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Active Ageing: An Empirical Approach to the WHO Model

Active Ageing: An Empirical Approach to the WHO Model Hindawi Publishing Corporation Current Gerontology and Geriatrics Research Volume 2012, Article ID 382972, 10 pages doi:10.1155/2012/382972 Research Article 1 1, 2, 3 1 Constanc¸a Paul, ´ Oscar Ribeiro, and Laetitia Teixeira Research and Education Unit on Ageing, UnIFai, ICBAS, Institute of Biomedical Sciences Abel Salazar, Universidade do Porto, 4050-313 Porto, Portugal School of Health Sciences, University of Aveiro, Campus Universitar ´ io de Santiago, 3810-193 Aveiro, Portugal Instituto Superior de Servi¸co Social do Porto Cooperativa de Ensino Superior de Servic¸o Social, C.R.L., Avenue Dr. Manuel Teixeira Ruela, 370, 4460-362 Senhora da Hora, Portugal Correspondence should be addressed to Constanc¸a Paul, ´ paul@icbas.up.pt Received 19 April 2012; Accepted 16 September 2012 Academic Editor: Roc´ıo Fernandez-Bal ´ lesteros Copyright © 2012 Constanc¸a Paul ´ et al. This is an open access article distributed under the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. Background. In the beginning of the 21st century, the world summit on population taking place in Madrid approved active ageing, WHO (2002) as the main objective of health and social policies for old people. Few studies have been done on the scientific validity of the construct. This study aims to validate the construct of active ageing and test empirically the WHO (2002) model of Active Ageing in a sample of community-dwelling seniors. Methods. 1322 old people living in the community were interviewed using an extensive assessment protocol to measure WHO’s determinants of active ageing and performed an exploratory factor analysis followed by a confirmatory factor analyses. Results. We did not confirm the active ageing model, as most of the groups of determinants are either not independent or not significant. We got to a six-factor model (health, psychological component, cognitive performance, social relationships, biobehavioural component, and personality) explaining 54.6% of total variance. Conclusion. The present paper shows that there are objective as well as subjective variables contributing to active ageing and that psychological variables seem to give a very important contribute to the construct. The profile of active ageing is expected to vary between contexts and cultures and can be used to guide specific community and individually based interventions. 1. Introduction multidimensional approach and a broad view of “health.” In fact, for many years WHO used to talk about healthy ageing, The World Health Organization (WHO) defines active considering primary ageing without major pathologies, and ageing as “... the process of optimizing opportunities for health, only in the XXI century this concept was substituted by the participation, and security in order to enhance quality of life more comprehensive concept of active ageing, considering as people age”[1]. The emergence of this concept back in not only health indicators but also psychological, social, and the 1990s developed through the WHO and several other economic aspects, which are to be looked through commu- governmental and nongovernmental organization initiatives nities’ approaches within gender and cultural perspectives. offers a policy framework that emphasizes the link between Notwithstanding the established importance of WHO’s activity, health, independence, and ageing well. In being of concept of active ageing as the leading global policy strategy unquestionable importance as a key policy concept, efforts in Europe [3], the scientific interest on its empirical dimen- to add some empirical evidence on its operative definition sion seems scarce at an international level. Based on a litera- and criteria are still scarce. As a potential variation of other ture review using the key words “active ageing” and “WHO terms used interchangeably in the gerontological literature as (2002)” on HighWire plus Medline, we found only 8 articles positive and productive ageing, the interpretation of active referring to the existence of the political framework proposed ageing often focuses on the labour market participation by WHO. In PsyInfo database, results were even scarcer anchored in an economic framework [2] or in a perspective with only two comments on Fernandez-Ballesteros’ book on strongly health oriented, though the WHO does take an active ageing [4]. It seems that the document produced by 2 Current Gerontology and Geriatrics Research WHO is more relevant in Europe than in the USA, with actual behaviors of individuals on ageing outcomes. Based on many countries introducing the model recommendations latent profile analyses, they concluded that successful ageing into their national health and social plans of action although, is a multidimensional construct that includes both objective in general, it did not elicit many scientific discussion. In USA, and subjective characteristics, and that ageing outcomes researchers seem not to use the concept boosted by WHO in can be modifiable by current behaviors. In another paper, 2002 in their scientific papers and prefer to use the parallel Pruchno et al. [9] tested the two factor model of successful concept of “successful ageing” as proposed by Rowe and ageing by doing a confirmatory factor analyses. Factors were Kahn [5, 6] when referring to ageing well or optimal ageing. objective success (ample functional abilities, little or no pain, As a matter of fact, for the concept “successful ageing” we and few chronic diseases) and subjective success (perceptions found 3587 papers in the same data bases. of ageing successfully, ageing well, and overall evaluation of current state of one’s life). They showed that age and gender were associated with objective but not subjective perceptions 1.1. The Active Ageing Model. The concept of active ageing of successful ageing. [1] is based on three pillars mentioned in the definition: Previous discussion on the issue of objective versus participation, health, and security. The proposed model subjective variables of successful ageing had stressed the idea encompasses six groups of determinants, each one including that the proportion of people claiming ageing successfully is several aspects: (1) health and social services (promoting higher than the proportion of people classified as successful health and preventing disease; health services; continuous agers by objective indicators [10]. These authors found 92% care; mental health care); (2) behavioral (smoking; physical of old people perceiving themselves as successful, although activity; food intake; oral health; alcohol; medication); (3) they were not free of disease or disability. The majority of personal (biology and genetics and psychological factors); subjects met the criteria for independent living, mastery, (4) physical environment (friendly environment; safety positive adaptation, life satisfaction, and active engagement, houses; falls; absence of pollution); (5) social (social support; and only 15% met the criteria for absence of physical violence and abuse; education); (6) economic (wage; social illness, and 28% reported no physical limitation. Successful security; work), embedded in cultural and gender context, ageing was not related to age, gender, ethnicity, marital with recommendations for health policy for old people, to status, education, and income which emphasize, in our view, be implemented through national health plans all over the the psychosocial variables of successful ageing over other world, during the first decade of the XXI century. characteristics of individuals. According to the WHO document on active ageing [1], In a different society (Taiwan), Lee et al. [11]confirmed the key aspects of active ageing are (1) autonomy which a four-factor model of successful ageing. Again leisure is the perceived ability to control, cope with, and make activities appeared as a very relevant factor to the successful personal decisions about how one lives on a day-to-day ageing process. Chaves et al. [12] studied the predictors of basis, according to one’s own rules and preferences; (2) normal and successful ageing in urban old Brazilians and independence, the ability to perform functions related to found 62% successful old people that fulfill the criteria of daily living—that is the capacity of living independently in health and independence, differing from “normal” ones, the community with no and/or little help from others; (3) namely, in the amount of leisure activities. In this same quality of life that is “an individual’s perception of his or her study, the number of living children appeared as a risk position in life in the context of the culture and value system factor, whereas confidents and family income were protective where they live, and in relation to their goals, expectations, factors of successful ageing. Authors discussed these findings standards, and concerns. It is a broad ranging concept, considering that in developing countries as Brazil, contrarily incorporating in a complex way the person’s physical health, to developed ones, socioeconomic status and social network psychological state, level of independence, social relationships, seem to be more important than biological variables to personal beliefs, and relationship to salient features in the predict successful ageing. environment.” [7]. As people age, their quality of life is When examining the concept of ageing well in Europe largely determined by their ability to maintain autonomy and and Latin America, Fernandez-Bal ´ lesteros et al. [13, 14] independence and (4) healthy life expectancy which is how found evidence of considerable consistency across countries, long people can expect to live without disabilities. continents, and ages. The common thoughts toward ageing Active ageing appears as an outcome of different determi- were that healthy ageing was the most important factor nants that should allow us to identify particular profiles that followed by independence (ability to manage oneself) and are more at risk or, on the other hand, are more favorable to social implication which included positive affect. The ability age actively. to learn new things and the ability to work after retirement, as well as feeling able to influence others and staying involved 1.2. Measuring Successful and Active Ageing. Recently, with the world and people were considered less important. Pruchno et al. [8]wrote apaper on the earlyand con- These results are quite similar to those of Bowling [15] that reported that over three-quarters of respondents were temporary characteristics of successful ageing. The authors stressed the proliferation of research on this topic over classified as ageing successfully, with self-perceived health the past 50 years yet the inexistence of harmony on its status and quality of life as predictors of self-rated successful ageing. This author considers that the biomedical perspective definition and measure. The main point was to understand the influence of genetic and early experiences, as well as of successful ageing needs balancing with a psychosocial one. Current Gerontology and Geriatrics Research 3 McLaughlin et al. [16] based on the Rowe and Kahn In this paper, we explore the WHO’s model of active model [5, 6] had already estimated the prevalence of ageing [1] that embraces positive outcomes of the ageing successful ageing on a national sample of older adults. The process. It is a challenge to examine the validity of the factors considered were disease and disability, cognitive and model and its empirical potential to foster quality of life in physical functioning, and social connections and productive old people. Although we cannot really speak about “deter- activities. Results showed that only 11.9% individuals were minants of active ageing” as we cannot assert any causality ageing successfully every year, and that this percentage low- without having a clear dependent variable and by doing a ered in 25% between 1998 and 2004. The probability of being cross-sectional research, we intended to understand which successful is lower for those with advanced age, male gender, and how the groups of variables are associated with active and lower socioeconomic status. Based in this analysis, the ageing. The main purpose of this research was to (i) built a authors considered that there is a need for modification in protocol to assess WHO active ageing model and (ii) to verify the concept of successful ageing for public health purposes. which are the determinants that better explain active ageing. Depp and Jeste [17] made an extensive review on successful ageing studies and found in 28 selected studies that 26 of 2. Methods them included disability and very few psychosocial variables. The most frequent correlates of successful ageing were young 2.1. Data Collection. This paper is part of an extensive Por- age, no smoking, and absence of disability, arthritis, and tuguese project on active ageing (DIA project) that includes diabetes. About 1/3 of individuals were ageing successfully, a cross-sectional survey of adults aged 55+ years living although the differences from study to study were large. in the community. For this study, subjects were recruited When explicitly exploring the concept of active ageing, through announcements in local newspapers, local agencies Bowling [18] reported that a third of respondents rated (e.g., seniors clubs), and NGO’s and using the snowball themselves as ageing “very actively” and almost a half as method by which participants indicate other persons with “fairly actively.” The most common perceptions of active similar conditions. The study ran in different Portuguese ageing were having/maintaining physical health and func- regions, including the Madeira and Azores islands. The tioning (43%), leisure and social activities (34%), mental survey was conducted by trained interviewers, using a functioning and activity (18%), and social relationships and structured questionnaire format that entailed demographic, contacts (15%). The predictors of positive self-rated active psychological, and social questions. A full description of ageing were optimum health and quality of life. More the assessment protocol (P3A) can be found in Paul ´ et al. recently, Stenner et al. [19] reported the subjective aspects of [22]and at http://www.projectodia.com. The interviews took active ageing by inquiring people about the meaning of the place in local community facilities (e.g., parish hall) or at words “active ageing.” The authors showed that most people the participants’ homes. Informed written consents were refer physical activity but also autonomy, interest in life, cop- obtained from all the participants. ing with challenges, and keeping up with the world. As men- tioned, people mix physical, mental, and social factors and stressed agentic capacities and living by one’s own norms. The 2.2. Sample Characteristics. The sample comprises 1322 authors criticized the deterministic view of the WHO model persons aged 55–101 years old. The average age was 70.4 and emphasized the need for a “challenge and response” years (SD 8.7 years), and females comprised 71.1% (n = framework, a psychosocial approach to the conflict between 939) of the sample. The majority of participants were facts and expectations, and the proactive attitude of people. married/partnered (n = 729, 55.7%), 400 (30.6%) were In overall, successful ageing, active ageing, and other widowed, 114 (8.7%) were single, and 65 (5.0%) were related terms as positive ageing or ageing well are viewed divorced. As for the social network, 24.7% of the participants as scientific concepts operationally portrayed by a broad set lived alone. Primary school education was reported by 55.3% of biopsychosocial factors, assessed through objective and of the respondents, 19.1% had never attended school, 17.8% subjective indicators as well as being closely related to lay had completed high-school, and 7.7% had higher education concepts reported cross-culturally by older persons [20]. (trade qualification or university degree). Most participants Considering the heterogeneity of old people and the huge (49.6%) had a monthly income equal or less than 386C variety of individual trajectories, it is difficult, and probably (by reference to the Portuguese Minimum National Wage ineffective, to define the core concept of successful ageing. in 2006). For the statistical analysis, as the distribution A strict pattern of success excludes too much people all of missing values did not follow a pattern, participants around the world, and an attempt to establish a standard for with at least one missing response were eliminated, and successful ageing, even a hypothetical biomedical objective the final sample contains 925 persons. The actual sample standard, does not embrace the differences observed in old diverges from the national distribution of characteristics of people (e.g., those with born or acquired incapacity). The old people [23], in the percentage of men and women in the concept of active ageing, although very difficult to measure, sample, with a higher percentage of women in our sample seems less deterministic, either as an outcome or as a process than the existing in the Portuguese population 55+ years of achieving it. On the contrary, the well-known concept of (71% versus 57% women) and the percentage of married successful ageing of Rowe and Kahn [5] looks more narrow individuals and widows (55.7% versus 71.1% married and and unrealistic, considering the very small amount of people 30.6% versus 20.1% widows). A special mention is to be (around 8.5%) that fulfill the criteria of ageing well [21]. made on the percentage of illiterate people in our study 4 Current Gerontology and Geriatrics Research Table 1: Instruments used for each of the WHO’s active ageing model determinants. WHO (2002) Assessment protocol “P3A” Determinants contents Psychological distress GHQ-12 [28] Happiness QBE/F [32] Biology and genetics Cognitive functioning MMSE [25] Personal factors psychological factors Personality NEO (Costa and McCrae, 1992 [31]) Optimism LOT-R [30] Loneliness Loneliness scale (Paul ´ et al., 2008 [22]) Pulmonary function Peak flow Strength Hand grip Subjective health Smoking Illness Physical activity Sleep problems Behavior Food intake Subj. physical activity Health and life styles questionnaire determinants Oral health (ESAP, Fernandez-Bal ´ lesteros et al., 2004 Alcohol Vision [24]) Medication Audition Smoking Drinking ADL and IADL Social support Lubben scale of social support (Lubben, Social network Determinants of 1988) [27] Violence and abuse social environment Education Education Sociodemographic questionnaire Health and disease Determinants of Health services Inventory of life satisfaction (Fonseca et health and social Life satisfaction Continuous care al., 2011 [34]) services Mental health care Friendly environment Determinants of WHOQOL Brief—physical environment Environment domain Safety houses physical subscale (Harper et al.,1998 [7], of quality of life Falls environment Canavarro et al., 2010 [33]) Absence of pollution Wage Economic Socioeconomic status (National Institute Social security Income determinants of Statistics) Work which is similar to the national figures: 19.1% versus 17% with General Health Questionnaire (GHQ-12) [28]; opti- for people 15+ years. mism was assessed with the Portuguese Version of the Life Orientation Test-Revised (LOT-R) [29, 30]; personality was evaluated with the NEO Personality Inventory [31]which 2.3. Measures. Theprotocolmeasuresthe different groups comprises three subscales—neuroticism, extraversion, and of determinants of WHO’s active ageing model and was openness to experience; happiness was assessed with a single elaborated considering an extensive literature review of most common instruments used in Gerontology and previously question with four categories [32]; and environment domain of quality of life was measured with World Health Organi- used the European Survey on Ageing Protocol [24](Table 1). All instruments are adapted to Portuguese. zation Quality of Life-BREF (WHOQOL-BREF) [7, 33]and Along with socio demographic characteristics (gender, Inventory of Life Satisfaction [34]. Biobehavioral measures, age, education, and income), we analyzed cognitive function- including pulmonary function and strength, were assessed ing as measured by the Portuguese version of the Minimental using a standard “Mini Peak Flow Meter” (Datosprir Peak- 10, Sibelmed) and with an electronic dynamometer (Grip-D, State Examination (MMSE) adapted to illiterate people and to people with very few years of education [25, 26]; social TAKEI Scientific Instruments Co., LTD), respectively. Finally, network was assessed with the Lubben Social Network Scale health and physical condition were evaluated by self-report (LSNS) which comprises three subscales—family, friends, indicators (determined by a standard health-rating item: “In and confidants [27]; psychological distress was measured general, how would you rate your health?”), illness (sum Current Gerontology and Geriatrics Research 5 Table 2: Definition of variables. Variable Coding Subjective health 1 = very good; 2 = good; 3 = reasonable; 4 = poor; 5 = very poor Sleep problems 0 = no; 1 = yes Subjective physical activity 1 = very good; 2 = good; 3 = reasonable; 4 = poor; 5 = very poor ADL 0 = with difficulties; 1 = without difficulties Illness 0 = none;1 = 1 illness; 2 = 2 illness; 3 = 3 illness; 4 = 4ormoreillness Psychological distress 1 = <9; 2 = [9, 12[; 3 = [12, 16[; 4 = ≥16 Happiness 1 = nothing; 2 = 2; 3 = 3; 4 = very Optimism 1 = <11; 2 = [11, 13[; 3 = [13, 15[; 4 = ≥15 Quality of life 1 = <24; 2 = [24, 26[; 3 = [26, 29[; 4 = ≥29 Loneliness 0 = yes; 1 = no Cognitive impairment 1 = <25; 2 = [25, 28[; 3 = [28, 30[; 4 = ≥30 1 = no specs and very poor/poor vision; 2 = no specs and acceptable vision; 3 = no Vision specs and good/very good vision; 4 = specs and very poor/poor vision; 5 = specs and acceptable vision; 6 = specs and good/very good vision 1 = no device use and very good/good audition; 2 = no device use and acceptable Audition audition/3 = no device use and poor/very poor audition; 4 = use device Smoking 1 = no; 2 = ex-smoker; 3 = yes Drinking 1 = never; 2 = special occasions; 3 = occasionally; 4 = regularly Income 1 = ≤386 C;2 = 386 C–772 C;3 = 772 C–1158 C;4 = >1158 C Education level 1 = no formal; 2 = primary; 3 = 5–8 years; 4 = 9–12 years; 5 = university Peak flow 1 = <180; 2 = [180, 250[; 3 = [250, 340[; 4 = ≥340 Grip strength 1 = <18.3; 2 = [18.3, 22.9[; 3 = [22.9, 29.0[; 4 = ≥29.0 Family 1 = <9; 2 = [9, 11[; 3 = [11, 13[; 4 = ≥13 Friends 1 = <5; 2 = [5, 8[; 3 = [8, 10[; 4 = ≥10 Confidents 1 = <4; 2 = [4, 7[; 3 = [7, 9[; 4 = ≥9 Neuroticism 1 = <30; 2 = [30, 34[; 3 = [34, 37[; 4 = ≥37 Extraversion 1 = <39; 2 = [39, 41[; 3 = [41, 44[; 4 = ≥44 Openness to experience 1 = <35; 2 = [35, 37[; 3 = [37, 40[; 4 = ≥40 Quartiles; by reference to the Portuguese Minimum National Wage in 2006. of self-reported health problems), sleep problems, subjective were obtained using factor score regressions generated from physical activity (determined by the item: “In general, how the confirmatory factor analysis as proportional weight to would you rate your physical condition?”), ADL, loneliness, combine item scores. Our process of analysis started with the vision, audition, smoking, and drinking. Details regarding full factors and items, and then we used a nested models variables and coding are shown in Table 2. approach to test alternative nested structures to test fit improvement. In addition to theoretical and practical con- siderations, evaluation of fit of model was based on the 2.4. Exploratory Factor Analysis. The factor structure of following goodness of fit criteria, including normed chi- P3A was examined by exploratory factor analysis, using squared (χ /df ), the comparative fit index (CFI), the good- principal-components extraction with varimax rotation. For ness of fit index (GFI), the Akaike’s information criteria the continuous variables, we used the quartiles in order to (AIC), and the Browne-Cudeck criterion (BCC). CFI and standardize the variables and use only categorical variables GFI indices assume values in range from 0 to 1, with higher in the exploratory factor analysis. Exploratory factor analysis scores indicating better fit. Models with the lowest values of was conducted using SPSS 17.0 for Windows. AIC are most likely to be good fits. We used the chi-square difference statistics to test the significance of the change in 2.5. Confirmatory Factor Analysis. Confirmatory factor anal- the chi-square test for each alternative model over the full model. Lastly, we examined the effect of age and gender on ysis was conducted to test the viability of a hypothesized the final model estimating paths between age and gender and structure that had been formulated from theoretical con- siderations and results of the exploratory factor analysis. factors. Nonsignificant paths were removed, and the model was estimated over and over until only significant paths Confirmatory factor analysis was conducted using AMOS 18 for Windows. Satisfaction scores for each dimension remained. 6 Current Gerontology and Geriatrics Research Table 3: Factor structure of P3A—exploratory factor analysis. Factors Questions 12 3 4 5 6 Subjective health 0.652 −0.298 −0.312 −0.071 −0.131 −0.104 Sleep problems 0.620 −0.154 0.152 0.133 −0.114 0.260 Subjective physical condition 0.670 −0.218 −0.250 −0.061 −0.104 −0.223 ADL −0.563 0.052 0.262 0.160 −0.103 0.139 Illness 0.673 −0.067 0.004 −0.241 0.009 0.035 Psychological distress 0.437 −0.586 −0.101 −0.084 −0.112 −0.005 Happiness −0.265 0.540 0.105 −0.085 0.260 0.213 Optimism −0.050 0.683 −0.035 0.039 0.065 0.068 Neuroticism 0.096 −0.695 −0.114 −0.163 0.171 0.108 Quality of life—environment −0.076 0.616 0.286 0.075 0.051 0.132 Loneliness −0.149 0.492 −0.011 0.126 0.351 −0.084 Cognitive impairment −0.096 0.180 0.594 0.396 0.103 −0.146 Vision −0.100 −0.001 0.592 −0.211 0.056 0.242 Income −0.162 0.135 0.699 0.261 0.126 −0.198 Education level −0.098 0.133 0.807 0.204 0.034 −0.199 Peak flow −0.044 0.157 0.295 0.700 0.056 −0.051 Grip strength −0.266 0.098 0.042 0.782 0.060 0.058 Social relations—family −0.028 0.109 −0.006 0.112 0.727 −0.063 Social relations—friends −0.131 0.074 0.130 0.078 0.400 0.269 Social relations—confidence 0.024 0.013 0.104 −0.065 0.700 0.011 Extraversion −0.196 0.106 −0.027 −0.199 0.055 0.655 Openness to experience 0.123 0.014 −0.190 0.143 −0.016 0.734 % of variance explained 11.6 11.2 10.6 7.7 6.9 6.6 Health Behavioural determinants Social Social Health and determinants relationship social services Active ageing Economic Physical determinants environment Personal determinants Cognitive Personality Biobehavioral Psychological performance Figure 1: The WHO model and the empirically achieved model. Current Gerontology and Geriatrics Research 7 Table 4: Goodness-of-fit statistics for confirmatory factor analysis models of P3A. 2 2 Model χ df χ /df CFI GFI χ AIC BCC dif 1 701.342 194 3.615 0.891 0.936 — 819.342 822.354 2 562.046 172 3.268 0.913 0.946 139.30 680.046 682.924 3 557.039 155 3.594 0.908 0.944 5.01 667.039 669.597 4 489.170 153 3.197 0.923 0.950 67.87 603.170 605.822 0.7 e1 Subjective health 0.83 0.75 0.57 Subjective physical Health e3 condition 0.24 e4 ADL −0.49 0.24 0.49 e5 Illness 0.51 Psychological 0.73 e6 0.72 distress 0.37 −0.6 Happiness e7 −0.45 0.2 Optimism e8 −0.15 Psychological 0.23 −0.48 Neuroticism e9 0.48 0.32 −0.43 Quality of life e10 −0.56 −0.48 0.23 −0.37 Loneliness e11 −0.43 0.59 0.77 Cognitive impairment e12 −0.26 −0.46 −0.63 Cognitive 0.77 −0.51 Income e14 0.88 0.6 −0.26 Education level 0.61 0.77 e15 0.54 0.74 Peak flow e16 0.31 Biobehavioral 0.35 Handgrip e17 0.59 −0.22 0.28 0.52 0.27 Social relationship e18 Family 0.41 0.17 Social relationship Social relationship −0.14 e19 Friends 0.12 Social relationship e20 0.15 Confidence 0.35 0.42 0.65 Extraversion e21 Personality Openness to 0.12 e22 experience 0.35 Figure 2: Factor structure model for P3A. 3. Results skewed, showing a pattern of responses in only one or two categories (e.g., no smokers; no heavy drinkers). 3.1. Descriptive Analysis. Descriptive analysis (absolute and relative frequencies) was performed for all variables described in Table 2. When exploring the results, the 3.2. Exploratory Factor Analysis. The factor structure was variables “smoking” and “drinking” were excluded to the examined by principal-components extraction with varimax final analysis because distribution for this two variables were rotation for the pooled sample (n = 925). The Bartlett 8 Current Gerontology and Geriatrics Research sphericity test and the Kaiser-Meyer-Olkin (KMO) test were follows in weight showing the importance of wage, edu- performed; the first revealed a 0.001 level of significance and cation, vision, and cognitive performance. The “biobehav- a KMO value of 0.855, indicating that factor analysis seemed ioral component,” comprising respiratory capacity and grip to be highly adjusted to this analysis. Six distinct factors, strength clearly shows the importance of biological aspects accordingly to the theoretical six determinants of the WHO during the ageing process. “social relationship”, including model, were revealed (Table 3), explaining 54.6% of total family, friends, and confidents, illustrates the relevance of variance. The item “hearing” was eliminated because it had a social network for the quality of life of old people. Finally, the loading lower than 0.3 in all factors. “personality component” was reduced to extraversion and openness to experience, as neuroticism merged with other (i) Factor 1. Health component: this factor comprises psychological variables in the “psychological component.” five variables (subjective health, sleep problems, The profile is quite homogeneous with factors loading subjective physical condition, ADL, and illness) and between 11.6% and 6.6% and explaining a good amount of explained 11.6% of total variance. total variance (54.6%). (ii) Factor 2. Psychological component: six variables 3.3. Confirmatory Factor Analysis. We analyzed the full load heavily of this factor (psychological distress, six-factor model for the 22 variables by using the six happiness, optimism, neuroticism, quality of life— item clusters derived from the exploratory factor analysis environment, and loneliness), which accounted for (presented in Table 3). From the results of this first full 11.2% of the total variance. model that replicated the measurement structure derived (iii) Factor 3. Cognitive performance component: four from the original exploratory factor analysis, we proposed questions have their highest loadings on this factor alternative models. We used a nested models approach to (cognitive impairment, vision, income, and educa- test alternatives to the full model (Model 1), elimination tion level) and explained 10.6% of total variance. of item “sleep problems” (Model 2), elimination of item “vision” (Model 3), adding the following covarying error (iv) Factor 4. Biological component: this factor comprises variances between “optimism” and “neuroticism” items and only two variables (peak flow and grip strength) and between “cognitive impairment” and “income” items (Model explained 7.7% of total variance. 4). However, these do not introduce any change in the final (v) Factor 5. Social relationship component: three vari- model. Fit statistics of the full model and subsequent models ables have their highest loadings on this factor are presented in Table 4. (family, friends, and confidence), accounting for The confirmatory factor analyses structure describes 6.9% of total variance. adequately the 6 factors reinforcing the adequacy of the proposed model. The various indices of fit presented in (vi) Factor 6. Personality component: the last factor con- Table 4 suggest that satisfaction structure can be adequately tains only two variables (extraversion and openness described by the 6 correlated factors which are graphically to experience) and explained 6.6% of total variance. presented in Figure 2 (Model 4). Latent constructs (active ageing components) are shown as ellipses, and questionnaire Comparing to the original model [1], our findings revealed items measuring these latent constructs are represented as a somewhat different one, depicted in Figure 1. Health rectangles. and social services determinants merged with behavior Finally, testing the effects of age and gender, only the determinants in a single component entitled “health” that paths between gender and the “cognition component” and includes functionality and life style. Personal determinants gender and the “Biobehavioral component” were significant split into several components, namely, “psychological,” (P< 0.05, for both). Nonsignificant paths were removed, and “cognitive performance,” “personality,” and “biobehavioral.” the final model revealed that the model fit the data very well Physical determinants and environment determinants moved (χ = 624.19, df = 171, P< 0.001, CFI = 0.906, GFI = to the “psychological component” as a variable of perceived 0.941). Women had higher levels of “Cognitive performance subjective well-being. Economic determinants migrated to component” and lower levels of “Biobehavioral component.” the new component called “cognitive performance.” Only social determinants stayed as an independent factor that we renamed “social relationships.” 4. Discussion The achieved model shows that the “health component” is the major factor associated with active ageing and includes When we look at the WHO model we can see that self-perception of health, the number of diagnosis, function- apart from the social determinant all the others endured a ality (ADL and IADL), and life style. The second component rearrangement that lead to six factors not similar to the was “psychological,” which is frequently forgotten in liter- original ones. However, “active ageing” remained a complex ature, with the exception of psychopathological indicators. construct, where health and psychological adaptation play In this study, psychological variables include both negative the major role. Many of the determinants proved to be affect (psychological distress, loneliness, and neuroticism) entwined, reflecting the transaction between individual and and positive affect (happiness, quality of life—environment, environmental factors in shaping adaptation to the ageing and optimism). The “cognitive performance component” process. Current Gerontology and Geriatrics Research 9 The economic determinants as well as the physical environ- The WHO active ageing model [1]based on 6deter- ment and health and social services relevance were found to minants was not empirically validated in its structure for be associated with personal needs, resources, and outcomes the sample here considered. Some groups of determinants and do not configure independent factors. According to were found to be deeply intertwined. The proposed model our findings, people seem to perceive and assess reality requires further developments, namely, by studying psy- concerning social and personal conditions through the chological mechanisms that might be related to the ability glasses of their own values and needs, adding to their real to cope with ageing, and particularly among the very old. circumstances a self-perceived valuation of what they are Culture-based approaches are also to be considered in future experiencing. Globally, we can say that subjective and objec- studies. tive health and functionality constitute the main component This study has two main limitations. The first one regards of active ageing which goes in line with Pruchno et al. to the exclusive use of self-rated measures that may had led to [8, 9] findings; the psychological component, be it positive an overall “perceived reality” whilst some of the active ageing characteristics of individuals (e.g., happiness, optimism) or determinants are to be more objective (e.g., actual presence pathological ones (e.g., psychological distress, neuroticism), of social and health services), although Portugal has a NHS is the second most relevant factor, reinforcing the idea of with universal and free access and a reasonable coverage of positive affect associated with less mortality and longevity services for the elderly (nursing homes and day centres and (e.g., [35]); cognition appearing close to vision supports a not so extensive service of home care). On this aspect, it Baltes and Mayer’s [36] findings on the importance of senses is worthwhile mentioning that most of the municipalities in cognition and in the overall optimal ageing. Income and have conventional services for old people and that self-report education levels that contribute for this factor show, on one of availability and satisfaction of community health and hand, the importance of cognition in the process of ageing social services is thought to better reflect the reality and the and, on the other hand, a close association between income, experience of the present cohort of old people. Moreover, access to education, and cognitive performance. Biological the use of mostly self-reported measures except for cognitive variables proved to be very sensitive to gender and age as performance and biological parameters, although missing clinical diagnosis and objective environmental variables, expected (e.g., peak flow and grip strength), and contributing independently to active ageing; social relationship including constitutes a reliable overview of old people perspective of their own condition and that of the context in which they family, friends, and confidents networks supports Bowling’s live. Both these aspects must be considered when interpreting [15] findings on the importance of social networks to our findings and when conducting further research. The successful ageing; finally, personality seems to introduce second main limitation has to do with the sampling process a factor of more or less adaptability to the challenges of (e.g., using announcements in newspapers, senior clubs) ageing. which may have resulted in a selection towards the most This achieved six-factor model reveals the major contri- active older adults. We consider that further studies should butions the active ageing constructs and goes beyond the comprise different sample selection procedures and a wider successful ageing model that establishes a strict pattern of coverage of older people towards a more representative success by considering that different profiles of old people overview of the Portuguese population. in different contexts may be classified as active with areas The challenge of active ageing is health and independent in debt being compensated by more advantaged ones. The functioning, whereas psychological variables appear to be relative load of each factor will presumably change in diverse highly relevant determining the individual adaptation to the contexts or groups of people, emphasizing the need for ageing process. In this sense, interventions are to consider the different intervention programs to foster quality of life prevention of health problems from adulthood and the allocating diverse life trajectories, and where, for instance, increasing of psychological resilience, avoiding loneliness or high income can compensate smaller social networks or increasing happiness and subjective wellbeing. Other social optimistic disposition can compensate disability to balance and political variables demand different kinds of interven- positively the process of ageing. Furthermore, rather than tion at a community-based level, namely, rising income health problems that most of old people have (and/or and carefully planning the retirement process and pensions expected to have in some extent) and some functional limita- regimens. tions, the difference between old people ageing actively or not may vary with the psychological characteristics and status that enable them to cope with ageing related declines, look Acknowledgment forward, and keep committed to life. By keeping active in the broader sense of the concept, old people seem to overcome This paper draws from a research project supported by the Foundation for Science and Technology (FCT), Portugal difficulties and keep highly motivated to participate in the (Grant POCTI/PSI/56505/2004). social world and engage in healthy behaviors which raise quality of life during the ageing process. 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Active Ageing: An Empirical Approach to the WHO Model

Current Gerontology and Geriatrics Research , Volume 2012 – Oct 31, 2012

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Copyright © 2012 Constança Paúl et al.
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1687-7063
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10.1155/2012/382972
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Abstract

Hindawi Publishing Corporation Current Gerontology and Geriatrics Research Volume 2012, Article ID 382972, 10 pages doi:10.1155/2012/382972 Research Article 1 1, 2, 3 1 Constanc¸a Paul, ´ Oscar Ribeiro, and Laetitia Teixeira Research and Education Unit on Ageing, UnIFai, ICBAS, Institute of Biomedical Sciences Abel Salazar, Universidade do Porto, 4050-313 Porto, Portugal School of Health Sciences, University of Aveiro, Campus Universitar ´ io de Santiago, 3810-193 Aveiro, Portugal Instituto Superior de Servi¸co Social do Porto Cooperativa de Ensino Superior de Servic¸o Social, C.R.L., Avenue Dr. Manuel Teixeira Ruela, 370, 4460-362 Senhora da Hora, Portugal Correspondence should be addressed to Constanc¸a Paul, ´ paul@icbas.up.pt Received 19 April 2012; Accepted 16 September 2012 Academic Editor: Roc´ıo Fernandez-Bal ´ lesteros Copyright © 2012 Constanc¸a Paul ´ et al. This is an open access article distributed under the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. Background. In the beginning of the 21st century, the world summit on population taking place in Madrid approved active ageing, WHO (2002) as the main objective of health and social policies for old people. Few studies have been done on the scientific validity of the construct. This study aims to validate the construct of active ageing and test empirically the WHO (2002) model of Active Ageing in a sample of community-dwelling seniors. Methods. 1322 old people living in the community were interviewed using an extensive assessment protocol to measure WHO’s determinants of active ageing and performed an exploratory factor analysis followed by a confirmatory factor analyses. Results. We did not confirm the active ageing model, as most of the groups of determinants are either not independent or not significant. We got to a six-factor model (health, psychological component, cognitive performance, social relationships, biobehavioural component, and personality) explaining 54.6% of total variance. Conclusion. The present paper shows that there are objective as well as subjective variables contributing to active ageing and that psychological variables seem to give a very important contribute to the construct. The profile of active ageing is expected to vary between contexts and cultures and can be used to guide specific community and individually based interventions. 1. Introduction multidimensional approach and a broad view of “health.” In fact, for many years WHO used to talk about healthy ageing, The World Health Organization (WHO) defines active considering primary ageing without major pathologies, and ageing as “... the process of optimizing opportunities for health, only in the XXI century this concept was substituted by the participation, and security in order to enhance quality of life more comprehensive concept of active ageing, considering as people age”[1]. The emergence of this concept back in not only health indicators but also psychological, social, and the 1990s developed through the WHO and several other economic aspects, which are to be looked through commu- governmental and nongovernmental organization initiatives nities’ approaches within gender and cultural perspectives. offers a policy framework that emphasizes the link between Notwithstanding the established importance of WHO’s activity, health, independence, and ageing well. In being of concept of active ageing as the leading global policy strategy unquestionable importance as a key policy concept, efforts in Europe [3], the scientific interest on its empirical dimen- to add some empirical evidence on its operative definition sion seems scarce at an international level. Based on a litera- and criteria are still scarce. As a potential variation of other ture review using the key words “active ageing” and “WHO terms used interchangeably in the gerontological literature as (2002)” on HighWire plus Medline, we found only 8 articles positive and productive ageing, the interpretation of active referring to the existence of the political framework proposed ageing often focuses on the labour market participation by WHO. In PsyInfo database, results were even scarcer anchored in an economic framework [2] or in a perspective with only two comments on Fernandez-Ballesteros’ book on strongly health oriented, though the WHO does take an active ageing [4]. It seems that the document produced by 2 Current Gerontology and Geriatrics Research WHO is more relevant in Europe than in the USA, with actual behaviors of individuals on ageing outcomes. Based on many countries introducing the model recommendations latent profile analyses, they concluded that successful ageing into their national health and social plans of action although, is a multidimensional construct that includes both objective in general, it did not elicit many scientific discussion. In USA, and subjective characteristics, and that ageing outcomes researchers seem not to use the concept boosted by WHO in can be modifiable by current behaviors. In another paper, 2002 in their scientific papers and prefer to use the parallel Pruchno et al. [9] tested the two factor model of successful concept of “successful ageing” as proposed by Rowe and ageing by doing a confirmatory factor analyses. Factors were Kahn [5, 6] when referring to ageing well or optimal ageing. objective success (ample functional abilities, little or no pain, As a matter of fact, for the concept “successful ageing” we and few chronic diseases) and subjective success (perceptions found 3587 papers in the same data bases. of ageing successfully, ageing well, and overall evaluation of current state of one’s life). They showed that age and gender were associated with objective but not subjective perceptions 1.1. The Active Ageing Model. The concept of active ageing of successful ageing. [1] is based on three pillars mentioned in the definition: Previous discussion on the issue of objective versus participation, health, and security. The proposed model subjective variables of successful ageing had stressed the idea encompasses six groups of determinants, each one including that the proportion of people claiming ageing successfully is several aspects: (1) health and social services (promoting higher than the proportion of people classified as successful health and preventing disease; health services; continuous agers by objective indicators [10]. These authors found 92% care; mental health care); (2) behavioral (smoking; physical of old people perceiving themselves as successful, although activity; food intake; oral health; alcohol; medication); (3) they were not free of disease or disability. The majority of personal (biology and genetics and psychological factors); subjects met the criteria for independent living, mastery, (4) physical environment (friendly environment; safety positive adaptation, life satisfaction, and active engagement, houses; falls; absence of pollution); (5) social (social support; and only 15% met the criteria for absence of physical violence and abuse; education); (6) economic (wage; social illness, and 28% reported no physical limitation. Successful security; work), embedded in cultural and gender context, ageing was not related to age, gender, ethnicity, marital with recommendations for health policy for old people, to status, education, and income which emphasize, in our view, be implemented through national health plans all over the the psychosocial variables of successful ageing over other world, during the first decade of the XXI century. characteristics of individuals. According to the WHO document on active ageing [1], In a different society (Taiwan), Lee et al. [11]confirmed the key aspects of active ageing are (1) autonomy which a four-factor model of successful ageing. Again leisure is the perceived ability to control, cope with, and make activities appeared as a very relevant factor to the successful personal decisions about how one lives on a day-to-day ageing process. Chaves et al. [12] studied the predictors of basis, according to one’s own rules and preferences; (2) normal and successful ageing in urban old Brazilians and independence, the ability to perform functions related to found 62% successful old people that fulfill the criteria of daily living—that is the capacity of living independently in health and independence, differing from “normal” ones, the community with no and/or little help from others; (3) namely, in the amount of leisure activities. In this same quality of life that is “an individual’s perception of his or her study, the number of living children appeared as a risk position in life in the context of the culture and value system factor, whereas confidents and family income were protective where they live, and in relation to their goals, expectations, factors of successful ageing. Authors discussed these findings standards, and concerns. It is a broad ranging concept, considering that in developing countries as Brazil, contrarily incorporating in a complex way the person’s physical health, to developed ones, socioeconomic status and social network psychological state, level of independence, social relationships, seem to be more important than biological variables to personal beliefs, and relationship to salient features in the predict successful ageing. environment.” [7]. As people age, their quality of life is When examining the concept of ageing well in Europe largely determined by their ability to maintain autonomy and and Latin America, Fernandez-Bal ´ lesteros et al. [13, 14] independence and (4) healthy life expectancy which is how found evidence of considerable consistency across countries, long people can expect to live without disabilities. continents, and ages. The common thoughts toward ageing Active ageing appears as an outcome of different determi- were that healthy ageing was the most important factor nants that should allow us to identify particular profiles that followed by independence (ability to manage oneself) and are more at risk or, on the other hand, are more favorable to social implication which included positive affect. The ability age actively. to learn new things and the ability to work after retirement, as well as feeling able to influence others and staying involved 1.2. Measuring Successful and Active Ageing. Recently, with the world and people were considered less important. Pruchno et al. [8]wrote apaper on the earlyand con- These results are quite similar to those of Bowling [15] that reported that over three-quarters of respondents were temporary characteristics of successful ageing. The authors stressed the proliferation of research on this topic over classified as ageing successfully, with self-perceived health the past 50 years yet the inexistence of harmony on its status and quality of life as predictors of self-rated successful ageing. This author considers that the biomedical perspective definition and measure. The main point was to understand the influence of genetic and early experiences, as well as of successful ageing needs balancing with a psychosocial one. Current Gerontology and Geriatrics Research 3 McLaughlin et al. [16] based on the Rowe and Kahn In this paper, we explore the WHO’s model of active model [5, 6] had already estimated the prevalence of ageing [1] that embraces positive outcomes of the ageing successful ageing on a national sample of older adults. The process. It is a challenge to examine the validity of the factors considered were disease and disability, cognitive and model and its empirical potential to foster quality of life in physical functioning, and social connections and productive old people. Although we cannot really speak about “deter- activities. Results showed that only 11.9% individuals were minants of active ageing” as we cannot assert any causality ageing successfully every year, and that this percentage low- without having a clear dependent variable and by doing a ered in 25% between 1998 and 2004. The probability of being cross-sectional research, we intended to understand which successful is lower for those with advanced age, male gender, and how the groups of variables are associated with active and lower socioeconomic status. Based in this analysis, the ageing. The main purpose of this research was to (i) built a authors considered that there is a need for modification in protocol to assess WHO active ageing model and (ii) to verify the concept of successful ageing for public health purposes. which are the determinants that better explain active ageing. Depp and Jeste [17] made an extensive review on successful ageing studies and found in 28 selected studies that 26 of 2. Methods them included disability and very few psychosocial variables. The most frequent correlates of successful ageing were young 2.1. Data Collection. This paper is part of an extensive Por- age, no smoking, and absence of disability, arthritis, and tuguese project on active ageing (DIA project) that includes diabetes. About 1/3 of individuals were ageing successfully, a cross-sectional survey of adults aged 55+ years living although the differences from study to study were large. in the community. For this study, subjects were recruited When explicitly exploring the concept of active ageing, through announcements in local newspapers, local agencies Bowling [18] reported that a third of respondents rated (e.g., seniors clubs), and NGO’s and using the snowball themselves as ageing “very actively” and almost a half as method by which participants indicate other persons with “fairly actively.” The most common perceptions of active similar conditions. The study ran in different Portuguese ageing were having/maintaining physical health and func- regions, including the Madeira and Azores islands. The tioning (43%), leisure and social activities (34%), mental survey was conducted by trained interviewers, using a functioning and activity (18%), and social relationships and structured questionnaire format that entailed demographic, contacts (15%). The predictors of positive self-rated active psychological, and social questions. A full description of ageing were optimum health and quality of life. More the assessment protocol (P3A) can be found in Paul ´ et al. recently, Stenner et al. [19] reported the subjective aspects of [22]and at http://www.projectodia.com. The interviews took active ageing by inquiring people about the meaning of the place in local community facilities (e.g., parish hall) or at words “active ageing.” The authors showed that most people the participants’ homes. Informed written consents were refer physical activity but also autonomy, interest in life, cop- obtained from all the participants. ing with challenges, and keeping up with the world. As men- tioned, people mix physical, mental, and social factors and stressed agentic capacities and living by one’s own norms. The 2.2. Sample Characteristics. The sample comprises 1322 authors criticized the deterministic view of the WHO model persons aged 55–101 years old. The average age was 70.4 and emphasized the need for a “challenge and response” years (SD 8.7 years), and females comprised 71.1% (n = framework, a psychosocial approach to the conflict between 939) of the sample. The majority of participants were facts and expectations, and the proactive attitude of people. married/partnered (n = 729, 55.7%), 400 (30.6%) were In overall, successful ageing, active ageing, and other widowed, 114 (8.7%) were single, and 65 (5.0%) were related terms as positive ageing or ageing well are viewed divorced. As for the social network, 24.7% of the participants as scientific concepts operationally portrayed by a broad set lived alone. Primary school education was reported by 55.3% of biopsychosocial factors, assessed through objective and of the respondents, 19.1% had never attended school, 17.8% subjective indicators as well as being closely related to lay had completed high-school, and 7.7% had higher education concepts reported cross-culturally by older persons [20]. (trade qualification or university degree). Most participants Considering the heterogeneity of old people and the huge (49.6%) had a monthly income equal or less than 386C variety of individual trajectories, it is difficult, and probably (by reference to the Portuguese Minimum National Wage ineffective, to define the core concept of successful ageing. in 2006). For the statistical analysis, as the distribution A strict pattern of success excludes too much people all of missing values did not follow a pattern, participants around the world, and an attempt to establish a standard for with at least one missing response were eliminated, and successful ageing, even a hypothetical biomedical objective the final sample contains 925 persons. The actual sample standard, does not embrace the differences observed in old diverges from the national distribution of characteristics of people (e.g., those with born or acquired incapacity). The old people [23], in the percentage of men and women in the concept of active ageing, although very difficult to measure, sample, with a higher percentage of women in our sample seems less deterministic, either as an outcome or as a process than the existing in the Portuguese population 55+ years of achieving it. On the contrary, the well-known concept of (71% versus 57% women) and the percentage of married successful ageing of Rowe and Kahn [5] looks more narrow individuals and widows (55.7% versus 71.1% married and and unrealistic, considering the very small amount of people 30.6% versus 20.1% widows). A special mention is to be (around 8.5%) that fulfill the criteria of ageing well [21]. made on the percentage of illiterate people in our study 4 Current Gerontology and Geriatrics Research Table 1: Instruments used for each of the WHO’s active ageing model determinants. WHO (2002) Assessment protocol “P3A” Determinants contents Psychological distress GHQ-12 [28] Happiness QBE/F [32] Biology and genetics Cognitive functioning MMSE [25] Personal factors psychological factors Personality NEO (Costa and McCrae, 1992 [31]) Optimism LOT-R [30] Loneliness Loneliness scale (Paul ´ et al., 2008 [22]) Pulmonary function Peak flow Strength Hand grip Subjective health Smoking Illness Physical activity Sleep problems Behavior Food intake Subj. physical activity Health and life styles questionnaire determinants Oral health (ESAP, Fernandez-Bal ´ lesteros et al., 2004 Alcohol Vision [24]) Medication Audition Smoking Drinking ADL and IADL Social support Lubben scale of social support (Lubben, Social network Determinants of 1988) [27] Violence and abuse social environment Education Education Sociodemographic questionnaire Health and disease Determinants of Health services Inventory of life satisfaction (Fonseca et health and social Life satisfaction Continuous care al., 2011 [34]) services Mental health care Friendly environment Determinants of WHOQOL Brief—physical environment Environment domain Safety houses physical subscale (Harper et al.,1998 [7], of quality of life Falls environment Canavarro et al., 2010 [33]) Absence of pollution Wage Economic Socioeconomic status (National Institute Social security Income determinants of Statistics) Work which is similar to the national figures: 19.1% versus 17% with General Health Questionnaire (GHQ-12) [28]; opti- for people 15+ years. mism was assessed with the Portuguese Version of the Life Orientation Test-Revised (LOT-R) [29, 30]; personality was evaluated with the NEO Personality Inventory [31]which 2.3. Measures. Theprotocolmeasuresthe different groups comprises three subscales—neuroticism, extraversion, and of determinants of WHO’s active ageing model and was openness to experience; happiness was assessed with a single elaborated considering an extensive literature review of most common instruments used in Gerontology and previously question with four categories [32]; and environment domain of quality of life was measured with World Health Organi- used the European Survey on Ageing Protocol [24](Table 1). All instruments are adapted to Portuguese. zation Quality of Life-BREF (WHOQOL-BREF) [7, 33]and Along with socio demographic characteristics (gender, Inventory of Life Satisfaction [34]. Biobehavioral measures, age, education, and income), we analyzed cognitive function- including pulmonary function and strength, were assessed ing as measured by the Portuguese version of the Minimental using a standard “Mini Peak Flow Meter” (Datosprir Peak- 10, Sibelmed) and with an electronic dynamometer (Grip-D, State Examination (MMSE) adapted to illiterate people and to people with very few years of education [25, 26]; social TAKEI Scientific Instruments Co., LTD), respectively. Finally, network was assessed with the Lubben Social Network Scale health and physical condition were evaluated by self-report (LSNS) which comprises three subscales—family, friends, indicators (determined by a standard health-rating item: “In and confidants [27]; psychological distress was measured general, how would you rate your health?”), illness (sum Current Gerontology and Geriatrics Research 5 Table 2: Definition of variables. Variable Coding Subjective health 1 = very good; 2 = good; 3 = reasonable; 4 = poor; 5 = very poor Sleep problems 0 = no; 1 = yes Subjective physical activity 1 = very good; 2 = good; 3 = reasonable; 4 = poor; 5 = very poor ADL 0 = with difficulties; 1 = without difficulties Illness 0 = none;1 = 1 illness; 2 = 2 illness; 3 = 3 illness; 4 = 4ormoreillness Psychological distress 1 = <9; 2 = [9, 12[; 3 = [12, 16[; 4 = ≥16 Happiness 1 = nothing; 2 = 2; 3 = 3; 4 = very Optimism 1 = <11; 2 = [11, 13[; 3 = [13, 15[; 4 = ≥15 Quality of life 1 = <24; 2 = [24, 26[; 3 = [26, 29[; 4 = ≥29 Loneliness 0 = yes; 1 = no Cognitive impairment 1 = <25; 2 = [25, 28[; 3 = [28, 30[; 4 = ≥30 1 = no specs and very poor/poor vision; 2 = no specs and acceptable vision; 3 = no Vision specs and good/very good vision; 4 = specs and very poor/poor vision; 5 = specs and acceptable vision; 6 = specs and good/very good vision 1 = no device use and very good/good audition; 2 = no device use and acceptable Audition audition/3 = no device use and poor/very poor audition; 4 = use device Smoking 1 = no; 2 = ex-smoker; 3 = yes Drinking 1 = never; 2 = special occasions; 3 = occasionally; 4 = regularly Income 1 = ≤386 C;2 = 386 C–772 C;3 = 772 C–1158 C;4 = >1158 C Education level 1 = no formal; 2 = primary; 3 = 5–8 years; 4 = 9–12 years; 5 = university Peak flow 1 = <180; 2 = [180, 250[; 3 = [250, 340[; 4 = ≥340 Grip strength 1 = <18.3; 2 = [18.3, 22.9[; 3 = [22.9, 29.0[; 4 = ≥29.0 Family 1 = <9; 2 = [9, 11[; 3 = [11, 13[; 4 = ≥13 Friends 1 = <5; 2 = [5, 8[; 3 = [8, 10[; 4 = ≥10 Confidents 1 = <4; 2 = [4, 7[; 3 = [7, 9[; 4 = ≥9 Neuroticism 1 = <30; 2 = [30, 34[; 3 = [34, 37[; 4 = ≥37 Extraversion 1 = <39; 2 = [39, 41[; 3 = [41, 44[; 4 = ≥44 Openness to experience 1 = <35; 2 = [35, 37[; 3 = [37, 40[; 4 = ≥40 Quartiles; by reference to the Portuguese Minimum National Wage in 2006. of self-reported health problems), sleep problems, subjective were obtained using factor score regressions generated from physical activity (determined by the item: “In general, how the confirmatory factor analysis as proportional weight to would you rate your physical condition?”), ADL, loneliness, combine item scores. Our process of analysis started with the vision, audition, smoking, and drinking. Details regarding full factors and items, and then we used a nested models variables and coding are shown in Table 2. approach to test alternative nested structures to test fit improvement. In addition to theoretical and practical con- siderations, evaluation of fit of model was based on the 2.4. Exploratory Factor Analysis. The factor structure of following goodness of fit criteria, including normed chi- P3A was examined by exploratory factor analysis, using squared (χ /df ), the comparative fit index (CFI), the good- principal-components extraction with varimax rotation. For ness of fit index (GFI), the Akaike’s information criteria the continuous variables, we used the quartiles in order to (AIC), and the Browne-Cudeck criterion (BCC). CFI and standardize the variables and use only categorical variables GFI indices assume values in range from 0 to 1, with higher in the exploratory factor analysis. Exploratory factor analysis scores indicating better fit. Models with the lowest values of was conducted using SPSS 17.0 for Windows. AIC are most likely to be good fits. We used the chi-square difference statistics to test the significance of the change in 2.5. Confirmatory Factor Analysis. Confirmatory factor anal- the chi-square test for each alternative model over the full model. Lastly, we examined the effect of age and gender on ysis was conducted to test the viability of a hypothesized the final model estimating paths between age and gender and structure that had been formulated from theoretical con- siderations and results of the exploratory factor analysis. factors. Nonsignificant paths were removed, and the model was estimated over and over until only significant paths Confirmatory factor analysis was conducted using AMOS 18 for Windows. Satisfaction scores for each dimension remained. 6 Current Gerontology and Geriatrics Research Table 3: Factor structure of P3A—exploratory factor analysis. Factors Questions 12 3 4 5 6 Subjective health 0.652 −0.298 −0.312 −0.071 −0.131 −0.104 Sleep problems 0.620 −0.154 0.152 0.133 −0.114 0.260 Subjective physical condition 0.670 −0.218 −0.250 −0.061 −0.104 −0.223 ADL −0.563 0.052 0.262 0.160 −0.103 0.139 Illness 0.673 −0.067 0.004 −0.241 0.009 0.035 Psychological distress 0.437 −0.586 −0.101 −0.084 −0.112 −0.005 Happiness −0.265 0.540 0.105 −0.085 0.260 0.213 Optimism −0.050 0.683 −0.035 0.039 0.065 0.068 Neuroticism 0.096 −0.695 −0.114 −0.163 0.171 0.108 Quality of life—environment −0.076 0.616 0.286 0.075 0.051 0.132 Loneliness −0.149 0.492 −0.011 0.126 0.351 −0.084 Cognitive impairment −0.096 0.180 0.594 0.396 0.103 −0.146 Vision −0.100 −0.001 0.592 −0.211 0.056 0.242 Income −0.162 0.135 0.699 0.261 0.126 −0.198 Education level −0.098 0.133 0.807 0.204 0.034 −0.199 Peak flow −0.044 0.157 0.295 0.700 0.056 −0.051 Grip strength −0.266 0.098 0.042 0.782 0.060 0.058 Social relations—family −0.028 0.109 −0.006 0.112 0.727 −0.063 Social relations—friends −0.131 0.074 0.130 0.078 0.400 0.269 Social relations—confidence 0.024 0.013 0.104 −0.065 0.700 0.011 Extraversion −0.196 0.106 −0.027 −0.199 0.055 0.655 Openness to experience 0.123 0.014 −0.190 0.143 −0.016 0.734 % of variance explained 11.6 11.2 10.6 7.7 6.9 6.6 Health Behavioural determinants Social Social Health and determinants relationship social services Active ageing Economic Physical determinants environment Personal determinants Cognitive Personality Biobehavioral Psychological performance Figure 1: The WHO model and the empirically achieved model. Current Gerontology and Geriatrics Research 7 Table 4: Goodness-of-fit statistics for confirmatory factor analysis models of P3A. 2 2 Model χ df χ /df CFI GFI χ AIC BCC dif 1 701.342 194 3.615 0.891 0.936 — 819.342 822.354 2 562.046 172 3.268 0.913 0.946 139.30 680.046 682.924 3 557.039 155 3.594 0.908 0.944 5.01 667.039 669.597 4 489.170 153 3.197 0.923 0.950 67.87 603.170 605.822 0.7 e1 Subjective health 0.83 0.75 0.57 Subjective physical Health e3 condition 0.24 e4 ADL −0.49 0.24 0.49 e5 Illness 0.51 Psychological 0.73 e6 0.72 distress 0.37 −0.6 Happiness e7 −0.45 0.2 Optimism e8 −0.15 Psychological 0.23 −0.48 Neuroticism e9 0.48 0.32 −0.43 Quality of life e10 −0.56 −0.48 0.23 −0.37 Loneliness e11 −0.43 0.59 0.77 Cognitive impairment e12 −0.26 −0.46 −0.63 Cognitive 0.77 −0.51 Income e14 0.88 0.6 −0.26 Education level 0.61 0.77 e15 0.54 0.74 Peak flow e16 0.31 Biobehavioral 0.35 Handgrip e17 0.59 −0.22 0.28 0.52 0.27 Social relationship e18 Family 0.41 0.17 Social relationship Social relationship −0.14 e19 Friends 0.12 Social relationship e20 0.15 Confidence 0.35 0.42 0.65 Extraversion e21 Personality Openness to 0.12 e22 experience 0.35 Figure 2: Factor structure model for P3A. 3. Results skewed, showing a pattern of responses in only one or two categories (e.g., no smokers; no heavy drinkers). 3.1. Descriptive Analysis. Descriptive analysis (absolute and relative frequencies) was performed for all variables described in Table 2. When exploring the results, the 3.2. Exploratory Factor Analysis. The factor structure was variables “smoking” and “drinking” were excluded to the examined by principal-components extraction with varimax final analysis because distribution for this two variables were rotation for the pooled sample (n = 925). The Bartlett 8 Current Gerontology and Geriatrics Research sphericity test and the Kaiser-Meyer-Olkin (KMO) test were follows in weight showing the importance of wage, edu- performed; the first revealed a 0.001 level of significance and cation, vision, and cognitive performance. The “biobehav- a KMO value of 0.855, indicating that factor analysis seemed ioral component,” comprising respiratory capacity and grip to be highly adjusted to this analysis. Six distinct factors, strength clearly shows the importance of biological aspects accordingly to the theoretical six determinants of the WHO during the ageing process. “social relationship”, including model, were revealed (Table 3), explaining 54.6% of total family, friends, and confidents, illustrates the relevance of variance. The item “hearing” was eliminated because it had a social network for the quality of life of old people. Finally, the loading lower than 0.3 in all factors. “personality component” was reduced to extraversion and openness to experience, as neuroticism merged with other (i) Factor 1. Health component: this factor comprises psychological variables in the “psychological component.” five variables (subjective health, sleep problems, The profile is quite homogeneous with factors loading subjective physical condition, ADL, and illness) and between 11.6% and 6.6% and explaining a good amount of explained 11.6% of total variance. total variance (54.6%). (ii) Factor 2. Psychological component: six variables 3.3. Confirmatory Factor Analysis. We analyzed the full load heavily of this factor (psychological distress, six-factor model for the 22 variables by using the six happiness, optimism, neuroticism, quality of life— item clusters derived from the exploratory factor analysis environment, and loneliness), which accounted for (presented in Table 3). From the results of this first full 11.2% of the total variance. model that replicated the measurement structure derived (iii) Factor 3. Cognitive performance component: four from the original exploratory factor analysis, we proposed questions have their highest loadings on this factor alternative models. We used a nested models approach to (cognitive impairment, vision, income, and educa- test alternatives to the full model (Model 1), elimination tion level) and explained 10.6% of total variance. of item “sleep problems” (Model 2), elimination of item “vision” (Model 3), adding the following covarying error (iv) Factor 4. Biological component: this factor comprises variances between “optimism” and “neuroticism” items and only two variables (peak flow and grip strength) and between “cognitive impairment” and “income” items (Model explained 7.7% of total variance. 4). However, these do not introduce any change in the final (v) Factor 5. Social relationship component: three vari- model. Fit statistics of the full model and subsequent models ables have their highest loadings on this factor are presented in Table 4. (family, friends, and confidence), accounting for The confirmatory factor analyses structure describes 6.9% of total variance. adequately the 6 factors reinforcing the adequacy of the proposed model. The various indices of fit presented in (vi) Factor 6. Personality component: the last factor con- Table 4 suggest that satisfaction structure can be adequately tains only two variables (extraversion and openness described by the 6 correlated factors which are graphically to experience) and explained 6.6% of total variance. presented in Figure 2 (Model 4). Latent constructs (active ageing components) are shown as ellipses, and questionnaire Comparing to the original model [1], our findings revealed items measuring these latent constructs are represented as a somewhat different one, depicted in Figure 1. Health rectangles. and social services determinants merged with behavior Finally, testing the effects of age and gender, only the determinants in a single component entitled “health” that paths between gender and the “cognition component” and includes functionality and life style. Personal determinants gender and the “Biobehavioral component” were significant split into several components, namely, “psychological,” (P< 0.05, for both). Nonsignificant paths were removed, and “cognitive performance,” “personality,” and “biobehavioral.” the final model revealed that the model fit the data very well Physical determinants and environment determinants moved (χ = 624.19, df = 171, P< 0.001, CFI = 0.906, GFI = to the “psychological component” as a variable of perceived 0.941). Women had higher levels of “Cognitive performance subjective well-being. Economic determinants migrated to component” and lower levels of “Biobehavioral component.” the new component called “cognitive performance.” Only social determinants stayed as an independent factor that we renamed “social relationships.” 4. Discussion The achieved model shows that the “health component” is the major factor associated with active ageing and includes When we look at the WHO model we can see that self-perception of health, the number of diagnosis, function- apart from the social determinant all the others endured a ality (ADL and IADL), and life style. The second component rearrangement that lead to six factors not similar to the was “psychological,” which is frequently forgotten in liter- original ones. However, “active ageing” remained a complex ature, with the exception of psychopathological indicators. construct, where health and psychological adaptation play In this study, psychological variables include both negative the major role. Many of the determinants proved to be affect (psychological distress, loneliness, and neuroticism) entwined, reflecting the transaction between individual and and positive affect (happiness, quality of life—environment, environmental factors in shaping adaptation to the ageing and optimism). The “cognitive performance component” process. Current Gerontology and Geriatrics Research 9 The economic determinants as well as the physical environ- The WHO active ageing model [1]based on 6deter- ment and health and social services relevance were found to minants was not empirically validated in its structure for be associated with personal needs, resources, and outcomes the sample here considered. Some groups of determinants and do not configure independent factors. According to were found to be deeply intertwined. The proposed model our findings, people seem to perceive and assess reality requires further developments, namely, by studying psy- concerning social and personal conditions through the chological mechanisms that might be related to the ability glasses of their own values and needs, adding to their real to cope with ageing, and particularly among the very old. circumstances a self-perceived valuation of what they are Culture-based approaches are also to be considered in future experiencing. Globally, we can say that subjective and objec- studies. tive health and functionality constitute the main component This study has two main limitations. The first one regards of active ageing which goes in line with Pruchno et al. to the exclusive use of self-rated measures that may had led to [8, 9] findings; the psychological component, be it positive an overall “perceived reality” whilst some of the active ageing characteristics of individuals (e.g., happiness, optimism) or determinants are to be more objective (e.g., actual presence pathological ones (e.g., psychological distress, neuroticism), of social and health services), although Portugal has a NHS is the second most relevant factor, reinforcing the idea of with universal and free access and a reasonable coverage of positive affect associated with less mortality and longevity services for the elderly (nursing homes and day centres and (e.g., [35]); cognition appearing close to vision supports a not so extensive service of home care). On this aspect, it Baltes and Mayer’s [36] findings on the importance of senses is worthwhile mentioning that most of the municipalities in cognition and in the overall optimal ageing. Income and have conventional services for old people and that self-report education levels that contribute for this factor show, on one of availability and satisfaction of community health and hand, the importance of cognition in the process of ageing social services is thought to better reflect the reality and the and, on the other hand, a close association between income, experience of the present cohort of old people. Moreover, access to education, and cognitive performance. Biological the use of mostly self-reported measures except for cognitive variables proved to be very sensitive to gender and age as performance and biological parameters, although missing clinical diagnosis and objective environmental variables, expected (e.g., peak flow and grip strength), and contributing independently to active ageing; social relationship including constitutes a reliable overview of old people perspective of their own condition and that of the context in which they family, friends, and confidents networks supports Bowling’s live. Both these aspects must be considered when interpreting [15] findings on the importance of social networks to our findings and when conducting further research. The successful ageing; finally, personality seems to introduce second main limitation has to do with the sampling process a factor of more or less adaptability to the challenges of (e.g., using announcements in newspapers, senior clubs) ageing. which may have resulted in a selection towards the most This achieved six-factor model reveals the major contri- active older adults. We consider that further studies should butions the active ageing constructs and goes beyond the comprise different sample selection procedures and a wider successful ageing model that establishes a strict pattern of coverage of older people towards a more representative success by considering that different profiles of old people overview of the Portuguese population. in different contexts may be classified as active with areas The challenge of active ageing is health and independent in debt being compensated by more advantaged ones. The functioning, whereas psychological variables appear to be relative load of each factor will presumably change in diverse highly relevant determining the individual adaptation to the contexts or groups of people, emphasizing the need for ageing process. In this sense, interventions are to consider the different intervention programs to foster quality of life prevention of health problems from adulthood and the allocating diverse life trajectories, and where, for instance, increasing of psychological resilience, avoiding loneliness or high income can compensate smaller social networks or increasing happiness and subjective wellbeing. Other social optimistic disposition can compensate disability to balance and political variables demand different kinds of interven- positively the process of ageing. Furthermore, rather than tion at a community-based level, namely, rising income health problems that most of old people have (and/or and carefully planning the retirement process and pensions expected to have in some extent) and some functional limita- regimens. tions, the difference between old people ageing actively or not may vary with the psychological characteristics and status that enable them to cope with ageing related declines, look Acknowledgment forward, and keep committed to life. By keeping active in the broader sense of the concept, old people seem to overcome This paper draws from a research project supported by the Foundation for Science and Technology (FCT), Portugal difficulties and keep highly motivated to participate in the (Grant POCTI/PSI/56505/2004). social world and engage in healthy behaviors which raise quality of life during the ageing process. 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Current Gerontology and Geriatrics ResearchPubmed Central

Published: Oct 31, 2012

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