrializedcountrieswascausedbyNCDs,
mentalhealthdisordersandinjuries.By2020,
theburdenofthesediseaseswillrisetoap-
proximately78percent(SeeFigure10).
By2020,over70percentoftheglobalburdenofdiseaseindevelopingandnewlyindustrializedcountrieswillbecausedbynoncommunicablediseases,mentalhealthdisordersandinjuries.
4.ChallengesofanAgeingPopulation
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PAGE34
Thereisnoquestionthatpolicymakersand
donorsmustcontinuetoputresourcesto-
wardthecontrolanderadicationofinfectious
diseases.Butitisalsocriticaltoputpolicies,
programmesandintersectoralpartnerships
intoplacethatcanhelptohaltthemassive
expansionofchronicNCDs.Whilenotneces-
sarilyeasytoimplement,thosethatfocuson
communitydevelopment,healthpromotion,
diseasepreventionandincreasingparticipa-
tionareoftenthemosteffectiveincontrol-
lingtheburdenofdisease.Furthermoreother
long-termpoliciesthattargetmalnutritionand
povertywillhelptoreducebothchroniccom-
municableandnoncommunicablediseases.
Supportforrelevantresearchismost
urgentlyneededforlessdevelopedcountries.
Currently,lowandmiddle-incomecountries
have85percentoftheworldspopulationand
92percentofthediseaseburden,butonly
10per
centoft
heworl
d
shealt
hr
esear
chspending(WHO,2000).
HIV/AIDSandolderpeopleInAfricaan dotherdevelop ingre g ions,HIV/ AIDShashadmultip leim pactsonolderpeop le,intermsoflivingw iththed iseasethemselves,car ingforotherswhoareinfect-edan dta kingontheparent ingro lew ithorphansofAIDS.Th isimpacthasbeenlargely
ignoredtodate.
Infact,
mostdataonHIVandAIDSinfectionratesareonlyco mp iledu pto age49 . Improved dataco llection (w ithoutageli m ita tions) thathelpsusbetterunderstandtheim pactofHIV/ AIDSono ld erpeop leisurgentlyneeded.HIV/ AIDSinfor-mat ion,ed ucat ionan dpreventionactivitiesaswellastreatmentser vicesshou ldap p lytoallages.
Numerousstud ieshavefoundthatmostadultch ildrenw ithAIDSreturnhometod ie.Wives,mothers,aunts,siste rs,siste rs-in-lawandgrandmotherstakeontheb ulkofthecare.Then,inmanycases,thesewomentakeonthecareoftheorphanedch ildren.Governments,nongovernmentalorgan iza tionsandpr ivatein dustryneedto addressthefinancial,socialandtra in ingneedsofolderpeop lewhocareforfam ilymembersandne ighbourswhoareinfecte dandra isechildsur vivo rs,so meofwhomthemse lvesarealsoinfecte d (WH O,2002).
Challenge 2: Increased Risk of
Disability
Inbothdevelopinganddevelopedcountries,
chronicdiseasesaresignificantandcostly
causesofdisabilityandreducedqualityoflife.
Anolderpersonsindependenceisthreatened
whenphysicalormentaldisabilitiesmakeitdif-
ficulttocarryouttheactivitiesofdailyliving.
Astheygrowolder,peoplewithdisabilities
arelikelytoencounteradditionalbarriersrelat-
edtotheageingprocess.Forexample,mobil-
ityproblemsduetopoliomyelitisinchildhood
maybeconsiderablyaggravatedlaterinlife.
Nowthatmanyyoungpeoplewithintellectual
disabilitiessurviveatmucholderagesandlive
beyondtheirparents,thisspecialgroupalso
requirescarefulattentionfrompolicymakers.
Manypeopledevelopdisabilitiesinlaterlife
relatedtothewearandtearofageing(e.g.,
art
hriti
s)ort
heonsetofa
chr
onicd
isea
se,
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PAGE35
ACTIVEAGEING:APOLICYFRAMEWORK
whichcouldhavebeenpreventedinthefirst
place(e.g.,lungcancer,diabetesandperiph-
eralvasculardisease)oradegenerativeillness
(e.g.,dementia).Thelikelihoodofexperienc-ingseriouscognitiveandphysicaldisabilities
dramaticallyincreasesinveryoldage.Signifi-
cantly,adultsovertheageof80arethefastest
growingagegroupworldwide.
Butdisabilitiesassociatedwithageingandthe
onsetofchronicdiseasecanbeprevented
ordelayed.Forexample,asmentionedon
page18,therehasbeenasignificantdecline
overthelast20yearsinage-specificdisability
ratesintheU.S.A(seeFigure11),England,
Swedenandotherdevelopedcountries.
Figure10showstheactualdeclineindisabili-
tiesamongolderAmericansbetween1982
and1999comparedtotheprojectednumbers
ifratesofdisabilityhadremainedstableover
thattimeperiod.
Someofthisdeclineislikelyduetoincreased
educationlevels,improvedstandardsofliv-
ingandbetterhealthintheearlyyears.The
adoptionofpositivelifestylebehavioursis
alsoafactor.Asalreadymentioned,choosing
nottosmokeandmakingmodestincreasesin
physicalactivitylevelscansignificantlyreduce
one sriskforheartdiseaseandotherillnesses.
Supportivechangesinthecommunityare
alsoimportant,bothintermsofpreventing
disabilitiesandreducingtherestrictionsthat
peoplewithdisabilitiesoftenface.Inaddition,
impressiveprogressinthemanagementof
chroniccond itionshasbeenobserved,includ-
ingnewtechniquesforearlydiagnosisand
treatment,aswellaslong-termmanagement
ofchronicdiseases,suchashypertensionand
arthritis.Recentstudieshavealsoemphasized
thattheincreasinguseofaidsfromsimple
personalaids,suchascanes,walkers,hand-
rails,totechnologiesaimedatthepopulation
asawhole,suchastelephonesmayreduce
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PAGE36
dependenceamongdisabledpeople.Inthe
USAtheuseofsuchaidsbydependentolder
peopleincreasedfrom76percentin1984to
over90percentin1999(Cutler,2001).
VisionandHearing
Othercommonage-relateddisabilitiesinclude
visionandhearinglosses.Worldwide,there
arecurrently180millionpeoplewithvisual
disability,upto45millionofwhomareblind.
Mostoftheseareolderpeople,asvisualim-
pairmentandblindnessincreasesharplywith
age.Overall,approximatelyfourpercentofpersonsaged60yearsandabovearethought
tobeblind,and60percentofthemlivein
Sub-SaharanAfrica,ChinaandIndia.Thema-
jorage-relatedcausesofblindnessandvisual
disabilityincludecataracts(nearly50percent
ofallblindness),glaucoma,maculardegenera-
tionanddiabeticretinopathy(WHO,1997).
Thereisanurgentneedforpoliciesandpro-
grammesdesignedtopreventvisualimpair-
mentandtoincreaseappropriateeyecare
services,particularlyindevelopingcountries.
Inallcountries,correctivelensesandcataract
surgeryshouldbeaccessibleandaffordable
forolderpeoplewhoneedthem.
Hearingimpairmentleadstooneofthemost
widespreaddisabilities,particularlyinolder
people.Itisestimatedthatworldwideover
50percentofpeopleaged65yearsandover
havesomedegreeofhearingloss(WHO,
2002a).Hearinglosscancausedifficultieswith
communication.This,inturncanleadtofrus-
tration,lowself-esteem,withdrawalandsocial
isolation(Pal,1974,Wilson,1999).
Policiesandprogrammesneedtobeinplace
toreduceandeventuallyeliminateavoidable
hearingimpairmentandtohelppeoplewith
hearinglossobtainhearingaids.Hearingloss
maybepreventedbyavoidingexposureto
excessivenoiseandtheuseofpotentially
damagingdrugsandbyearlytreatmentofdis-
easesleadingtohearingloss,suchasmiddle
earinfections,diabetesandpossiblyhyperten-
sion.Hearinglosscansometimesbetreated,
especiallyifthecauseisintheearcanalor
middleear.Mostoften,however,thedisability
isreducedbyamplificationofsounds,usually
byusingahearingaid.
AnEnablingEnvironment
Aspopulationsaroundtheworldlivelonger,
policiesandprogrammesthathelpprevent
andreducetheburdenofdisabilityinold
ageareurgentlyneededinbothdeveloping
anddevelopedcountries.Oneusefulwayto
lookatdecision-makinginthisareaistothinkaboutenablementinsteadofdisablement.Dis-
ablingprocessesincreasetheneedsofolder
peopleandleadtoisolationanddependence.
Enablingprocessesrestorefunctionand
expandtheparticipationofolderpeopleinall
aspectsofsociety.
Avarietyofsectorscanenactage-friendly
policiesthatpreventdisabilityandenable
thosewhohavedisabilitiestofullyparticipate
incommunitylife.Herearesomeexamplesof
enablingprogrammes,environmentsandpoli-
ciesinavarietyofsectors:
barrier-freeworkplaces,flexiblework
hours,modifiedworkenvironmentsand
part-timeworkforpeoplewhoexperience
disabilitiesastheyageorarerequiredto
careforotherswithdisabilities(private
industryandemployers)
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ACTIVEAGEING:APOLICYFRAMEWORK
well-litstreetsforsafewalking,accessible
publictoiletsandtrafficlightsthatgive
peoplemoretimetocrossthestreet(local
governments)
exerciseprogrammesthathelpolder
peoplemaintaintheirmobilityorrecover
thelegstrengththeyneedtobemobile
(recreationservicesandnongovernmental
agencies)
life-longlearningandliteracyprogrammes
(educationsectorandnongovernmental
organizations)
hearingaidsorinstructioninsignlanguage
thatenablesolderpeoplewhoarehardof
hearingtocontinuetocommunicatewith
others(socialservicesandnongovernmen-
talorganizations)
barrier-freeaccesstohealthcentres,reha-
bilitationprogrammesandcost-effective
proceduressuchascataractsurgeryandhip
replacements(healthsector)
creditschemesandaccesstosmallbusi-
nessanddevelopmentopportunitiessothat
olderpeoplecancontinuetoearnaliving
(governmentsandinternationalagencies).
Changingtheattitudesofhealthandsocial
ser
vicep
r
ovide
r
sisp
aramoun
tt
oensuri
ngt
hat
theirpracticesenableandempowerindividu-
alstoremainasautonomousandindependent
aspossibleforaslongaspossible.Profession-
alcaregiversneedtorespectolderpeoples
dignityatalltimesandtobecarefultoavoid
prematureinterventionsthatmayunintention-
allyinducethelossofindependence.
Researchersneedtobetterdefineandstan-
dardizethetoolsusedtoassessabilityand
disabilityandtoprovidepolicymakerswith
additionalevidenceonkeyenablingprocesses
inthebroaderenvironment,aswellasinmed-
icineandhealth.Carefulattentionneedstobe
paidtogenderdifferencesintheseanalyses.
Challen ge 3: Pr oviding Care for
Agein g Populations
Aspopulationsage,oneofthegreatestchal-
lengesinhealthpolicyistostrikeabalance
amongsupportforself-care(peoplelook-ingafterthemselves),informalsupport(care
fromfamilymembersandfriends)andformal
care(healthandsocialservices).Formalcare
includesbothprimaryhealthcare(delivered
mostlyatthecommunitylevel)andinstitution-
alcare(eitherinhospitalsornursinghomes).
Whileitisclearthatmostofthecareindividu-
alsneedisprovidedbythemselvesortheir
informalcaregivers,mostcountriesallottheir
financialresourcesinversely,i.e.,thegreatest
shareofexpenditureisoninstitutionalcare.
Allovertheworld,familymembers,friends
andneighbours(mostofwhomarewomen)
providethebulkofsupportandcaretoolder
adultsthatneedassistance.Somepolicymak-
ersfearthatprovidingmoreformalcareser-
viceswilllessent
heinvolvem
entoff
amilies.
Studiesshowthatthisisnotthecase.When
appropriateformalservicesareprovided,
informalcareremainsthekeypartner(WHO,
2000c).Ofconcernthougharerecentdemo-
graphictrendsinalargenumberofcountries
indicatingtheincreaseintheproportionof
childlesswomen,changesindivorceandmar-
riagepatternsandtheoverallmuchsmaller
num
berofchild
renoffu
turecoho
rtsofolde
r
people,allcontributingtoashrinkingpoolof
familysupport(Wolf,2001).
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PAGE38
Formalcarethroughhealthandsocialservice
systemsneedstobeequallyaccessibletoall.
Inmanycountriesolderpeoplewhoarepoor
andwholiveinruralareashavelimitedor
noaccesstoneededhealthcare.Adeclinein
publicsupportforprimaryhealthcareservices
inmanyareashasputincreasedfinancialand
intergenerationalstrainonolderpeopleand
theirfamilies.
Mostolderpersonsinneedofcarepreferto
becaredforintheirownhomes.Butcare-
givers(whoareoftenolderpeople)mustbe
supportediftheyaretocontinuetoprovide
carewithoutbecomingillthemselves.Above
all,theyneedtobewellinformedaboutthe
conditiontheyarefacedwithandhowitis
likelytoprogress,andabouthowtoobtain
thesupportservicesthatareavailable.Visiting
nurses,homecare,peersupportprogrammes,
rehabilitationservices,theprovisionof
assistivedevices(rangingfrombasicdevices
suchasahearingaidtomoresophisticated
ones,suchasanelectronicalarmsystem),
respitecareandadultdaycareareallimpor-tantservicesthatenableinformalcaregiversto
continuetoprovidecaretoindividualswho
requirehelp,whatevertheirage.Otherforms
ofsupportincludetraining,incomesecurity
(e.g.,socialsecuritycoverageandpensions),
helpwithhousingadjustmentsthatenable
familiestolookafterpeoplewhoaredisabled
anddisbursementstohelpcovercaringcosts.
Astheproportionofolderpeopleincreasesin
allcountries,livingathomeintoveryoldage
withhelpfromfamilymemberswillbecome
increasinglycommon.Homecareandcom-
munityservicestoassistinformalcaregivers
needtobeavailabletoall,notjusttothose
whoknowaboutthemorcanaffordtopay
forthem.
Sexratiosforpopulationsage60andoverreflectthelargerproportionofwomenthanmeninallregionsoftheworld,particularlyinthemoredevelopedregions.
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PAGE39
ACTIVEAGEING:APOLICYFRAMEWORK
Professionalcaregiversalsoneedtraining
andpracticeinenablingmode lsofcarethat
recognizeolderpeoplesstrengthsandem-
powerthemtomaintainevensmallmeasures
ofindependencewhentheyareillorfrail.
Paternalisticordisrespectfulattitudesbypro-
fessionalscanhaveadevastatingeffectonthe
self-esteemandindependenceofolderpeople
whorequireservices.
Informationandeducationaboutactiveage-
ingneedstobeincorporatedintocurricula
andtrainingprogrammesforallhealth,social
serviceandrecreationworkersaswellascity
plannersandarchitects.Basicprinciplesand
approachesinold-agecareshou ldbemanda-
toryinthetrainingofallmedicalandnursing
studentsaswellasotherhealthprofessions.
Challenge 4: The Feminization of
Agein g
Womenlivelongerthanmenalmostevery-
where.Thisisreflectedinthehigherratioof
womenversusmeninolderagegroups.For
example,in2002,therewere678menfor
every1,000womenaged60plusinEurope.
Inlessdevelopedregions,therewere879men
per1,000women(SeeFigure12).Women
makeupapproximatelytwo-thirdsofthe
populationoverage75incountriessuchas
BrazilandSouthAfrica.Whilewomenhave
theadvantageinlengthoflife,theyaremore
likelythanmentoexperiencedomesticvio-
lenceanddiscriminationinaccesstoeduca-
tion,income,food ,meaningfulwork,health
care,inheritances,socialsecuritymeasuresand
politicalpower.Thesecumulativedisadvan-
tagesmeanthatwomenaremorelikelythan
Incontrasttothepyramidform,theJapanesepopulationstructurehaschangedduetopopulationageingtowardsaconeshape.By2025,theshapewillbesimilartoanup-side-downpyramid,withpersonsage80andoveraccountingforthelarg-estpopulationgroup.Thefeminizationofoldageishighlyvisible.
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PAGE40
mentobepoorandtosufferdisabilitiesin
olderage.Becauseoftheirsecond-classstatus,
thehealthofolderwomenisoftenneglected
orignored.Inaddition,manywomenhave
lowornoincomesbecauseofyearsspentin
unpaidcaregivingroles.Theprovisionoffam-
ilycareisoftenachievedatthedetrimentof
femalecaregiverseconomicsecurityandgood
healthinlaterlife.
Womenarealsomorelikelythanmentolive
toveryoldagewhendisabilitiesandmultiple
healthproblemsaremorecommon.Atage
80andover,theworldaverageisbelow600
menforevery1,000women.Inthemore
developedregionswomenage80andover
outnumbermenbymorethantwotoone(see
theexampleofJapaninFigure13).
Becauseofwomenslongerlifeexpectancy
andthetendencyofmentomarryyounger
womenandtoremarryiftheirspousesdie,
femalewidowsdramaticallyoutnumbermale
widowersinallcountries.Forexample,inthe
EasternEuropeancountriesineconomictran-
sitionover70percentofwomenage70and
overarewidows(Botev,1999).
Olderwomenwhoarealonearehighly
vulnerabletopovertyandsocialisolation.In
somecultures,degradinganddestructiveat-
titudesandpracticesaroundburialrightsandinheritancemayrobwidowsoftheirproperty
andpossessions,theirhealthandindepen-
denceand,insomecases,theirverylives.
Challen ge 5: Ethics an d Inequities
Aspopulationsage,arangeofethicalcon-
siderationscomestothefore.Theyareoften
linkedtoagediscriminationinresourceal-
location,issuesrelatedtotheendoflifeanda
hostofdilemmaslinkedtolong-termcareand
thehumanrightsofpooranddisabledolder
citizens.Scientificadvancementsandmodern
medicinehaveledtomanyethicalquestions
relatedtogeneticresearchandmanipulation,
biotechnology,stemcellresearchandtheuse
oftechno logytosustainlifewhilecompromis-
ingqualityoflife.Inallcultures,consumers
needtobefullyinformedaboutfalseclaims
ofanti-ageingproductsandprogrammesthat
areineffectiveorharmful.Theyneedprotec-
tionfromfraudulentmarketingandfinancing
schemes,especiallyastheygrowolder.
Societiesthatvaluesocialjusticemuststriveto
ensurethatallpoliciesandpracticesuphold
andguaranteetherightsofallpeople,re-
gardlessofage.Advocacyandethicaldeci-
sion-makingmustbecentralstrategiesinall
programmes,practices,policiesandresearch
onageing.
Olderageoftenexacerbatesotherpre-existing
inequalitiesbasedonrace,ethnicityorgender.
Whilewomenareuniversallydisadvantaged
intermsofpoverty,menhaveshorterlifeexpectanciesinmostcountries.Theexclusion
andimpoverishmentofolderwomenandmen
isoftenaproductofstructuralinequitiesin
bothdevelopinganddevelopedcountries.In-
equalitiesexperiencedinearlierlifeinaccess
toeducation,employmentandhealthcare,as
wellasthosebasedongenderandracehave
acriticalbearingonstatusandwellbeingin
oldage.Forolderpeoplewhoarepoor,theconsequencesoftheseearlierexperiences
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ACTIVEAGEING:APOLICYFRAMEWORK
areworsenedthroughfurtherexclusionfrom
healthservices,creditschemes,income-gener-
atingactivitiesanddecision-making.Inequities
incareoccurwhensmallandcomparatively
welloffportionsoftheageingpopulation,
particularlythoseindevelopingcountries,
consumeadisproportionatelyhighamountof
publicresourcesfortheircare.
Inmanycases,themeansforolderpeopleto
achievedignityandindependence,receive
careandparticipateincivicaffairsarevery
limited.Theseconditionsareoftenworsefor
olderpeoplelivinginruralareas,incountries
intransitionandinsituationsofconflictor
humanitariandisasters.
Inallregionsoftheworld,relativewealthand
poverty,gender,ownershipofassets,accessto
workandcontrolofresourcesarekeyfactors
insocioeconomicstatus.RecentWorldBank
datarevealthatinmanydevelopingcountries
welloverhalfofthepopulationlivesonless
thantwopurchasingpowerparity(PPP)dol-larsperday(seeTable4).
Itiswellknownthatsocioeconomicstatus
andhealthareintimatelyrelated.Witheach
stepupthesocioeconomicladder,peoplelive
longer,healthierlives(Wilkinson,1996).Inre-
centyears,thegapbetweenrichandpoorand
subsequentinequalitiesinhealthstatushas
beenincreasingincountriesinallpartsofthe
world(Lynchetal,2000).Failuretoaddress
thisproblemwillhaveseriousconsequences
fortheglobaleconomyandsocialorder,as
wellasforindividualsocietiesandpeopleof
allages.
Table4.Percentageofthepopulationbelowinternationalpovertylinesincountrieswithapopulationapproachingorabove100millionintheyear2000Countries Popu lation
(millions)#Percentagewith
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PAGE42
Challenge 6: The Economics of an
Agein g Population
Perhapsmorethananythingelse,policymak-
ersfearthatrapidpopulationageingwilllead
toanunmanageableexplosioninhealthcare
andsocialsecuritycosts.Whilethereisno
doubtthatageingpopulationswillincrease
demandsintheseareas,thereisalsoevidence
thatinnovation,cooperationfromallsectors,
planningaheadandmakingevidence-based,
culturally-appropriatepolicychoiceswill
enablecountriestosuccessfullymanagethe
economicsofanageingpopulation.
Researchincountrieswithagedpopulations
hasshownthatageingperseisnotlikelyto
leadtohealthcarecoststhatarespiralingout
ofcontrol,fortworeasons.
First,accordingtoOECDdata,themajor
causesofescalatinghealthcarecostsare
relatedtocircumstancesthatareunrelatedtothedemographicageingofagivenpopulation.
Inefficienciesincaredelivery,buildingtoo
manyhospitals,paymentsystemsthatencour-
agelonghospitalstays,excessivenumbers
ofmedicalinterventionsandtheinappropri-
ateuseofhighcosttechno logiesarethekey
factorsinescalationsinhealthcarecosts.For
example,intheUnitedStatesandotherOECD
countries,newtechno logiesweresometimesrapidlyintroducedandusedwherealternative
andlessexpensiveproceduresalreadyexisted,
andforwhichthemarginaleffectivenesswas
relativelylow(JacobzoneandOxley,2002).
Thereappearstobeconsiderablescopefor
policymakerstoaddresstheseissuesand
improvetheeffectivenessofhealthcare.
Second,thecostsoflong-termcarecanbe
managedifpoliciesandprogrammesaddress
preventionandtheroleofinformalcare.Poli-
ciesandhealthpromotionprogrammesthat
preventchronicdiseasesandlessenthedegree
ofdisabilityamongoldercitizensenable
themtoliveindependentlylonger.Another
majorfactoristhecapacityandwillingness
offamiliestoprovidecareandsupportfor
olderfamilymembers.Thiswilldependtoa
largeextentontheratesoffemaleparticipa-
tioninthelabourforceandonworkplaceand
publicpoliciesthatrecognizeandsupportthe
caregivingrole.
Inmanycountries,thebulkofspendingison
curativemedicine.Careforchronicconditions
leadstoanimprovedqualityoflife;however,
itisalwayspreferableifthoseconditionscould
bepreventedordelayeduntilverylateinlife.
Decisionmakersneedtoevaluatewhethersuch
outcomescanbeachievedthroughpoliciesthataddressthebroaddeterminantsofactiveage-
ing,suchasinterventionstopreventinjuries,
improvedietsandphysicalactivity,increase
literacyorincreaseemployment.
Ultimately,theleveloffund ingallocatedto
thehealthsystemisasocialandpolitical
choicewithnouniversallyapplicableanswer.
However,theWHOsuggeststhatitisbetter
tomakepre-paymentsonhealthcareasmuch
aspossible,whetherintheformofinsurance,
taxesorsocialsecurity.Theprincipleoffair
financingensuresequityofaccessregardless
ofage,sexorethnicityandthatthefinancial
burdenis