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Active Ageing: A Policy Framework

Active Ageing: A Policy Framework The Aging Mal e 2002 ;5:1–37 Report of the Wor ld H ealth Orga nization World Health Organization Noncommunicable Diseases and Mental Health Cluster Noncommunicable Disease Prevention and Health Promotion Department Ageing a nd Life Course The Policy F ramework is intended to inform dis cus- meeting w as convened at the WHO Centre f or H ealth sion and the formulation of a ction plans that promote Development (W KC) in Kobe, Ja pan, with 29 healthy and ac tive a geing. I t was de veloped by participants from 21 countries. D etailed com ments WHO’s Ageing a nd L ife Co urse Programme as a and re commendations f rom this meeting, a s well as contribution to the Second U nited Nations World those received thr ough the previous consultation pro- Assembly on Ageing, he ld in April 20 02, in Madrid, cess, were compiled to complete this final version. Spain. The preliminary ve rsion, pu blished in 2001 A c omplementary m onograph entitled Active and e ntitled Health and A geing: A D iscussion Ageing: Fr om Evidence to A ction is being Paper, wa s tra nslated into French an d Spa nish and prepared in collaboration w ith the International widely c irculated f or fe edback throu ghout 2001 Association of G erontology (IAG) and w ill b e av ail- (including at special w orkshops held in Brazil, able a t http://www.who.int/hpr/ageing where more Canada, the Netherlands, Spa in and t he United information ab out ag eing a nd the life cou rse is also Kingdom). In January 2 002, an ex pert gr oup provided. How O ld is O lder? This b ooklet u ses the Un ited Natio ns standard o f ag e 60 t o d escribe ‘o lder’ p eople. T his may seem young in th e d eveloped w orld a nd in t hose d eveloping c ountries w here m ajor gain s in life expectancy have already occurred. Ho wever, whatever age is used w ithin d ifferent c ontexts, it is important to acknowledge th at c hronological age is not a precise marker for th e c hanges th at a ccompany ag eing. There ar e dramatic variations in h ealth stat us, participation an d levels of in dependence amo ng o lder people o f th e s ame age. Decision-makers need to t ake t his into ac count w hen d esigning p olicies and programmes for th eir ‘o lder’ p opulations. E nacting b road s ocial policies based o n ch ronological age alone can be discriminatory and c ounterproductive to well being in older age. Note: The sp elling of ‘ ag eing’ an d a number o f o ther te rms in this report i s according to th e style o f the W orld He alth O rganiza- tion, rather than to the no rmal style of the Journal 1 Active Ageing: A Policy Framework World He alth Organization INTRODUCTION families, com munities a nd e conomies, as stated in th e WHO Brasilia Declaration o n A geing an d H ealth Population agein g raises many fundamental in 1996. questions f or p olicy-makers. How d o w e help people r emain independent an d ac tive as they age? Part 1 d escribes the rap id w orldwide g rowth How ca n w e strengthen h ealth p romotion an d of th e p opulation o ver age 60, especially in prevention p olicies, especially those d irected t o developing countries. older p eople? A s p eople a re living longer, h ow Part 2 exp lores the co ncept an d rat ionale for can t he q uality o f life in o ld a ge be imp roved? ‘act ive ageing’ as a goal f or p olicy an d p ro- Will large numbers o f o lder pe ople b ankrupt gramme formulation. our h ealth car e and so cial security systems? How d o we best balance th e ro le of t he f amily and t he state Part 3 su mmarizes the evide nce about th e when it comes to car ing f or p eople w ho ne ed factors t hat d etermine whether o r n ot ind ivi- assistance, as they g row o lder? Ho w d o we duals an d p opulations w ill enjoy a positive acknowledge an d su pport th e ma jor ro le that quality of life as they age. people play as they age in caring for o thers? Part 4 d iscusses seven key c hallenges associated This p aper is designed to ad dress these questions with an ag eing population fo r g overnments, and ot her co ncerns ab out p opulation ag eing. It the n ongovernmental, a cademic and p rivate targets government d ecision-makers at all levels, sectors. the n ongovernmental sec tor an d th e p rivate sector, all of w hom are responsible for t he fo rmulation o f Part 5 p rovides a policy f ramework fo r ac tive policies and p rogrammes on ag eing. It ap proaches ageing and co ncrete s uggestions for k ey p olicy health fro m a broad p erspective and ac knowledges proposals. T hese are intended to serve as a base- the f act th at h ealth c an o nly b e cr eated an d su s- line for t he d evelopment o f mo re specific action tained th rough t he p articipation o f mu ltiple steps at regional, national an d lo cal levels in sectors. It su ggests that h ealth p roviders and p rofes- keeping w ith t he ac tion p lan ad opted b y th e sionals must take a lead if we are to ach ieve the go al 2002 S econd Un ited Na tions Assembly on that healthy older pe rsons remain a r esource to their Ageing. 1. Global Ageing: A Trium ph and a Challenge Population ageing is first and foremost a success story for public health policies as well as social and economic development . . . Gro Harlem Brundtland, Director-General, World Health Organization, 1999 Population ag eing is one o f h umanity’s greatest triumphs. It is also one o f o ur g reatest challenges. In all cou ntries, b ut in developing cou ntries in As we en ter the 21 st century, glo bal ag eing will put particular, m easures t o help ol der peo ple re main increased economic an d so cial demands o n a ll healthy and active are a necessity, not a luxury. countries. A t t he same time, older p eople a re a precious, o ften-ignored r esource th at mak es an important co ntribution t o th e fab ric o f o ur These policies and pr ogrammes should b e b ased societies. on t he r ights, needs, preferences and cap acities of The W orld Health Organization ar gues that older p eople. T hey also need to emb race a life countries ca n aff ord to g et old if governments, course p erspective that rec ognizes t he imp ortant international o rganizations an d civil society enact influence of ear lier life experiences on th e w ay ‘ac tive ageing’ p olicies and p rogrammes that individuals age. enhance th e h ealth, participation an d s ecurity of older cit izens. The tim e to p lan an d to a ct is now. 2 The Agin g Ma le Active Ageing: A Policy Framework World He alth Organization THE DEMOGRAPHIC estimated that b y 20 25, 120 c ountries w ill have REVOLUTION reached t otal fert ility rates below rep lacement level (average fertility rate of 2.1 children p er w oman), a Worldwide, t he p roportion o f p eople age 60 an d substantial increase compared t o 19 75, when ju st over is growing faster than an y o ther ag e group. 22 co untries ha d a total fer tility rate below o r eq ual Between 1970 an d 20 25, a growth in o lder p ersons to t he rep lacement level. The c urrent fig ure is 70 of som e 694 millio n or 2 23 p ercent is expected. countries. In 20 25, there will be a total o f ab out 1.2 billion Until now, p opulation ag eing has been m ostly people o ver the age of 6 0. By 2050 th ere will be associated with th e mo re developed regio ns of th e 2 b illion w ith 8 0 p ercent o f t hem living in world. Fo r ex ample, currently n ine o f th e ten developing countries. countries w ith mo re than t en m illion inhabitants Age c omposition – th at is , the p roportionate and th e larg est proportion of o lder p eople are in numbers of c hildren, y oung ad ults, middle-aged Europe (s ee Table 1 ). Little change in th e ra nking is adults an d o lder ad ults i n an y given country – is an expected b y 20 25 w hen p eople ag ed 6 0 an d o ver important elem ent for p olicy-makers to tak e in to will make up ab out o ne-third o f t he p opulation in account. P opulation ag eing refers to a decline in countries lik e Japan, Germany and It aly, closely the p roportion o f ch ildren an d yo ung p eople an d followed b y o ther Eu ropean c ountries (see an in crease in t he p roportion o f p eople ag e 60 an d Table 1). over. As po pulations a ge, the tr iangular p opulation What is less known is the sp eed and s ignificance pyramid o f 2 002 w ill be rep laced w ith a more of p opulation agein g in le ss developed reg ions. cylinder-like structure in 2025 (see Figure 1). Already, m ost older p eople – ar ound 70 p ercent – Decreasing fertility rates and in creasing long- live in d eveloping c ountries (s ee Table 2). These evity will ensure the co ntinued ‘ gr eying’ o f numbers will continue t o r ise at a rapid pace. the w orld’s population, d espite setbacks in life In all countries, esp ecially in d eveloped o nes, expectancy in so me African co untries (d ue t o the o lder p opulation itself is also ageing. People AIDS) an d in so me newly in dependent stat es (due over the ag e of 8 0 c urrently n umber so me 69 to in creased deaths c aused b y ca rdiovascular disease million, the maj ority o f w hom live in mo re and vio lence). Sharp de creases in fer tility rates developed reg ions. Although p eople o ver the age are being o bserved throughout t he w orld. It is of 80 mak e up ab out o ne p ercent o f t he wo rld’s Age group Male Female 80+ 70–74 60–64 50–54 40–44 30–34 20–24 10–14 0–4 350 000 150 000 0 150 000 350 000 Population in thou sands Figure 1 Global population pyramid in 2002 and 2025. Source: UN, 2001 The Agin g Male 3 Active Ageing: A Policy Framework World He alth Organization Table 1 Countries w ith mo re th an 10 mil lion in habit- Table 3 Old-age depen dency ratio fo r selected ants (in 20 02) wit h th e h ighest p roportion o f persons above countries/regions. Source: UN, 2001 age 60. Source: UN, 2001 2002 2025 2002 2025 Japan 0.39 Japan 0.66 Italy 24.5% Japan 35.1% North America 0.26 North America 0.44 Japan 24.3% Italy 34.0% European Union 0.36 European Union 0.56 Germany 24.0% Germany 33.2% Greece 23.9% Greece 31.6% Belgium 22.3% Spain 31.4% Spain 22.1% Belgium 31.2% Old-age dep endency ra tios are cha nging quickly Portugal 21.1% United Kingdom 29.4% throughout the world. In Japan, f or e xample, the re United Kingdom 20.8% Netherlands 29.4% are cu rrently 39 people ove r a ge 60 for e very 100 in Ukraine 20.7% France 28.7% the age gro up 15–60. In 2025 this number wil l France 20.5% Canada 27.9% increase to 66. Table 2 Absolute n umbers of persons (in m illions) a bove 60 y ears o f age in co untries wit h a t otal po pulation However, most of th e o lder p eople in all approaching o r a bove 100 mi llion i nhabitants (i n 200 2). countries c ontinue t o b e a vital resource to th eir Source: UN, 2001 families and c ommunities. Many co ntinue to w ork 2002 2025 in b oth th e fo rmal and in formal labour sec tors. Thus, as an in dicator fo r fo recasting p opulation China 134.2 China 287.5 needs, the de pendency rat io is of limited use. India 81.0 India 168.5 More so phisticated in dices are needed to mo re United States of 46.9 United States of 86.1 accurately reflec t ‘d ependency’, rather th an f alsely America America categorizing in dividuals who co ntinue to b e f ully Japan 31.0 Japan 43.5 able and in dependent. Russian Federation 26.2 Indonesia 35.0 Indonesia 17.1 Brazil 33.4 At th e same time, active ageing policies and Brazil 14.1 Russian Federation 32.7 programmes are needed to en able people to co n- Pakistan 8.6 Pakistan 18.3 tinue to w ork acc ording t o th eir capacities and Mexico 7.3 Bangladesh 17.7 preferences as they g row o lder, an d t o p revent o r Bangladesh 7.2 Mexico 17.6 delay disabilities and c hronic d iseases that ar e costly Nigeria 5.7 Nigeria 11.4 to in dividuals, families and t he h ealth c are system. This is discussed further in th e sec tion o n w ork in Challenge 2: Increased Risk of D isability population an d th ree percent o f th e p opulation and C hallenge 6: the Eco nomics o f an A geing in de veloped reg ions, this age group is the f astest Population. growing segment of t he older population. In b oth d eveloped an d d eveloping co untries, RAPID PO PULATION AGEING IN the ag eing of th e po pulation raises concerns ab out DEVELOPING COUNTRIES whether or n ot a shrinking la bour fo rce w ill be ab le to sup port t hat p art o f th e po pulation w ho are In 2 002, almost 400 millio n people aged 60 an d commonly b elieved to b e d ependent on o thers over live in t he d eveloping w orld. By 2025, this (i.e. children and o lder people). will have increased to ap proximately 84 0 m illion The o ld-age d ependency rat io (i.e. the to tal representing 70 p ercent o f all older pe ople w orld- population a ge 60 an d o ver divided b y th e p opula- wide (see Figure 2). In ter ms of reg ions, over half tion a ge 15–60 – see Table 3) is primarily used b y of th e w orld’s older p eople live in A sia. Asia’s economists and act uaries who fo recast t he fin ancial share of th e w orld’s oldest p eople w ill continue implications of p ension po licies. However, it is also to i ncrease the mo st while Europe’s share as a pro- useful fo r th ose c oncerned w ith th e man agement portion o f t he glo bal o lder p opulation w ill decrease and planning of caring services. the mo st over the nex t tw o d ecades (see Figure 3). 4 The Agin g Ma le Active Ageing: A Policy Framework World He alth Organization 1970 2002 2025 World LDR MDR Figure 2 The nu mbers of people over ag e 60 i n le ss and mo re devel oped regions, 1 970, 200 2 a nd 202 5. LDR , less developed regions; MDR, more developed regions. Source: UN, 2001 NAm 8% NAm Oceania Africa 8% Africa Oceania 1% 7% LAmC 7% 1% LAmC 7% 8% Europe Europe 17% 24% Asia Asia 53% 59% 2002 2025 Figure 3 Distribution o f world population o ver a ge 60 by region, 2 002 a nd 20 25. NA m, No rth A merica; LA mC, La tin America and the Caribbean. Source: UN, 2001 Compared t o th e d eveloped w orld, so cio- developed c ountries g rew aff luent b efore t hey economic d evelopment in d eveloping co untries became old, d eveloping c ountries are getting o ld has often no t k ept p ace w ith th e ra pid sp eed of before a substantial increase in wealth occurs . population ag eing. For exa mple, while it took Rapid ag eing in d eveloping co untries is accom- 115 y ears for th e p roportion o f o lder p eople in panied b y d ramatic changes in fam ily structures an d France t o do uble f rom 7 to 14 p ercent, it will take roles, as well as in lab our p atterns an d mig ration. China o nly 27 year s to ac hieve the same increase. Urbanization, th e mig ration of yo ung p eople to In mo st of th e d eveloped w orld, p opulation a geing cities in s earch of jo bs, smaller families and mo re was a gradual p rocess f ollowing st eady socio- women en tering th e fo rmal workforce mea n that economic g rowth o ver several decades and g enera- fewer people ar e available to ca re for o lder p eople tions. In de veloping c ountries, th e p rocess is being when they need assistance. compressed into tw o o r t hree decades. Thus, w hile 2. Active Ageing: The Concept and Rationale If ag eing is to b e a positive experience, longer life Health Organization h as adopted th e ter m ‘ac tive must be ac companied b y co ntinuing o pportunities ageing’ to exp ress the p rocess f or a chieving for h ealth, p articipation an d secu rity. The W orld this vision. The Agin g Male 5 Millions Active Ageing: A Policy Framework World He alth Organization WHAT IS ‘A CTIVE AGEING’? ‘Healt h’ ref ers to p hysical, mental and so cial well being as expressed in th e W HO definition o f health. T hus, in an act ive ageing framework, p oli- Active a geing is the process of op timizing opportunities cies and p rogrammes that p romote m ental health for he alth, pa rticipation and sec urity in order to and so cial connections are as important as those enhance qu ality of life as people age. that improve physical health status. Active ageing applies to b oth in dividuals and Maintaining au tonomy an d in dependence as population g roups. It allo ws people to r ealize their one gro ws o lder i s a key g oal fo r b oth in dividuals potential f or p hysical, social, and men tal well being and p olicy m akers (see box o n d efinitions). throughout th e life course a nd t o p articipate in Moreover, ageing takes place w ithin t he co ntext society according t o t heir needs, desires and c apaci- of ot hers – fr iends, work asso ciates, neighbours ties, while providing th em with ad equate p rotec- and fam ily members. This is why in terdependence tion, secu rity and c are when t hey req uire as well as intergenerational so lidarity (two-way assistance. giving and rec eiving between in dividuals as well as The w ord ‘ ac tive’ ref ers to co ntinuing p articipa- older an d yo unger gen erations) are important tion i n so cial, economic, c ultural, sp iritual and tenets of ac tive ageing. Yesterday’s child is today’s civic affairs, not ju st th e a bility to b e p hysically adult an d t omorrow’s grandmother o r g rand- active or t o p articipate in th e lab our f orce. Old er father. The q uality o f life they will enjoy as grand- people w ho r etire from w ork an d th ose w ho are parents d epends o n t he risk s and o pportunities th ey ill or live with d isabilities can r emain active contri- experienced th roughout th e life course, a s well butors t o t heir families, peers, communities and as the man ner in w hich su cceeding g enerations nations. A ctive ageing aims to ext end h ealthy life provide mutual aid and support when n eeded. expectancy an d q uality o f lif e for all people as they The term ‘act ive ageing’ w as adopted by th e age, including th ose w ho ar e frail, disabled an d in World H ealth Organization in th e lat e 1990s. It is need of care. meant to co nvey a more inclusive message than Some ke y definitions Autonomy is the p erceived ability to co ntrol, c ope w ith an d mak e personal dec isions about h ow o ne lives on a day-to-day b asis, according t o o ne’s own rules and p references. Independence is commonly u nderstood as the ab ility to p erform f unctions relat ed to d aily living – i.e. the capacity of living independently in the community with no an d/or little help from others. Quality of life is ‘an in dividual’s perception o f h is or h er p osition in lif e in t he co ntext o f th e cu lture an d value system where th ey live, and in relat ion to th eir goals, expectations, st andards an d c oncerns. It is a broad r anging co ncept, in corporating in a complex w ay a person’s physical h ealth, p sychological st ate, level of in dependence, so cial relationships, personal b eliefs and re lationship t o s alient features in th e environment’ . As p eople a ge, their quality o f li fe is largely determined by th eir ability to main tain autonomy and independence. Healthy l ife expectancy is commonly u sed a s a synonym f or ‘ d isability-free life expectancy’. While life expectancy at birth r emains an imp ortant measu re of p opulation agein g, how lo ng p eople can ex pect to live without disabilities is especially important t o a n ageing population. With th e e xception o f au tonomy w hich is notoriously d ifficult to measu re, all of t he ab ove concepts have been elab orated b y a ttempts to measu re the d egree of d ifficulty an old er p erson h as in pe rforming activities related to d aily living (ADLs) and in strumental activities of d aily living (IADLs). ADLs in clude, for ex ample, bathing, eatin g, using th e to ilet and w alking acr oss the ro om. IA DLs in clude ac tivities such as shopping, h ousework an d meal preparation. R ecently, a number o f valid ated, more holistic measu res of h ealth-related quality o f lif e have been d eveloped. T hese indices need t o be sh ared an d a dapted fo r u se in a variety of c ultures and settings. 6 The Agin g Ma le Active Ageing: A Policy Framework World He alth Organization ‘h ealthy ag eing’ an d t o reco gnize th e fa ctors in As in dividuals age, noncommunicable d iseases addition to h ealth c are that aff ect h ow in dividuals (NCDs) become t he lead ing ca uses of m orbidity, and populations age . disability and m ortality in all regions of t he w orld, The ac tive ageing approach is based on t he including in d eveloping c ountries, as shown recognition o f t he h uman r ights of o lder p eople in F igures 5 an d 6. NCDs, which ar e essentially and th e U nited Nat ions Principles of i nde- diseases of lat er life, are costly t o in dividuals, pendence, p articipation, d ignity, car e and self- families and t he p ublic p urse. But man y NCDs fulfillment. It sh ifts strategic planning a way from a are preventable or c an b e p ostponed. Fa iling to ‘n eeds-based’ ap proach (w hich assu mes that o lder prevent o r m anage the gro wth o f NCD s appropri- people are passive targets) to a ‘righ ts-based’ ately will result in en ormous h uman an d so cial approach th at rec ognizes t he rig hts of p eople t o costs that w ill absorb a disproportionate am ount o f equality of op portunity an d trea tment in all aspects resources, which co uld h ave been u sed to ad dress of li fe as they gro w o lder. It sup ports th eir respons- the health problems of other age groups. ibility to exer cise their participation i n th e p olitical In th e early years, communicable d iseases, process and other aspects of community life. maternal and p erinatal conditions an d n utritional deficiencies are the m ajor c auses of d eath an d disease. In la ter childhood, ad olescence an d yo ung A LIF E COURSE APPROACH TO adulthood, i njuries and n oncommunicable c ondi- ACTIVE AGEING tions b egin to ass ume a much gr eater role. By A lif e course p erspective on ag eing recognizes th at midlife (age 45) and in t he later years, NCDs older p eople are not o ne h omogeneous g roup an d are responsible for th e vast majority o f d eaths an d that ind ividual d iversity tends to in crease with ag e. diseases (see Figures 5 an d 6 ). Research is increas- Interventions t hat cr eate supportive en vironments ingly sh owing t hat th e o rigins of risk for c hronic and f oster h ealthy c hoices a re important at all stages conditions, su ch a s diabetes and h eart disease, of life (see Figure 4). begin in ea rly childhood o r even earlier. This risk is Early Life Adult Life Older Age Growth and Maintaining highest Maintaining independence and development possible level of function preventing disab ility Range of function in individuals Disability threshold ( *) Rehabilitation and ens uring the quality of life Age Figure 4 Maintaining f unctional capa city ove r th e li fe co urse. Fu nctional ca pacity (su ch as ve ntilatory ca pacity, m uscular strength, a nd ca rdiovascular o utput) i ncreases i n ch ildhood an d pea ks in e arly a dulthood, eve ntually f ollowed b y a decl ine. The ra te o f decline, h owever, is largely det ermined by factors rel ated t o a dult l ifestyle – su ch a s smo king, a lcohol con sump- tion, l evels o f physical act ivity a nd diet – as wel l a s e xternal an d en vironmental fact ors. Th e g radient o f decline ma y beco me so stee p as t o resu lt in prem ature disa bility. Ho wever, the a cceleration in decli ne can be influenced a nd m ay be reversible at any ag e th rough i ndividual a nd publi c policy mea sures. Changes i n t he e nvironment c an l ower t he disa bility th reshold, thus decreasing the number of disabled people in a given community. Source: Kalache and Kickbusch, 1997 The Agin g Male 7 Functional capacity Active Ageing: A Policy Framework World He alth Organization Major C hronic C onditions A ffecting O lder Pe ople W orldwide Cardiovascular diseases (such as coronary heart disease) Hypertension Stroke Diabetes Cancer Chronic obstructive pulmonary disease Musculoskeletal conditions (such as arthritis and osteoporosis) Mental health conditions (mostly dementia and depression) Blindness and visual impairment Note: The c auses of d isability in o lder ag e are similar for w omen an d men although w omen ar e more likely to report musculoskeletal problems. Source: WHO, 1998 0–4 Years 5–14 Years 15–44 Years 45–59 Years > 60 Years Noncommunicable conditions Injuries Communicable diseases, maternal and perinatal conditions a nd nutr itional deficiencies Figure 5 Leading ca uses of death, bot h sex es, 1998, lo w- an d m iddle-income co untries by age. So urce: Wo rld H ealth Report 1999 Database 0–4 Years 5–14 Years 15–44 Years 45–59 Years > 60 Years Noncommunicable c onditions Injuries Communicable dise ases, maternal a nd pe rinatal conditions and nutritional deficiencies Figure 6 Leading c auses of burden of disease, both se xes, 1998, l ow- a nd m iddle-income cou ntries by age. So urce: World Health Report 1999 Database 8 The Agin g Ma le Active Ageing: A Policy Framework World He alth Organization subsequently sh aped an d mo dified b y fac tors, su ch More p eople p articipating ac tively as they age in as socioeconomic stat us and e xperiences across the the so cial, cultural, eco nomic an d po litical whole lif e span. T he risk of d eveloping NC Ds con- aspects of s ociety, in p aid an d u npaid r oles and in tinues to in crease as individuals age. But it is domestic, family and community lif e tobacco u se, lack of p hysical ac tivity, inadequate Lower co sts related to med ical treatment and diet an d ot her estab lished adult r isk factors w hich care services. will put in dividuals at relatively greater risk of developing N CDs at older ages (see Figure 7). Active ageing policies and p rogrammes recognize Thus, it is important to ad dress the risk s of the n eed to en courage an d b alance p ersonal non-communicable d isease from early life to late responsibility (self-care), age-friendly environ- life, i.e. throughout the life course. ments and in tergenerational so lidarity. Individuals and fam ilies need to pla n an d p repare f or o lder age, and mak e personal ef forts to ad opt p ositive ACTIVE AGEING PO LICIES AND personal h ealth p ractices at all stages of life. At th e PROGRAMMES same time supportive en vironments are required to ‘mak e the healthy choices the easy choices’. An ac tive ageing approach to p olicy an d There are good ec onomic reaso ns for en acting programme development h as the p otential t o policies and p rogrammes that p romote ac tive address many of th e ch allenges of b oth in dividual ageing in te rms of in creased participation an d and p opulation agein g. When h ealth, labour reduced co sts in c are. People w ho r emain healthy market, employment, education an d so cial policies as they ag e face fewer impediments to co ntinued support active ageing there will potentially be: work. T he cu rrent tren d to ward ear ly retirement Fewer premature deaths in t he h ighly p roduc- in in dustrialised countries is largely the resu lt tive stages of life of p ublic po licies that h ave encouraged ea rly withdrawal fro m th e la bour fo rce. A s p opulations Fewer disabilities associated with ch ronic age, there will be inc reasing pressures for su ch diseases in older age policies to c hange – particularly if more and mo re More p eople en joying a positive quality o f life individuals reach o ld ag e in go od he alth, i.e. are as they grow older ‘fit for w ork’. This w ould h elp t o o ffset th e risin g Fetal Infancy and Adolescence A dult L ife Life Childhood Established adult behavioural/biological risk fa ctors Obesity High SES lack of PA diseases smoking growth rate SES; maternal nutritional Accumulated status; birth weight risk (range) Low Age Figure 7 Scope for noncommunicable disea ses (NCD) prevention, a l ife co urse a pproach. S ES, so cioeconomic sta tus; PA, physical activity. Source: Aboderin, et al., 2002 The Agin g Male 9 Development of NCD Active Ageing: A Policy Framework World He alth Organization costs in p ensions an d in come sec urity schemes as 20 p ercent o ver the n ext 50 yea rs . Between 1982 well as those re lated to med ical and soc ial care and 19 94, in th e U SA, the s avings in n ursing h ome costs. costs alone we re estimated to ex ceed $17 billion . With reg ard to rising public exp enditures fo r Moreover, if increased numbers o f h ealthy o lder medical care, available data in creasingly indicate people w ere to ext end th eir participation in th e that o ld age itself is not asso ciated with in creased work fo rce ( through eith er full o r p art-time medical spending. Rat her, it is disability and po or employment), their contribution to p ublic reve- health – often ass ociated with o ld ag e – th at are nues w ould c ontinuously in crease. Finally, it is costly. As p eople ag e in b etter h ealth, med ical often less costly to p revent disease than to tr eat it. spending may not increase as rapidly. For exam ple, it has been estim ated that a Policy-makers need t o loo k at the f ull p icture one-dollar in vestment in me asures to en courage and c onsider t he savin gs achieved by d eclines in moderate physical act ivity leads to a cost saving of disability rates. In t he US A, for ex ample, such $3.2 in medical costs . declines might lower med ical spending b y ab out 3. The Determinants of Active Ageing: Understanding the Evidence Active ageing depends o n a variety of in fluences emphasis here is on th e h ealth an d q uality o f life or ‘ de terminants’ that sur round in dividuals, of old er p ersons. At t his point, it is not p ossible families and n ations (Figu re 8). Understanding t he to at tribute d irect c ausation t o an y o ne d etermi- evidence we have about t hese determinants helps nant; h owever, the su bstantial body o f evi dence on us design policies and programmes that work. what d etermines health s uggests that all of th ese The fo llowing sect ion su mmarizes what we factors (an d th e int erplay b etween th em) are good know ab out h ow t he b road d eterminants of h ealth predictors o f h ow w ell both i ndividuals and po pu- affect t he p rocess o f agein g. These determinants lations age. More r esearch is needed to c larify and apply to th e h ealth of a ll age groups, alt hough t he specify the r ole of eac h d eterminant, as well as the Gender Economic Health and social determinants services Social Active Behavioural determinants ageing determinants Physical Personal environment determinants Culture Figure 8 The determinants of active ageing 10 The Agin g Ma le Active Ageing: A Policy Framework World He alth Organization interaction b etween d eterminants, in th e a ctive Policies and p rogrammes need t o re spect current ageing process. We also need to be tter u nderstand cultures an d t raditions w hile de-bunking o utdated the pa thways t hat ex plain how th ese broad d eter- stereotypes and misinf ormation. Moreover, there minants actually affect health and well being. are critical universal values that t ranscend c ulture, Moreover, it is helpful to co nsider th e in fluence such as ethics and h uman r ights. of vario us determinants over the life course s o as to take ad vantage of t ransitions and ‘ w indows o f Gender is a ‘ le ns’ throu gh which to consider the appro- opportunity’ fo r en hancing h ealth, p articipation priateness of v arious policy options and ho w they will and sec urity at different sta ges. For e xample, there affect the well being of both men and women . is evidence that stimu lation and sec ure attachments in in fancy i nfluence an in dividual’s ability to lear n and get along w ith ot hers th roughout all of t he la ter In m any societies, girls and w omen ha ve lower stages of lif e. Employment, which is a determinant social status and less access to n utritious f oods, throughout ad ult life greatly influences o ne’s education, mean ingful w ork an d h ealth ser vices. financial r eadiness for o ld age. Access to h igh Women’s traditional ro le as family caregivers may quality, d ignified lo ng-term ca re is particularly also contribute to t heir increased poverty an d ill important in la ter life. Often, a s is the c ase with health in o lder age . Some women ar e forced to exposure to p ollution, t he y oung an d t he old are give up p aid e mployment t o c arry o ut th eir the most vulnerable population groups. caregiving responsibilities. Others never have access to p aid emp loyment b ecause they w ork full-time in u npaid car egiving roles, looking af ter CROSS-CUTTING DETERMINANTS: children, o lder p arents, spouses who a re ill and CULTURE AND G ENDER grandchildren. A t th e sam e time, boys an d men are Culture is a cross-cutting de terminant w ithin t he more likely to su ffer d ebilitating inj uries or d eath framework for understanding a ctive ageing. due t o vio lence, occupational h azards, an d su icide. They also engage in mo re risk-taking b ehaviours such as smoking, alc ohol an d d rug co nsumption Culture, w hich surrounds all in dividuals and popul a- and u nnecessary exposure to the risk of injury. tions, shapes the way in which we a ge b ecause it influ- ences all of the other determinants of active ageing . DETERMINANTS RELATED TO HEALTH AND SO CIAL SE RVICE Cultural valu es and t raditions d etermine to a large SYSTEMS extent h ow a given society views older p eople an d the ag eing process. When so cieties are more likely to at tribute sy mptoms of d isease to t he a geing To promote ac tive a geing, hea lth systems need t o take process, they ar e less likely to p rovide p revention, a lif e c ourse pe rspective tha t focuses on health promo- early detection an d ap propriate tr eatment services. tion, disease prevention a nd e quitable a ccess to quality Culture i s a key f actor in w hether o r n ot c o-resi- primary health care a nd long-term care . dency wit h y ounger gen erations is the p referred way o f li ving. For exa mple, in m ost Asian coun- tries, the c ultural n orm is to valu e extended fam ilies Health and so cial services need to b e in tegrated, and t o live together in mu ltigenerational house- coordinated an d c ost-effective. There m ust be n o holds. Cu ltural fac tors also influence age discrimination in th e p rovision o f s ervices and health-seeking behaviours. For e xample, attitudes service providers need to tr eat people o f all ages toward smo king ar e gradually c hanging i n a range with dignity an d respect. of countries. There is enormous cu ltural d iversity and co m- Health p romotion a nd d isease plexity within co untries an d amo ng co untries an d prevention regions of t he w orld. Fo r exa mple, diverse ethnici- ties bring a variety of valu es, attitudes an d tra di- Health promotion i s the p rocess of en abling p eople tions t o th e main stream culture w ithin a country. to t ake c ontrol o ver and to im prove their health. The Agin g Male 11 Active Ageing: A Policy Framework World He alth Organization Disease prevention i ncludes t he p revention an d Long-term ca re management of t he c onditions t hat ar e particularly Long-term c are is defined b y W HO as ‘the sy stem common as individuals age: noncommunicable of act ivities undertaken b y in formal caregivers diseases and i njuries. Prevention r efers both t o (family, friends a nd/or n eighbours) an d/or p rofes- ‘p rimary’ p revention (e.g. avoidance o f t obacco sionals (health and so cial services) to en sure that a use) as well as ‘seco ndary’ p revention (e.g. screen- person w ho is not fu lly c apable o f self-c are can ing f or t he early detection o f ch ronic d iseases), or maintain the h ighest p ossible quality o f life, ‘ter tiary’ p revention (e.g. appropriate clin ical man- according to his or h er in dividual p references, with agement of d iseases). All co ntribute to red ucing th e the g reatest possible degree of in dependence, risk of d isabilities. Disease prevention str ategies – autonomy, pa rticipation, p ersonal fu lfillment and which may also address infectious d iseases – save human dignity’ . money at any age. For ex ample, vaccinating Thus, lo ng-term ca re includes b oth in formal older ad ults ag ainst influenza saves an e stimated and fo rmal support sy stems. The lat ter may include $30 to $6 0 in tr eatment costs per $1 spent o n a broad ra nge o f c ommunity servic es (e.g. public vaccines . health, p rimary care, home c are, rehabilitation services and p alliative care) as well as institutional care in n ursing h omes and h ospices. It a lso refers Curative s ervices to treat ments that h alt o r reverse the co urse o f disease and disability. Despite best efforts in h ealth p romotion an d disease prevention, p eople ar e at increasing risk of d eveloping d iseases as they ag e. Thus ac cess to Mental he alth s ervices curative services becomes indispensable. As t he Mental h ealth ser vices, which p lay a crucial ro le in vast majority of old er p ersons in a ny given country active ageing, should b e an in tegral part o f live in th e c ommunity, mo st curative services must long-term car e. Particular at tention nee ds to b e be o ffered b y th e p rimary health c are sector. This paid to th e u nder-diagnosis o f men tal illness sector is best equipped t o mak e referrals to t he (especially depression) and to su icide rates among secondary a nd t ertiary levels of car e where mo st older people . acute and e mergency care is also provided. Ultimately, the w orldwide shif t in t he g lobal burden o f d isease toward c hronic d iseases requires BEHAVIOURAL DETERMINANTS a shift fr om a ‘find it and fix it’ m odel to a co- ordinated an d c omprehensive continuum o f car e. The adoption of hea lthy lifestyles an d a ctively par tici- This will require a reorientation in h ealth system s pating in one’s own ca re a re im portant at all sta ges of that ar e currently o rganized aro und ac ute, e pisodic the life c ourse. On e o f the myths of age ing is that it is experiences of d isease. The p resent acu te c are too late to adopt such lifestyles in the later ye ars. O n models of h ealth ser vice delivery are inadequate the contrary, en gaging in appropriate physical activity, to a ddress the h ealth n eeds of rap idly a geing healthy eating, n ot smoking and u sing alcohol a nd populations . medications wisely in older ag e ca n pre vent dis ease and As th e p opulation ag es, the d emand w ill con- functional de cline, e xtend l ongevity a nd en hance o ne’s tinue to r ise for med ications that a re used to d elay quality of life. and t reat chronic d iseases, alleviate pain an d improve quality o f lif e. This ca lls for a renewed effort to in crease affordable acc ess to es sential safe Tobacco u se medications and to b etter en sure the ap propriate, cost-effective use of cu rrent an d n ew d rugs. Smoking is the mo st important mo difiable risk Partners in t his effort n eed t o in clude g overnments, factor f or NC Ds for yo ung a nd o ld alik e and a health p rofessionals, the p harmaceutical in dustry, major p reventable cause of p remature death. traditional h ealers, employers and o rganizations Smoking n ot o nly in creases the r isk for d iseases representing older people. such as lung c ancer, it is also negatively related 12 The Agin g Ma le Active Ageing: A Policy Framework World He alth Organization to fac tors th at m ay lead to imp ortant losses in Physical a ctivity functional c apacity. F or ex ample, smoking acc eler- Participation in r egular, moderate physical a ctivity ates the rate of d ecline o f b one de nsity, muscular can d elay functional d eclines. It can r educe th e strength a nd r espiratory function. R esearch on t he onset o f c hronic d iseases in b oth h ealthy an d effects of smo king revealed not j ust t hat smo king chronically ill older p eople. Fo r ex ample, regular is a risk factor fo r a large and inc reasing number moderate physical act ivity reduces th e risk of of d iseases but a lso that its ill effects are cumulative cardiac d eath b y 2 0 to 25 p ercent am ong p eople and lo ng lastin g. The risk of c ontracting at least one with es tablished heart d isease . It c an also substan- of t he d iseases associated with sm oking inc reases tially reduce t he severit y of d isabilities associated with the duration and the amount of exposure. with h eart d isease and o ther c hronic illn esses . A cr itical message for y oung peo ple sh ould Active living improves mental health an d of ten always be ‘ I f y ou w ant to gr ow old er, d on’t s moke. promotes so cial contacts. Bein g active can h elp Moreover, if you w ant t o g row o lder an d t o older p eople r emain as independent as possible for increase your ch ance to ag e well, again don’t the lo ngest p eriod o f time. It c an also reduce th e smoke’. risk of f alls. There ar e thus imp ortant ec onomic The b enefits of q uitting are wide-ranging an d benefits when o lder p eople are physically ac tive. apply to an y ag e group. It is never too late to q uit Medical costs are substantially lower f or o lder smoking. F or in stance, stroke risk decreases after people w ho are active . two y ears of ab stinence fro m cig arette smoking Despite all of th ese benefits, high p roportions and, a fter five years, it becomes the sam e as that of o lder p eople in m ost countries lead sedentary for in dividuals who h ave never smoked. Fo r o ther lives. Populations w ith lo w in comes, ethnic diseases, e.g. lung can cer an d o bstructive p ulmo- minorities and old er pe ople w ith d isabilities are the nary d isease, quitting d ecreases the risk but o nly most likely to b e in active. Policies and pr ogrammes very slowly. Thus, cu rrent ex posure is not a very should en courage i nactive people t o b ecome mo re good in dicator o f c urrent an d fu ture risk s and p ast active as they ag e and to p rovide th em with o ppor- exposure s hould b e tak en in to acc ount as well; tunities to d o so. It is particularly imp ortant to the eff ects of smo king are cumulative and lo ng provide saf e areas for w alking an d t o su pport standing . culturally ap propriate c ommunity a ctivities that Smoking may interfere with t he effe ct o f n eeded stimulate physical ac tivity and are organized an d medications. Exposure to sec ond-hand s moke can led b y old er p eople th emselves. Professional ad vice also have a negative effect o n o lder peo ple’s health, to ‘ go f rom d oing n othing to d oing so mething’ an d especially if they su ffer f rom asth ma or o ther r espi- physical r ehabilitation p rogrammes that h elp o lder ratory problems. people rec over from mo bility problems ar e both Most s mokers start young an d are quickly effective and cost-efficient. addicted t o th e n icotine in to bacco. T herefore, In t he least developed co untries, th e o pposite efforts to p revent c hildren an d y outh fro m sta rting problem m ay occur. In t hese countries, ind ivi- to smo ke must be a primary strategy in t obacco duals are often en gaged in str enuous p hysical control. A t th e same time, it is important to red uce work an d c hores th at may hasten disab ilities, the d emand f or to bacco am ong ad ults (th rough cause injuries and a ggravate previous conditions, comprehensive actions su ch as taxation an d rest ric- especially as they ap proach o ld age. This m ay tions o n ad vertising) and t o h elp ad ults o f all ages include hea vy caregiving responsibilities for ill to q uit. Stu dies h ave shown t hat to bacco co ntrol and d ying rela tives. Health promotion eff orts is highly co st-effective in lo w- an d m iddle- in th ese areas should b e d irected at providing income c ountries. I n C hina, for ex ample, conser- relief from rep etitive, strenuous ta sks and mak ing vative estimates suggest that a 10 p ercent in crease adjustments to u nsafe p hysical mo vements at in t obacco tax es would re duce c onsumption b y work t hat w ill decrease injuries and p ain. five percent an d in crease overall revenue by f ive Older people w ho r egularly engage in vig orous percent. T his inc reased revenue would b e su ffi- physical w ork n eed o pportunities fo r rest and cient t o f inance a package o f ess ential health c are recreation. services for o ne-third o f C hina’s poorest cit izens . The Agin g Male 13 Active Ageing: A Policy Framework World He alth Organization Healthy e ating Alcohol Eating and fo od s ecurity problems at all ages While older p eople t end t o dr ink less than y ounger include b oth un der-nutrition (m ostly, but n ot people, me tabolism changes t hat acc ompany a ge- exclusively, in th e least developed c ountries) an d ing in crease their susceptibility to alco hol-related excess energy in take. In old er p eople, maln utrition diseases, including maln utrition an d liver , gastric can b e ca used b y limite d access to fo od, so cio- and p ancreatic d iseases. Older people also have economic h ardships, a lack o f inf ormation an d greater risks for alco hol-related f alls and in juries, as knowledge ab out nu trition, p oor fo od ch oices well as the p otential h azards asso ciated with mixin g (e.g. eating high fat fo ods), d isease and th e u se of alcohol a nd med ications. Treatment ser vices for medications, tooth lo ss, social isolation, cognitive alcohol p roblems s hould b e availa ble to o lder or p hysical d isabilities that in hibit o ne’s ability to people as well as younger people. buy fo ods a nd p repare th em, emergency situations According to a recent W HO review of th e and a lack of physical activity. literature, there is evidence that alc ohol u se at very Excess energy in take gre atly increases the risk low levels (up to o ne d rink a day) may offer so me for ob esity, chronic d iseases and d isabilities as form o f p rotection ag ainst coronary h eart d isease people grow older. and str oke f or p eople age d 4 5 an d o ver. However, in t erms of o verall excess mortality, the ad verse effects of d rinking o utweigh an y p rotection Diets high in (saturated) fat a nd sa lt, low in fruits and against coronary h eart d isease, even in h igh r isk vegetables an d pro viding insufficient a mounts of fib re populations . and v itamins combined with sedentarism, a re m ajor risks factors f or c hronic conditions like dia betes, ca rdio- Medications vascular disea se, high blood pressure, obe sity, ar thritis and some cancers. Because older p eople o ften h ave chronic h ealth problems, they ar e more likely than y ounger Insufficient c alcium and vitam in D is associated people to n eed an d u se medications – trad itional, with a loss of b one d ensity in old er age and c onse- over-the-counter an d p rescribed. I n mo st quently an in crease in p ainful, c ostly an d d ebilitat- countries, o lder p eople w ith lo w in comes have ing b one fra ctures, especially in old er w omen. I n little or n o ac cess to in surance fo r me dications. As a populations w ith h igh f racture i ncidence, risk can result, many go w ithout o r sp end a n in appropri- be d ecreased through ensu ring ad equate c alcium ately large part o f t heir meager incomes on d rugs. and vitamin D intake. In co ntrast, med ications are sometimes over- prescribed to o lder p eople (esp ecially to o lder women) w ho h ave insurance o r th e me ans to p ay Oral h ealth for th ese drugs. A dverse drug-related rea ctions an d falls associated with med ication u se (especially Poor o ral hea lth – primarily dental c aries, perio- sleeping pills and t ranquilizers) are significant dontal d iseases, tooth lo ss and o ral can cer – cau se causes of p ersonal su ffering an d c ostly pr eventable other sy stemic health p roblems. They cr eate a hospital admissions . financial b urden fo r i ndividuals and so ciety and c an reduce self -confidence an d q uality o f li fe. Studies Iatrogenesis – health p roblems th at ar e induced b y show t hat p oor o ral health is associated with diagnoses or t reatments – ca used b y t he u se of malnutrition an d t herefore in creased risks for drugs is common in o ld ag e, due to t he in teraction various noncommunicable d iseases. Oral health of d rugs, in adequate d osages and a higher f re- promotion a nd cavit y prevention p rogrammes quency o f un predictable reac tions th rough u n- designed to en courage pe ople to k eep th eir natural known me chanisms. With t he ad vent o f m any new teeth n eed t o b egin ea rly in life and co ntinue o ver therapies, there is an i ncreasing need to est ablish the life course. B ecause of th e p ain an d red uced systems for p reventing ad verse drug rea ctions and quality o f life associated with or al h ealth p roblems, for in forming bo th he alth p rofessionals and th e basic dental tr eatment services and ac cessibility to ageing public a bout t he r isks and b enefits of dentures ar e required. modern therapies. 14 The Agin g Ma le Active Ageing: A Policy Framework World He alth Organization Adherence general agreement that th e lifelo ng tr ajectory o f health an d d isease for an in dividual is the resu lt Access to n eeded med ications is insufficient in itself of a combination o f g enetics, environment, life- unless adherence to lo ng-term t herapy fo r ag eing- style, nutrition, an d to a n imp ortant ex tent, related chronic illn esses is high. A dherence chance . includes th e ad option an d ma intenance o f a wide Therefore, th e in fluence o f gen etics on th e range o f b ehaviours ( e.g. healthy d iet, physical development of c hronic co nditions su ch as dia- activity, not s moking), as well as taking m edica- betes, heart d isease, Alzheimer’s disease and c ertain tions as directed b y a health p rofessional. It is esti- cancers varies greatly among in dividuals. For m any mated that in deve loped c ountries a dherence t o people, li festyle behaviours s uch as not smo king, long-term th erapy aver ages only 50 p ercent. I n personal c oping sk ills and a network o f clo se kin developing co untries th e rat es are even lower. and f riends ca n eff ectively modify th e in fluence o f Such p oor ad herence severely compromises the heredity on f unctional d ecline an d th e o nset o f effectiveness of t reatments and h as dramatic quality disease. of life and ec onomic i mplications for p ublic h ealth. Population hea lth o utcomes p redicted by tr eat- ment efficacy d ata can o nly b e ac hieved if adher- ence in formation is provided t o all health Psychological f actors professionals and p lanners. Without a system that Psychological fac tors in cluding in telligence and addresses the inf luences o n ad herence, ad vances in cognitive capacity (fo r ex ample, the a bility to s olve biomedical technology w ill fail to r ealize their problems an d ad apt to c hange an d lo ss) are strong potential t o r educe th e b urden of ch ronic d isease . predictors o f ac tive ageing and lo ngevity . During normal agein g, some cognitive capacities (includ- ing learn ing speed and memo ry) naturally DETERMINANTS RELATED TO decline w ith age . However, these losses can b e PERSONAL FACTORS compensated b y gain s in w isdom, knowledge an d experience. Often, d eclines in c ognitive function- Biology a nd g enetics ing ar e triggered by disu se (lack of p ractice), illness Biology an d g enetics greatly influence h ow a (such as depression), behavioural fa ctors (suc h as person ag es. Ageing is a set of b iological p rocesses the u se of a lcohol an d med ications), psychological that ar e genetically determined. Ageing ca n be factors ( such as lack of m otivation, low e xpecta- defined as a progressive, generalized impairment of tions an d lack o f co nfidence), an d so cial factors function r esulting in a loss of ad aptative response to (such as loneliness and i solation), rather th an ag eing a stress and in a growing risk of ag e-associated per se. disease . In o ther w ords, th e main reason why Other p sychological f actors th at ar e acquired older p ersons g et sick more frequently t han across the life course g reatly influence t he w ay younger p ersons is that, d ue t o th eir longer lives, in w hich p eople a ge. Self-efficacy (the belief they h ave been exp osed to e xternal, behavioural, people h ave in th eir capacity to exert control o ver and en vironmental factors t hat c ause disease for a their lives) is linked t o p ersonal b ehaviour ch oices longer time than their younger counterparts . as one ag es and to p reparation f or retir ement. Coping sty les determine how w ell people ad apt to the t ransitions (such as retirement) and c rises of While g enes m ay be in volved in the causation of ageing (such as bereavement and t he o nset disease, for m any dise ases the cause is environmental of illness). and ex ternal to a gre ater de gree tha n it is genetic an d Men an d w omen w ho p repare fo r o ld age and internal. are adaptable to ch ange mak e a better ad justment to life after age 60. Most p eople r emain resilient as It sh ould a lso be n oted th at th ere is evidence in they a ge and, on t he w hole, o lder p eople d o n ot human p opulations th at lo ngevity tends to r un vary significantly from y ounger p eople in th eir in f amilies. But, all things c onsidered, t here is ability to cope. The Agin g Male 15 Active Ageing: A Policy Framework World He alth Organization DETERMINANTS RELATED TO slums and sh anty to wns is rising quickly as many, THE PHYSICAL ENVIRONMENT who mo ved to th e c ities long a go, h ave become long-term s lum-dwellers, while other o lder p eople Physical e nvironments migrate to cities to jo in y ounger fam ily members Physical environments that are age friendly ca n who h ave already moved there. Older people make the d ifference b etween i ndependence an d living in th ese settlements are at high risk for so cial dependence fo r all individuals but a re of p articular isolation and poor health. importance fo r th ose g rowing o lder. F or exam ple, In times of c risis and co nflict, d isplaced o lder older p eople w ho live in an un safe en vironment o r people are particularly vu lnerable. Often th ey are areas with mu ltiple physical b arriers are less likely unable t o w alk t o r efugee camps. Even if they mak e to get out an d th erefore mo re prone t o is olation, it to cam ps, it may be h ard t o o btain sh elter and depression, reduced f itness and in creased mobility food, esp ecially for o lder w omen a nd o lder p ersons problems. with d isabilities who ex perience low so cial status Specific a ttention mu st be g iven to o lder p eople and m ultiple other barriers. who live in r ural areas (some 60 p ercent w orld- wide) where d isease patterns may be d ifferent d ue Falls to en vironmental conditions an d a lack o f availa ble support servic es. Urbanization an d t he m igration Falls among o lder pe ople are a large and in creasing of yo unger p eople in s earch of j obs may leave older cause of in jury, tr eatment costs and d eath. people is olated in ru ral areas with lit tle means of Environmental hazards th at in crease the risk s of support an d little or n o ac cess to h ealth an d so cial falling include p oor lig hting, slipp ery or ir regular services. walking s urfaces and a lack of su pportive h andrails. Accessible and a ffordable p ublic t ransportation Most of ten, th ese falls occur in t he h ome en viron- services are needed in b oth ru ral an d u rban area s so ment and are preventable. that p eople o f all ages can fu lly p articipate in f amily The c onsequences o f in juries sustained in o lder and c ommunity li fe. This is especially important age are more severe than amo ng yo unger p eople. for o lder persons who have mobility problems. For in juries of th e same severity, older p eople Hazards in th e ph ysical en vironment can lead to experience more disability, longer h ospital s tays, debilitating an d p ainful inj uries among o lder extended p eriods o f r ehabilitation, a higher r isk of people. In juries f rom f alls, fires and t raffic c ollisions subsequent d ependency a nd a higher risk of dy ing. are most common. The great m ajority of in juries are pre ventable; Safe ho using however, the traditional view of in juries as ‘a ccidents’ has resulted in historical neglect of this area in public Safe, adequate h ousing a nd n eighbourhoods are health. essential to t he w ell-being of y oung an d o ld. Fo r older p eople, lo cation, in cluding p roximity t o family members, services and tr ansportation ca n Clean w ater, c lean a ir a nd s afe fo ods mean the d ifference be tween p ositive social inter- action an d iso lation. Building c odes nee d to ta ke Clean water, clean air and a ccess to safe foods are the h ealth an d safet y needs of o lder pe ople in to particularly imp ortant fo r th e mo st vulnerable account. Ho usehold h azards t hat in crease the risk population g roups, i.e. children a nd o lder p ersons, of falling need to b e remedied or removed. and fo r th ose w ho h ave chronic illn esses and c om- Worldwide, t here is an inc reasing trend fo r promised immune systems. older p eople to live alone – esp ecially unattached older w omen w ho ar e mainly widows an d are DETERMINANTS RELATED TO often p oor, even in d eveloped c ountries. O thers THE SOCIAL EN VIRONMENT may be fo rced t o li ve in arr angements that are not of t heir choice, s uch as with relat ives in a lready Social support, o pportunities f or ed ucation an d crowded h ouseholds. I n ma ny developing lifelong lear ning, peace, and pr otection f rom countries, th e p roportion o f o lder p eople livin g in violence and ab use ar e key fa ctors in th e so cial 16 The Agin g Ma le Active Ageing: A Policy Framework World He alth Organization environment th at en hance h ealth, p articipation disorganization w hen o verall crime and ex ploita - and secu rity as people ag e. Loneliness, social isola- tion t ends to in crease. tion, illi teracy and a lack o f ed ucation, ab use an d exposure t o c onflict situ ations greatly increase According to the International N etwork for the older p eople’s risks for d isabilities and ea rly death. Prevention of E lder A buse, e lder ab use is ‘a sing le or repeated a ct, o r lack of a ppropriate action occurring within any relationship where the re is an expectation Social s upport of tr ust which causes ha rm o r distress to an olde r Inadequate so cial support is associated not o nly person’ . with an in crease in mo rtality, morbidity an d psychological d istress but a decrease in o verall Elder abuse in cludes p hysical, sexual, psychological general health an d w ell being. D isruption o f and f inancial ab use as well as neglect. Older p eople personal ties, loneliness and c onflictual in teractions themselves perceive abuse as including t he fo llow- are major so urces of str ess, while supportive so cial ing s ocietal factors: n eglect (so cial exclusion an d connections an d in timate relations are vital sources abandonment), vio lation (h uman, leg al and of emo tional str ength . In Jap an, for exam ple, medical rights) and d eprivation ( choices, decisions, older p eople wh o r eported a lack o f s ocial contact status, finances an d r espect) . Elder abuse is a were 1.5 times more likely to d ie in t he n ext th ree violation of hu man r ights and a significant cause years than w ere those w ith h igher so cial support . of inj ury, illn ess, lost productivity, isola tion an d Older peo ple are more likely to lo se family despair. Ty pically, it is underreported in all members and frien ds an d to b e m ore vulnerable to cultures. loneliness, social isolation an d t he availab ility of a Confronting an d r educing eld er abuse req uires a ‘smaller social pool’. Social isolation an d lo neliness multisectoral, multidisciplinary approach i nvolv- in o ld ag e are linked t o a decline in b oth p hysical ing ju stice officials, law enforcement o fficers, and men tal well being. In mo st societies, men are health an d so cial service workers, la bour lead ers, less likely than w omen to h ave supportive so cial spiritual leaders, faith in stitutions, ad vocacy o rga- networks. H owever, in s ome cultures, older nizations an d o lder p eople t hemselves. Sustained women w ho are widowed ar e systematically efforts to in crease public a wareness of th e p roblem excluded fro m main stream society or even and to sh ift valu es that p erpetuate g ender in equities rejected by their community. and a geist attitudes are also required. Decision-makers, nongovernmental o rganiza- tions, private industry an d h ealth a nd so cial service Education a nd li teracy professionals can he lp f oster so cial networks fo r ageing people b y su pporting trad itional so cieties Low levels of e ducation an d illite racy are associated and c ommunity g roups ru n b y o lder p eople, with inc reased risks for d isability and d eath amo ng voluntarism, neighbourhood h elping, p eer men- people as they age, as well as with hig her ra tes of toring an d visitin g, family caregivers, intergenera- unemployment. E ducation in ear ly life combined tional programmes and outreach services. with o pportunities fo r lif elong lea rning can h elp people d evelop t he sk ills and c onfidence th ey n eed to ad apt an d st ay independent, as they g row o lder. Violence a nd a buse Studies h ave shown t hat emp loyment p roblems Older p eople w ho ar e frail or live alone may feel of o lder w orkers ar e often ro oted in th eir relatively particularly vu lnerable to c rimes such a s theft an d low liter acy skills, not in ag eing per se. If p eople are assault. A c ommon fo rm o f vio lence against older to rem ain engaged in mean ingful an d pr oductive people (esp ecially against older w omen) is ‘eld er activities as they gro w o lder, th ere is a need fo r continuous train ing in th e w orkplace an d li felong abuse’ c ommitted b y fa mily members and in stitu- tional car egivers who a re well known t o t he learning opportunities in the community . victims. Elder abuse o ccurs in families at all Like younger p eople, o lder c itizens need economic levels. It is likely to esc alate in so cieties training in n ew tec hnologies, esp ecially in agr icul- experiencing eco nomic u pheaval an d so cial ture an d elec tronic co mmunication. Se lf-directed The Agin g Male 17 Active Ageing: A Policy Framework World He alth Organization learning, increased practice an d ph ysical ad just - tradition o f gen erations livin g together b egins to ments (such as the u se of lar ge print) ca n co mpen- decline, countries ar e increasingly called on to sate for red uctions in v isual acuity, h earing an d develop m echanisms that p rovide s ocial protection short-term memory. Older p eople c an an d d o for o lder p eople w ho are unable to ea rn a living and remain creative and flexib le. Intergenerational are alone an d vu lnerable. In d eveloping co untries, learning bridges age differences, enhances t he older pe ople w ho ne ed assistan ce tend to rely on transmission of c ultural valu es and p romotes t he family support, in formal service transfers and worth o f all ages. Studies h ave shown th at yo ung personal savin gs. Social insurance p rogrammes in people w ho le arn with o lder p eople h ave more these settings are minimal and in so me cases redis- positive and rea listic attitudes a bout th e o lder tribute in come to m inorities in th e p opulation wh o generation. are less in n eed. Ho wever, in c ountries s uch as Unfortunately, th ere continue t o b e str iking d is- South A frica an d Namib ia, which ha ve a national parities in liter acy rates between men and wo men. old ag e pension, th ese benefits are a major so urce In 19 95 in th e least developed c ountries, 31 of inc ome fo r man y poor fam ilies as well as the percent o f a dult w omen w ere illiterate compared older ad ults w ho liv e in th ese families. The mo ney to 20 percent of adult men . from th ese small pensions is used to p urchase f ood for th e h ousehold, to s end ch ildren to s chool, to invest in f arming technologies an d to en sure survival for many urban poor f amilies. ECONOMIC D ETERMINANTS In d eveloped c ountries, s ocial security measures Three a spects of th e ec onomic en vironment h ave can in clude o ld-age p ensions, o ccupational p en- a particularly sig nificant ef fect o n ac tive ageing: sion sch emes, voluntary savin gs incentives, com- income, social protection and work. pulsory savin gs funds a nd in surance p rogrammes for d isability, sickness, long-term c are and u n- employment. In re cent ye ars, policy refo rms have Income favoured a multi-pillared approach t hat mix es state Active ageing policies need to in tersect with and p rivate support fo r o ld a ge security and en - broader sc hemes to r educe p overty at all ages. courages w orking lo nger an d g radual retir ement . While poor p eople o f all ages face an in creased risk of ill health an d d isabilities, older p eople ar e partic- Work ularly vulnerable. Many o lder p eople – es pecially those w ho ar e female, live alone o r in ru ral areas – Throughout th e w orld, if more people w ould do n ot h ave reliable or su fficient inc omes. This enjoy o pportunities fo r d ignified w ork ( properly seriously affects their access to n utritious fo ods, remunerated, in ad equate en vironments, protected adequate h ousing an d h ealth car e. In f act, s tudies against the h azards) earlier in lif e, people w ould have shown th at o lder p eople w ith lo w in comes reach o ld age able to p articipate in th e w orkforce. are one-third as likely to h ave high levels of Thus, th e w hole soc iety would b enefit. In a ll parts functioning as those with high incomes . of th e w orld, t here is an in creasing recognition o f The mo st vulnerable are older w omen an d m en the n eed to su pport th e ac tive and p roductive co n- who h ave no a ssets, little or n o savin gs, no p ensions tribution th at old er p eople c an an d do ma ke in or soc ial security payments or w ho are part o f formal work, in formal work, u npaid ac tivities in families with lo w o r u ncertain in comes. Particu- the home and in voluntary occupations. larly, those w ithout c hildren o r f amily members In d eveloped co untries, t he p otential g ain o f often fa ce an u ncertain f uture an d ar e at high risk encouraging o lder p eople to w ork lo nger is not for h omelessness and destitution. being fu lly realiz ed. But w hen u nemployment is high, t here is often a tendency to see reducing th e number o f o lder w orkers as a way to crea te jobs fo r Social p rotection younger p eople. Ho wever, experience has shown In all countries o f th e w orld, fam ilies provide t he that th e u se of ear ly retirement to fre e up n ew j obs majority o f su pport fo r old er p eople w ho req uire for t he u nemployed h as not be en a n ef fective help. H owever, as societies develop an d t he solution . 18 The Agin g Ma le Active Ageing: A Policy Framework World He alth Organization Africa Asia LAm/C NAm Oceania Europe Figure 9 Percentage of labour fo rce participation by people 65 a nd ol der by region. LA m/C, Lat in A merica a nd th e Caribbean; NAm, North America. Source: ILO, 2000 In less developed co untries, o lder p eople are In b oth d eveloping an d d eveloped co untries, by n ecessity more likely to r emain economically older p eople o ften t ake p rime responsibility for active into old age (see Figure 9). However, indus- household m anagement and c hildcare so t hat trialization, adoption o f n ew tec hnologies an d younger a dults can work o utside the home. labour mark et mobility is threatening mu ch o f In all countries, sk illed and exp erienced o lder the tra ditional w ork o f old er p eople, pa rticularly people act as volunteers in sc hools, c ommunities, in r ural areas. Development projects n eed to e nsure religious institutions, b usinesses and h ealth an d that o lder p eople are eligible for cr edit sc hemes and political o rganizations. V oluntary w ork b enefits full p articipation in in come-generating o pportuni- older p eople b y in creasing social contacts an d ties. psychological w ell being w hile making a signifi- cant co ntribution to t heir communities and nations. Concentrating on ly on work in the formal la bour market ten ds to ignore the valuable c ontribution that older p eople m ake in work in the informal se ctor (e.g. small sc ale, se lf-employed a ctivities and d omestic work) and unpaid work in the home. 4. Challenges of an Ageing Population The ch allenges of p opulation agein g are global, CHALLENGE 1: T HE DOUBLE national an d lo cal. Meeting th ese challenges will BURDEN OF D ISEASE require innovative planning an d s ubstantive policy As n ations in dustrialize, changing pa tterns o f reforms in d eveloped co untries an d in co untries in living and w orking ar e inevitably accompanied b y transition. D eveloping co untries, mo st of wh om a shift in d isease patterns. These changes imp act do n ot y et have comprehensive policies on agein g, developing co untries mo st. Even as these countries face the biggest challenges. continue to s truggle with in fectious d iseases, The Agin g Male 19 % Active Ageing: A Policy Framework World He alth Organization malnutrition an d co mplications f rom ch ildbirth, By 2020, the b urden o f th ese diseases will rise to they ar e faced w ith th e r apid gr owth o f n on approximately 78 percent (see Figure 10). communicable d iseases (NCDs). This ‘ d ouble There is no q uestion t hat p olicy m akers and burden o f d isease’ strains already scarce resources to donors mu st continue to p ut reso urces toward th e the limit. control an d e radication of in fectious d iseases. But i t The sh ift f rom c ommunicable t o NCD s is fast is also critical to pu t p olicies, programmes and occurring in m ost of th e d eveloping w orld, w here intersectoral partnerships i nto p lace t hat c an h elp chronic illn esses such as heart d isease, cancer an d to h alt th e massive expansion o f c hronic NC Ds. depression are quickly b ecoming th e lea ding cau ses While not n ecessarily easy to imp lement, those t hat of m orbidity an d d isability. This tr end w ill escalate focus o n co mmunity d evelopment, health p romo- over the n ext few d ecades. In 19 95, 51 p ercent o f tion, d isease prevention an d in creasing participa- the g lobal b urden o f d isease in d eveloping an d tion ar e often t he mo st effective in c ontrolling th e newly i ndustrialized c ountries w as caused b y burden o f d isease. Furthermore o ther lo ng-term NCDs, mental health d isorders and in juries. policies that tar get malnutrition a nd p overty w ill 1990 2020 Communicable diseases Neuropsychiatric diseases Noncommunicable diseases Injuries Figure 10 Global bur den of disease 1990 a nd 202 0: con tribution by disease group in devel oping a nd ne wly i ndustrialized countries. By 202 0, o ver 70 p ercent of the g lobal burde n of disease in devel oping a nd n ewly in dustrialized cou ntries wil l be caused by noncommunicable diseases, mental health disorders and injuries. Source: Murray and Lopez, 1996 HIV/AIDS a nd O lder Pe ople In A frica an d o ther d eveloping reg ions, HIV/AIDS ha s had mu ltiple impacts on o lder p eople, in te rms of livin g with th e d isease themselves, caring fo r o thers w ho are infected an d tak ing o n th e p arenting ro le with o rphans o f A IDS. T his im pact has been larg ely ignored t o d ate. In fa ct, m ost data o n H IV and A IDS infection rat es are only co mpiled up t o age 49. Improved d ata co llection (w ithout ag e limitations) that helps us better un derstand th e imp act of HIV /AIDS o n o lder p eople is urgently n eeded. HIV /AIDS information, ed ucation an d pr evention act ivities as well as treatment services should ap ply to all ages. Numerous studies have found t hat mo st adult c hildren w ith A IDS retu rn h ome to d ie. Wives, mothers, aunts, sister s, sisters-in-law and g randmothers tak e o n th e b ulk o f th e car e. Then, in m any cases, these women t ake o n th e car e of th e o rphaned c hildren. G overnments, nongovernmental organizations an d p rivate industry n eed t o ad dress the fin ancial, social and tr aining n eeds of o lder people w ho car e for f amily members and n eighbours w ho are infected an d raise child su rvivors, some of whom themselves are also infected . 20 The Agin g Ma le Active Ageing: A Policy Framework World He alth Organization help to red uce bo th ch ronic c ommunicable an d age. Significantly, ad ults o ver the ag e of 8 0 ar e the noncommunicable diseases. fastest growing age group worldwide. Support f or relevan t research is most urgently But d isabilities associated with age ing and th e needed f or less developed co untries. Cu rrently, onset o f c hronic d isease can b e p revented o r low- an d mid dle-income countries ha ve 85 delayed. For ex ample, as mentioned p reviously, percent o f t he w orld’s population a nd 9 2 p ercent there has been a significant d ecline o ver the last of th e d isease burden, b ut o nly 10 per cent o f 20 y ears in age- specific disability rates in th e the world’s health research spending . USA (see Figure 11), England, Sw eden an d o ther developed countries. Figure 11 sh ows t he act ual de cline in d isabilities CHALLENGE 2: IN CREASED RISK among o lder A mericans between 1 982 an d 1 999 OF D ISABILITY compared t o t he p rojected n umbers if rates of d is- In b oth d eveloping an d d eveloped co untries, ability had remained stable over that time period. chronic d iseases are significant an d c ostly cau ses of Some of th is decline is likely due to i ncreased disability and r educed qu ality o f lif e. An o lder education levels, improved standards o f livin g and person’s independence is threatened w hen p hysical better h ealth in th e early years. The a doption o f or men tal disabilities make it difficult to c arry o ut positive lifestyle behaviours is also a factor. A s the activities of daily living. already mentioned, ch oosing no t t o smo ke and As t hey g row o lder, p eople wit h d isabilities are making mo dest increases in p hysical act ivity levels likely to en counter ad ditional b arriers related to th e can sign ificantly reduce o ne’s risk for h eart d isease ageing process. For exa mple, mobility problems and o ther illn esses. Supportive ch anges in th e c om- due to p oliomyelitis in ch ildhood m ay be c on- munity a re also important, b oth in ter ms of p re- siderably aggravated later in li fe. Now th at man y venting d isabilities and red ucing t he rest rictions young p eople w ith in tellectual disabilities survive that p eople w ith d isabilities often fac e. In a ddition, at much old er a ges and live beyond th eir parents, impressive progress in th e man agement of c hronic this special group also requires careful atte ntion conditions ha s been o bserved, including ne w t ech- from policy makers. niques fo r ear ly diagnosis and t reatment, as well as Many p eople d evelop d isabilities in later life long-term man agement of c hronic d iseases, such a s related to t he w ear and tear of ag eing (e.g. arthritis) hypertension an d art hritis. Recent st udies have also or th e o nset o f a chronic d isease, which co uld h ave emphasized that th e in creasing use of aid s – fro m been p revented in t he f irst place (e.g . lung c ancer, simple personal aid s, such as canes, walkers, hand- diabetes and p eripheral vasc ular disease) or a rails, to tec hnologies aim ed at the p opulation as a degenerative illness (e.g. dementia). The li keli- whole, su ch as telephones – may reduce d epend- hood o f exp eriencing ser ious cognitive and p hysi- ence am ong disab led p eople. In th e USA t he u se of cal disabilities dramatically increases in very old such aid s by d ependent o lder p eople i ncreased 9.5 8.5 7.5 6.5 1982 1983 198 4 198 5 1 986 19 87 19 88 198 9 1 990 1 991 1992 1993 199 4 1 995 1 996 19 97 199 8 199 9 Actual numbers Projected nu mbers Figure 11 Numbers of chronically d isabled Americans a ged 65 a nd ove r (in m illions), 1 982 to 199 9, a ctual a nd proje cted numbers. Total nu mber of older p eople in t he US A ( millions): 19 82, 26 .9; 19 94, 33 .1; 19 99, 35 .3. So urce: M anton an d Gu , The Agin g Male 21 Millions Active Ageing: A Policy Framework World He alth Organization from 76 p ercent in 1 984 t o o ver 90 p ercent in the b urden o f d isability in o ld ag e are urgently 1999 . needed in b oth d eveloping an d d eveloped co un- tries. One u seful w ay t o lo ok at decision-making in this area is to th ink a bout e nablement instead of Vision a nd he aring disablement. Disabling processes increase the n eeds Other co mmon ag e-related disabilities include of old er p eople an d lead to iso lation an d d epend- vision and h earing lo sses. Worldwide, th ere are ence. Enabling p rocesses restore function an d currently 1 80 m illion people w ith visua l disability, expand th e p articipation o f o lder p eople i n all up to 45 m illion of w hom ar e blind. M ost o f t hese aspects of so ciety. are older p eople, a s visual impairment and b lind- A variety of sec tors can en act ‘ a ge-friendly’ ness increase sharply w ith ag e. Overall, approxi- policies that p revent disability and e nable those mately four p ercent o f per sons ag ed 6 0 ye ars and who h ave disabilities to fu lly p articipate in above ar e thought to b e b lind, an d 6 0 p ercent o f community life. Here are some examples of en abl- them live in Su b-Saharan A frica, Ch ina an d I ndia. ing pr ogrammes, environments and p olicies in a The m ajor ag e-related causes of b lindness an d variety of sectors: visual disability include c ataracts (nearly 50 p ercent Barrier-free workplaces, flex ible work ho urs, of all blindness), glaucoma, macular degeneration modified w ork en vironments and p art-time and diabetic retinopathy . work f or p eople w ho exp erience disabilities as There is an ur gent n eed f or p olicies and they ag e or are required t o c are for o thers w ith programmes designed t o p revent visual impair- disabilities (private industry and e mployers) ment and to i ncrease appropriate ey e care services, particularly in d eveloping c ountries. In a ll Well-lit streets for saf e walking, ac cessible countries, c orrective lenses and c ataract su rgery public to ilets and tra ffic lig hts that give should b e ac cessible and aff ordable f or o lder p eople people mo re time to cr oss the st reet (local who n eed them. governments) Hearing impairment leads to o ne o f t he mo st Exercise programmes that h elp o lder p eople widespread d isabilities, particularly in o lder pe ople. maintain their mobility or r ecover the leg It is estimated that w orldwide o ver 50 p ercent o f strength th ey n eed to b e mo bile (recreation people aged 6 5 y ears and ove r have some degree services and nongovernmental a gencies) of h earing lo ss . Hearing loss can c ause difficulties with co mmunication. T his, in tu rn can lead to Life-long lear ning and li teracy programmes frustration, lo w self-e steem, withdrawal an d so cial (education sect or an d n ongovernmental 39,40 isolation . organizations) Policies and p rogrammes need t o b e in p lace t o Hearing aids or in struction in s ign language t hat reduce an d even tually eliminate avoidable hearing enables older pe ople w ho are hard o f h earing to impairment and t o h elp pe ople w ith h earing lo ss continue t o co mmunicate wit h o thers (so cial obtain h earing aid s. Hearing loss may be p revented services and nongovernmental o rganizations) by avo iding ex posure t o e xcessive noise and t he use of p otentially d amaging d rugs an d b y early treat- Barrier-free access to h ealth cen tres, rehabilita- ment of d iseases leading t o h earing lo ss, such as tion p rogrammes and c ost-effective procedures middle ear infections, d iabetes and p ossibly h yper- such as cataract s urgery and h ip rep lacements tension. Hearin g loss can so metimes be t reated, (health sector) especially if the c ause is in t he ear canal o r m iddle Credit schemes and ac cess to small business and ear. Most o ften, ho wever, the d isability is reduced development o pportunities so t hat o lder p eople by amp lification o f sou nds, u sually by u sing a can co ntinue to earn a living (governments and hearing aid. international agencies). Changing t he at titudes o f h ealth an d so cial service An en abling e nvironment providers is paramount t o en suring t hat t heir prac- As po pulations aro und t he w orld live longer, p oli- tices enable and em power in dividuals to r emain as cies and p rogrammes that he lp p revent and r educe autonomous an d i ndependent as possible for as 22 The Agin g Ma le Active Ageing: A Policy Framework World He alth Organization long as possible. Professional c aregivers need t o Most o lder p ersons in n eed o f car e prefer to b e respect older p eople’s dignity at all times and t o be cared fo r in th eir own h omes. But ca regivers (who careful t o avo id premature interventions that may are often o lder p eople) mu st be sup ported if they unintentionally in duce t he loss of independence. are to c ontinue t o pr ovide c are without b ecoming Researchers need t o b etter d efine an d stan dard- ill themselves. Above all, they n eed t o b e w ell ize the to ols used to ass ess ability and disab ility and informed ab out t he co ndition th ey are faced w ith to p rovide p olicy mak ers with ad ditional evid ence and h ow it is likely to p rogress, and ab out h ow to on k ey en abling p rocesses in th e b roader envir on- obtain th e su pport services that a re available. ment, as well as in m edicine and h ealth. C areful Visiting nurses, home car e, peer support p ro- attention n eeds to b e p aid to g ender d ifferences in grammes, rehabilitation servic es, the p rovision o f these analyses. assistive devices (ranging fro m b asic devises such as a hearing aid t o mo re sophisticated on es, such as an electronic a larm system), respite care and ad ult d ay CHALLENGE 3: PR OVIDING CARE care are all important ser vices that en able informal FOR A GEING PO PULATIONS caregivers to co ntinue to p rovide c are to ind ivi- As p opulations ag e, one o f t he g reatest challenges duals w ho req uire help, w hatever their age. Other in h ealth p olicy i s to st rike a balance am ong su pport forms of su pport in clude t raining, income secu rity for self-c are (people lo oking aft er themselves), (e.g. social security coverage and p ensions), help informal support (ca re from fam ily members and with h ousing ad justments th at en able families to friends) and f ormal care (health and so cial services). look a fter people wh o ar e disabled a nd d isburse- Formal care includes b oth p rimary health c are ments to help cover caring costs. (delivered mostly at the c ommunity level) and As th e p roportion o f o lder p eople in creases in all institutional c are (either in h ospitals or n ursing countries, livin g at home in to very old age with homes). While it is clear that m ost of t he c are help f rom f amily members will become in creas- individuals need is provided b y th emselves or th eir ingly c ommon. Ho me care and co mmunity informal caregivers, most countries allo t their services to assi st informal caregivers need t o b e financial r esources inversely, i.e. the gr eatest share available to a ll, not ju st to th ose wh o k now ab out of expenditure is on institutional care. them or can afford to pay for them. All over the w orld, family members, friends an d Professional caregivers also need t raining an d neighbours ( most of w hom are women) p rovide practice in en abling mo dels of c are that r ecognize the bu lk o f su pport an d c are to o lder a dults w ho older p eople’s strengths an d e mpower th em to need a ssistance. Some policy mak ers fear that p ro- maintain even small measures of in dependence viding more formal care services will lessen the when t hey are ill or fr ail. Paternalistic or d is- involvement of f amilies. Studies s how t hat t his is respectful at titudes b y pr ofessionals can h ave a not th e c ase. When a ppropriate fo rmal services are devastating effect on t he s elf-esteem and i ndepend- provided, in formal care remains the k ey p artner . ence of older people who require services. Of co ncern th ough are recent d emographic t rends Information an d ed ucation ab out ac tive ageing in a large number o f c ountries in dicating t he needs to b e in corporated in to c urricula an d t rain- increase in th e p roportion o f c hildless women, ing p rogrammes for a ll health, so cial service and changes in d ivorce an d m arriage patterns a nd t he recreation w orkers as well as city p lanners an d overall much smaller number o f ch ildren o f fu ture architects. Basic principles an d ap proaches in o ld- cohorts o f o lder p eople, all contributing to a age care should b e ma ndatory in th e t raining o f shrinking pool of family support . all medical and n ursing stu dents a s well as other Formal care through h ealth an d soc ial service health professions. systems needs to b e e qually acc essible to all . In many countries o lder p eople w ho are poor an d CHALLENGE 4: T HE who live in ru ral ar eas have limited or n o a ccess to FEMINIZATION OF A GEING needed he alth car e. A d ecline in pu blic su pport for p rimary health car e services in man y areas has Women live longer t han men almost everywhere. put in creased financial an d in tergenerational str ain This is reflected in t he h igher ra tio o f w omen on o lder people and their families. versus men in o lder a ge groups. F or exam ple, in The Agin g Male 23 Active Ageing: A Policy Framework World He alth Organization World LDR MDR 0 100 2 00 30 0 40 0 50 0 600 700 8 00 90 0 10 00 2002 2020 Figure 12 Sex r atios b y world regions, a ge 6 0 y ears an d ove r, 20 02 an d 202 0. S ex r atios f or populations a ge 6 0 a nd o ver reflect t he la rger pro portion o f women t han men in a ll reg ions o f the wo rld, pa rticularly in t he mo re devel oped regions. LDR, less developed regions; MDR, more developed regions; medium variant fertility. Source: UN, 2001 2002, there were 678 men for ever y 1000 w omen countries in ec onomic tr ansition o ver 70 p ercent aged 6 0 p lus in Eu rope. In less developed r egions, of women age 70 and o ver are widows . there were 879 men per 1 000 w omen (see Figure Older women w ho ar e alone ar e highly vu lner- 12). Women m ake up ap proximately tw o-thirds o f able to p overty an d s ocial isolation. In s ome cul- the p opulation o ver age 75 in co untries su ch as tures, degrading an d d estructive attitudes an d Brazil and So uth A frica. Wh ile women h ave the practices around b urial righ ts and in heritance m ay advantage in leng th o f lif e, they ar e more likely rob w idows o f t heir property an d p ossessions, their than men to ex perience domestic violence and d is- health an d in dependence an d, in s ome cases, crimination in acc ess to ed ucation, i ncome, food, their very lives. meaningful wo rk, h ealth c are, inheritances, social security measures and p olitical p ower. T hese CHALLENGE 5: E THICS AND cumulative disadvantages mean that wo men are INEQUITIES more likely than me n to b e p oor an d to su ffer d is- abilities in o lder age. Because of th eir second-class As p opulations a ge, a range o f eth ical consider- status, the h ealth o f o lder w omen is often ne glected ations c omes to t he fo re. They a re often lin ked to or ig nored. In ad dition, man y women ha ve low o r age discrimination in reso urce allo cation, iss ues no i ncomes because of y ears spent in un paid c are- related to t he en d o f lif e and a host o f d ilemmas giving roles. The p rovision o f f amily care is often linked t o lo ng-term car e and t he hu man r ights achieved at the d etriment of fem ale caregivers’ of p oor an d d isabled o lder cit izens. Scientific economic security and good health in later life. advancements and mo dern med icine have led to Women are also more likely than men to liv e to many ethical questions r elated to ge netic research very old ag e when d isabilities and m ultiple health and man ipulation, b iotechnology, stem cell problems are more common. A t a ge 80 an d o ver, research and t he u se of tec hnology to s ustain life the w orld avera ge is below 60 0 m en for every 1000 while compromising q uality o f lif e. In all cultures, women. I n th e mo re developed reg ions, women consumers need to b e f ully in formed ab out false age 80 an d over outnumber men by mo re than tw o claims of ‘ an ti-ageing’ p roducts an d p rogrammes to one (see the example of Japan in Figure 13). that ar e ineffective or h armful. They ne ed p rotec- Because of w omen’s longer life expectancy an d tion fro m f raudulent ma rketing an d f inancing the t endency o f men to marr y younger w omen an d schemes, especially as they grow o lder. to r emarry if their spouses die, female widows Societies that valu e social justice mu st strive to dramatically outnumber male widowers in a ll ensure that all policies and p ractices uphold an d countries. Fo r ex ample, in th e E astern European guarantee th e r ights of a ll people, r egardless of age. 24 The Agin g Ma le Number of men per 1000 women Active Ageing: A Policy Framework World He alth Organization Age group Male Female 80+ 70–74 60–64 50–54 40–44 30–34 20–24 10–14 0–4 6000 3000 0 3000 6000 9000 Population in t housands Figure 13 Population pyr amid for Japan in 20 02 an d 20 25. In co ntrast t o th e p yramid form, the Japa nese po pulation structure h as ch anged due to po pulation a geing to wards a co ne sh ape. By 202 5, th e sh ape wil l be similar t o a n up- side-down pyramid, with pe rsons age 8 0 a nd ove r a ccounting for the la rgest p opulation gro up. T he fem inization o f old a ge is highly visible. Source: UN, 2001 Table 4 Percentage o f the popu lation b elow in ter- Advocacy an d eth ical decision-making mu st be national p overty li nes in co untries wit h a po pulation central str ategies in a ll programmes, practices, approaching o r abo ve 100 mi llion in th e y ear 20 00. So urce: policies and research on ageing. 44 † 1 World Bank, 2001 and UN, 2001 Older age often exa cerbates other p re-existing inequalities based o n rac e, ethnicity o r gen der. Percentage Percentage with with While women are universally disadvantaged in Population < 1 < 2 terms of p overty, men have shorter li fe expectan- Countries (millions) dollar/day dollars/day * * cies in mo st countries. T he exc lusion an d im pov- erishment of o lder w omen an d m en is often a China 1275 18.5 53.7 product o f st ructural in equities in b oth d eveloping India 1008 44.2 86.2 and d eveloped c ountries. I nequalities experienced Indonesia 212 7.7 55.3 Brazil 170 9.0 25.4 in ear lier life in ac cess to ed ucation, em ployment Russian Federation 145 7.1 25.1 and h ealth c are, as well as those b ased o n gen der Pakistan 141 31.0 84.7 and r ace have a critical bearing o n sta tus and we ll Bangladesh 137 29.1 77.8 being in o ld a ge. For o lder p eople w ho ar e poor, Nigeria 113 70.2 90.8 the c onsequences o f t hese earlier experiences are Mexico 98 12.2 34.8 worsened t hrough fu rther exc lusion fro m h ealth services, credit sch emes, income-generating *Adjusted for purchasing power activities and d ecision-making. Inequities in c are occur w hen small and co mparatively well off portions o f th e ag eing population, pa rticularly and pa rticipate in civic affairs are very limited. those in d eveloping co untries, c onsume a dispro- These conditions a re often w orse for o lder p eople portionately h igh amo unt o f p ublic r esources for living in ru ral areas, in c ountries in tr ansition an d in their care. situations of conflict or humanitarian disasters. In man y cases, the mean s for o lder p eople t o In all regions of t he w orld, r elative wealth an d achieve dignity a nd ind ependence, rec eive care poverty, g ender, o wnership o f assets, access to The Agin g Male 25 Active Ageing: A Policy Framework World He alth Organization work an d c ontrol o f r esources are key f actors in Second, t he c osts of lo ng-term c are can b e socioeconomic sta tus. Recent W orld Ban k d ata managed if policies and p rogrammes address pre- reveal that in man y developing co untries w ell over vention an d th e r ole of in formal care. Policies and half o f th e p opulation lives on less than tw o p ur- health p romotion p rogrammes that p revent chasing po wer p arity (P PP) d ollars per d ay (s ee chronic d iseases and less en the d egree of d isability Table 4). among o lder c itizens enable them to live inde- It is well known th at so cioeconomic st atus and pendently lon ger. A nother maj or fa ctor is the health are intimately related. With eac h step up capacity an d willin gness of f amilies to p rovide c are the so cioeconomic lad der, people live longer, and s upport fo r o lder fa mily members. This w ill healthier lives . In rec ent yea rs, the gap b etween depend to a large extent o n t he rat es of f emale rich an d p oor an d su bsequent in equalities in h ealth participation in th e lab our f orce an d o n wo rkplace status has been in creasing in co untries in all parts o f and p ublic po licies that rec ognize an d su pport th e the world . Failure to ad dress this problem w ill caregiving role. have serious consequences f or th e glo bal e conomy In m any countries, t he b ulk of s pending is on and so cial order, as well as for in dividual so cieties curative medicine. Care for ch ronic c onditions and people o f all ages. leads to an imp roved q uality o f life; however, it is always preferable if those co nditions co uld b e p re- vented o r d elayed u ntil very late in life. Decision- CHALLENGE 6: TH E ECONOMICS makers need t o evalu ate whether su ch o utcomes OF A N A GEING PO PULATION can b e ac hieved through p olicies that ad dress Perhaps m ore than an ything else, policy-makers the b road d eterminants of ac tive ageing, such as fear that r apid p opulation ag eing will lead to a n interventions to p revent in juries, improve diets unmanageable ex plosion in hea lth c are and so cial and p hysical act ivity, increase literacy or in crease security costs. While there is no do ubt th at a geing employment. populations w ill increase demands in t hese areas, Ultimately, the level of f unding allo cated to th e there is also evidence that in novation, co operation health system is a social and p olitical c hoice w ith from a ll sectors, planning ah ead an d m aking evi- no u niversally applicable an swer. However, the dence-based, cu lturally ap propriate p olicy ch oices WHO suggests that it is better t o ma ke pre- will enable countries to suc cessfully manage the payments on h ealth car e as much as possible, economics of an ageing population. whether in t he f orm o f insu rance, tax es or so cial Research in co untries w ith ag ed p opulations h as security. The p rinciple o f ‘ fair financing’ en sures shown t hat a geing per se is not lik ely to lead to equity o f ac cess regardless of ag e, sex or eth nicity ‘h ealth c are costs that are spiraling out of co ntrol’, and t hat th e f inancial b urden i s shared in a fair for t wo reasons. way . First, according t o OE CD data, the maj or ca uses A s econd m ajor c oncern t o p olicy-makers is the of escala ting health car e costs are related to cir- demand t hat an agein g population may put o n cumstances that are unrelated t o th e d emographic social security systems. Alarmists point to th e ageing of a given population. In efficiencies in c are growing p roportion o f th e ‘ d ependent’ p opulation delivery, building t oo man y hospitals, payment that h as retired from th e fo rmal labour f orce. T he systems that e ncourage lo ng h ospital sta ys, exces- idea that every one over age 60 i s dependent i s, sive numbers o f med ical interventions and t he however, a false assumption. Many pe ople co n- inappropriate u se of h igh c ost tec hnologies are the tinue to w ork in t he fo rmal labour m arket in la ter key fa ctors in escalat ions in h ealth c are costs. For life or w ould c hoose t o d o so if the o pportunity example, in th e U nited S tates and o ther O ECD existed. Many o thers c ontinue t o c ontribute to th e countries, n ew te chnologies w ere sometimes economy th rough in formal work an d vo luntary rapidly in troduced an d u sed w here alt ernative and activities, as well as intergenerational ex changes o f less expensive procedures alrea dy existed, and fo r cash an d f amily support. F or e xample, older pe ople which t he marg inal effectiveness was relatively who lo ok af ter grandchildren allo w yo unger ad ults low . There a ppears to b e c onsiderable sc ope fo r to participate in the labour market. policy-makers to ad dress these issues and imp rove An age ing population p rovides other ad vantages the effectiveness of h ealth care. to th e over all economy. Nat ions with d eclining 26 The Agin g Ma le Active Ageing: A Policy Framework World He alth Organization working-age p opulations w ill be ab le to d raw o n provide an imp ortant ec onomic an d so cial contri- older ex perienced w orkers an d in dustries will bution t o so ciety. be a ble to gro w as they serve the n eeds of o lder consumers. It is time f or a ne w par adigm, one tha t views ol der Global agein g does req uire governments and t he people as active pa rticipants in an a ge-integrated private sector to ad dress the ch allenges to so cial society and as active c ontributors as well a s beneficiaries security and p ension syst ems. A b alanced ap proach of development. to t he p rovision o f so cial protection an d e conomic goals suggests that so cieties who are willing to pla n can aff ord t o gro w o ld. L abour ma rket policies This inc ludes r ecognition o f t he c ontributions o f (for ex ample, incentives for early retirement and older p eople w ho are ill, frail and vu lnerable and mandatory re tirement practices) have a more dra- championing their rights to care and security. matic impact on a nation’s ability to p rovide so cial This p aradigm tak es an int ergenerational protection in o ld ag e than d emographic agein g per approach th at r ecognizes t he imp ortance o f rela- se. The g oal mu st be to en sure adequate livin g tionships a nd sup port am ong an d b etween fa mily standards f or p eople as they gr ow old er, w hile members and gen erations. It r einforces ‘a society recognizing an d h arnessing their skills and exp eri- for all ages’ – th e c entral f ocus o f t he 1 999 Un ited ence an d enc ouraging h armonious in tergenera- Nations International Year of O lder Persons. tional transfers. The n ew p aradigm a lso challenges the t radi- tional view that lear ning is the b usiness of ch ildren and y outh, w ork is the b usiness of mid life and retirement is the bu siness of o ld ag e. The n ew p ara- CHALLENGE 7: FO RGING A N EW digm calls for pr ogrammes that su pport lear ning at PARADIGM all ages and allo w p eople t o en ter or leave the Traditionally, o ld age has been ass ociated with labour m arket in o rder to assum e caregiving roles at retirement, illness and d ependency. P olicies and different t imes over the life course. T his ap proach programmes that are stuck i n th is out-dated p ara- supports in tergenerational so lidarity and p rovides digm do n ot ref lect reality. Indeed, mo st people increased security for c hildren, pa rents an d p eople remain independent in to ver y old a ge. Especially in in their old age. developing c ountries, m any people o ver age 60 Older p eople th emselves and th e m edia must continue t o p articipate in t he lab our f orce. Old er take th e lead in fo rging a new, m ore positive image people are active in t he in formal work s ector (e.g . of ag eing. Political and so cial recognition o f domestic work an d small scale, self-employed the c ontributions th at o lder p eople ma ke and th e activities) although t his is often n ot r ecognized in inclusion o f o lder m en and w omen in lead ership labour mark et statistics. Older people’s unpaid roles will support t his new i mage and h elp d e-bunk contributions in th e ho me (su ch as looking af ter negative stereotypes. Educating y oung p eople children an d p eople w ho ar e ill) allow yo unger about ag eing and p aying car eful at tention to u p- family members to en gage in p aid lab our. In a ll holding th e righ ts of o lder p eople w ill help to countries, th e v oluntary ac tivities of o lder p eople reduce and eliminate discrimination and a buse. 5. The Policy Response The agein g of t he p opulation is a global p henome- will have socioeconomic an d p olitical co nse- non t hat d emands in ternational, n ational, reg ional quences everywhere. and lo cal ac tion. In an i ncreasingly inter- connected w orld, failu re to d eal with th e d emo- Ultimately, a col lective appr oach to ageing an d olde r graphic im perative and rap id c hanges in d isease people wil l de termine how we, ou r chil dren an d ou r patterns in a rational w ay in an y p art o f th e wo rld grandchildren w ill experience l ife in later years. The Agin g Male 27 Active Ageing: A Policy Framework World He alth Organization The p olicy f ramework fo r act ive ageing shown according to th eir basic human rig hts, capacities, in Fig ure 14 is guided b y t he United Nations needs and p references, people will continue to Principles f or Ol der P eople (the outer circ le). These make a productive c ontribution to so ciety in b oth are independence, p articipation, c are, self- paid an d unpaid a ctivities as they age. fulfillment and d ignity. Dec isions are based o n a n Security When p olicies and p rogrammes address understanding o f h ow t he determinants of a ctive the so cial, financial an d p hysical sec urity needs and ageing influence th e w ay th at in dividuals and rights of p eople as they ag e, older p eople are populations ag e. ensured o f p rotection, d ignity an d c are in th e even t The p olicy fra mework req uires action o n th ree that t hey are no lo nger ab le to su pport an d p rotect basic pillars: themselves. Families and c ommunities are Health When th e risk factors (bo th en vironmen- supported in ef forts t o ca re for t heir older tal and b ehavioural) for c hronic d iseases and fu nc- members. tional d ecline are kept lo w w hile the p rotective factors ar e kept h igh, p eople w ill enjoy bo th a longer qu antity an d qu ality o f life; they w ill remain INTERSECTORAL ACTION healthy an d ab le to man age their own li ves as they Attaining t he g oal o f ac tive ageing will require grow o lder; few er older ad ults w ill need c ostly action in a variety of sec tors in ad dition to h ealth medical treatment and care services. and s ocial services, including ed ucation, e mploy- For th ose w ho d o n eed c are, they sh ould h ave ment and la bour, f inance, so cial security, housing, access to t he en tire range o f h ealth an d so cial transportation, j ustice an d r ural an d u rban services that ad dress the n eeds and righ ts of w omen development. While it is clear that th e h ealth sec tor and men as they age. does n ot h ave direct r esponsibility for p olicies in all Participation When lab our ma rket, employment, of t hese other sect ors, they b elong in th e b roadest education, h ealth an d so cial policies and p ro- sense within th e sc ope o f p ublic h ealth b ecause grammes support t heir full pa rticipation in so cio- they su pport t he g oals of im proved health th rough economic, cu ltural an d spir itual activities, intersectoral action. T his k ind o f an ap proach Active Ageing Participation Health Security Determinants of Active Ageing United Nations Principles for Older People Figure 14 The three pillars of a policy framework for Active Ageing 28 The Agin g Ma le Active Ageing: A Policy Framework World He alth Organization stresses the imp ortance o f th e nu merous d ifferent Make ef fective, cost-efficient treat ments that public h ealth pa rtners an d r einforces the r ole of reduce d isabilities (such as cataract remo val the health sector as a catalyst for action . and h ip rep lacements) more accessible to o lder Furthermore, all policies need to su pport in ter- people w ith low incomes. generational so lidarity and inc lude sp ecific targets Age-friendly, s afe en vironments Create age- to red uce ine quities between w omen an d men and friendly h ealth c are centres and st andards t hat among d ifferent su bgroups w ithin t he o lder help p revent the o nset o r w orsening o f disab ili- population. Pa rticular att ention n eeds to b e p aid ties. Prevent injuries by p rotecting o lder to old er p eople w ho a re poor an d mar ginalized, pedestrians in t raffic, making w alking safe, and who live in rural areas. implementing fall prevention p rogrammes, An act ive ageing approach seek s to elim inate age eliminating hazards in th e h ome an d p roviding discrimination and reco gnize th e d iversity of o lder safety advice. Stringently en force o ccupational populations. O lder people an d th eir caregivers safety standards th at p rotect o lder w orkers need to b e act ively involved in th e p lanning, from in jury. M odify fo rmal and i nformal work implementation and e valuation of po licies, pro- environments so t hat p eople c an c ontinue to grammes and k nowledge d evelopment a ctivities work p roductively a nd safely as they age. related to active ageing. Hearing a nd vision Reduce a voidable hearing impairment through ap propriate p revention measures and s upport ac cess to h earing aid s for KEY POLICY PROPOSALS older pe ople w ho ha ve hearing lo ss. Aim to The f ollowing p olicy p roposals ar e designed t o reduce an d e liminate avoidable blindness b y address the th ree pillars of ac tive ageing: health, 2020 . Provide ap propriate ey e care services participation an d sec urity. Some are broad an d for p eople w ith ag e-related visual disabilities. encompass all age groups w hile others ar e targeted Reduce in equities in acc ess to co rrective glasses specifically to th ose ap proaching o ld a ge and/or for ageing women and men. older people t hemselves. Barrier-free liv ing Develop barrier-free housing options f or a geing people w ith disab ilities. 1. Health Work t o m ake public b uildings an d tr ansporta- tion ac cessible for all people w ith disab ilities. 1.1 Prev ent and reduce the burden of e xcess Provide ac cessible toilets in p ublic p laces and disabilities, chronic disease and premature workplaces. mortality Quality of l ife Enact p olicies and p rogrammes Goals a nd tar gets Set gender-specific, measur- that imp rove the q uality of li fe of p eople w ith able targets for imp rovements in hea lth stat us disabilities and ch ronic illn esses. Support th eir among o lder p eople an d in th e red uction o f continuing in dependence an d in terdependence chronic d iseases, disabilities and p remature mor- by assis ting with ch anges in th e en vironment, tality as people a ge. providing reh abilitation servic es and c ommu- Economic in fluences on health Enact p olicies and nity su pport fo r f amilies, and in creasing afford- programmes that ad dress the ec onomic fa ctors able access to ef fective assistive devices (e.g. that c ontribute to t he o nset o f d isease and d is- corrective eyeglasses, walkers). abilities in later life (i.e. poverty, in come i n- Social su pport Reduce r isks for lo neliness and equities and so cial exclusion, lo w lit eracy levels, social isolation b y su pporting co mmunity lack o f ed ucation). Give priority to imp roving groups r un b y o lder p eople, trad itional so cieties, the he alth sta tus of p oor an d mar ginalized self-help and m utual aid g roups, p eer and p ro- population groups. fessional outreach p rogrammes, neighbourhood Prevention a nd ef fective tr eatments Make screen ing visiting, telephone su pport p rogrammes, and services that ar e proven to b e eff ective, available family caregivers. Support int ergenerational and af fordable t o w omen an d m en as they ag e. contact an d p rovide h ousing an d c ommunities The Agin g Male 29 Active Ageing: A Policy Framework World He alth Organization that en courage d aily social interaction an d in ter - for m en and w omen as they ag e. Support dependence among young and old. improved diets and h ealthy w eights in old er age through th e p rovision o f in formation (in cluding HIV and AIDS Remove the age limitation on information sp ecific to t he n utrition n eeds of data co llection r elated to HI V/AIDS. A ssess and older p eople), education ab out nu trition at all address the im pact of HIV /AIDS o n o lder ages, and f ood p olicies that en able women, men people, in cluding t hose w ho are infected an d and f amilies to make healthy food c hoices. those wh o are caring f or o thers w ho a re infected and/or for AIDS o rphans. Oral health Promote or al h ealth amo ng o lder people a nd en courage w omen an d men to r etain Mental he alth Promote po sitive mental health their natural teet h fo r as long as possible. Set throughout th e li fe course b y p roviding in for- culturally ap propriate p olicy go als for o ral health mation an d ch allenging stereo typical beliefs and p rovide ap propriate o ral h ealth p romotion about m ental health p roblems an d men tal programmes and t reatment services during th e illness. life course. Clean en vironments Put p olicies and p ro- Psychological factors Encourage an d en able grammes in p lace th at en sure equal ac cess for a ll people t o bu ild self-e fficacy, cognitive skills to clea n water, safe food an d clea n air. Minimize such as problem-solving, pro-social b ehaviour exposure t o p ollution th roughout th e life and ef fective coping sk ills throughout th e life course, b ut p articularly in ch ildhood an d o ld course. R ecognize an d c apitalize on t he ex peri- age. ence an d st rengths o f o lder p eople w hile helping them improve their psychological well being. 1.2 Re duce risk factors associated with major Alcohol a nd dru gs Determine the ex tent o f th e diseases and increase factors that protect health use of alc ohol a nd dr ugs b y pe ople a s they age throughout th e life course and p ut p ractices and po licies in p lace to r educe Tobacco Take c omprehensive action at local, misuse and abuse. national an d in ternational levels to c ontrol t he Medications Increase affordable acc ess to essen - marketing an d u se of to bacco pr oducts. P rovide tial safe medications among o lder p eople wh o older people w ith h elp to quit smoking. need th em but c annot a fford th em. Put p ractices Physical activity Develop culturally ap propriate, and p olicies in p lace t o r educe ina ppropriate population-based in formation an d gu idelines prescribing b y h ealth p rofessionals and o ther on p hysical act ivity for o lder men and wo men. health ad visors. Inform an d ed ucate p eople Provide a ccessible, pleasant and af fordable about the wise use of medications. opportunities to b e ac tive (e.g. safe walking Adherence Undertake co mprehensive measures areas and p arks). Support p eer leaders and to b etter u nderstand an d c orrect p oor ad herence groups t hat p romote reg ular, moderate physical to t herapies, which severely compromise treat- activity for p eople as they age . Inform an d ment effectiveness, particularly in relat ion to educate p eople an d p rofessionals about t he long-term therapies. importance o f stay ing active as one g rows old er. Nutrition Ensure adequate n utrition th rough- out th e life course, pa rticularly in ch ildhood an d 1.3 D evelop a continuum of affordable, a ccessible, among w omen in th e rep roductive year s. high quality and age-friendly health and social Ensure that n ational n utrition p olicies and services that address the needs and rights of women action p lans re cognize o lder p ersons a s a poten- and men as they age tially vulnerable group. In clude sp ecial measures A con tinuum of c are thr oughout the life c ourse to p revent m alnutrition an d en sure food Taking in to c onsideration th eir opinions an d security and safety as people ag e. preferences, provide a continuum o f c are for Healthy e ating Develop culturally ap propriate, women an d men as they g row o lder. R e-orient population-based g uidelines for h ealthy eatin g current system s that are organized a round ac ute 30 The Agin g Ma le Active Ageing: A Policy Framework World He alth Organization care to p rovide a seamless continuum o f c are Iatrogenesis Prevent iatrogenesis (disease and that i ncludes h ealth p romotion, d isease preven- disability that is induced by t he p rocess of d iag- tion, th e a ppropriate t reatment of ch ronic nosis or treat ment). Establish adequate sy stems diseases, the eq uitable p rovision o f co mmunity for p reventing a dverse drug reac tions with a support an d d ignified lo ng-term an d p alliative special focus o n old age. Raise awareness of th e care through all the stages of life. relative risks and b enefits of mo dern th erapies among h ealth p rofessionals and t he p ublic at Affordable a nd e quitable a ccess Ensure affordable large. and eq uitable ac cess to q uality p rimary health care (both ac ute an d ch ronic), as well as long- Ageing at home a nd in the community Provide term care services for all. policies, programmes and ser vices that en able people to remain in th eir homes as they gro w Informal ca regivers Recognize an d ad dress older, wit h o r w ithout o ther f amily members gender d ifferences in th e b urden o f ca regiving according to t heir circumstances and p refer- and ma ke a special effort t o sup port c aregivers, ences. Support fa milies that in clude o lder most of w hom are older w omen w ho c are for people w ho n eed car e in th eir households. partners, children, g randchildren an d o thers Provide h elp w ith m eals and h ome m ainte- who are sick or d isabled. Support in formal care- nance, an d at -home nursing su pport w hen it is givers through init iatives such as respite care, required. pension c redits, financial su bsidies, training an d home c are nursing services. Recognize th at Partnerships and qua lity care Provide a compre- older car egivers may become so cially isolated, hensive approach to lo ng-term car e (by in for- financially disadvantaged an d sic k themselves, mal and fo rmal caregivers) that st imulates and attend to their needs. collaboration b etween t he p ublic a nd p rivate sectors and in volves all levels of g overnment, Formal ca regivers Provide pa id car egivers with civil society and th e n ot-for-profit sec tor. adequate w orking c onditions a nd r emunera- Ensure high q uality st andards an d stim ulating tion, w ith sp ecial attention to th ose w ho are environments in resid ential care facilities for unskilled an d h ave low so cial and p rofessional men and w omen w ho r equire this care, as they status (most of whom are women). grow older. Mental he alth services Provide co mprehensive mental health services for m en and w omen as 1.4 Pr ovide training and education to caregivers they age, ranging f rom men tal health p romotion to tr eatment services for men tal illness, rehabili- Informal ca regivers Provide family members, peer tation an d re-in tegration in to t he c ommunity as counsellors an d o ther i nformal caregivers with required. P ay sp ecial attention to in creased information an d t raining o n h ow t o car e for depression a nd su icidal tendencies d ue to lo ss people as they g row o lder. Su pport o lder h ealers and so cial isolation. Provide q uality c are for who are knowledgeable a bout tr aditional an d older p eople w ith d ementia and o ther n euro- complementary m edicines while also assessing logical and c ognitive problems in th eir homes their training needs. and in resid ential facilities when ap propriate. Formal c aregivers Educate h ealth an d so cial Pay sp ecial attention to a geing people w ith service workers in en abling m odels of p rimary long-term intellectual disabilities. health c are and lo ng-term car e that r ecognize Coordinated ethical sys tems of c are Eliminate age the stre ngths an d co ntributions o f o lder p eople. discrimination in h ealth an d s ocial service Incorporate mo dules o n ac tive ageing in systems. Improve the co ordination o f h ealth an d medical and h ealth cu rricula at all levels. social services and in tegrate these systems when Provide sp ecialist education in ger ontology an d feasible. Set and main tain appropriate sta ndards geriatrics for med ical, health an d so cial service of c are for agein g persons th rough regu latory professionals. mechanisms, guidelines, education, co nsulta- Inform all health a nd so cial service profes- tion and c ollaboration. sionals about th e p rocess of ag eing and w ays to The Agin g Male 31 Active Ageing: A Policy Framework World He alth Organization optimize ac tive ageing among in dividuals, com - participation of p eople in me aningful w ork as munities and p opulation g roups. P rovide in cen- they g row o lder, acc ording to th eir individual tives and t raining fo r h ealth an d so cial service needs, preferences and ca pacities (e.g. the elimi- professionals to su pport self-c are and c ounsel nation o f age discrimination in th e hir ing an d healthy lifesty le practices among m en and retention o f o lder wo rkers). Support p ension women as they age. Increase the aw areness reforms that e ncourage p roductivity, a diverse and sen sitivity of a ll health p rofessionals and system of p ension sch emes and m ore flex - community w orkers o f th e imp ortance o f so cial ible retirement options ( e.g. gradual o r p artial networks f or w ell being in old ag e. Train h ealth retirement). promotion w orkers to id entify o lder p eople Informal w ork Enact p olicies and p rogrammes who ar e at risk for lo neliness and so cial isolation. that rec ognize an d su pport t he c ontribution th at older wo men an d men make in u npaid w ork in 2. Pa rticipation the in formal sector an d in c aregiving in th e home. 2.1 Pro vide education and learning opportunities throughout th e life course Voluntary a ctivities Recognize th e valu e of volunteering an d ex pand o pportunities to Basic education a nd he alth literacy Make b asic edu- participate in me aningful vo lunteer act ivities as cation ava ilable to all across the lif e course. A im people a ge, especially those w ho w ant t o v olun- to ac hieve literacy for all. Promote h ealth liter- teer but can not b ecause of h ealth, in come, or acy b y p roviding h ealth ed ucation th roughout transportation restrictions. the life course. T each p eople h ow to c are for themselves and eac h o ther as they g et older. Educate an d emp ower o lder pe ople o n h ow t o 2.3 E ncourage p eople to participate fully in effectively select and u se health an d co mmunity family community life, as they grow older services. Transportation Provide a ccessible, affordable Lifelong l earning Enable the fu ll p articipation o f public t ransportation service s in ru ral an d u rban older p eople b y p roviding p olicies and p ro- areas so t hat o lder p eople ( especially those w ith grammes in ed ucation an d tra ining th at su pport compromised mo bility) can p articipate f ully in lifelong lea rning for w omen an d men as they family and c ommunity life. age. Provide o lder p eople w ith o pportunities t o develop n ew sk ills, particularly i n ar eas such as Leadership Involve older p eople i n po litical information tec hnologies an d n ew agric ultural processes that af fect th eir rights. Include o lder techniques. women an d men in t he p lanning, imp lementa- tion an d e valuation of lo cally based he alth an d social service and r ecreation p rogrammes. 2.2 Re cognize and enable the active participation Include old er p eople in p revention a nd ed uca- of people in economic development activities, tion ef forts t o red uce t he sp read o f HIV /AIDS. formal and informal work and voluntary activities Involve older p eople in eff orts to d evelop as they age, according to their individual needs, research agendas on ac tive ageing, both as preferences and capacities advisors and as investigators. Poverty r eduction a nd inc ome ge neration Include A soc iety for a ll a ges Provide gr eater flexibility in older pe ople in t he p lanning, im plementation periods d evoted to ed ucation, w ork an d c are- and evalu ation of so cial development in itiatives giving responsibilities throughout th e life and ef forts to red uce p overty. En sure that o lder course. D evelop a range o f h ousing o ptions fo r people h ave the same access to d evelopment older p eople t hat elimin ate barriers to in de- grants, income-generation p rojects an d c redit as pendence an d i nterdependence w ith fa mily younger people d o. members, and en courage f ull p articipation Formal work Enact lab our mark et and emp loy- in c ommunity an d f amily life. Provide ment policies and p rogrammes that en able the intergenerational ac tivities in sch ools an d 32 The Agin g Ma le Active Ageing: A Policy Framework World He alth Organization communities. Encourage o lder p eople t o care for p eople w ith HIV /AIDS an d tak e o n become ro le models for ac tive ageing and t o surrogate p arenting r oles for o rphans o f A IDS. mentor y oung p eople. R ecognize an d su pport Provide in -kind su pport, aff ordable h ealth c are the im portant r ole and resp onsibilities of gra nd- and lo ans to o lder p eople t o h elp th em meet the parents. Foster collaboration amo ng n on- needs of ch ildren a nd g randchildren aff ected b y governmental organizations th at w ork w ith HIV/AIDS. children, youth a nd older people. Consumer prote ction Protect co nsumers f rom A positiv e image of age ing Work w ith g roups unsafe med ications and t reatments, and u nscru- representing older p eople an d th e med ia to pulous ma rketing practices, particularly in o lder provide realist ic and p ositive images of a ctive age. ageing, as well as educational in formation o n Social ju stice Ensure that d ecisions being mad e active ageing. Confront n egative stereotypes concerning c are in o lder age are based o n th e and ageism. rights of o lder p eople an d g uided b y t he UN Reduce ine quities in participation by women Principles for Old er P ersons. Uphold o lder Recognize an d sup port th e imp ortant co ntribu- persons’ rig hts to m aintain independence an d tion t hat o lder w omen m ake to fam ilies and autonomy fo r th e lon gest pe riod o f time communities through c aregiving and p articipa- possible. tion in th e in formal economy. En able the f ull Shelter Explicitly recognize o lder p eople’s participation o f w omen in p olitical lif e and right to a nd n eed fo r secu re, appropriate sh elter, decision-making p ositions as they ag e. Provide especially in time s of c onflict a nd c risis. education an d lifelo ng lear ning opportunities t o Provide h ousing assis tance for old er p eople women as they ag e, in th e sam e way th at th ey and th eir families when req uired (p aying sp ecial are provided to men. attention to th e c ircumstances of th ose wh o Support organizations representing ol der pe ople Pro- live alone) through re nt su bsidies, cooperative vide in-kind an d fin ancial su pport an d train ing housing in itiatives, support fo r h ousing ren ova- for m embers of t hese organizations so that th ey tions, etc. can ad vocate, promote an d en hance t he h ealth, Crises Uphold th e rig hts of o lder p eople d uring security and f ull p articipation o f o lder w omen conflict. Sp ecifically recognize an d ac t o n th e and men in all aspects of community life. need to p rotect o lder p eople in emer gency situations (e.g. by p roviding tr ansportation to relief centres to t hose w ho can not w alk th ere). 3. Security Recognize t he co ntribution th at o lder p eople can mak e to rec overy efforts in t he af termath of 3.1 Ensu re the protection, safety and dignity o f an emerg ency and in clude th em in rec overy older people by addressing the social, financial and initiatives. physical security rights and needs of people as they age Elder abuse Recognize eld er abuse (ph ysical, sexual, psychological, fin ancial an d n eglect) and Social sec urity Support t he pr ovision o f a social encourage t he p rosecution of o ffenders. T rain safety net f or old er p eople w ho are poor an d law enforcement o fficers, health an d so cial alone, as well as social security initiatives that service providers, spiritual leaders, advocacy provide a steady and ad equate s tream of in come organizations an d g roups o f o lder p eople to during o ld ag e. Encourage y oung ad ults t o recognize an d d eal with eld er abuse. Increase prepare f or o ld age in th eir health, s ocial and awareness of th e in justice o f eld er abuse th rough financial practices. public in formation a nd aw areness campaigns. HIV/AIDS Support th e so cial, economic an d Involve the m edia and y oung p eople, as well as psychological w ell being o f old er p eople w ho older people in these efforts. The Agin g Male 33 Active Ageing: A Policy Framework World He alth Organization 3.2 Re duce inequities in the security rights and Enact legislatio n and en force law s that p rotect needs of older women women fr om d omestic and o ther fo rms of violence as they age. Enact legislat ion and en force law s that p rotect widows f rom t he th eft o f p roperty an d p osses- Provide s ocial security (income support) fo r sions and f rom h armful p ractices such as older w omen w ho h ave no p ensions o r meag er health-threatening b urial rit uals and c harges of retirement incomes because they h ave worked witchcraft. all or mo st of th eir lives in t he h ome o r in formal sector. WHO a nd A geing In 19 95 w hen W HO renamed its ‘Hea lth of th e Eld erly Programme’ to ‘ A geing an d H ealth’, it signaled an im portant c hange in o rientation. R ather t han co mpartmentalizing o lder p eople, th e ne w n ame embraced a life course p erspective: we are all ageing and t he b est way t o en sure good h ealth f or fu ture cohorts of old er p eople is by p reventing d iseases and p romoting h ealth th roughout th e life course. Co n- versely, the h ealth o f th ose n ow in old er age can o nly be f ully u nderstood if the life events they h ave gone through a re taken into consideration. The aim of t he A geing an d He alth Programme has been to d evelop p olicies that en sure ‘the at tain- ment of t he b est possible quality o f life for as long as possible, for th e large st possible number of p eople’. For t his to b e ac hieved, WHO is required t o a dvance th e k nowledge b ase of ger ontology a nd g eriatric medicine through r esearch and t raining eff orts. Emphasis is needed on fo stering in terdisciplinary and intersectoral initiatives, particularly th ose d irected a t developing c ountries fa ced w ith u nprecedented rapid rate s of p opulation ag eing within a context o f p revailing poverty an d u nsolved in frastructure problems. In addition t he Programme highlighted t he importance o f: Adopting co mmunity-based ap proaches b y emp hasizing the c ommunity as a key sett ing for i nter- ventions Respecting cultural c ontexts and in fluences Recognizing the importance o f g ender differences Strengthening intergenerational links Respecting and u nderstanding ethical issues related to health and well being in old age. The I nternational Y ear of Old er P ersons (19 99) was a landmark in t he evo lution o f th e W HO’s work o n ageing and h ealth. T hat year , the W orld Healt h Day th eme was ‘act ive ageing makes the d ifference’ an d the ‘ G lobal M ovement for A ctive Ageing’ w as launched b y th e WH O Director G eneral, Dr G ro Harlem Brundtland. A t th is occasion, D r Bru ndtland stat ed: Maintaining he alth and q uality of l ife ac ross the lifespan w ill do much tow ards building fulfilled liv es, a har monious intergenerational c ommunity a nd a dyna mic economy. W HO is committed to promoting Active A geing a s an in dispensable c omponent of al l de velopment programmes. In 20 00, the n ame of th e W HO programme was changed a gain to ‘ A geing an d L ife Course’ to r eflect the imp ortance of th e life -course perspective. The mu lti-focus o f t he p revious programme and th e emphasis on de veloping ac tivities with m ultiple partners f rom all sectors and several disciplines have been ma intained. A fu rther r efinement of t he ‘ act ive ageing’ c oncept h as been ad ded an d tr anslated into all the p rogramme activities, including r esearch and tr aining, information d issemination, advocacy an d policy d evelopment. In ad dition to th e A geing an d Lif e Course Programme at WHO headquarters, eac h o f t he six WHO Regional O ffices have their own ad viser on A geing in o rder to ad dress specific issues from a regional perspective. 34 The Agin g Ma le Active Ageing: A Policy Framework World He alth Organization INTERNATIONAL CONCLUSION COLLABORATION In th is document, W HO offers a framework With th e lau nch o f t he I nternational P lan o f A ction for ac tion fo r p olicy-makers. Together w ith th e on A geing, th e 200 2 W orld A ssembly on A geing newly-adopted U N Plan o f A ction o n A geing, t his marks a turning p oint in ad dressing the ch allenges framework p rovides a roadmap f or d esigning and ce lebrating th e tr iumphs o f an agein g world. multisectoral active ageing policies which w ill As w e embark o n th e im plementation phase, enhance h ealth an d p articipation amo ng ag eing cross-national, regional and g lobal s haring o f populations w hile ensuring th at o lder p eople h ave research and p olicy op tions w ill be c ritical. Increas- adequate sec urity, protection an d c are when t hey ingly, member states, nongovernmental o rganiza- require assistance. tions, academic institutions an d t he p rivate sector WHO recognizes t hat p ublic h ealth invo lves a will be c alled upon t o d evelop age- sensitive solu- wide r ange o f ac tions to i mprove the h ealth o f tions to t he c hallenges of an age ing world. T hey the p opulation a nd t hat h ealth go es beyond th e will need t o tak e in to co nsideration th e c onse- provision o f b asic health servic es. Therefore, it is quences o f th e ep idemiological transition, r apid committed t o wo rk in c ooperation w ith o ther changes in th e he alth sec tor, globalization, u rban- international ag encies and th e Un ited N ations itself ization, ch anging f amily patterns an d en vironmen- to en courage th e imp lementation of ac tive ageing tal degradation, as well as persistent inequalities and policies at global, reg ional and n ational levels. Due poverty, p articularly in d eveloping co untries to t he sp ecialist nature o f its work, W HO will where th e maj ority o f o lder pe rsons a re already provide tec hnical ad vice and p lay a catalytic role living. for he alth d evelopment. However, this can o nly be To ad vance t he mo vement for ac tive ageing, all done as a joint ef fort. T ogether, w e must provide stakeholders w ill need t o c larify and p opularize t he the evid ence and d emonstrate th e ef fectiveness of term ‘act ive ageing’ through d ialogue, d iscussion the vario us proposed co urses of act ion. U ltimately, and d ebate in th e p olitical a rena, the ed ucation however, it will be u p to n ations an d lo cal c om- sector, public f ora a nd med ia such a s radio an d munities to d evelop c ulturally sen sitive, gender- television programming. specific, realistic goals and t argets, and im plement Action o n all three pillars of ac tive ageing needs policies and p rogrammes tailored t o th eir unique to b e su pported b y k nowledge d evelopment a ctiv- circumstances. ities including evalu ation, research and sur veillance The ac tive ageing approach p rovides a frame- and th e dissemin ation of resear ch findings. T he work fo r th e d evelopment o f g lobal, n ational an d results of r esearch need t o b e s hared in c lear lan- local str ategies on p opulation ag eing. By pulling guage a nd ac cessible and p ractical fo rmats with together th e t hree pillars for ac tion o f h ealth, policy-makers, nongovernmental o rganizations participation an d s ecurity, it offers a platform fo r representing older p eople, t he p rivate sector an d consensus b uilding th at a ddresses the co ncerns o f the public at large. multiple sectors and all regions. Policy pr oposals International ag encies, countries an d reg ions and re commendations ar e of litt le use unless will need t o w ork c ollaboratively to d evelop a rele- follow-up a ctions are put in p lace. The time to ac t vant research agenda for active ageing. is now. ACKNOWLEDGEMENTS WHO is committed to work in collaboration w ith other intergovernmental organ izations, NGOs and This t ext and t he p reliminary version of th e p aper the academic sec tor for the development of a gl obal were drafted b y P eggy Ed wards, a Health Canada framework f or rese arch on ageing. S uch a f ramework consultant b ased fo r si x months a t WHO, under should reflect the priorities expressed in the Inter- the g uidance o f WH O’s Ageing an d Lif e Course national P lan o f A ction on Ageing 20 02 and those in Programme. this document. A co ntribution o f t he W orld Healt h Organiza- tion to t he Sec ond U nited Nat ions World Assembly on A geing, Madrid, Spain, April 2002. The Agin g Male 35 Active Ageing: A Policy Framework World He alth Organization We gratefully ac knowledge th e su pport p ro - The view s expressed in d ocuments b y n amed vided by He alth Canada. UNFPA contributed t o authors are solely the resp onsibility of th ese the p rinting o f th e b rochure t hrough th e G eneva authors. International Network on Ageing (G INA). Please send comments to: Graphic D esign: Marilyn Langfeld World Health Organization Noncommunicable Disease Prevention and Ó Copyright W orld H ealth Organization, 2002 Health Promotion This d ocument is not a formal publication o f t he Ageing an d Life Course World Hea lth Organization ( WHO), and all rights 20 Avenue Appia, CH 1211 Geneva 27, are reserved by th e O rganization. T he p aper may , Switzerland however, be f reely reviewed, abstracted, rep ro- Fax: +41-22-791 4839 duced a nd t ranslated, in p art o r i n w hole, b ut n ot E-mail: activeageing@who.int for sale nor f or u se in c onjunction w ith c ommercial purposes. References 1. United N ations (U N). World Po pulation P rospects: Services, Centers fo r D isease Co ntrol a nd P reven- The 2000 Revis ion . New Yo rk: UN, 2001 tion, 1999 2. Kalache A, Keller I. The g reying wo rld: a cha llenge 12. WHO. Innovative Care for Chro nic C onditions . for the 21st century. Sci Progr 2000;83:33–54 Meeting Report, 30–31 Ma y 200 1, WHO/MNC/ 3. WHO. Statement d eveloped b y W HO Qu ality of CCH/01.01. Geneva: Wo rld H ealth Orga niza- Life Working G roup (1 994). Pu blished in t he tion, 2001 WHO H ealth Promotion Gl ossary . WHO/HPR/ 13. WHO. Home-Based an d Long-term Care, Report of a HEP/98.1. Geneva: W orld H ealth Org anization, WHO S tudy Group . WHO Tech nical Report 1998 Series 898. Geneva: Wo rld H ealth Org anization, 4. Kalache A, Kickbusch I. A global s trategy fo r healthy a geing. World H ealth 1997;No. 4 , July– 14. WHO. Mental Health: New Understanding, New August:4–5 Hope. (World H ealth Rep ort). G eneva: W orld 5. WHO. Life in the 21st Century: A Vision fo r All . Health Org anization, 20 01 (World H ealth Rep ort). G eneva: W orld H ealth 15. Doll R . 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Stayin g Well. Age ing a nd on p rojections o f h ealth se rvice needs fo r t he Physical Activity in Every day Life . Prepared b y elderly population o f th e U nited Sta tes. Proc Nat Heikkinen RL. Geneva: W orld H ealth Orga niza- Acad Sci 1998;23:321–35 tion, 1998 10. US Ce nters fo r D isease Co ntrol. Lower D irect 20. Jernigan D H, Mo nteiro M, Room R, Saxena S. Medical Co sts Ass ociated with Physical A ctivity . Toward a glo bal a lcohol p olicy: alcohol, p ublic Atlanta: CDC, 1999. See http:// www.cdc.gov/ health an d th e ro le of WH O. Bull W orld H ealth nccdphp/dn pa/pr-cost.htm Organization 2000;78:491 11. US De partment of H ealth a nd H uman S ervices. An 21. Gurwitz JH, Avo rn J. Th e am biguous rela tionship Ounce of Pre vention . . . What Are the Returns? between ag ing a nd ad verse d rug rea ctions. Ann Atlanta: US D epartment o f H ealth a nd H uman Intern Med 1991;114:956–66 36 The Agin g Ma le Active Ageing: A Policy Framework World He alth Organization 22. Dipollina L, Sabate E . Medication adherence to nonblack p opulation ab ove ag e 6 5 fro m 1 982 t o long term t reatments in the eld erly. In S abate E , ed. 1999. Proc Nat Acad Sci 2001;22:6354–9 WHO Adhe rence Rep ort: A review of the evidence . 37. WHO. Global El imination of Avo idable Blindness . Geneva: W orld H ealth Orga nization, 20 02 WHO/PBL/97.61 Rev.2. Geneva: Wo rld H ealth 23. Kirkwood T . Mechanisms o f ag eing. In E brahim S , Organization, 19 97 Kalache A, eds. Epidemiology in O ld Ag e . London: 38. WHO. Global Bu rden of D isease. Review . Geneva: BMJ Pu blishing Gro up, 19 96 World Health Orga nization, 200 2:in press 24. Gray MJA . Preventive medicine. In Ebrahim S , 39. Pal J, et al. Deafness a mong th e urb an c ommunity – Kalache A, eds. Epidemiology in O ld Ag e . London: an ep idemiological su rvey at Luck now ( U.P.). BMJ Pu blishing Gro up, 19 96 Indian J Med Res 1974;62:857–68 25. Smits C H, Deeg DM, Schmand B. Cognitive 40. Wilson D H, et al. The ep idemiology of h earing functioning an d h ealth a s d eterminants o f m ortality impairment in the Au stralian a dult p opulation. Int J in a n old er p opulation. Am J Epide miol 1999; Epidemiol 1999;28:247–52 41. WHO. Long-Term C are Laws in Five Developed 150:978–86 26. Gironda M, Lubben J. Preve nting loneliness a nd Countries: A Review . WHO/NMH/CCL/ 00.2. isolation in older a dulthood. In Gu llotta T, Bloom Geneva: Wo rld Health Organization, 2000 42. Wolf D A. Population ch ange: f riend o r foe o f th e M, eds. Encyclopedia o f Prim ary Prevention an d Health chronic care system. Health Affairs 2001;20:28–42 Promotion. New Yo rk: Klu wer Academic/ Plenum 43. Botev N. Older persons i n c ountries with econ o- Publishers, 2002:in p ress mies in tra nsition. In Population Ag eing: C hallenges 27. Sugiswawa S, Liang J , Liu X. Social networks, for Po licies an d Programmes in De veloped a nd social support a nd m ortality am ong o lder p eople in Developing C ountries . United N ations Po pulation Japan. J Gerontol 1994;49:S3–13 28. Action on Elde r Abu se (AEA) Bulletin , May–June, Fund a nd CB GS P opulation an d Fam ily Stu dy No. 11 . London, 1995 Centre. New Yo rk: U nited Na tions Po pulation 29. WHO/INPEA. Missing Voic es: Vie ws of O lder Fund, 1999 Persons o n El der Abus e . WHO/NMH/NPH/02.2. 44. World Ba nk. World De velopment I ndicator Database . Geneva: W orld H ealth Orga nization, 20 02 Washington: Wo rld Ba nk, 2 001. See http://www. 30. OECD. Maintaining Prosperity in an Ageing So ciety . worldbank.org/data/wdi2001/pdfs/tab2_6.pdf Paris: Organization fo r E conomic C ooperation a nd 45. Wilkinson R G. Unhealthy Societies: The Affliction o f Development, 1998 Inequality. Lo ndon: Ro utledge, 1996 31. Guralnick J M, Kaplan G . Predictors of he althy 46. Lynch JW , S mith G D, Kap lan GA , House J S. aging: p rospective evid ence from th e Alm eda Income in equality a nd m ortality: importance t o County Stu dy. Am J Pu blic Health 1989;79:703–8 health o f in dividual i ncome, psychosocial en viron- 32. International Lab our O ffice (ILO). Income ment a nd m aterial conditions. Br Med J 2000; security and so cial protection in a c hanging w orld. 320:1200–4 World Labo ur Report . G eneva: ILO, 2000 47. Jacobzone S , Oxley H. Ag eing an d h ealth care 33. Murray C, Lopez A. The Global Bu rden of D isease . Costs. International P olitics an d Society (1). h ttp:// Oxford: Ox ford U niversity Press, 1996 www . fes.d e /ipg/ ON L IN E2 _2 002 /IND E X E. 34. WHO. Developing and validating a methodology to HTM examine the impact of H IV/AIDS on ol der c aregivers – 48. WHO. Health Systems: Improving Pe rformance . Zimbabwe case s tudy . Geneva: W orld H ealth (World H ealth R eport). G eneva: W orld H ealth Organization, 20 02:in pre ss Organization, 20 00 35. WHO. Global Fo rum f or H ealth Research: The 10/90 49. Yach D . Redefining th e s cope o f p ublic h ealth Report on He alth Research . Geneva: Wo rld H ealth beyond th e ye ar 2 000. Current I ssues in Pu blic H ealth Organization, 20 00 1996;2:247–52 36. Manton K, Gu X . Changes in the p revalence of chronic disability i n th e U nited S tates, b lack a nd The Agin g Male 37 http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png The Aging Male Taylor & Francis

Active Ageing: A Policy Framework

The Aging Male , Volume 5 (1): 37 – Jan 1, 2002

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Abstract

The Aging Mal e 2002 ;5:1–37 Report of the Wor ld H ealth Orga nization World Health Organization Noncommunicable Diseases and Mental Health Cluster Noncommunicable Disease Prevention and Health Promotion Department Ageing a nd Life Course The Policy F ramework is intended to inform dis cus- meeting w as convened at the WHO Centre f or H ealth sion and the formulation of a ction plans that promote Development (W KC) in Kobe, Ja pan, with 29 healthy and ac tive a geing. I t was de veloped by participants from 21 countries. D etailed com ments WHO’s Ageing a nd L ife Co urse Programme as a and re commendations f rom this meeting, a s well as contribution to the Second U nited Nations World those received thr ough the previous consultation pro- Assembly on Ageing, he ld in April 20 02, in Madrid, cess, were compiled to complete this final version. Spain. The preliminary ve rsion, pu blished in 2001 A c omplementary m onograph entitled Active and e ntitled Health and A geing: A D iscussion Ageing: Fr om Evidence to A ction is being Paper, wa s tra nslated into French an d Spa nish and prepared in collaboration w ith the International widely c irculated f or fe edback throu ghout 2001 Association of G erontology (IAG) and w ill b e av ail- (including at special w orkshops held in Brazil, able a t http://www.who.int/hpr/ageing where more Canada, the Netherlands, Spa in and t he United information ab out ag eing a nd the life cou rse is also Kingdom). In January 2 002, an ex pert gr oup provided. How O ld is O lder? This b ooklet u ses the Un ited Natio ns standard o f ag e 60 t o d escribe ‘o lder’ p eople. T his may seem young in th e d eveloped w orld a nd in t hose d eveloping c ountries w here m ajor gain s in life expectancy have already occurred. Ho wever, whatever age is used w ithin d ifferent c ontexts, it is important to acknowledge th at c hronological age is not a precise marker for th e c hanges th at a ccompany ag eing. There ar e dramatic variations in h ealth stat us, participation an d levels of in dependence amo ng o lder people o f th e s ame age. Decision-makers need to t ake t his into ac count w hen d esigning p olicies and programmes for th eir ‘o lder’ p opulations. E nacting b road s ocial policies based o n ch ronological age alone can be discriminatory and c ounterproductive to well being in older age. Note: The sp elling of ‘ ag eing’ an d a number o f o ther te rms in this report i s according to th e style o f the W orld He alth O rganiza- tion, rather than to the no rmal style of the Journal 1 Active Ageing: A Policy Framework World He alth Organization INTRODUCTION families, com munities a nd e conomies, as stated in th e WHO Brasilia Declaration o n A geing an d H ealth Population agein g raises many fundamental in 1996. questions f or p olicy-makers. How d o w e help people r emain independent an d ac tive as they age? Part 1 d escribes the rap id w orldwide g rowth How ca n w e strengthen h ealth p romotion an d of th e p opulation o ver age 60, especially in prevention p olicies, especially those d irected t o developing countries. older p eople? A s p eople a re living longer, h ow Part 2 exp lores the co ncept an d rat ionale for can t he q uality o f life in o ld a ge be imp roved? ‘act ive ageing’ as a goal f or p olicy an d p ro- Will large numbers o f o lder pe ople b ankrupt gramme formulation. our h ealth car e and so cial security systems? How d o we best balance th e ro le of t he f amily and t he state Part 3 su mmarizes the evide nce about th e when it comes to car ing f or p eople w ho ne ed factors t hat d etermine whether o r n ot ind ivi- assistance, as they g row o lder? Ho w d o we duals an d p opulations w ill enjoy a positive acknowledge an d su pport th e ma jor ro le that quality of life as they age. people play as they age in caring for o thers? Part 4 d iscusses seven key c hallenges associated This p aper is designed to ad dress these questions with an ag eing population fo r g overnments, and ot her co ncerns ab out p opulation ag eing. It the n ongovernmental, a cademic and p rivate targets government d ecision-makers at all levels, sectors. the n ongovernmental sec tor an d th e p rivate sector, all of w hom are responsible for t he fo rmulation o f Part 5 p rovides a policy f ramework fo r ac tive policies and p rogrammes on ag eing. It ap proaches ageing and co ncrete s uggestions for k ey p olicy health fro m a broad p erspective and ac knowledges proposals. T hese are intended to serve as a base- the f act th at h ealth c an o nly b e cr eated an d su s- line for t he d evelopment o f mo re specific action tained th rough t he p articipation o f mu ltiple steps at regional, national an d lo cal levels in sectors. It su ggests that h ealth p roviders and p rofes- keeping w ith t he ac tion p lan ad opted b y th e sionals must take a lead if we are to ach ieve the go al 2002 S econd Un ited Na tions Assembly on that healthy older pe rsons remain a r esource to their Ageing. 1. Global Ageing: A Trium ph and a Challenge Population ageing is first and foremost a success story for public health policies as well as social and economic development . . . Gro Harlem Brundtland, Director-General, World Health Organization, 1999 Population ag eing is one o f h umanity’s greatest triumphs. It is also one o f o ur g reatest challenges. In all cou ntries, b ut in developing cou ntries in As we en ter the 21 st century, glo bal ag eing will put particular, m easures t o help ol der peo ple re main increased economic an d so cial demands o n a ll healthy and active are a necessity, not a luxury. countries. A t t he same time, older p eople a re a precious, o ften-ignored r esource th at mak es an important co ntribution t o th e fab ric o f o ur These policies and pr ogrammes should b e b ased societies. on t he r ights, needs, preferences and cap acities of The W orld Health Organization ar gues that older p eople. T hey also need to emb race a life countries ca n aff ord to g et old if governments, course p erspective that rec ognizes t he imp ortant international o rganizations an d civil society enact influence of ear lier life experiences on th e w ay ‘ac tive ageing’ p olicies and p rogrammes that individuals age. enhance th e h ealth, participation an d s ecurity of older cit izens. The tim e to p lan an d to a ct is now. 2 The Agin g Ma le Active Ageing: A Policy Framework World He alth Organization THE DEMOGRAPHIC estimated that b y 20 25, 120 c ountries w ill have REVOLUTION reached t otal fert ility rates below rep lacement level (average fertility rate of 2.1 children p er w oman), a Worldwide, t he p roportion o f p eople age 60 an d substantial increase compared t o 19 75, when ju st over is growing faster than an y o ther ag e group. 22 co untries ha d a total fer tility rate below o r eq ual Between 1970 an d 20 25, a growth in o lder p ersons to t he rep lacement level. The c urrent fig ure is 70 of som e 694 millio n or 2 23 p ercent is expected. countries. In 20 25, there will be a total o f ab out 1.2 billion Until now, p opulation ag eing has been m ostly people o ver the age of 6 0. By 2050 th ere will be associated with th e mo re developed regio ns of th e 2 b illion w ith 8 0 p ercent o f t hem living in world. Fo r ex ample, currently n ine o f th e ten developing countries. countries w ith mo re than t en m illion inhabitants Age c omposition – th at is , the p roportionate and th e larg est proportion of o lder p eople are in numbers of c hildren, y oung ad ults, middle-aged Europe (s ee Table 1 ). Little change in th e ra nking is adults an d o lder ad ults i n an y given country – is an expected b y 20 25 w hen p eople ag ed 6 0 an d o ver important elem ent for p olicy-makers to tak e in to will make up ab out o ne-third o f t he p opulation in account. P opulation ag eing refers to a decline in countries lik e Japan, Germany and It aly, closely the p roportion o f ch ildren an d yo ung p eople an d followed b y o ther Eu ropean c ountries (see an in crease in t he p roportion o f p eople ag e 60 an d Table 1). over. As po pulations a ge, the tr iangular p opulation What is less known is the sp eed and s ignificance pyramid o f 2 002 w ill be rep laced w ith a more of p opulation agein g in le ss developed reg ions. cylinder-like structure in 2025 (see Figure 1). Already, m ost older p eople – ar ound 70 p ercent – Decreasing fertility rates and in creasing long- live in d eveloping c ountries (s ee Table 2). These evity will ensure the co ntinued ‘ gr eying’ o f numbers will continue t o r ise at a rapid pace. the w orld’s population, d espite setbacks in life In all countries, esp ecially in d eveloped o nes, expectancy in so me African co untries (d ue t o the o lder p opulation itself is also ageing. People AIDS) an d in so me newly in dependent stat es (due over the ag e of 8 0 c urrently n umber so me 69 to in creased deaths c aused b y ca rdiovascular disease million, the maj ority o f w hom live in mo re and vio lence). Sharp de creases in fer tility rates developed reg ions. Although p eople o ver the age are being o bserved throughout t he w orld. It is of 80 mak e up ab out o ne p ercent o f t he wo rld’s Age group Male Female 80+ 70–74 60–64 50–54 40–44 30–34 20–24 10–14 0–4 350 000 150 000 0 150 000 350 000 Population in thou sands Figure 1 Global population pyramid in 2002 and 2025. Source: UN, 2001 The Agin g Male 3 Active Ageing: A Policy Framework World He alth Organization Table 1 Countries w ith mo re th an 10 mil lion in habit- Table 3 Old-age depen dency ratio fo r selected ants (in 20 02) wit h th e h ighest p roportion o f persons above countries/regions. Source: UN, 2001 age 60. Source: UN, 2001 2002 2025 2002 2025 Japan 0.39 Japan 0.66 Italy 24.5% Japan 35.1% North America 0.26 North America 0.44 Japan 24.3% Italy 34.0% European Union 0.36 European Union 0.56 Germany 24.0% Germany 33.2% Greece 23.9% Greece 31.6% Belgium 22.3% Spain 31.4% Spain 22.1% Belgium 31.2% Old-age dep endency ra tios are cha nging quickly Portugal 21.1% United Kingdom 29.4% throughout the world. In Japan, f or e xample, the re United Kingdom 20.8% Netherlands 29.4% are cu rrently 39 people ove r a ge 60 for e very 100 in Ukraine 20.7% France 28.7% the age gro up 15–60. In 2025 this number wil l France 20.5% Canada 27.9% increase to 66. Table 2 Absolute n umbers of persons (in m illions) a bove 60 y ears o f age in co untries wit h a t otal po pulation However, most of th e o lder p eople in all approaching o r a bove 100 mi llion i nhabitants (i n 200 2). countries c ontinue t o b e a vital resource to th eir Source: UN, 2001 families and c ommunities. Many co ntinue to w ork 2002 2025 in b oth th e fo rmal and in formal labour sec tors. Thus, as an in dicator fo r fo recasting p opulation China 134.2 China 287.5 needs, the de pendency rat io is of limited use. India 81.0 India 168.5 More so phisticated in dices are needed to mo re United States of 46.9 United States of 86.1 accurately reflec t ‘d ependency’, rather th an f alsely America America categorizing in dividuals who co ntinue to b e f ully Japan 31.0 Japan 43.5 able and in dependent. Russian Federation 26.2 Indonesia 35.0 Indonesia 17.1 Brazil 33.4 At th e same time, active ageing policies and Brazil 14.1 Russian Federation 32.7 programmes are needed to en able people to co n- Pakistan 8.6 Pakistan 18.3 tinue to w ork acc ording t o th eir capacities and Mexico 7.3 Bangladesh 17.7 preferences as they g row o lder, an d t o p revent o r Bangladesh 7.2 Mexico 17.6 delay disabilities and c hronic d iseases that ar e costly Nigeria 5.7 Nigeria 11.4 to in dividuals, families and t he h ealth c are system. This is discussed further in th e sec tion o n w ork in Challenge 2: Increased Risk of D isability population an d th ree percent o f th e p opulation and C hallenge 6: the Eco nomics o f an A geing in de veloped reg ions, this age group is the f astest Population. growing segment of t he older population. In b oth d eveloped an d d eveloping co untries, RAPID PO PULATION AGEING IN the ag eing of th e po pulation raises concerns ab out DEVELOPING COUNTRIES whether or n ot a shrinking la bour fo rce w ill be ab le to sup port t hat p art o f th e po pulation w ho are In 2 002, almost 400 millio n people aged 60 an d commonly b elieved to b e d ependent on o thers over live in t he d eveloping w orld. By 2025, this (i.e. children and o lder people). will have increased to ap proximately 84 0 m illion The o ld-age d ependency rat io (i.e. the to tal representing 70 p ercent o f all older pe ople w orld- population a ge 60 an d o ver divided b y th e p opula- wide (see Figure 2). In ter ms of reg ions, over half tion a ge 15–60 – see Table 3) is primarily used b y of th e w orld’s older p eople live in A sia. Asia’s economists and act uaries who fo recast t he fin ancial share of th e w orld’s oldest p eople w ill continue implications of p ension po licies. However, it is also to i ncrease the mo st while Europe’s share as a pro- useful fo r th ose c oncerned w ith th e man agement portion o f t he glo bal o lder p opulation w ill decrease and planning of caring services. the mo st over the nex t tw o d ecades (see Figure 3). 4 The Agin g Ma le Active Ageing: A Policy Framework World He alth Organization 1970 2002 2025 World LDR MDR Figure 2 The nu mbers of people over ag e 60 i n le ss and mo re devel oped regions, 1 970, 200 2 a nd 202 5. LDR , less developed regions; MDR, more developed regions. Source: UN, 2001 NAm 8% NAm Oceania Africa 8% Africa Oceania 1% 7% LAmC 7% 1% LAmC 7% 8% Europe Europe 17% 24% Asia Asia 53% 59% 2002 2025 Figure 3 Distribution o f world population o ver a ge 60 by region, 2 002 a nd 20 25. NA m, No rth A merica; LA mC, La tin America and the Caribbean. Source: UN, 2001 Compared t o th e d eveloped w orld, so cio- developed c ountries g rew aff luent b efore t hey economic d evelopment in d eveloping co untries became old, d eveloping c ountries are getting o ld has often no t k ept p ace w ith th e ra pid sp eed of before a substantial increase in wealth occurs . population ag eing. For exa mple, while it took Rapid ag eing in d eveloping co untries is accom- 115 y ears for th e p roportion o f o lder p eople in panied b y d ramatic changes in fam ily structures an d France t o do uble f rom 7 to 14 p ercent, it will take roles, as well as in lab our p atterns an d mig ration. China o nly 27 year s to ac hieve the same increase. Urbanization, th e mig ration of yo ung p eople to In mo st of th e d eveloped w orld, p opulation a geing cities in s earch of jo bs, smaller families and mo re was a gradual p rocess f ollowing st eady socio- women en tering th e fo rmal workforce mea n that economic g rowth o ver several decades and g enera- fewer people ar e available to ca re for o lder p eople tions. In de veloping c ountries, th e p rocess is being when they need assistance. compressed into tw o o r t hree decades. Thus, w hile 2. Active Ageing: The Concept and Rationale If ag eing is to b e a positive experience, longer life Health Organization h as adopted th e ter m ‘ac tive must be ac companied b y co ntinuing o pportunities ageing’ to exp ress the p rocess f or a chieving for h ealth, p articipation an d secu rity. The W orld this vision. The Agin g Male 5 Millions Active Ageing: A Policy Framework World He alth Organization WHAT IS ‘A CTIVE AGEING’? ‘Healt h’ ref ers to p hysical, mental and so cial well being as expressed in th e W HO definition o f health. T hus, in an act ive ageing framework, p oli- Active a geing is the process of op timizing opportunities cies and p rogrammes that p romote m ental health for he alth, pa rticipation and sec urity in order to and so cial connections are as important as those enhance qu ality of life as people age. that improve physical health status. Active ageing applies to b oth in dividuals and Maintaining au tonomy an d in dependence as population g roups. It allo ws people to r ealize their one gro ws o lder i s a key g oal fo r b oth in dividuals potential f or p hysical, social, and men tal well being and p olicy m akers (see box o n d efinitions). throughout th e life course a nd t o p articipate in Moreover, ageing takes place w ithin t he co ntext society according t o t heir needs, desires and c apaci- of ot hers – fr iends, work asso ciates, neighbours ties, while providing th em with ad equate p rotec- and fam ily members. This is why in terdependence tion, secu rity and c are when t hey req uire as well as intergenerational so lidarity (two-way assistance. giving and rec eiving between in dividuals as well as The w ord ‘ ac tive’ ref ers to co ntinuing p articipa- older an d yo unger gen erations) are important tion i n so cial, economic, c ultural, sp iritual and tenets of ac tive ageing. Yesterday’s child is today’s civic affairs, not ju st th e a bility to b e p hysically adult an d t omorrow’s grandmother o r g rand- active or t o p articipate in th e lab our f orce. Old er father. The q uality o f life they will enjoy as grand- people w ho r etire from w ork an d th ose w ho are parents d epends o n t he risk s and o pportunities th ey ill or live with d isabilities can r emain active contri- experienced th roughout th e life course, a s well butors t o t heir families, peers, communities and as the man ner in w hich su cceeding g enerations nations. A ctive ageing aims to ext end h ealthy life provide mutual aid and support when n eeded. expectancy an d q uality o f lif e for all people as they The term ‘act ive ageing’ w as adopted by th e age, including th ose w ho ar e frail, disabled an d in World H ealth Organization in th e lat e 1990s. It is need of care. meant to co nvey a more inclusive message than Some ke y definitions Autonomy is the p erceived ability to co ntrol, c ope w ith an d mak e personal dec isions about h ow o ne lives on a day-to-day b asis, according t o o ne’s own rules and p references. Independence is commonly u nderstood as the ab ility to p erform f unctions relat ed to d aily living – i.e. the capacity of living independently in the community with no an d/or little help from others. Quality of life is ‘an in dividual’s perception o f h is or h er p osition in lif e in t he co ntext o f th e cu lture an d value system where th ey live, and in relat ion to th eir goals, expectations, st andards an d c oncerns. It is a broad r anging co ncept, in corporating in a complex w ay a person’s physical h ealth, p sychological st ate, level of in dependence, so cial relationships, personal b eliefs and re lationship t o s alient features in th e environment’ . As p eople a ge, their quality o f li fe is largely determined by th eir ability to main tain autonomy and independence. Healthy l ife expectancy is commonly u sed a s a synonym f or ‘ d isability-free life expectancy’. While life expectancy at birth r emains an imp ortant measu re of p opulation agein g, how lo ng p eople can ex pect to live without disabilities is especially important t o a n ageing population. With th e e xception o f au tonomy w hich is notoriously d ifficult to measu re, all of t he ab ove concepts have been elab orated b y a ttempts to measu re the d egree of d ifficulty an old er p erson h as in pe rforming activities related to d aily living (ADLs) and in strumental activities of d aily living (IADLs). ADLs in clude, for ex ample, bathing, eatin g, using th e to ilet and w alking acr oss the ro om. IA DLs in clude ac tivities such as shopping, h ousework an d meal preparation. R ecently, a number o f valid ated, more holistic measu res of h ealth-related quality o f lif e have been d eveloped. T hese indices need t o be sh ared an d a dapted fo r u se in a variety of c ultures and settings. 6 The Agin g Ma le Active Ageing: A Policy Framework World He alth Organization ‘h ealthy ag eing’ an d t o reco gnize th e fa ctors in As in dividuals age, noncommunicable d iseases addition to h ealth c are that aff ect h ow in dividuals (NCDs) become t he lead ing ca uses of m orbidity, and populations age . disability and m ortality in all regions of t he w orld, The ac tive ageing approach is based on t he including in d eveloping c ountries, as shown recognition o f t he h uman r ights of o lder p eople in F igures 5 an d 6. NCDs, which ar e essentially and th e U nited Nat ions Principles of i nde- diseases of lat er life, are costly t o in dividuals, pendence, p articipation, d ignity, car e and self- families and t he p ublic p urse. But man y NCDs fulfillment. It sh ifts strategic planning a way from a are preventable or c an b e p ostponed. Fa iling to ‘n eeds-based’ ap proach (w hich assu mes that o lder prevent o r m anage the gro wth o f NCD s appropri- people are passive targets) to a ‘righ ts-based’ ately will result in en ormous h uman an d so cial approach th at rec ognizes t he rig hts of p eople t o costs that w ill absorb a disproportionate am ount o f equality of op portunity an d trea tment in all aspects resources, which co uld h ave been u sed to ad dress of li fe as they gro w o lder. It sup ports th eir respons- the health problems of other age groups. ibility to exer cise their participation i n th e p olitical In th e early years, communicable d iseases, process and other aspects of community life. maternal and p erinatal conditions an d n utritional deficiencies are the m ajor c auses of d eath an d disease. In la ter childhood, ad olescence an d yo ung A LIF E COURSE APPROACH TO adulthood, i njuries and n oncommunicable c ondi- ACTIVE AGEING tions b egin to ass ume a much gr eater role. By A lif e course p erspective on ag eing recognizes th at midlife (age 45) and in t he later years, NCDs older p eople are not o ne h omogeneous g roup an d are responsible for th e vast majority o f d eaths an d that ind ividual d iversity tends to in crease with ag e. diseases (see Figures 5 an d 6 ). Research is increas- Interventions t hat cr eate supportive en vironments ingly sh owing t hat th e o rigins of risk for c hronic and f oster h ealthy c hoices a re important at all stages conditions, su ch a s diabetes and h eart disease, of life (see Figure 4). begin in ea rly childhood o r even earlier. This risk is Early Life Adult Life Older Age Growth and Maintaining highest Maintaining independence and development possible level of function preventing disab ility Range of function in individuals Disability threshold ( *) Rehabilitation and ens uring the quality of life Age Figure 4 Maintaining f unctional capa city ove r th e li fe co urse. Fu nctional ca pacity (su ch as ve ntilatory ca pacity, m uscular strength, a nd ca rdiovascular o utput) i ncreases i n ch ildhood an d pea ks in e arly a dulthood, eve ntually f ollowed b y a decl ine. The ra te o f decline, h owever, is largely det ermined by factors rel ated t o a dult l ifestyle – su ch a s smo king, a lcohol con sump- tion, l evels o f physical act ivity a nd diet – as wel l a s e xternal an d en vironmental fact ors. Th e g radient o f decline ma y beco me so stee p as t o resu lt in prem ature disa bility. Ho wever, the a cceleration in decli ne can be influenced a nd m ay be reversible at any ag e th rough i ndividual a nd publi c policy mea sures. Changes i n t he e nvironment c an l ower t he disa bility th reshold, thus decreasing the number of disabled people in a given community. Source: Kalache and Kickbusch, 1997 The Agin g Male 7 Functional capacity Active Ageing: A Policy Framework World He alth Organization Major C hronic C onditions A ffecting O lder Pe ople W orldwide Cardiovascular diseases (such as coronary heart disease) Hypertension Stroke Diabetes Cancer Chronic obstructive pulmonary disease Musculoskeletal conditions (such as arthritis and osteoporosis) Mental health conditions (mostly dementia and depression) Blindness and visual impairment Note: The c auses of d isability in o lder ag e are similar for w omen an d men although w omen ar e more likely to report musculoskeletal problems. Source: WHO, 1998 0–4 Years 5–14 Years 15–44 Years 45–59 Years > 60 Years Noncommunicable conditions Injuries Communicable diseases, maternal and perinatal conditions a nd nutr itional deficiencies Figure 5 Leading ca uses of death, bot h sex es, 1998, lo w- an d m iddle-income co untries by age. So urce: Wo rld H ealth Report 1999 Database 0–4 Years 5–14 Years 15–44 Years 45–59 Years > 60 Years Noncommunicable c onditions Injuries Communicable dise ases, maternal a nd pe rinatal conditions and nutritional deficiencies Figure 6 Leading c auses of burden of disease, both se xes, 1998, l ow- a nd m iddle-income cou ntries by age. So urce: World Health Report 1999 Database 8 The Agin g Ma le Active Ageing: A Policy Framework World He alth Organization subsequently sh aped an d mo dified b y fac tors, su ch More p eople p articipating ac tively as they age in as socioeconomic stat us and e xperiences across the the so cial, cultural, eco nomic an d po litical whole lif e span. T he risk of d eveloping NC Ds con- aspects of s ociety, in p aid an d u npaid r oles and in tinues to in crease as individuals age. But it is domestic, family and community lif e tobacco u se, lack of p hysical ac tivity, inadequate Lower co sts related to med ical treatment and diet an d ot her estab lished adult r isk factors w hich care services. will put in dividuals at relatively greater risk of developing N CDs at older ages (see Figure 7). Active ageing policies and p rogrammes recognize Thus, it is important to ad dress the risk s of the n eed to en courage an d b alance p ersonal non-communicable d isease from early life to late responsibility (self-care), age-friendly environ- life, i.e. throughout the life course. ments and in tergenerational so lidarity. Individuals and fam ilies need to pla n an d p repare f or o lder age, and mak e personal ef forts to ad opt p ositive ACTIVE AGEING PO LICIES AND personal h ealth p ractices at all stages of life. At th e PROGRAMMES same time supportive en vironments are required to ‘mak e the healthy choices the easy choices’. An ac tive ageing approach to p olicy an d There are good ec onomic reaso ns for en acting programme development h as the p otential t o policies and p rogrammes that p romote ac tive address many of th e ch allenges of b oth in dividual ageing in te rms of in creased participation an d and p opulation agein g. When h ealth, labour reduced co sts in c are. People w ho r emain healthy market, employment, education an d so cial policies as they ag e face fewer impediments to co ntinued support active ageing there will potentially be: work. T he cu rrent tren d to ward ear ly retirement Fewer premature deaths in t he h ighly p roduc- in in dustrialised countries is largely the resu lt tive stages of life of p ublic po licies that h ave encouraged ea rly withdrawal fro m th e la bour fo rce. A s p opulations Fewer disabilities associated with ch ronic age, there will be inc reasing pressures for su ch diseases in older age policies to c hange – particularly if more and mo re More p eople en joying a positive quality o f life individuals reach o ld ag e in go od he alth, i.e. are as they grow older ‘fit for w ork’. This w ould h elp t o o ffset th e risin g Fetal Infancy and Adolescence A dult L ife Life Childhood Established adult behavioural/biological risk fa ctors Obesity High SES lack of PA diseases smoking growth rate SES; maternal nutritional Accumulated status; birth weight risk (range) Low Age Figure 7 Scope for noncommunicable disea ses (NCD) prevention, a l ife co urse a pproach. S ES, so cioeconomic sta tus; PA, physical activity. Source: Aboderin, et al., 2002 The Agin g Male 9 Development of NCD Active Ageing: A Policy Framework World He alth Organization costs in p ensions an d in come sec urity schemes as 20 p ercent o ver the n ext 50 yea rs . Between 1982 well as those re lated to med ical and soc ial care and 19 94, in th e U SA, the s avings in n ursing h ome costs. costs alone we re estimated to ex ceed $17 billion . With reg ard to rising public exp enditures fo r Moreover, if increased numbers o f h ealthy o lder medical care, available data in creasingly indicate people w ere to ext end th eir participation in th e that o ld age itself is not asso ciated with in creased work fo rce ( through eith er full o r p art-time medical spending. Rat her, it is disability and po or employment), their contribution to p ublic reve- health – often ass ociated with o ld ag e – th at are nues w ould c ontinuously in crease. Finally, it is costly. As p eople ag e in b etter h ealth, med ical often less costly to p revent disease than to tr eat it. spending may not increase as rapidly. For exam ple, it has been estim ated that a Policy-makers need t o loo k at the f ull p icture one-dollar in vestment in me asures to en courage and c onsider t he savin gs achieved by d eclines in moderate physical act ivity leads to a cost saving of disability rates. In t he US A, for ex ample, such $3.2 in medical costs . declines might lower med ical spending b y ab out 3. The Determinants of Active Ageing: Understanding the Evidence Active ageing depends o n a variety of in fluences emphasis here is on th e h ealth an d q uality o f life or ‘ de terminants’ that sur round in dividuals, of old er p ersons. At t his point, it is not p ossible families and n ations (Figu re 8). Understanding t he to at tribute d irect c ausation t o an y o ne d etermi- evidence we have about t hese determinants helps nant; h owever, the su bstantial body o f evi dence on us design policies and programmes that work. what d etermines health s uggests that all of th ese The fo llowing sect ion su mmarizes what we factors (an d th e int erplay b etween th em) are good know ab out h ow t he b road d eterminants of h ealth predictors o f h ow w ell both i ndividuals and po pu- affect t he p rocess o f agein g. These determinants lations age. More r esearch is needed to c larify and apply to th e h ealth of a ll age groups, alt hough t he specify the r ole of eac h d eterminant, as well as the Gender Economic Health and social determinants services Social Active Behavioural determinants ageing determinants Physical Personal environment determinants Culture Figure 8 The determinants of active ageing 10 The Agin g Ma le Active Ageing: A Policy Framework World He alth Organization interaction b etween d eterminants, in th e a ctive Policies and p rogrammes need t o re spect current ageing process. We also need to be tter u nderstand cultures an d t raditions w hile de-bunking o utdated the pa thways t hat ex plain how th ese broad d eter- stereotypes and misinf ormation. Moreover, there minants actually affect health and well being. are critical universal values that t ranscend c ulture, Moreover, it is helpful to co nsider th e in fluence such as ethics and h uman r ights. of vario us determinants over the life course s o as to take ad vantage of t ransitions and ‘ w indows o f Gender is a ‘ le ns’ throu gh which to consider the appro- opportunity’ fo r en hancing h ealth, p articipation priateness of v arious policy options and ho w they will and sec urity at different sta ges. For e xample, there affect the well being of both men and women . is evidence that stimu lation and sec ure attachments in in fancy i nfluence an in dividual’s ability to lear n and get along w ith ot hers th roughout all of t he la ter In m any societies, girls and w omen ha ve lower stages of lif e. Employment, which is a determinant social status and less access to n utritious f oods, throughout ad ult life greatly influences o ne’s education, mean ingful w ork an d h ealth ser vices. financial r eadiness for o ld age. Access to h igh Women’s traditional ro le as family caregivers may quality, d ignified lo ng-term ca re is particularly also contribute to t heir increased poverty an d ill important in la ter life. Often, a s is the c ase with health in o lder age . Some women ar e forced to exposure to p ollution, t he y oung an d t he old are give up p aid e mployment t o c arry o ut th eir the most vulnerable population groups. caregiving responsibilities. Others never have access to p aid emp loyment b ecause they w ork full-time in u npaid car egiving roles, looking af ter CROSS-CUTTING DETERMINANTS: children, o lder p arents, spouses who a re ill and CULTURE AND G ENDER grandchildren. A t th e sam e time, boys an d men are Culture is a cross-cutting de terminant w ithin t he more likely to su ffer d ebilitating inj uries or d eath framework for understanding a ctive ageing. due t o vio lence, occupational h azards, an d su icide. They also engage in mo re risk-taking b ehaviours such as smoking, alc ohol an d d rug co nsumption Culture, w hich surrounds all in dividuals and popul a- and u nnecessary exposure to the risk of injury. tions, shapes the way in which we a ge b ecause it influ- ences all of the other determinants of active ageing . DETERMINANTS RELATED TO HEALTH AND SO CIAL SE RVICE Cultural valu es and t raditions d etermine to a large SYSTEMS extent h ow a given society views older p eople an d the ag eing process. When so cieties are more likely to at tribute sy mptoms of d isease to t he a geing To promote ac tive a geing, hea lth systems need t o take process, they ar e less likely to p rovide p revention, a lif e c ourse pe rspective tha t focuses on health promo- early detection an d ap propriate tr eatment services. tion, disease prevention a nd e quitable a ccess to quality Culture i s a key f actor in w hether o r n ot c o-resi- primary health care a nd long-term care . dency wit h y ounger gen erations is the p referred way o f li ving. For exa mple, in m ost Asian coun- tries, the c ultural n orm is to valu e extended fam ilies Health and so cial services need to b e in tegrated, and t o live together in mu ltigenerational house- coordinated an d c ost-effective. There m ust be n o holds. Cu ltural fac tors also influence age discrimination in th e p rovision o f s ervices and health-seeking behaviours. For e xample, attitudes service providers need to tr eat people o f all ages toward smo king ar e gradually c hanging i n a range with dignity an d respect. of countries. There is enormous cu ltural d iversity and co m- Health p romotion a nd d isease plexity within co untries an d amo ng co untries an d prevention regions of t he w orld. Fo r exa mple, diverse ethnici- ties bring a variety of valu es, attitudes an d tra di- Health promotion i s the p rocess of en abling p eople tions t o th e main stream culture w ithin a country. to t ake c ontrol o ver and to im prove their health. The Agin g Male 11 Active Ageing: A Policy Framework World He alth Organization Disease prevention i ncludes t he p revention an d Long-term ca re management of t he c onditions t hat ar e particularly Long-term c are is defined b y W HO as ‘the sy stem common as individuals age: noncommunicable of act ivities undertaken b y in formal caregivers diseases and i njuries. Prevention r efers both t o (family, friends a nd/or n eighbours) an d/or p rofes- ‘p rimary’ p revention (e.g. avoidance o f t obacco sionals (health and so cial services) to en sure that a use) as well as ‘seco ndary’ p revention (e.g. screen- person w ho is not fu lly c apable o f self-c are can ing f or t he early detection o f ch ronic d iseases), or maintain the h ighest p ossible quality o f life, ‘ter tiary’ p revention (e.g. appropriate clin ical man- according to his or h er in dividual p references, with agement of d iseases). All co ntribute to red ucing th e the g reatest possible degree of in dependence, risk of d isabilities. Disease prevention str ategies – autonomy, pa rticipation, p ersonal fu lfillment and which may also address infectious d iseases – save human dignity’ . money at any age. For ex ample, vaccinating Thus, lo ng-term ca re includes b oth in formal older ad ults ag ainst influenza saves an e stimated and fo rmal support sy stems. The lat ter may include $30 to $6 0 in tr eatment costs per $1 spent o n a broad ra nge o f c ommunity servic es (e.g. public vaccines . health, p rimary care, home c are, rehabilitation services and p alliative care) as well as institutional care in n ursing h omes and h ospices. It a lso refers Curative s ervices to treat ments that h alt o r reverse the co urse o f disease and disability. Despite best efforts in h ealth p romotion an d disease prevention, p eople ar e at increasing risk of d eveloping d iseases as they ag e. Thus ac cess to Mental he alth s ervices curative services becomes indispensable. As t he Mental h ealth ser vices, which p lay a crucial ro le in vast majority of old er p ersons in a ny given country active ageing, should b e an in tegral part o f live in th e c ommunity, mo st curative services must long-term car e. Particular at tention nee ds to b e be o ffered b y th e p rimary health c are sector. This paid to th e u nder-diagnosis o f men tal illness sector is best equipped t o mak e referrals to t he (especially depression) and to su icide rates among secondary a nd t ertiary levels of car e where mo st older people . acute and e mergency care is also provided. Ultimately, the w orldwide shif t in t he g lobal burden o f d isease toward c hronic d iseases requires BEHAVIOURAL DETERMINANTS a shift fr om a ‘find it and fix it’ m odel to a co- ordinated an d c omprehensive continuum o f car e. The adoption of hea lthy lifestyles an d a ctively par tici- This will require a reorientation in h ealth system s pating in one’s own ca re a re im portant at all sta ges of that ar e currently o rganized aro und ac ute, e pisodic the life c ourse. On e o f the myths of age ing is that it is experiences of d isease. The p resent acu te c are too late to adopt such lifestyles in the later ye ars. O n models of h ealth ser vice delivery are inadequate the contrary, en gaging in appropriate physical activity, to a ddress the h ealth n eeds of rap idly a geing healthy eating, n ot smoking and u sing alcohol a nd populations . medications wisely in older ag e ca n pre vent dis ease and As th e p opulation ag es, the d emand w ill con- functional de cline, e xtend l ongevity a nd en hance o ne’s tinue to r ise for med ications that a re used to d elay quality of life. and t reat chronic d iseases, alleviate pain an d improve quality o f lif e. This ca lls for a renewed effort to in crease affordable acc ess to es sential safe Tobacco u se medications and to b etter en sure the ap propriate, cost-effective use of cu rrent an d n ew d rugs. Smoking is the mo st important mo difiable risk Partners in t his effort n eed t o in clude g overnments, factor f or NC Ds for yo ung a nd o ld alik e and a health p rofessionals, the p harmaceutical in dustry, major p reventable cause of p remature death. traditional h ealers, employers and o rganizations Smoking n ot o nly in creases the r isk for d iseases representing older people. such as lung c ancer, it is also negatively related 12 The Agin g Ma le Active Ageing: A Policy Framework World He alth Organization to fac tors th at m ay lead to imp ortant losses in Physical a ctivity functional c apacity. F or ex ample, smoking acc eler- Participation in r egular, moderate physical a ctivity ates the rate of d ecline o f b one de nsity, muscular can d elay functional d eclines. It can r educe th e strength a nd r espiratory function. R esearch on t he onset o f c hronic d iseases in b oth h ealthy an d effects of smo king revealed not j ust t hat smo king chronically ill older p eople. Fo r ex ample, regular is a risk factor fo r a large and inc reasing number moderate physical act ivity reduces th e risk of of d iseases but a lso that its ill effects are cumulative cardiac d eath b y 2 0 to 25 p ercent am ong p eople and lo ng lastin g. The risk of c ontracting at least one with es tablished heart d isease . It c an also substan- of t he d iseases associated with sm oking inc reases tially reduce t he severit y of d isabilities associated with the duration and the amount of exposure. with h eart d isease and o ther c hronic illn esses . A cr itical message for y oung peo ple sh ould Active living improves mental health an d of ten always be ‘ I f y ou w ant to gr ow old er, d on’t s moke. promotes so cial contacts. Bein g active can h elp Moreover, if you w ant t o g row o lder an d t o older p eople r emain as independent as possible for increase your ch ance to ag e well, again don’t the lo ngest p eriod o f time. It c an also reduce th e smoke’. risk of f alls. There ar e thus imp ortant ec onomic The b enefits of q uitting are wide-ranging an d benefits when o lder p eople are physically ac tive. apply to an y ag e group. It is never too late to q uit Medical costs are substantially lower f or o lder smoking. F or in stance, stroke risk decreases after people w ho are active . two y ears of ab stinence fro m cig arette smoking Despite all of th ese benefits, high p roportions and, a fter five years, it becomes the sam e as that of o lder p eople in m ost countries lead sedentary for in dividuals who h ave never smoked. Fo r o ther lives. Populations w ith lo w in comes, ethnic diseases, e.g. lung can cer an d o bstructive p ulmo- minorities and old er pe ople w ith d isabilities are the nary d isease, quitting d ecreases the risk but o nly most likely to b e in active. Policies and pr ogrammes very slowly. Thus, cu rrent ex posure is not a very should en courage i nactive people t o b ecome mo re good in dicator o f c urrent an d fu ture risk s and p ast active as they ag e and to p rovide th em with o ppor- exposure s hould b e tak en in to acc ount as well; tunities to d o so. It is particularly imp ortant to the eff ects of smo king are cumulative and lo ng provide saf e areas for w alking an d t o su pport standing . culturally ap propriate c ommunity a ctivities that Smoking may interfere with t he effe ct o f n eeded stimulate physical ac tivity and are organized an d medications. Exposure to sec ond-hand s moke can led b y old er p eople th emselves. Professional ad vice also have a negative effect o n o lder peo ple’s health, to ‘ go f rom d oing n othing to d oing so mething’ an d especially if they su ffer f rom asth ma or o ther r espi- physical r ehabilitation p rogrammes that h elp o lder ratory problems. people rec over from mo bility problems ar e both Most s mokers start young an d are quickly effective and cost-efficient. addicted t o th e n icotine in to bacco. T herefore, In t he least developed co untries, th e o pposite efforts to p revent c hildren an d y outh fro m sta rting problem m ay occur. In t hese countries, ind ivi- to smo ke must be a primary strategy in t obacco duals are often en gaged in str enuous p hysical control. A t th e same time, it is important to red uce work an d c hores th at may hasten disab ilities, the d emand f or to bacco am ong ad ults (th rough cause injuries and a ggravate previous conditions, comprehensive actions su ch as taxation an d rest ric- especially as they ap proach o ld age. This m ay tions o n ad vertising) and t o h elp ad ults o f all ages include hea vy caregiving responsibilities for ill to q uit. Stu dies h ave shown t hat to bacco co ntrol and d ying rela tives. Health promotion eff orts is highly co st-effective in lo w- an d m iddle- in th ese areas should b e d irected at providing income c ountries. I n C hina, for ex ample, conser- relief from rep etitive, strenuous ta sks and mak ing vative estimates suggest that a 10 p ercent in crease adjustments to u nsafe p hysical mo vements at in t obacco tax es would re duce c onsumption b y work t hat w ill decrease injuries and p ain. five percent an d in crease overall revenue by f ive Older people w ho r egularly engage in vig orous percent. T his inc reased revenue would b e su ffi- physical w ork n eed o pportunities fo r rest and cient t o f inance a package o f ess ential health c are recreation. services for o ne-third o f C hina’s poorest cit izens . The Agin g Male 13 Active Ageing: A Policy Framework World He alth Organization Healthy e ating Alcohol Eating and fo od s ecurity problems at all ages While older p eople t end t o dr ink less than y ounger include b oth un der-nutrition (m ostly, but n ot people, me tabolism changes t hat acc ompany a ge- exclusively, in th e least developed c ountries) an d ing in crease their susceptibility to alco hol-related excess energy in take. In old er p eople, maln utrition diseases, including maln utrition an d liver , gastric can b e ca used b y limite d access to fo od, so cio- and p ancreatic d iseases. Older people also have economic h ardships, a lack o f inf ormation an d greater risks for alco hol-related f alls and in juries, as knowledge ab out nu trition, p oor fo od ch oices well as the p otential h azards asso ciated with mixin g (e.g. eating high fat fo ods), d isease and th e u se of alcohol a nd med ications. Treatment ser vices for medications, tooth lo ss, social isolation, cognitive alcohol p roblems s hould b e availa ble to o lder or p hysical d isabilities that in hibit o ne’s ability to people as well as younger people. buy fo ods a nd p repare th em, emergency situations According to a recent W HO review of th e and a lack of physical activity. literature, there is evidence that alc ohol u se at very Excess energy in take gre atly increases the risk low levels (up to o ne d rink a day) may offer so me for ob esity, chronic d iseases and d isabilities as form o f p rotection ag ainst coronary h eart d isease people grow older. and str oke f or p eople age d 4 5 an d o ver. However, in t erms of o verall excess mortality, the ad verse effects of d rinking o utweigh an y p rotection Diets high in (saturated) fat a nd sa lt, low in fruits and against coronary h eart d isease, even in h igh r isk vegetables an d pro viding insufficient a mounts of fib re populations . and v itamins combined with sedentarism, a re m ajor risks factors f or c hronic conditions like dia betes, ca rdio- Medications vascular disea se, high blood pressure, obe sity, ar thritis and some cancers. Because older p eople o ften h ave chronic h ealth problems, they ar e more likely than y ounger Insufficient c alcium and vitam in D is associated people to n eed an d u se medications – trad itional, with a loss of b one d ensity in old er age and c onse- over-the-counter an d p rescribed. I n mo st quently an in crease in p ainful, c ostly an d d ebilitat- countries, o lder p eople w ith lo w in comes have ing b one fra ctures, especially in old er w omen. I n little or n o ac cess to in surance fo r me dications. As a populations w ith h igh f racture i ncidence, risk can result, many go w ithout o r sp end a n in appropri- be d ecreased through ensu ring ad equate c alcium ately large part o f t heir meager incomes on d rugs. and vitamin D intake. In co ntrast, med ications are sometimes over- prescribed to o lder p eople (esp ecially to o lder women) w ho h ave insurance o r th e me ans to p ay Oral h ealth for th ese drugs. A dverse drug-related rea ctions an d falls associated with med ication u se (especially Poor o ral hea lth – primarily dental c aries, perio- sleeping pills and t ranquilizers) are significant dontal d iseases, tooth lo ss and o ral can cer – cau se causes of p ersonal su ffering an d c ostly pr eventable other sy stemic health p roblems. They cr eate a hospital admissions . financial b urden fo r i ndividuals and so ciety and c an reduce self -confidence an d q uality o f li fe. Studies Iatrogenesis – health p roblems th at ar e induced b y show t hat p oor o ral health is associated with diagnoses or t reatments – ca used b y t he u se of malnutrition an d t herefore in creased risks for drugs is common in o ld ag e, due to t he in teraction various noncommunicable d iseases. Oral health of d rugs, in adequate d osages and a higher f re- promotion a nd cavit y prevention p rogrammes quency o f un predictable reac tions th rough u n- designed to en courage pe ople to k eep th eir natural known me chanisms. With t he ad vent o f m any new teeth n eed t o b egin ea rly in life and co ntinue o ver therapies, there is an i ncreasing need to est ablish the life course. B ecause of th e p ain an d red uced systems for p reventing ad verse drug rea ctions and quality o f life associated with or al h ealth p roblems, for in forming bo th he alth p rofessionals and th e basic dental tr eatment services and ac cessibility to ageing public a bout t he r isks and b enefits of dentures ar e required. modern therapies. 14 The Agin g Ma le Active Ageing: A Policy Framework World He alth Organization Adherence general agreement that th e lifelo ng tr ajectory o f health an d d isease for an in dividual is the resu lt Access to n eeded med ications is insufficient in itself of a combination o f g enetics, environment, life- unless adherence to lo ng-term t herapy fo r ag eing- style, nutrition, an d to a n imp ortant ex tent, related chronic illn esses is high. A dherence chance . includes th e ad option an d ma intenance o f a wide Therefore, th e in fluence o f gen etics on th e range o f b ehaviours ( e.g. healthy d iet, physical development of c hronic co nditions su ch as dia- activity, not s moking), as well as taking m edica- betes, heart d isease, Alzheimer’s disease and c ertain tions as directed b y a health p rofessional. It is esti- cancers varies greatly among in dividuals. For m any mated that in deve loped c ountries a dherence t o people, li festyle behaviours s uch as not smo king, long-term th erapy aver ages only 50 p ercent. I n personal c oping sk ills and a network o f clo se kin developing co untries th e rat es are even lower. and f riends ca n eff ectively modify th e in fluence o f Such p oor ad herence severely compromises the heredity on f unctional d ecline an d th e o nset o f effectiveness of t reatments and h as dramatic quality disease. of life and ec onomic i mplications for p ublic h ealth. Population hea lth o utcomes p redicted by tr eat- ment efficacy d ata can o nly b e ac hieved if adher- ence in formation is provided t o all health Psychological f actors professionals and p lanners. Without a system that Psychological fac tors in cluding in telligence and addresses the inf luences o n ad herence, ad vances in cognitive capacity (fo r ex ample, the a bility to s olve biomedical technology w ill fail to r ealize their problems an d ad apt to c hange an d lo ss) are strong potential t o r educe th e b urden of ch ronic d isease . predictors o f ac tive ageing and lo ngevity . During normal agein g, some cognitive capacities (includ- ing learn ing speed and memo ry) naturally DETERMINANTS RELATED TO decline w ith age . However, these losses can b e PERSONAL FACTORS compensated b y gain s in w isdom, knowledge an d experience. Often, d eclines in c ognitive function- Biology a nd g enetics ing ar e triggered by disu se (lack of p ractice), illness Biology an d g enetics greatly influence h ow a (such as depression), behavioural fa ctors (suc h as person ag es. Ageing is a set of b iological p rocesses the u se of a lcohol an d med ications), psychological that ar e genetically determined. Ageing ca n be factors ( such as lack of m otivation, low e xpecta- defined as a progressive, generalized impairment of tions an d lack o f co nfidence), an d so cial factors function r esulting in a loss of ad aptative response to (such as loneliness and i solation), rather th an ag eing a stress and in a growing risk of ag e-associated per se. disease . In o ther w ords, th e main reason why Other p sychological f actors th at ar e acquired older p ersons g et sick more frequently t han across the life course g reatly influence t he w ay younger p ersons is that, d ue t o th eir longer lives, in w hich p eople a ge. Self-efficacy (the belief they h ave been exp osed to e xternal, behavioural, people h ave in th eir capacity to exert control o ver and en vironmental factors t hat c ause disease for a their lives) is linked t o p ersonal b ehaviour ch oices longer time than their younger counterparts . as one ag es and to p reparation f or retir ement. Coping sty les determine how w ell people ad apt to the t ransitions (such as retirement) and c rises of While g enes m ay be in volved in the causation of ageing (such as bereavement and t he o nset disease, for m any dise ases the cause is environmental of illness). and ex ternal to a gre ater de gree tha n it is genetic an d Men an d w omen w ho p repare fo r o ld age and internal. are adaptable to ch ange mak e a better ad justment to life after age 60. Most p eople r emain resilient as It sh ould a lso be n oted th at th ere is evidence in they a ge and, on t he w hole, o lder p eople d o n ot human p opulations th at lo ngevity tends to r un vary significantly from y ounger p eople in th eir in f amilies. But, all things c onsidered, t here is ability to cope. The Agin g Male 15 Active Ageing: A Policy Framework World He alth Organization DETERMINANTS RELATED TO slums and sh anty to wns is rising quickly as many, THE PHYSICAL ENVIRONMENT who mo ved to th e c ities long a go, h ave become long-term s lum-dwellers, while other o lder p eople Physical e nvironments migrate to cities to jo in y ounger fam ily members Physical environments that are age friendly ca n who h ave already moved there. Older people make the d ifference b etween i ndependence an d living in th ese settlements are at high risk for so cial dependence fo r all individuals but a re of p articular isolation and poor health. importance fo r th ose g rowing o lder. F or exam ple, In times of c risis and co nflict, d isplaced o lder older p eople w ho live in an un safe en vironment o r people are particularly vu lnerable. Often th ey are areas with mu ltiple physical b arriers are less likely unable t o w alk t o r efugee camps. Even if they mak e to get out an d th erefore mo re prone t o is olation, it to cam ps, it may be h ard t o o btain sh elter and depression, reduced f itness and in creased mobility food, esp ecially for o lder w omen a nd o lder p ersons problems. with d isabilities who ex perience low so cial status Specific a ttention mu st be g iven to o lder p eople and m ultiple other barriers. who live in r ural areas (some 60 p ercent w orld- wide) where d isease patterns may be d ifferent d ue Falls to en vironmental conditions an d a lack o f availa ble support servic es. Urbanization an d t he m igration Falls among o lder pe ople are a large and in creasing of yo unger p eople in s earch of j obs may leave older cause of in jury, tr eatment costs and d eath. people is olated in ru ral areas with lit tle means of Environmental hazards th at in crease the risk s of support an d little or n o ac cess to h ealth an d so cial falling include p oor lig hting, slipp ery or ir regular services. walking s urfaces and a lack of su pportive h andrails. Accessible and a ffordable p ublic t ransportation Most of ten, th ese falls occur in t he h ome en viron- services are needed in b oth ru ral an d u rban area s so ment and are preventable. that p eople o f all ages can fu lly p articipate in f amily The c onsequences o f in juries sustained in o lder and c ommunity li fe. This is especially important age are more severe than amo ng yo unger p eople. for o lder persons who have mobility problems. For in juries of th e same severity, older p eople Hazards in th e ph ysical en vironment can lead to experience more disability, longer h ospital s tays, debilitating an d p ainful inj uries among o lder extended p eriods o f r ehabilitation, a higher r isk of people. In juries f rom f alls, fires and t raffic c ollisions subsequent d ependency a nd a higher risk of dy ing. are most common. The great m ajority of in juries are pre ventable; Safe ho using however, the traditional view of in juries as ‘a ccidents’ has resulted in historical neglect of this area in public Safe, adequate h ousing a nd n eighbourhoods are health. essential to t he w ell-being of y oung an d o ld. Fo r older p eople, lo cation, in cluding p roximity t o family members, services and tr ansportation ca n Clean w ater, c lean a ir a nd s afe fo ods mean the d ifference be tween p ositive social inter- action an d iso lation. Building c odes nee d to ta ke Clean water, clean air and a ccess to safe foods are the h ealth an d safet y needs of o lder pe ople in to particularly imp ortant fo r th e mo st vulnerable account. Ho usehold h azards t hat in crease the risk population g roups, i.e. children a nd o lder p ersons, of falling need to b e remedied or removed. and fo r th ose w ho h ave chronic illn esses and c om- Worldwide, t here is an inc reasing trend fo r promised immune systems. older p eople to live alone – esp ecially unattached older w omen w ho ar e mainly widows an d are DETERMINANTS RELATED TO often p oor, even in d eveloped c ountries. O thers THE SOCIAL EN VIRONMENT may be fo rced t o li ve in arr angements that are not of t heir choice, s uch as with relat ives in a lready Social support, o pportunities f or ed ucation an d crowded h ouseholds. I n ma ny developing lifelong lear ning, peace, and pr otection f rom countries, th e p roportion o f o lder p eople livin g in violence and ab use ar e key fa ctors in th e so cial 16 The Agin g Ma le Active Ageing: A Policy Framework World He alth Organization environment th at en hance h ealth, p articipation disorganization w hen o verall crime and ex ploita - and secu rity as people ag e. Loneliness, social isola- tion t ends to in crease. tion, illi teracy and a lack o f ed ucation, ab use an d exposure t o c onflict situ ations greatly increase According to the International N etwork for the older p eople’s risks for d isabilities and ea rly death. Prevention of E lder A buse, e lder ab use is ‘a sing le or repeated a ct, o r lack of a ppropriate action occurring within any relationship where the re is an expectation Social s upport of tr ust which causes ha rm o r distress to an olde r Inadequate so cial support is associated not o nly person’ . with an in crease in mo rtality, morbidity an d psychological d istress but a decrease in o verall Elder abuse in cludes p hysical, sexual, psychological general health an d w ell being. D isruption o f and f inancial ab use as well as neglect. Older p eople personal ties, loneliness and c onflictual in teractions themselves perceive abuse as including t he fo llow- are major so urces of str ess, while supportive so cial ing s ocietal factors: n eglect (so cial exclusion an d connections an d in timate relations are vital sources abandonment), vio lation (h uman, leg al and of emo tional str ength . In Jap an, for exam ple, medical rights) and d eprivation ( choices, decisions, older p eople wh o r eported a lack o f s ocial contact status, finances an d r espect) . Elder abuse is a were 1.5 times more likely to d ie in t he n ext th ree violation of hu man r ights and a significant cause years than w ere those w ith h igher so cial support . of inj ury, illn ess, lost productivity, isola tion an d Older peo ple are more likely to lo se family despair. Ty pically, it is underreported in all members and frien ds an d to b e m ore vulnerable to cultures. loneliness, social isolation an d t he availab ility of a Confronting an d r educing eld er abuse req uires a ‘smaller social pool’. Social isolation an d lo neliness multisectoral, multidisciplinary approach i nvolv- in o ld ag e are linked t o a decline in b oth p hysical ing ju stice officials, law enforcement o fficers, and men tal well being. In mo st societies, men are health an d so cial service workers, la bour lead ers, less likely than w omen to h ave supportive so cial spiritual leaders, faith in stitutions, ad vocacy o rga- networks. H owever, in s ome cultures, older nizations an d o lder p eople t hemselves. Sustained women w ho are widowed ar e systematically efforts to in crease public a wareness of th e p roblem excluded fro m main stream society or even and to sh ift valu es that p erpetuate g ender in equities rejected by their community. and a geist attitudes are also required. Decision-makers, nongovernmental o rganiza- tions, private industry an d h ealth a nd so cial service Education a nd li teracy professionals can he lp f oster so cial networks fo r ageing people b y su pporting trad itional so cieties Low levels of e ducation an d illite racy are associated and c ommunity g roups ru n b y o lder p eople, with inc reased risks for d isability and d eath amo ng voluntarism, neighbourhood h elping, p eer men- people as they age, as well as with hig her ra tes of toring an d visitin g, family caregivers, intergenera- unemployment. E ducation in ear ly life combined tional programmes and outreach services. with o pportunities fo r lif elong lea rning can h elp people d evelop t he sk ills and c onfidence th ey n eed to ad apt an d st ay independent, as they g row o lder. Violence a nd a buse Studies h ave shown t hat emp loyment p roblems Older p eople w ho ar e frail or live alone may feel of o lder w orkers ar e often ro oted in th eir relatively particularly vu lnerable to c rimes such a s theft an d low liter acy skills, not in ag eing per se. If p eople are assault. A c ommon fo rm o f vio lence against older to rem ain engaged in mean ingful an d pr oductive people (esp ecially against older w omen) is ‘eld er activities as they gro w o lder, th ere is a need fo r continuous train ing in th e w orkplace an d li felong abuse’ c ommitted b y fa mily members and in stitu- tional car egivers who a re well known t o t he learning opportunities in the community . victims. Elder abuse o ccurs in families at all Like younger p eople, o lder c itizens need economic levels. It is likely to esc alate in so cieties training in n ew tec hnologies, esp ecially in agr icul- experiencing eco nomic u pheaval an d so cial ture an d elec tronic co mmunication. Se lf-directed The Agin g Male 17 Active Ageing: A Policy Framework World He alth Organization learning, increased practice an d ph ysical ad just - tradition o f gen erations livin g together b egins to ments (such as the u se of lar ge print) ca n co mpen- decline, countries ar e increasingly called on to sate for red uctions in v isual acuity, h earing an d develop m echanisms that p rovide s ocial protection short-term memory. Older p eople c an an d d o for o lder p eople w ho are unable to ea rn a living and remain creative and flexib le. Intergenerational are alone an d vu lnerable. In d eveloping co untries, learning bridges age differences, enhances t he older pe ople w ho ne ed assistan ce tend to rely on transmission of c ultural valu es and p romotes t he family support, in formal service transfers and worth o f all ages. Studies h ave shown th at yo ung personal savin gs. Social insurance p rogrammes in people w ho le arn with o lder p eople h ave more these settings are minimal and in so me cases redis- positive and rea listic attitudes a bout th e o lder tribute in come to m inorities in th e p opulation wh o generation. are less in n eed. Ho wever, in c ountries s uch as Unfortunately, th ere continue t o b e str iking d is- South A frica an d Namib ia, which ha ve a national parities in liter acy rates between men and wo men. old ag e pension, th ese benefits are a major so urce In 19 95 in th e least developed c ountries, 31 of inc ome fo r man y poor fam ilies as well as the percent o f a dult w omen w ere illiterate compared older ad ults w ho liv e in th ese families. The mo ney to 20 percent of adult men . from th ese small pensions is used to p urchase f ood for th e h ousehold, to s end ch ildren to s chool, to invest in f arming technologies an d to en sure survival for many urban poor f amilies. ECONOMIC D ETERMINANTS In d eveloped c ountries, s ocial security measures Three a spects of th e ec onomic en vironment h ave can in clude o ld-age p ensions, o ccupational p en- a particularly sig nificant ef fect o n ac tive ageing: sion sch emes, voluntary savin gs incentives, com- income, social protection and work. pulsory savin gs funds a nd in surance p rogrammes for d isability, sickness, long-term c are and u n- employment. In re cent ye ars, policy refo rms have Income favoured a multi-pillared approach t hat mix es state Active ageing policies need to in tersect with and p rivate support fo r o ld a ge security and en - broader sc hemes to r educe p overty at all ages. courages w orking lo nger an d g radual retir ement . While poor p eople o f all ages face an in creased risk of ill health an d d isabilities, older p eople ar e partic- Work ularly vulnerable. Many o lder p eople – es pecially those w ho ar e female, live alone o r in ru ral areas – Throughout th e w orld, if more people w ould do n ot h ave reliable or su fficient inc omes. This enjoy o pportunities fo r d ignified w ork ( properly seriously affects their access to n utritious fo ods, remunerated, in ad equate en vironments, protected adequate h ousing an d h ealth car e. In f act, s tudies against the h azards) earlier in lif e, people w ould have shown th at o lder p eople w ith lo w in comes reach o ld age able to p articipate in th e w orkforce. are one-third as likely to h ave high levels of Thus, th e w hole soc iety would b enefit. In a ll parts functioning as those with high incomes . of th e w orld, t here is an in creasing recognition o f The mo st vulnerable are older w omen an d m en the n eed to su pport th e ac tive and p roductive co n- who h ave no a ssets, little or n o savin gs, no p ensions tribution th at old er p eople c an an d do ma ke in or soc ial security payments or w ho are part o f formal work, in formal work, u npaid ac tivities in families with lo w o r u ncertain in comes. Particu- the home and in voluntary occupations. larly, those w ithout c hildren o r f amily members In d eveloped co untries, t he p otential g ain o f often fa ce an u ncertain f uture an d ar e at high risk encouraging o lder p eople to w ork lo nger is not for h omelessness and destitution. being fu lly realiz ed. But w hen u nemployment is high, t here is often a tendency to see reducing th e number o f o lder w orkers as a way to crea te jobs fo r Social p rotection younger p eople. Ho wever, experience has shown In all countries o f th e w orld, fam ilies provide t he that th e u se of ear ly retirement to fre e up n ew j obs majority o f su pport fo r old er p eople w ho req uire for t he u nemployed h as not be en a n ef fective help. H owever, as societies develop an d t he solution . 18 The Agin g Ma le Active Ageing: A Policy Framework World He alth Organization Africa Asia LAm/C NAm Oceania Europe Figure 9 Percentage of labour fo rce participation by people 65 a nd ol der by region. LA m/C, Lat in A merica a nd th e Caribbean; NAm, North America. Source: ILO, 2000 In less developed co untries, o lder p eople are In b oth d eveloping an d d eveloped co untries, by n ecessity more likely to r emain economically older p eople o ften t ake p rime responsibility for active into old age (see Figure 9). However, indus- household m anagement and c hildcare so t hat trialization, adoption o f n ew tec hnologies an d younger a dults can work o utside the home. labour mark et mobility is threatening mu ch o f In all countries, sk illed and exp erienced o lder the tra ditional w ork o f old er p eople, pa rticularly people act as volunteers in sc hools, c ommunities, in r ural areas. Development projects n eed to e nsure religious institutions, b usinesses and h ealth an d that o lder p eople are eligible for cr edit sc hemes and political o rganizations. V oluntary w ork b enefits full p articipation in in come-generating o pportuni- older p eople b y in creasing social contacts an d ties. psychological w ell being w hile making a signifi- cant co ntribution to t heir communities and nations. Concentrating on ly on work in the formal la bour market ten ds to ignore the valuable c ontribution that older p eople m ake in work in the informal se ctor (e.g. small sc ale, se lf-employed a ctivities and d omestic work) and unpaid work in the home. 4. Challenges of an Ageing Population The ch allenges of p opulation agein g are global, CHALLENGE 1: T HE DOUBLE national an d lo cal. Meeting th ese challenges will BURDEN OF D ISEASE require innovative planning an d s ubstantive policy As n ations in dustrialize, changing pa tterns o f reforms in d eveloped co untries an d in co untries in living and w orking ar e inevitably accompanied b y transition. D eveloping co untries, mo st of wh om a shift in d isease patterns. These changes imp act do n ot y et have comprehensive policies on agein g, developing co untries mo st. Even as these countries face the biggest challenges. continue to s truggle with in fectious d iseases, The Agin g Male 19 % Active Ageing: A Policy Framework World He alth Organization malnutrition an d co mplications f rom ch ildbirth, By 2020, the b urden o f th ese diseases will rise to they ar e faced w ith th e r apid gr owth o f n on approximately 78 percent (see Figure 10). communicable d iseases (NCDs). This ‘ d ouble There is no q uestion t hat p olicy m akers and burden o f d isease’ strains already scarce resources to donors mu st continue to p ut reso urces toward th e the limit. control an d e radication of in fectious d iseases. But i t The sh ift f rom c ommunicable t o NCD s is fast is also critical to pu t p olicies, programmes and occurring in m ost of th e d eveloping w orld, w here intersectoral partnerships i nto p lace t hat c an h elp chronic illn esses such as heart d isease, cancer an d to h alt th e massive expansion o f c hronic NC Ds. depression are quickly b ecoming th e lea ding cau ses While not n ecessarily easy to imp lement, those t hat of m orbidity an d d isability. This tr end w ill escalate focus o n co mmunity d evelopment, health p romo- over the n ext few d ecades. In 19 95, 51 p ercent o f tion, d isease prevention an d in creasing participa- the g lobal b urden o f d isease in d eveloping an d tion ar e often t he mo st effective in c ontrolling th e newly i ndustrialized c ountries w as caused b y burden o f d isease. Furthermore o ther lo ng-term NCDs, mental health d isorders and in juries. policies that tar get malnutrition a nd p overty w ill 1990 2020 Communicable diseases Neuropsychiatric diseases Noncommunicable diseases Injuries Figure 10 Global bur den of disease 1990 a nd 202 0: con tribution by disease group in devel oping a nd ne wly i ndustrialized countries. By 202 0, o ver 70 p ercent of the g lobal burde n of disease in devel oping a nd n ewly in dustrialized cou ntries wil l be caused by noncommunicable diseases, mental health disorders and injuries. Source: Murray and Lopez, 1996 HIV/AIDS a nd O lder Pe ople In A frica an d o ther d eveloping reg ions, HIV/AIDS ha s had mu ltiple impacts on o lder p eople, in te rms of livin g with th e d isease themselves, caring fo r o thers w ho are infected an d tak ing o n th e p arenting ro le with o rphans o f A IDS. T his im pact has been larg ely ignored t o d ate. In fa ct, m ost data o n H IV and A IDS infection rat es are only co mpiled up t o age 49. Improved d ata co llection (w ithout ag e limitations) that helps us better un derstand th e imp act of HIV /AIDS o n o lder p eople is urgently n eeded. HIV /AIDS information, ed ucation an d pr evention act ivities as well as treatment services should ap ply to all ages. Numerous studies have found t hat mo st adult c hildren w ith A IDS retu rn h ome to d ie. Wives, mothers, aunts, sister s, sisters-in-law and g randmothers tak e o n th e b ulk o f th e car e. Then, in m any cases, these women t ake o n th e car e of th e o rphaned c hildren. G overnments, nongovernmental organizations an d p rivate industry n eed t o ad dress the fin ancial, social and tr aining n eeds of o lder people w ho car e for f amily members and n eighbours w ho are infected an d raise child su rvivors, some of whom themselves are also infected . 20 The Agin g Ma le Active Ageing: A Policy Framework World He alth Organization help to red uce bo th ch ronic c ommunicable an d age. Significantly, ad ults o ver the ag e of 8 0 ar e the noncommunicable diseases. fastest growing age group worldwide. Support f or relevan t research is most urgently But d isabilities associated with age ing and th e needed f or less developed co untries. Cu rrently, onset o f c hronic d isease can b e p revented o r low- an d mid dle-income countries ha ve 85 delayed. For ex ample, as mentioned p reviously, percent o f t he w orld’s population a nd 9 2 p ercent there has been a significant d ecline o ver the last of th e d isease burden, b ut o nly 10 per cent o f 20 y ears in age- specific disability rates in th e the world’s health research spending . USA (see Figure 11), England, Sw eden an d o ther developed countries. Figure 11 sh ows t he act ual de cline in d isabilities CHALLENGE 2: IN CREASED RISK among o lder A mericans between 1 982 an d 1 999 OF D ISABILITY compared t o t he p rojected n umbers if rates of d is- In b oth d eveloping an d d eveloped co untries, ability had remained stable over that time period. chronic d iseases are significant an d c ostly cau ses of Some of th is decline is likely due to i ncreased disability and r educed qu ality o f lif e. An o lder education levels, improved standards o f livin g and person’s independence is threatened w hen p hysical better h ealth in th e early years. The a doption o f or men tal disabilities make it difficult to c arry o ut positive lifestyle behaviours is also a factor. A s the activities of daily living. already mentioned, ch oosing no t t o smo ke and As t hey g row o lder, p eople wit h d isabilities are making mo dest increases in p hysical act ivity levels likely to en counter ad ditional b arriers related to th e can sign ificantly reduce o ne’s risk for h eart d isease ageing process. For exa mple, mobility problems and o ther illn esses. Supportive ch anges in th e c om- due to p oliomyelitis in ch ildhood m ay be c on- munity a re also important, b oth in ter ms of p re- siderably aggravated later in li fe. Now th at man y venting d isabilities and red ucing t he rest rictions young p eople w ith in tellectual disabilities survive that p eople w ith d isabilities often fac e. In a ddition, at much old er a ges and live beyond th eir parents, impressive progress in th e man agement of c hronic this special group also requires careful atte ntion conditions ha s been o bserved, including ne w t ech- from policy makers. niques fo r ear ly diagnosis and t reatment, as well as Many p eople d evelop d isabilities in later life long-term man agement of c hronic d iseases, such a s related to t he w ear and tear of ag eing (e.g. arthritis) hypertension an d art hritis. Recent st udies have also or th e o nset o f a chronic d isease, which co uld h ave emphasized that th e in creasing use of aid s – fro m been p revented in t he f irst place (e.g . lung c ancer, simple personal aid s, such as canes, walkers, hand- diabetes and p eripheral vasc ular disease) or a rails, to tec hnologies aim ed at the p opulation as a degenerative illness (e.g. dementia). The li keli- whole, su ch as telephones – may reduce d epend- hood o f exp eriencing ser ious cognitive and p hysi- ence am ong disab led p eople. In th e USA t he u se of cal disabilities dramatically increases in very old such aid s by d ependent o lder p eople i ncreased 9.5 8.5 7.5 6.5 1982 1983 198 4 198 5 1 986 19 87 19 88 198 9 1 990 1 991 1992 1993 199 4 1 995 1 996 19 97 199 8 199 9 Actual numbers Projected nu mbers Figure 11 Numbers of chronically d isabled Americans a ged 65 a nd ove r (in m illions), 1 982 to 199 9, a ctual a nd proje cted numbers. Total nu mber of older p eople in t he US A ( millions): 19 82, 26 .9; 19 94, 33 .1; 19 99, 35 .3. So urce: M anton an d Gu , The Agin g Male 21 Millions Active Ageing: A Policy Framework World He alth Organization from 76 p ercent in 1 984 t o o ver 90 p ercent in the b urden o f d isability in o ld ag e are urgently 1999 . needed in b oth d eveloping an d d eveloped co un- tries. One u seful w ay t o lo ok at decision-making in this area is to th ink a bout e nablement instead of Vision a nd he aring disablement. Disabling processes increase the n eeds Other co mmon ag e-related disabilities include of old er p eople an d lead to iso lation an d d epend- vision and h earing lo sses. Worldwide, th ere are ence. Enabling p rocesses restore function an d currently 1 80 m illion people w ith visua l disability, expand th e p articipation o f o lder p eople i n all up to 45 m illion of w hom ar e blind. M ost o f t hese aspects of so ciety. are older p eople, a s visual impairment and b lind- A variety of sec tors can en act ‘ a ge-friendly’ ness increase sharply w ith ag e. Overall, approxi- policies that p revent disability and e nable those mately four p ercent o f per sons ag ed 6 0 ye ars and who h ave disabilities to fu lly p articipate in above ar e thought to b e b lind, an d 6 0 p ercent o f community life. Here are some examples of en abl- them live in Su b-Saharan A frica, Ch ina an d I ndia. ing pr ogrammes, environments and p olicies in a The m ajor ag e-related causes of b lindness an d variety of sectors: visual disability include c ataracts (nearly 50 p ercent Barrier-free workplaces, flex ible work ho urs, of all blindness), glaucoma, macular degeneration modified w ork en vironments and p art-time and diabetic retinopathy . work f or p eople w ho exp erience disabilities as There is an ur gent n eed f or p olicies and they ag e or are required t o c are for o thers w ith programmes designed t o p revent visual impair- disabilities (private industry and e mployers) ment and to i ncrease appropriate ey e care services, particularly in d eveloping c ountries. In a ll Well-lit streets for saf e walking, ac cessible countries, c orrective lenses and c ataract su rgery public to ilets and tra ffic lig hts that give should b e ac cessible and aff ordable f or o lder p eople people mo re time to cr oss the st reet (local who n eed them. governments) Hearing impairment leads to o ne o f t he mo st Exercise programmes that h elp o lder p eople widespread d isabilities, particularly in o lder pe ople. maintain their mobility or r ecover the leg It is estimated that w orldwide o ver 50 p ercent o f strength th ey n eed to b e mo bile (recreation people aged 6 5 y ears and ove r have some degree services and nongovernmental a gencies) of h earing lo ss . Hearing loss can c ause difficulties with co mmunication. T his, in tu rn can lead to Life-long lear ning and li teracy programmes frustration, lo w self-e steem, withdrawal an d so cial (education sect or an d n ongovernmental 39,40 isolation . organizations) Policies and p rogrammes need t o b e in p lace t o Hearing aids or in struction in s ign language t hat reduce an d even tually eliminate avoidable hearing enables older pe ople w ho are hard o f h earing to impairment and t o h elp pe ople w ith h earing lo ss continue t o co mmunicate wit h o thers (so cial obtain h earing aid s. Hearing loss may be p revented services and nongovernmental o rganizations) by avo iding ex posure t o e xcessive noise and t he use of p otentially d amaging d rugs an d b y early treat- Barrier-free access to h ealth cen tres, rehabilita- ment of d iseases leading t o h earing lo ss, such as tion p rogrammes and c ost-effective procedures middle ear infections, d iabetes and p ossibly h yper- such as cataract s urgery and h ip rep lacements tension. Hearin g loss can so metimes be t reated, (health sector) especially if the c ause is in t he ear canal o r m iddle Credit schemes and ac cess to small business and ear. Most o ften, ho wever, the d isability is reduced development o pportunities so t hat o lder p eople by amp lification o f sou nds, u sually by u sing a can co ntinue to earn a living (governments and hearing aid. international agencies). Changing t he at titudes o f h ealth an d so cial service An en abling e nvironment providers is paramount t o en suring t hat t heir prac- As po pulations aro und t he w orld live longer, p oli- tices enable and em power in dividuals to r emain as cies and p rogrammes that he lp p revent and r educe autonomous an d i ndependent as possible for as 22 The Agin g Ma le Active Ageing: A Policy Framework World He alth Organization long as possible. Professional c aregivers need t o Most o lder p ersons in n eed o f car e prefer to b e respect older p eople’s dignity at all times and t o be cared fo r in th eir own h omes. But ca regivers (who careful t o avo id premature interventions that may are often o lder p eople) mu st be sup ported if they unintentionally in duce t he loss of independence. are to c ontinue t o pr ovide c are without b ecoming Researchers need t o b etter d efine an d stan dard- ill themselves. Above all, they n eed t o b e w ell ize the to ols used to ass ess ability and disab ility and informed ab out t he co ndition th ey are faced w ith to p rovide p olicy mak ers with ad ditional evid ence and h ow it is likely to p rogress, and ab out h ow to on k ey en abling p rocesses in th e b roader envir on- obtain th e su pport services that a re available. ment, as well as in m edicine and h ealth. C areful Visiting nurses, home car e, peer support p ro- attention n eeds to b e p aid to g ender d ifferences in grammes, rehabilitation servic es, the p rovision o f these analyses. assistive devices (ranging fro m b asic devises such as a hearing aid t o mo re sophisticated on es, such as an electronic a larm system), respite care and ad ult d ay CHALLENGE 3: PR OVIDING CARE care are all important ser vices that en able informal FOR A GEING PO PULATIONS caregivers to co ntinue to p rovide c are to ind ivi- As p opulations ag e, one o f t he g reatest challenges duals w ho req uire help, w hatever their age. Other in h ealth p olicy i s to st rike a balance am ong su pport forms of su pport in clude t raining, income secu rity for self-c are (people lo oking aft er themselves), (e.g. social security coverage and p ensions), help informal support (ca re from fam ily members and with h ousing ad justments th at en able families to friends) and f ormal care (health and so cial services). look a fter people wh o ar e disabled a nd d isburse- Formal care includes b oth p rimary health c are ments to help cover caring costs. (delivered mostly at the c ommunity level) and As th e p roportion o f o lder p eople in creases in all institutional c are (either in h ospitals or n ursing countries, livin g at home in to very old age with homes). While it is clear that m ost of t he c are help f rom f amily members will become in creas- individuals need is provided b y th emselves or th eir ingly c ommon. Ho me care and co mmunity informal caregivers, most countries allo t their services to assi st informal caregivers need t o b e financial r esources inversely, i.e. the gr eatest share available to a ll, not ju st to th ose wh o k now ab out of expenditure is on institutional care. them or can afford to pay for them. All over the w orld, family members, friends an d Professional caregivers also need t raining an d neighbours ( most of w hom are women) p rovide practice in en abling mo dels of c are that r ecognize the bu lk o f su pport an d c are to o lder a dults w ho older p eople’s strengths an d e mpower th em to need a ssistance. Some policy mak ers fear that p ro- maintain even small measures of in dependence viding more formal care services will lessen the when t hey are ill or fr ail. Paternalistic or d is- involvement of f amilies. Studies s how t hat t his is respectful at titudes b y pr ofessionals can h ave a not th e c ase. When a ppropriate fo rmal services are devastating effect on t he s elf-esteem and i ndepend- provided, in formal care remains the k ey p artner . ence of older people who require services. Of co ncern th ough are recent d emographic t rends Information an d ed ucation ab out ac tive ageing in a large number o f c ountries in dicating t he needs to b e in corporated in to c urricula an d t rain- increase in th e p roportion o f c hildless women, ing p rogrammes for a ll health, so cial service and changes in d ivorce an d m arriage patterns a nd t he recreation w orkers as well as city p lanners an d overall much smaller number o f ch ildren o f fu ture architects. Basic principles an d ap proaches in o ld- cohorts o f o lder p eople, all contributing to a age care should b e ma ndatory in th e t raining o f shrinking pool of family support . all medical and n ursing stu dents a s well as other Formal care through h ealth an d soc ial service health professions. systems needs to b e e qually acc essible to all . In many countries o lder p eople w ho are poor an d CHALLENGE 4: T HE who live in ru ral ar eas have limited or n o a ccess to FEMINIZATION OF A GEING needed he alth car e. A d ecline in pu blic su pport for p rimary health car e services in man y areas has Women live longer t han men almost everywhere. put in creased financial an d in tergenerational str ain This is reflected in t he h igher ra tio o f w omen on o lder people and their families. versus men in o lder a ge groups. F or exam ple, in The Agin g Male 23 Active Ageing: A Policy Framework World He alth Organization World LDR MDR 0 100 2 00 30 0 40 0 50 0 600 700 8 00 90 0 10 00 2002 2020 Figure 12 Sex r atios b y world regions, a ge 6 0 y ears an d ove r, 20 02 an d 202 0. S ex r atios f or populations a ge 6 0 a nd o ver reflect t he la rger pro portion o f women t han men in a ll reg ions o f the wo rld, pa rticularly in t he mo re devel oped regions. LDR, less developed regions; MDR, more developed regions; medium variant fertility. Source: UN, 2001 2002, there were 678 men for ever y 1000 w omen countries in ec onomic tr ansition o ver 70 p ercent aged 6 0 p lus in Eu rope. In less developed r egions, of women age 70 and o ver are widows . there were 879 men per 1 000 w omen (see Figure Older women w ho ar e alone ar e highly vu lner- 12). Women m ake up ap proximately tw o-thirds o f able to p overty an d s ocial isolation. In s ome cul- the p opulation o ver age 75 in co untries su ch as tures, degrading an d d estructive attitudes an d Brazil and So uth A frica. Wh ile women h ave the practices around b urial righ ts and in heritance m ay advantage in leng th o f lif e, they ar e more likely rob w idows o f t heir property an d p ossessions, their than men to ex perience domestic violence and d is- health an d in dependence an d, in s ome cases, crimination in acc ess to ed ucation, i ncome, food, their very lives. meaningful wo rk, h ealth c are, inheritances, social security measures and p olitical p ower. T hese CHALLENGE 5: E THICS AND cumulative disadvantages mean that wo men are INEQUITIES more likely than me n to b e p oor an d to su ffer d is- abilities in o lder age. Because of th eir second-class As p opulations a ge, a range o f eth ical consider- status, the h ealth o f o lder w omen is often ne glected ations c omes to t he fo re. They a re often lin ked to or ig nored. In ad dition, man y women ha ve low o r age discrimination in reso urce allo cation, iss ues no i ncomes because of y ears spent in un paid c are- related to t he en d o f lif e and a host o f d ilemmas giving roles. The p rovision o f f amily care is often linked t o lo ng-term car e and t he hu man r ights achieved at the d etriment of fem ale caregivers’ of p oor an d d isabled o lder cit izens. Scientific economic security and good health in later life. advancements and mo dern med icine have led to Women are also more likely than men to liv e to many ethical questions r elated to ge netic research very old ag e when d isabilities and m ultiple health and man ipulation, b iotechnology, stem cell problems are more common. A t a ge 80 an d o ver, research and t he u se of tec hnology to s ustain life the w orld avera ge is below 60 0 m en for every 1000 while compromising q uality o f lif e. In all cultures, women. I n th e mo re developed reg ions, women consumers need to b e f ully in formed ab out false age 80 an d over outnumber men by mo re than tw o claims of ‘ an ti-ageing’ p roducts an d p rogrammes to one (see the example of Japan in Figure 13). that ar e ineffective or h armful. They ne ed p rotec- Because of w omen’s longer life expectancy an d tion fro m f raudulent ma rketing an d f inancing the t endency o f men to marr y younger w omen an d schemes, especially as they grow o lder. to r emarry if their spouses die, female widows Societies that valu e social justice mu st strive to dramatically outnumber male widowers in a ll ensure that all policies and p ractices uphold an d countries. Fo r ex ample, in th e E astern European guarantee th e r ights of a ll people, r egardless of age. 24 The Agin g Ma le Number of men per 1000 women Active Ageing: A Policy Framework World He alth Organization Age group Male Female 80+ 70–74 60–64 50–54 40–44 30–34 20–24 10–14 0–4 6000 3000 0 3000 6000 9000 Population in t housands Figure 13 Population pyr amid for Japan in 20 02 an d 20 25. In co ntrast t o th e p yramid form, the Japa nese po pulation structure h as ch anged due to po pulation a geing to wards a co ne sh ape. By 202 5, th e sh ape wil l be similar t o a n up- side-down pyramid, with pe rsons age 8 0 a nd ove r a ccounting for the la rgest p opulation gro up. T he fem inization o f old a ge is highly visible. Source: UN, 2001 Table 4 Percentage o f the popu lation b elow in ter- Advocacy an d eth ical decision-making mu st be national p overty li nes in co untries wit h a po pulation central str ategies in a ll programmes, practices, approaching o r abo ve 100 mi llion in th e y ear 20 00. So urce: policies and research on ageing. 44 † 1 World Bank, 2001 and UN, 2001 Older age often exa cerbates other p re-existing inequalities based o n rac e, ethnicity o r gen der. Percentage Percentage with with While women are universally disadvantaged in Population < 1 < 2 terms of p overty, men have shorter li fe expectan- Countries (millions) dollar/day dollars/day * * cies in mo st countries. T he exc lusion an d im pov- erishment of o lder w omen an d m en is often a China 1275 18.5 53.7 product o f st ructural in equities in b oth d eveloping India 1008 44.2 86.2 and d eveloped c ountries. I nequalities experienced Indonesia 212 7.7 55.3 Brazil 170 9.0 25.4 in ear lier life in ac cess to ed ucation, em ployment Russian Federation 145 7.1 25.1 and h ealth c are, as well as those b ased o n gen der Pakistan 141 31.0 84.7 and r ace have a critical bearing o n sta tus and we ll Bangladesh 137 29.1 77.8 being in o ld a ge. For o lder p eople w ho ar e poor, Nigeria 113 70.2 90.8 the c onsequences o f t hese earlier experiences are Mexico 98 12.2 34.8 worsened t hrough fu rther exc lusion fro m h ealth services, credit sch emes, income-generating *Adjusted for purchasing power activities and d ecision-making. Inequities in c are occur w hen small and co mparatively well off portions o f th e ag eing population, pa rticularly and pa rticipate in civic affairs are very limited. those in d eveloping co untries, c onsume a dispro- These conditions a re often w orse for o lder p eople portionately h igh amo unt o f p ublic r esources for living in ru ral areas, in c ountries in tr ansition an d in their care. situations of conflict or humanitarian disasters. In man y cases, the mean s for o lder p eople t o In all regions of t he w orld, r elative wealth an d achieve dignity a nd ind ependence, rec eive care poverty, g ender, o wnership o f assets, access to The Agin g Male 25 Active Ageing: A Policy Framework World He alth Organization work an d c ontrol o f r esources are key f actors in Second, t he c osts of lo ng-term c are can b e socioeconomic sta tus. Recent W orld Ban k d ata managed if policies and p rogrammes address pre- reveal that in man y developing co untries w ell over vention an d th e r ole of in formal care. Policies and half o f th e p opulation lives on less than tw o p ur- health p romotion p rogrammes that p revent chasing po wer p arity (P PP) d ollars per d ay (s ee chronic d iseases and less en the d egree of d isability Table 4). among o lder c itizens enable them to live inde- It is well known th at so cioeconomic st atus and pendently lon ger. A nother maj or fa ctor is the health are intimately related. With eac h step up capacity an d willin gness of f amilies to p rovide c are the so cioeconomic lad der, people live longer, and s upport fo r o lder fa mily members. This w ill healthier lives . In rec ent yea rs, the gap b etween depend to a large extent o n t he rat es of f emale rich an d p oor an d su bsequent in equalities in h ealth participation in th e lab our f orce an d o n wo rkplace status has been in creasing in co untries in all parts o f and p ublic po licies that rec ognize an d su pport th e the world . Failure to ad dress this problem w ill caregiving role. have serious consequences f or th e glo bal e conomy In m any countries, t he b ulk of s pending is on and so cial order, as well as for in dividual so cieties curative medicine. Care for ch ronic c onditions and people o f all ages. leads to an imp roved q uality o f life; however, it is always preferable if those co nditions co uld b e p re- vented o r d elayed u ntil very late in life. Decision- CHALLENGE 6: TH E ECONOMICS makers need t o evalu ate whether su ch o utcomes OF A N A GEING PO PULATION can b e ac hieved through p olicies that ad dress Perhaps m ore than an ything else, policy-makers the b road d eterminants of ac tive ageing, such as fear that r apid p opulation ag eing will lead to a n interventions to p revent in juries, improve diets unmanageable ex plosion in hea lth c are and so cial and p hysical act ivity, increase literacy or in crease security costs. While there is no do ubt th at a geing employment. populations w ill increase demands in t hese areas, Ultimately, the level of f unding allo cated to th e there is also evidence that in novation, co operation health system is a social and p olitical c hoice w ith from a ll sectors, planning ah ead an d m aking evi- no u niversally applicable an swer. However, the dence-based, cu lturally ap propriate p olicy ch oices WHO suggests that it is better t o ma ke pre- will enable countries to suc cessfully manage the payments on h ealth car e as much as possible, economics of an ageing population. whether in t he f orm o f insu rance, tax es or so cial Research in co untries w ith ag ed p opulations h as security. The p rinciple o f ‘ fair financing’ en sures shown t hat a geing per se is not lik ely to lead to equity o f ac cess regardless of ag e, sex or eth nicity ‘h ealth c are costs that are spiraling out of co ntrol’, and t hat th e f inancial b urden i s shared in a fair for t wo reasons. way . First, according t o OE CD data, the maj or ca uses A s econd m ajor c oncern t o p olicy-makers is the of escala ting health car e costs are related to cir- demand t hat an agein g population may put o n cumstances that are unrelated t o th e d emographic social security systems. Alarmists point to th e ageing of a given population. In efficiencies in c are growing p roportion o f th e ‘ d ependent’ p opulation delivery, building t oo man y hospitals, payment that h as retired from th e fo rmal labour f orce. T he systems that e ncourage lo ng h ospital sta ys, exces- idea that every one over age 60 i s dependent i s, sive numbers o f med ical interventions and t he however, a false assumption. Many pe ople co n- inappropriate u se of h igh c ost tec hnologies are the tinue to w ork in t he fo rmal labour m arket in la ter key fa ctors in escalat ions in h ealth c are costs. For life or w ould c hoose t o d o so if the o pportunity example, in th e U nited S tates and o ther O ECD existed. Many o thers c ontinue t o c ontribute to th e countries, n ew te chnologies w ere sometimes economy th rough in formal work an d vo luntary rapidly in troduced an d u sed w here alt ernative and activities, as well as intergenerational ex changes o f less expensive procedures alrea dy existed, and fo r cash an d f amily support. F or e xample, older pe ople which t he marg inal effectiveness was relatively who lo ok af ter grandchildren allo w yo unger ad ults low . There a ppears to b e c onsiderable sc ope fo r to participate in the labour market. policy-makers to ad dress these issues and imp rove An age ing population p rovides other ad vantages the effectiveness of h ealth care. to th e over all economy. Nat ions with d eclining 26 The Agin g Ma le Active Ageing: A Policy Framework World He alth Organization working-age p opulations w ill be ab le to d raw o n provide an imp ortant ec onomic an d so cial contri- older ex perienced w orkers an d in dustries will bution t o so ciety. be a ble to gro w as they serve the n eeds of o lder consumers. It is time f or a ne w par adigm, one tha t views ol der Global agein g does req uire governments and t he people as active pa rticipants in an a ge-integrated private sector to ad dress the ch allenges to so cial society and as active c ontributors as well a s beneficiaries security and p ension syst ems. A b alanced ap proach of development. to t he p rovision o f so cial protection an d e conomic goals suggests that so cieties who are willing to pla n can aff ord t o gro w o ld. L abour ma rket policies This inc ludes r ecognition o f t he c ontributions o f (for ex ample, incentives for early retirement and older p eople w ho are ill, frail and vu lnerable and mandatory re tirement practices) have a more dra- championing their rights to care and security. matic impact on a nation’s ability to p rovide so cial This p aradigm tak es an int ergenerational protection in o ld ag e than d emographic agein g per approach th at r ecognizes t he imp ortance o f rela- se. The g oal mu st be to en sure adequate livin g tionships a nd sup port am ong an d b etween fa mily standards f or p eople as they gr ow old er, w hile members and gen erations. It r einforces ‘a society recognizing an d h arnessing their skills and exp eri- for all ages’ – th e c entral f ocus o f t he 1 999 Un ited ence an d enc ouraging h armonious in tergenera- Nations International Year of O lder Persons. tional transfers. The n ew p aradigm a lso challenges the t radi- tional view that lear ning is the b usiness of ch ildren and y outh, w ork is the b usiness of mid life and retirement is the bu siness of o ld ag e. The n ew p ara- CHALLENGE 7: FO RGING A N EW digm calls for pr ogrammes that su pport lear ning at PARADIGM all ages and allo w p eople t o en ter or leave the Traditionally, o ld age has been ass ociated with labour m arket in o rder to assum e caregiving roles at retirement, illness and d ependency. P olicies and different t imes over the life course. T his ap proach programmes that are stuck i n th is out-dated p ara- supports in tergenerational so lidarity and p rovides digm do n ot ref lect reality. Indeed, mo st people increased security for c hildren, pa rents an d p eople remain independent in to ver y old a ge. Especially in in their old age. developing c ountries, m any people o ver age 60 Older p eople th emselves and th e m edia must continue t o p articipate in t he lab our f orce. Old er take th e lead in fo rging a new, m ore positive image people are active in t he in formal work s ector (e.g . of ag eing. Political and so cial recognition o f domestic work an d small scale, self-employed the c ontributions th at o lder p eople ma ke and th e activities) although t his is often n ot r ecognized in inclusion o f o lder m en and w omen in lead ership labour mark et statistics. Older people’s unpaid roles will support t his new i mage and h elp d e-bunk contributions in th e ho me (su ch as looking af ter negative stereotypes. Educating y oung p eople children an d p eople w ho ar e ill) allow yo unger about ag eing and p aying car eful at tention to u p- family members to en gage in p aid lab our. In a ll holding th e righ ts of o lder p eople w ill help to countries, th e v oluntary ac tivities of o lder p eople reduce and eliminate discrimination and a buse. 5. The Policy Response The agein g of t he p opulation is a global p henome- will have socioeconomic an d p olitical co nse- non t hat d emands in ternational, n ational, reg ional quences everywhere. and lo cal ac tion. In an i ncreasingly inter- connected w orld, failu re to d eal with th e d emo- Ultimately, a col lective appr oach to ageing an d olde r graphic im perative and rap id c hanges in d isease people wil l de termine how we, ou r chil dren an d ou r patterns in a rational w ay in an y p art o f th e wo rld grandchildren w ill experience l ife in later years. The Agin g Male 27 Active Ageing: A Policy Framework World He alth Organization The p olicy f ramework fo r act ive ageing shown according to th eir basic human rig hts, capacities, in Fig ure 14 is guided b y t he United Nations needs and p references, people will continue to Principles f or Ol der P eople (the outer circ le). These make a productive c ontribution to so ciety in b oth are independence, p articipation, c are, self- paid an d unpaid a ctivities as they age. fulfillment and d ignity. Dec isions are based o n a n Security When p olicies and p rogrammes address understanding o f h ow t he determinants of a ctive the so cial, financial an d p hysical sec urity needs and ageing influence th e w ay th at in dividuals and rights of p eople as they ag e, older p eople are populations ag e. ensured o f p rotection, d ignity an d c are in th e even t The p olicy fra mework req uires action o n th ree that t hey are no lo nger ab le to su pport an d p rotect basic pillars: themselves. Families and c ommunities are Health When th e risk factors (bo th en vironmen- supported in ef forts t o ca re for t heir older tal and b ehavioural) for c hronic d iseases and fu nc- members. tional d ecline are kept lo w w hile the p rotective factors ar e kept h igh, p eople w ill enjoy bo th a longer qu antity an d qu ality o f life; they w ill remain INTERSECTORAL ACTION healthy an d ab le to man age their own li ves as they Attaining t he g oal o f ac tive ageing will require grow o lder; few er older ad ults w ill need c ostly action in a variety of sec tors in ad dition to h ealth medical treatment and care services. and s ocial services, including ed ucation, e mploy- For th ose w ho d o n eed c are, they sh ould h ave ment and la bour, f inance, so cial security, housing, access to t he en tire range o f h ealth an d so cial transportation, j ustice an d r ural an d u rban services that ad dress the n eeds and righ ts of w omen development. While it is clear that th e h ealth sec tor and men as they age. does n ot h ave direct r esponsibility for p olicies in all Participation When lab our ma rket, employment, of t hese other sect ors, they b elong in th e b roadest education, h ealth an d so cial policies and p ro- sense within th e sc ope o f p ublic h ealth b ecause grammes support t heir full pa rticipation in so cio- they su pport t he g oals of im proved health th rough economic, cu ltural an d spir itual activities, intersectoral action. T his k ind o f an ap proach Active Ageing Participation Health Security Determinants of Active Ageing United Nations Principles for Older People Figure 14 The three pillars of a policy framework for Active Ageing 28 The Agin g Ma le Active Ageing: A Policy Framework World He alth Organization stresses the imp ortance o f th e nu merous d ifferent Make ef fective, cost-efficient treat ments that public h ealth pa rtners an d r einforces the r ole of reduce d isabilities (such as cataract remo val the health sector as a catalyst for action . and h ip rep lacements) more accessible to o lder Furthermore, all policies need to su pport in ter- people w ith low incomes. generational so lidarity and inc lude sp ecific targets Age-friendly, s afe en vironments Create age- to red uce ine quities between w omen an d men and friendly h ealth c are centres and st andards t hat among d ifferent su bgroups w ithin t he o lder help p revent the o nset o r w orsening o f disab ili- population. Pa rticular att ention n eeds to b e p aid ties. Prevent injuries by p rotecting o lder to old er p eople w ho a re poor an d mar ginalized, pedestrians in t raffic, making w alking safe, and who live in rural areas. implementing fall prevention p rogrammes, An act ive ageing approach seek s to elim inate age eliminating hazards in th e h ome an d p roviding discrimination and reco gnize th e d iversity of o lder safety advice. Stringently en force o ccupational populations. O lder people an d th eir caregivers safety standards th at p rotect o lder w orkers need to b e act ively involved in th e p lanning, from in jury. M odify fo rmal and i nformal work implementation and e valuation of po licies, pro- environments so t hat p eople c an c ontinue to grammes and k nowledge d evelopment a ctivities work p roductively a nd safely as they age. related to active ageing. Hearing a nd vision Reduce a voidable hearing impairment through ap propriate p revention measures and s upport ac cess to h earing aid s for KEY POLICY PROPOSALS older pe ople w ho ha ve hearing lo ss. Aim to The f ollowing p olicy p roposals ar e designed t o reduce an d e liminate avoidable blindness b y address the th ree pillars of ac tive ageing: health, 2020 . Provide ap propriate ey e care services participation an d sec urity. Some are broad an d for p eople w ith ag e-related visual disabilities. encompass all age groups w hile others ar e targeted Reduce in equities in acc ess to co rrective glasses specifically to th ose ap proaching o ld a ge and/or for ageing women and men. older people t hemselves. Barrier-free liv ing Develop barrier-free housing options f or a geing people w ith disab ilities. 1. Health Work t o m ake public b uildings an d tr ansporta- tion ac cessible for all people w ith disab ilities. 1.1 Prev ent and reduce the burden of e xcess Provide ac cessible toilets in p ublic p laces and disabilities, chronic disease and premature workplaces. mortality Quality of l ife Enact p olicies and p rogrammes Goals a nd tar gets Set gender-specific, measur- that imp rove the q uality of li fe of p eople w ith able targets for imp rovements in hea lth stat us disabilities and ch ronic illn esses. Support th eir among o lder p eople an d in th e red uction o f continuing in dependence an d in terdependence chronic d iseases, disabilities and p remature mor- by assis ting with ch anges in th e en vironment, tality as people a ge. providing reh abilitation servic es and c ommu- Economic in fluences on health Enact p olicies and nity su pport fo r f amilies, and in creasing afford- programmes that ad dress the ec onomic fa ctors able access to ef fective assistive devices (e.g. that c ontribute to t he o nset o f d isease and d is- corrective eyeglasses, walkers). abilities in later life (i.e. poverty, in come i n- Social su pport Reduce r isks for lo neliness and equities and so cial exclusion, lo w lit eracy levels, social isolation b y su pporting co mmunity lack o f ed ucation). Give priority to imp roving groups r un b y o lder p eople, trad itional so cieties, the he alth sta tus of p oor an d mar ginalized self-help and m utual aid g roups, p eer and p ro- population groups. fessional outreach p rogrammes, neighbourhood Prevention a nd ef fective tr eatments Make screen ing visiting, telephone su pport p rogrammes, and services that ar e proven to b e eff ective, available family caregivers. Support int ergenerational and af fordable t o w omen an d m en as they ag e. contact an d p rovide h ousing an d c ommunities The Agin g Male 29 Active Ageing: A Policy Framework World He alth Organization that en courage d aily social interaction an d in ter - for m en and w omen as they ag e. Support dependence among young and old. improved diets and h ealthy w eights in old er age through th e p rovision o f in formation (in cluding HIV and AIDS Remove the age limitation on information sp ecific to t he n utrition n eeds of data co llection r elated to HI V/AIDS. A ssess and older p eople), education ab out nu trition at all address the im pact of HIV /AIDS o n o lder ages, and f ood p olicies that en able women, men people, in cluding t hose w ho are infected an d and f amilies to make healthy food c hoices. those wh o are caring f or o thers w ho a re infected and/or for AIDS o rphans. Oral health Promote or al h ealth amo ng o lder people a nd en courage w omen an d men to r etain Mental he alth Promote po sitive mental health their natural teet h fo r as long as possible. Set throughout th e li fe course b y p roviding in for- culturally ap propriate p olicy go als for o ral health mation an d ch allenging stereo typical beliefs and p rovide ap propriate o ral h ealth p romotion about m ental health p roblems an d men tal programmes and t reatment services during th e illness. life course. Clean en vironments Put p olicies and p ro- Psychological factors Encourage an d en able grammes in p lace th at en sure equal ac cess for a ll people t o bu ild self-e fficacy, cognitive skills to clea n water, safe food an d clea n air. Minimize such as problem-solving, pro-social b ehaviour exposure t o p ollution th roughout th e life and ef fective coping sk ills throughout th e life course, b ut p articularly in ch ildhood an d o ld course. R ecognize an d c apitalize on t he ex peri- age. ence an d st rengths o f o lder p eople w hile helping them improve their psychological well being. 1.2 Re duce risk factors associated with major Alcohol a nd dru gs Determine the ex tent o f th e diseases and increase factors that protect health use of alc ohol a nd dr ugs b y pe ople a s they age throughout th e life course and p ut p ractices and po licies in p lace to r educe Tobacco Take c omprehensive action at local, misuse and abuse. national an d in ternational levels to c ontrol t he Medications Increase affordable acc ess to essen - marketing an d u se of to bacco pr oducts. P rovide tial safe medications among o lder p eople wh o older people w ith h elp to quit smoking. need th em but c annot a fford th em. Put p ractices Physical activity Develop culturally ap propriate, and p olicies in p lace t o r educe ina ppropriate population-based in formation an d gu idelines prescribing b y h ealth p rofessionals and o ther on p hysical act ivity for o lder men and wo men. health ad visors. Inform an d ed ucate p eople Provide a ccessible, pleasant and af fordable about the wise use of medications. opportunities to b e ac tive (e.g. safe walking Adherence Undertake co mprehensive measures areas and p arks). Support p eer leaders and to b etter u nderstand an d c orrect p oor ad herence groups t hat p romote reg ular, moderate physical to t herapies, which severely compromise treat- activity for p eople as they age . Inform an d ment effectiveness, particularly in relat ion to educate p eople an d p rofessionals about t he long-term therapies. importance o f stay ing active as one g rows old er. Nutrition Ensure adequate n utrition th rough- out th e life course, pa rticularly in ch ildhood an d 1.3 D evelop a continuum of affordable, a ccessible, among w omen in th e rep roductive year s. high quality and age-friendly health and social Ensure that n ational n utrition p olicies and services that address the needs and rights of women action p lans re cognize o lder p ersons a s a poten- and men as they age tially vulnerable group. In clude sp ecial measures A con tinuum of c are thr oughout the life c ourse to p revent m alnutrition an d en sure food Taking in to c onsideration th eir opinions an d security and safety as people ag e. preferences, provide a continuum o f c are for Healthy e ating Develop culturally ap propriate, women an d men as they g row o lder. R e-orient population-based g uidelines for h ealthy eatin g current system s that are organized a round ac ute 30 The Agin g Ma le Active Ageing: A Policy Framework World He alth Organization care to p rovide a seamless continuum o f c are Iatrogenesis Prevent iatrogenesis (disease and that i ncludes h ealth p romotion, d isease preven- disability that is induced by t he p rocess of d iag- tion, th e a ppropriate t reatment of ch ronic nosis or treat ment). Establish adequate sy stems diseases, the eq uitable p rovision o f co mmunity for p reventing a dverse drug reac tions with a support an d d ignified lo ng-term an d p alliative special focus o n old age. Raise awareness of th e care through all the stages of life. relative risks and b enefits of mo dern th erapies among h ealth p rofessionals and t he p ublic at Affordable a nd e quitable a ccess Ensure affordable large. and eq uitable ac cess to q uality p rimary health care (both ac ute an d ch ronic), as well as long- Ageing at home a nd in the community Provide term care services for all. policies, programmes and ser vices that en able people to remain in th eir homes as they gro w Informal ca regivers Recognize an d ad dress older, wit h o r w ithout o ther f amily members gender d ifferences in th e b urden o f ca regiving according to t heir circumstances and p refer- and ma ke a special effort t o sup port c aregivers, ences. Support fa milies that in clude o lder most of w hom are older w omen w ho c are for people w ho n eed car e in th eir households. partners, children, g randchildren an d o thers Provide h elp w ith m eals and h ome m ainte- who are sick or d isabled. Support in formal care- nance, an d at -home nursing su pport w hen it is givers through init iatives such as respite care, required. pension c redits, financial su bsidies, training an d home c are nursing services. Recognize th at Partnerships and qua lity care Provide a compre- older car egivers may become so cially isolated, hensive approach to lo ng-term car e (by in for- financially disadvantaged an d sic k themselves, mal and fo rmal caregivers) that st imulates and attend to their needs. collaboration b etween t he p ublic a nd p rivate sectors and in volves all levels of g overnment, Formal ca regivers Provide pa id car egivers with civil society and th e n ot-for-profit sec tor. adequate w orking c onditions a nd r emunera- Ensure high q uality st andards an d stim ulating tion, w ith sp ecial attention to th ose w ho are environments in resid ential care facilities for unskilled an d h ave low so cial and p rofessional men and w omen w ho r equire this care, as they status (most of whom are women). grow older. Mental he alth services Provide co mprehensive mental health services for m en and w omen as 1.4 Pr ovide training and education to caregivers they age, ranging f rom men tal health p romotion to tr eatment services for men tal illness, rehabili- Informal ca regivers Provide family members, peer tation an d re-in tegration in to t he c ommunity as counsellors an d o ther i nformal caregivers with required. P ay sp ecial attention to in creased information an d t raining o n h ow t o car e for depression a nd su icidal tendencies d ue to lo ss people as they g row o lder. Su pport o lder h ealers and so cial isolation. Provide q uality c are for who are knowledgeable a bout tr aditional an d older p eople w ith d ementia and o ther n euro- complementary m edicines while also assessing logical and c ognitive problems in th eir homes their training needs. and in resid ential facilities when ap propriate. Formal c aregivers Educate h ealth an d so cial Pay sp ecial attention to a geing people w ith service workers in en abling m odels of p rimary long-term intellectual disabilities. health c are and lo ng-term car e that r ecognize Coordinated ethical sys tems of c are Eliminate age the stre ngths an d co ntributions o f o lder p eople. discrimination in h ealth an d s ocial service Incorporate mo dules o n ac tive ageing in systems. Improve the co ordination o f h ealth an d medical and h ealth cu rricula at all levels. social services and in tegrate these systems when Provide sp ecialist education in ger ontology an d feasible. Set and main tain appropriate sta ndards geriatrics for med ical, health an d so cial service of c are for agein g persons th rough regu latory professionals. mechanisms, guidelines, education, co nsulta- Inform all health a nd so cial service profes- tion and c ollaboration. sionals about th e p rocess of ag eing and w ays to The Agin g Male 31 Active Ageing: A Policy Framework World He alth Organization optimize ac tive ageing among in dividuals, com - participation of p eople in me aningful w ork as munities and p opulation g roups. P rovide in cen- they g row o lder, acc ording to th eir individual tives and t raining fo r h ealth an d so cial service needs, preferences and ca pacities (e.g. the elimi- professionals to su pport self-c are and c ounsel nation o f age discrimination in th e hir ing an d healthy lifesty le practices among m en and retention o f o lder wo rkers). Support p ension women as they age. Increase the aw areness reforms that e ncourage p roductivity, a diverse and sen sitivity of a ll health p rofessionals and system of p ension sch emes and m ore flex - community w orkers o f th e imp ortance o f so cial ible retirement options ( e.g. gradual o r p artial networks f or w ell being in old ag e. Train h ealth retirement). promotion w orkers to id entify o lder p eople Informal w ork Enact p olicies and p rogrammes who ar e at risk for lo neliness and so cial isolation. that rec ognize an d su pport t he c ontribution th at older wo men an d men make in u npaid w ork in 2. Pa rticipation the in formal sector an d in c aregiving in th e home. 2.1 Pro vide education and learning opportunities throughout th e life course Voluntary a ctivities Recognize th e valu e of volunteering an d ex pand o pportunities to Basic education a nd he alth literacy Make b asic edu- participate in me aningful vo lunteer act ivities as cation ava ilable to all across the lif e course. A im people a ge, especially those w ho w ant t o v olun- to ac hieve literacy for all. Promote h ealth liter- teer but can not b ecause of h ealth, in come, or acy b y p roviding h ealth ed ucation th roughout transportation restrictions. the life course. T each p eople h ow to c are for themselves and eac h o ther as they g et older. Educate an d emp ower o lder pe ople o n h ow t o 2.3 E ncourage p eople to participate fully in effectively select and u se health an d co mmunity family community life, as they grow older services. Transportation Provide a ccessible, affordable Lifelong l earning Enable the fu ll p articipation o f public t ransportation service s in ru ral an d u rban older p eople b y p roviding p olicies and p ro- areas so t hat o lder p eople ( especially those w ith grammes in ed ucation an d tra ining th at su pport compromised mo bility) can p articipate f ully in lifelong lea rning for w omen an d men as they family and c ommunity life. age. Provide o lder p eople w ith o pportunities t o develop n ew sk ills, particularly i n ar eas such as Leadership Involve older p eople i n po litical information tec hnologies an d n ew agric ultural processes that af fect th eir rights. Include o lder techniques. women an d men in t he p lanning, imp lementa- tion an d e valuation of lo cally based he alth an d social service and r ecreation p rogrammes. 2.2 Re cognize and enable the active participation Include old er p eople in p revention a nd ed uca- of people in economic development activities, tion ef forts t o red uce t he sp read o f HIV /AIDS. formal and informal work and voluntary activities Involve older p eople in eff orts to d evelop as they age, according to their individual needs, research agendas on ac tive ageing, both as preferences and capacities advisors and as investigators. Poverty r eduction a nd inc ome ge neration Include A soc iety for a ll a ges Provide gr eater flexibility in older pe ople in t he p lanning, im plementation periods d evoted to ed ucation, w ork an d c are- and evalu ation of so cial development in itiatives giving responsibilities throughout th e life and ef forts to red uce p overty. En sure that o lder course. D evelop a range o f h ousing o ptions fo r people h ave the same access to d evelopment older p eople t hat elimin ate barriers to in de- grants, income-generation p rojects an d c redit as pendence an d i nterdependence w ith fa mily younger people d o. members, and en courage f ull p articipation Formal work Enact lab our mark et and emp loy- in c ommunity an d f amily life. Provide ment policies and p rogrammes that en able the intergenerational ac tivities in sch ools an d 32 The Agin g Ma le Active Ageing: A Policy Framework World He alth Organization communities. Encourage o lder p eople t o care for p eople w ith HIV /AIDS an d tak e o n become ro le models for ac tive ageing and t o surrogate p arenting r oles for o rphans o f A IDS. mentor y oung p eople. R ecognize an d su pport Provide in -kind su pport, aff ordable h ealth c are the im portant r ole and resp onsibilities of gra nd- and lo ans to o lder p eople t o h elp th em meet the parents. Foster collaboration amo ng n on- needs of ch ildren a nd g randchildren aff ected b y governmental organizations th at w ork w ith HIV/AIDS. children, youth a nd older people. Consumer prote ction Protect co nsumers f rom A positiv e image of age ing Work w ith g roups unsafe med ications and t reatments, and u nscru- representing older p eople an d th e med ia to pulous ma rketing practices, particularly in o lder provide realist ic and p ositive images of a ctive age. ageing, as well as educational in formation o n Social ju stice Ensure that d ecisions being mad e active ageing. Confront n egative stereotypes concerning c are in o lder age are based o n th e and ageism. rights of o lder p eople an d g uided b y t he UN Reduce ine quities in participation by women Principles for Old er P ersons. Uphold o lder Recognize an d sup port th e imp ortant co ntribu- persons’ rig hts to m aintain independence an d tion t hat o lder w omen m ake to fam ilies and autonomy fo r th e lon gest pe riod o f time communities through c aregiving and p articipa- possible. tion in th e in formal economy. En able the f ull Shelter Explicitly recognize o lder p eople’s participation o f w omen in p olitical lif e and right to a nd n eed fo r secu re, appropriate sh elter, decision-making p ositions as they ag e. Provide especially in time s of c onflict a nd c risis. education an d lifelo ng lear ning opportunities t o Provide h ousing assis tance for old er p eople women as they ag e, in th e sam e way th at th ey and th eir families when req uired (p aying sp ecial are provided to men. attention to th e c ircumstances of th ose wh o Support organizations representing ol der pe ople Pro- live alone) through re nt su bsidies, cooperative vide in-kind an d fin ancial su pport an d train ing housing in itiatives, support fo r h ousing ren ova- for m embers of t hese organizations so that th ey tions, etc. can ad vocate, promote an d en hance t he h ealth, Crises Uphold th e rig hts of o lder p eople d uring security and f ull p articipation o f o lder w omen conflict. Sp ecifically recognize an d ac t o n th e and men in all aspects of community life. need to p rotect o lder p eople in emer gency situations (e.g. by p roviding tr ansportation to relief centres to t hose w ho can not w alk th ere). 3. Security Recognize t he co ntribution th at o lder p eople can mak e to rec overy efforts in t he af termath of 3.1 Ensu re the protection, safety and dignity o f an emerg ency and in clude th em in rec overy older people by addressing the social, financial and initiatives. physical security rights and needs of people as they age Elder abuse Recognize eld er abuse (ph ysical, sexual, psychological, fin ancial an d n eglect) and Social sec urity Support t he pr ovision o f a social encourage t he p rosecution of o ffenders. T rain safety net f or old er p eople w ho are poor an d law enforcement o fficers, health an d so cial alone, as well as social security initiatives that service providers, spiritual leaders, advocacy provide a steady and ad equate s tream of in come organizations an d g roups o f o lder p eople to during o ld ag e. Encourage y oung ad ults t o recognize an d d eal with eld er abuse. Increase prepare f or o ld age in th eir health, s ocial and awareness of th e in justice o f eld er abuse th rough financial practices. public in formation a nd aw areness campaigns. HIV/AIDS Support th e so cial, economic an d Involve the m edia and y oung p eople, as well as psychological w ell being o f old er p eople w ho older people in these efforts. The Agin g Male 33 Active Ageing: A Policy Framework World He alth Organization 3.2 Re duce inequities in the security rights and Enact legislatio n and en force law s that p rotect needs of older women women fr om d omestic and o ther fo rms of violence as they age. Enact legislat ion and en force law s that p rotect widows f rom t he th eft o f p roperty an d p osses- Provide s ocial security (income support) fo r sions and f rom h armful p ractices such as older w omen w ho h ave no p ensions o r meag er health-threatening b urial rit uals and c harges of retirement incomes because they h ave worked witchcraft. all or mo st of th eir lives in t he h ome o r in formal sector. WHO a nd A geing In 19 95 w hen W HO renamed its ‘Hea lth of th e Eld erly Programme’ to ‘ A geing an d H ealth’, it signaled an im portant c hange in o rientation. R ather t han co mpartmentalizing o lder p eople, th e ne w n ame embraced a life course p erspective: we are all ageing and t he b est way t o en sure good h ealth f or fu ture cohorts of old er p eople is by p reventing d iseases and p romoting h ealth th roughout th e life course. Co n- versely, the h ealth o f th ose n ow in old er age can o nly be f ully u nderstood if the life events they h ave gone through a re taken into consideration. The aim of t he A geing an d He alth Programme has been to d evelop p olicies that en sure ‘the at tain- ment of t he b est possible quality o f life for as long as possible, for th e large st possible number of p eople’. For t his to b e ac hieved, WHO is required t o a dvance th e k nowledge b ase of ger ontology a nd g eriatric medicine through r esearch and t raining eff orts. Emphasis is needed on fo stering in terdisciplinary and intersectoral initiatives, particularly th ose d irected a t developing c ountries fa ced w ith u nprecedented rapid rate s of p opulation ag eing within a context o f p revailing poverty an d u nsolved in frastructure problems. In addition t he Programme highlighted t he importance o f: Adopting co mmunity-based ap proaches b y emp hasizing the c ommunity as a key sett ing for i nter- ventions Respecting cultural c ontexts and in fluences Recognizing the importance o f g ender differences Strengthening intergenerational links Respecting and u nderstanding ethical issues related to health and well being in old age. The I nternational Y ear of Old er P ersons (19 99) was a landmark in t he evo lution o f th e W HO’s work o n ageing and h ealth. T hat year , the W orld Healt h Day th eme was ‘act ive ageing makes the d ifference’ an d the ‘ G lobal M ovement for A ctive Ageing’ w as launched b y th e WH O Director G eneral, Dr G ro Harlem Brundtland. A t th is occasion, D r Bru ndtland stat ed: Maintaining he alth and q uality of l ife ac ross the lifespan w ill do much tow ards building fulfilled liv es, a har monious intergenerational c ommunity a nd a dyna mic economy. W HO is committed to promoting Active A geing a s an in dispensable c omponent of al l de velopment programmes. In 20 00, the n ame of th e W HO programme was changed a gain to ‘ A geing an d L ife Course’ to r eflect the imp ortance of th e life -course perspective. The mu lti-focus o f t he p revious programme and th e emphasis on de veloping ac tivities with m ultiple partners f rom all sectors and several disciplines have been ma intained. A fu rther r efinement of t he ‘ act ive ageing’ c oncept h as been ad ded an d tr anslated into all the p rogramme activities, including r esearch and tr aining, information d issemination, advocacy an d policy d evelopment. In ad dition to th e A geing an d Lif e Course Programme at WHO headquarters, eac h o f t he six WHO Regional O ffices have their own ad viser on A geing in o rder to ad dress specific issues from a regional perspective. 34 The Agin g Ma le Active Ageing: A Policy Framework World He alth Organization INTERNATIONAL CONCLUSION COLLABORATION In th is document, W HO offers a framework With th e lau nch o f t he I nternational P lan o f A ction for ac tion fo r p olicy-makers. Together w ith th e on A geing, th e 200 2 W orld A ssembly on A geing newly-adopted U N Plan o f A ction o n A geing, t his marks a turning p oint in ad dressing the ch allenges framework p rovides a roadmap f or d esigning and ce lebrating th e tr iumphs o f an agein g world. multisectoral active ageing policies which w ill As w e embark o n th e im plementation phase, enhance h ealth an d p articipation amo ng ag eing cross-national, regional and g lobal s haring o f populations w hile ensuring th at o lder p eople h ave research and p olicy op tions w ill be c ritical. Increas- adequate sec urity, protection an d c are when t hey ingly, member states, nongovernmental o rganiza- require assistance. tions, academic institutions an d t he p rivate sector WHO recognizes t hat p ublic h ealth invo lves a will be c alled upon t o d evelop age- sensitive solu- wide r ange o f ac tions to i mprove the h ealth o f tions to t he c hallenges of an age ing world. T hey the p opulation a nd t hat h ealth go es beyond th e will need t o tak e in to co nsideration th e c onse- provision o f b asic health servic es. Therefore, it is quences o f th e ep idemiological transition, r apid committed t o wo rk in c ooperation w ith o ther changes in th e he alth sec tor, globalization, u rban- international ag encies and th e Un ited N ations itself ization, ch anging f amily patterns an d en vironmen- to en courage th e imp lementation of ac tive ageing tal degradation, as well as persistent inequalities and policies at global, reg ional and n ational levels. Due poverty, p articularly in d eveloping co untries to t he sp ecialist nature o f its work, W HO will where th e maj ority o f o lder pe rsons a re already provide tec hnical ad vice and p lay a catalytic role living. for he alth d evelopment. However, this can o nly be To ad vance t he mo vement for ac tive ageing, all done as a joint ef fort. T ogether, w e must provide stakeholders w ill need t o c larify and p opularize t he the evid ence and d emonstrate th e ef fectiveness of term ‘act ive ageing’ through d ialogue, d iscussion the vario us proposed co urses of act ion. U ltimately, and d ebate in th e p olitical a rena, the ed ucation however, it will be u p to n ations an d lo cal c om- sector, public f ora a nd med ia such a s radio an d munities to d evelop c ulturally sen sitive, gender- television programming. specific, realistic goals and t argets, and im plement Action o n all three pillars of ac tive ageing needs policies and p rogrammes tailored t o th eir unique to b e su pported b y k nowledge d evelopment a ctiv- circumstances. ities including evalu ation, research and sur veillance The ac tive ageing approach p rovides a frame- and th e dissemin ation of resear ch findings. T he work fo r th e d evelopment o f g lobal, n ational an d results of r esearch need t o b e s hared in c lear lan- local str ategies on p opulation ag eing. By pulling guage a nd ac cessible and p ractical fo rmats with together th e t hree pillars for ac tion o f h ealth, policy-makers, nongovernmental o rganizations participation an d s ecurity, it offers a platform fo r representing older p eople, t he p rivate sector an d consensus b uilding th at a ddresses the co ncerns o f the public at large. multiple sectors and all regions. Policy pr oposals International ag encies, countries an d reg ions and re commendations ar e of litt le use unless will need t o w ork c ollaboratively to d evelop a rele- follow-up a ctions are put in p lace. The time to ac t vant research agenda for active ageing. is now. ACKNOWLEDGEMENTS WHO is committed to work in collaboration w ith other intergovernmental organ izations, NGOs and This t ext and t he p reliminary version of th e p aper the academic sec tor for the development of a gl obal were drafted b y P eggy Ed wards, a Health Canada framework f or rese arch on ageing. S uch a f ramework consultant b ased fo r si x months a t WHO, under should reflect the priorities expressed in the Inter- the g uidance o f WH O’s Ageing an d Lif e Course national P lan o f A ction on Ageing 20 02 and those in Programme. this document. A co ntribution o f t he W orld Healt h Organiza- tion to t he Sec ond U nited Nat ions World Assembly on A geing, Madrid, Spain, April 2002. The Agin g Male 35 Active Ageing: A Policy Framework World He alth Organization We gratefully ac knowledge th e su pport p ro - The view s expressed in d ocuments b y n amed vided by He alth Canada. UNFPA contributed t o authors are solely the resp onsibility of th ese the p rinting o f th e b rochure t hrough th e G eneva authors. International Network on Ageing (G INA). Please send comments to: Graphic D esign: Marilyn Langfeld World Health Organization Noncommunicable Disease Prevention and Ó Copyright W orld H ealth Organization, 2002 Health Promotion This d ocument is not a formal publication o f t he Ageing an d Life Course World Hea lth Organization ( WHO), and all rights 20 Avenue Appia, CH 1211 Geneva 27, are reserved by th e O rganization. T he p aper may , Switzerland however, be f reely reviewed, abstracted, rep ro- Fax: +41-22-791 4839 duced a nd t ranslated, in p art o r i n w hole, b ut n ot E-mail: activeageing@who.int for sale nor f or u se in c onjunction w ith c ommercial purposes. References 1. United N ations (U N). World Po pulation P rospects: Services, Centers fo r D isease Co ntrol a nd P reven- The 2000 Revis ion . New Yo rk: UN, 2001 tion, 1999 2. 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Journal

The Aging MaleTaylor & Francis

Published: Jan 1, 2002

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