Ageing and Health Ageing and Health

AgeingandHealth

AgeingandHealthA HEALTH PROMOTIONAPPROACH FORDEVELOPING COUNTRIES

World Health OrganizationRegional Office for the Western Pacific

AGEING AND HEALTH A

HEALTH PROMOTION APPROACH FOR DEVELOPING COUNTRIES

World Health OrganizationRegional Office for the Western PacificUnited Nations Avenue, PO Box 2932

1000 Manila, Philippineswww.wpro.who.int

Ageing and Health 1

The purpose of this publication is to outlineways of responding to the health needs ofageing populations in developing countries.It focuses on the Western Pacific Region ofthe World Health Organization (WHO). Theaims of the paper are essentially practical inthat it seeks to provide health workers witha framework for selecting appropriate waysof approaching the tasks of improving qual-ity of life, disease prevention and health ser-vices delivery for older people.

Populations in all countries of the West-ern Pacific Region are ageing – an increas-ing proportion of people are aged 65 andover. This, together with changing lifestyles,means that there has been a radical shift inthe types of health problems facing healthworkers in developing countries. Increas-ingly, health policies and programmes willhave to address the demands posed by therapidly emerging epidemic in chronic, non-communicable, lifestyle-based diseases anddisabilities. While these diseases present achallenge for health policy for people at allstages of the life course, they are particu-larly evident among older people where theirimpact is more obvious. The growing pro-portion of elderly people among the popula-tion simply highlights the importance ofaddressing these health problems.

The publication will summarize:n the main known facts about the nature

of chronic health problems among olderpeople in developing countries;

n the major factors that contribute to thecurrent epidemic of noncommunicable,chronic disease and disability in ageingpopulations;

n the ways in which a health promotionperspective can provide an important

means of addressing the health problemsamong older people in developing coun-tries.In order to outline the elements of a

health promotion approach to achievinghealthy and active ageing in developingcountries in the Western Pacific Region it isnecessary first to answer three preliminaryquestions:n What is ageing?n What is health?n What are the main factors contributing

to health and ill-health among olderpeople?It is only when these questions are an-

swered that an approach to healthy ageingcan be outlined.

The research baseThe approach outlined in this paper is basedon research relating to:n the link between ageing and chronic dis-

ease and disability;n the factors that contribute to chronic dis-

ease and disability in later life;n the factors that improve health outcomes

for older people;n the effectiveness of health promotion

strategies in achieving healthy ageing.It must be said at the outset that the evi-

dence base for some of these areas is mod-est 1 . While there is good evidence thatchronic diseases are more common in older

Introduction

1 There is considerable debate about what constitutes evi-dence in relation to the effectiveness of health promo-tion. For an excellent discussion of this issue. See:McQueen D. Strengthening the evidence base for health pro-motion. Fifth Global Conference for Health Promotion:Health Promotion: Bridging the Equity Gap, Mexico, 2000.

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Table 1: Some key health promotion evaluation resources

Key Web sites

Research on effectiveness of various interventionshttp://www.hda-online.org.uk/html/research/effectiveness.html

Health Development Agency International Union of Health Promotion and Educationhttp://www.iuhpe.nyu.edu

Effectiveness of mental health promotion interventionshttp://www.hda-online.org.uk/html/research/effectivenessreviews/effective4a.htmlhttp://www.hda-online.org.uk/html/research/effectivenessreviews/effective1b.html

Second International Symposium on the Effectiveness of Health Promotionhttp://www.utoronto.ca/chp/symposium.htm

Evidence basehttp://www.hda-online.org.uk/html/research/evidencebase.html

Public Health Electronic Libraryhttp://www.phel.gov.uk/information/evbase.html

Some Key References

Review and evaluation of health promotion: A Selection of papers from the Fourth InternationalConference on Health Promotion, Jakarta, July 1997 (http://www.who.int/hpr/archive/docs/ret.html)

Victor, C. and Howse, K. Promoting the health of older people. London, Health Education Authority,2000.

McQueen, D. Strengthening the evidence base for health promotion. Fifth Global Conference forHealth Promotion: Health Promotion: Bridging the Equity Gap, Mexico, 2000.

International Union of Health Promotion and Education . The evidence of health promotioneffectiveness: Shaping public health in a new Europe. Part 1. Vanves, France, IUHPE, 2000.

International Union of Health Promotion and Education The evidence of health promotioneffectiveness: Shaping public health in a new Europe. Part 2. Vanves, France, IUHPE, 2000.

World Health Organization Regional Office for Europe. Health promotion evaluation:Recommendations to policymakers. Copenhagen, WHO Regional Office for Europe, 1995.

Raeburn, J. and Corbett, T. Community development:: How effective is it as an approach inhealth promotion? http://www.utoronto.ca/chp/raeburn.doc 2001.

Health promotion journalsPromotion and education (P&E): The Quarterly Journal of the International Union for Health

Promotion and Education

Health education research (HER): An official research journal of the International Union forHealth Promotion and Education

Reviews of health promotion and education online (RHPEO): The electronic journal of theInternational Union for Health Promotion and Education.

Other resourcesSouth Australian Community Health Research Unit

http://www.sachru.sa.gov.au/navigate.htmThis site has a lot of resources to assist with planning community development health promotions.

University of Toronto Centre for Health Promotionhttp://www.utoronto.ca/chp/p-titles.htm#_Hlk476405657This site has many resources, lectures and other tools for those who work in health promotion.

Ageing and Health 3

people and good evidence concerning thefactors that contribute to chronic disease, theevidence is patchier regarding the types ofstrategies that improve health outcomes forolder people. The systematic, published evi-dence regarding the effectiveness of healthpromotion interventions is still relativelyweak – especially in relation to what worksfor older people, and particularly those indeveloping countries.2

In the face of these research gaps it isnecessary to draw on some research fromdeveloped countries and sometimes to relyon what is effective for other age groups.However, rather than relying on the veryspecific findings from some of this research,the material in this publication is based moreon the underlying principles learned fromprevious studies. In addition to using evi-dence from health promotion research, someof the ideas are drawn from a wider range ofresearch literature on community develop-ment, social change and individual behaviourand change. Table 1 and Appendix A pro-vide a list of further reading and web links

ActionDirected towards decision-makersAdvocate for all health promotion interven-tions to include appropriate evaluation sothat the effectiveness of particular strate-gies in particular cultures can be betterassessed.

on the research on the effectiveness ofhealth promotion. As far as is possible, theparticular circumstances in developing coun-tries have shaped the selection of the typesof strategies that are described and the rec-ommendations that are made.

The demographic contextWhile population ageing is an issue for allregions, it is a particularly pressing matterin the Western Pacific Region as can be seenin Figure 1. Four main points stand out fromthis Figure:n The rate of increase of the older popula-

tion will be faster in the Western PacificRegion than any almost other WHO re-gion.

n The proportion of the population agedover 65 is projected to more than treblefrom 7% (111 million people) to 23%(450 million) by 2050.

n By 2050, the Western Pacific Region willhave the second oldest population of allWHO regions – just below Europe where25% of the population will be aged over65.

n With a projected population of 450 mil-

2 Because of the lack of solid evidence in relation to de-veloping countries the International Union for Health Pro-motion and Education has established the Global Forumon Health Promotion Dialogue, one of the aims of whichis to strengthen the evidence base for health promotion indeveloping countries (http://www.iuhpe.nyu.edu/projects/index.html ).

Figure 1: Projected population aged 65 and over, 1997-2050, by WHO region

4 Ageing and Health

lion older people by 2050, the WesternPacific Region will have far more olderpeople than any other world region.The two main reasons for the ageing of

the population in the Western Pacific Regionare that women are having fewer babies (fer-tility decline) and both men and women areliving longer (increased longevity). In 1975the average life expectancy in the WesternPacific Region was 64 years. By 1997 thishad increased to 70 years and it is projectedto increase further to 75 years by 2025. 3

The extent to which populations in the

Table 2: Percentages of population under 15 and over 65 in countries in theWestern Pacific Region

Country %<15 %>65

American Samoa 37.7 3.7Australia 20.5 12.3Brunei Darussalam 32.5 3.4Cambodia 42.8 3.5China 23.9 7.6Cook Islands 28.3 7.0Fiji 33.4 3.4French Polynesia 32.5 4.0Guam 34.9 6.0Hong Kong, China 17.2 11.2Japan 14.8 16.7Kiribati 40.0 3.5Lao People’s Democratic Republic 44.0 4.0Macao, China 22.4 8.0Malaysia na naMariana Islands 24.7 1.7Marshall Islands 42.9 2.2Micronesia, The Federated States of 40.0 3.6Mongolia 35.1 3.9Nauru 38.9 1.5New Caledonia 29.0 5.6New Zealand 23.0 11.7Niue 32.6 8.3Palau 26.8 5.2Papua New Guinea 40.2 2.4Philippines 35.6 4.1Republic of Korea 21.7 7.1Samoa 41.5 4.6Singapore 21.5 7.3Solomon Islands 41.5 3.4Tokelau 41.7 6.6Tonga 39.0 5.2Tuvalu 33.7 6.6Vanuatu 43.2 2.8Viet Nam na naWallis and Futuna 34.8 5.4

Source: http://www.wpro.who.int/chips

Western Pacific Region have aged is summa-rized in Table 2 which shows the percentageof people aged over 65 and the percentageaged under 15. In general, the developedcountries in the Region have higher propor-tions of older people and fewer youngerpeople. However, even those countries witha young population structure will age in theyears ahead.

Population ageing presents a range ofchallenges to governments throughout theworld. It is projected to create economicproblems as the taxation base shrinks andthe support needs of an older populationincrease. The challenge for all countries isto develop health strategies that result inolder people remaining healthier for longer.Success will not only contain the costs ofhealth care but will improve the quality oflife of an increasing proportion of the popu-lation.

The challenge of an ageing populationis particularly pressing in developing coun-tries. Elderly populations are rapidly increas-ing in the developing world – at a much fasterrate than has occurred in the developedworld. For example, the older population ofFrance took 115 years to double from 7% to14%. It will take China just 27 years toachieve the same increase. 4 When the olderpopulation increases at such a rapid rate, thechallenges in making the necessary adjust-ments are great indeed. Perhaps even moreimportantly, developing countries must makethese adjustments before they have becomeaffluent. While developed countries may beable to accommodate gradual populationageing and the resulting income, housingand health expenditures, many developingcountries must adjust to rapid ageing withvery limited economic resources.5

In addition to the speed at which devel-oping countries in the Western Pacific Re-gion are projected to age and the limited

3 Men, ageing and health: achieving health across the lifespan. Geneva, World Health Organization, 2001.

4 Active ageing: a policy framework. Geneva, World HealthOrganization, 2002.

5 Kalache A., Keller I. The greying world: a challenge forthe 21st century. Science progress, 2000, 83(1): 33-54.

Ageing and Health 5

economic resources for responding to thistransition, other changes in the developingcountries in the Region add to the challengeof ensuring adequate health for this olderpopulation. Among these changes are:n Rapid urbanization, which means that

many younger people are migrating tocities and older people are remaining inrural areas. Where older people remainin rural areas they may have to managewithout adequate kin support. Whereolder people move to cities with theirchildren they lose the support providedby their local networks.

n The HIV/AIDS epidemic, which willmean that many older people will loseyounger family members on which theywould have relied on in later life.

n Changes in family structures and roles,which mean that the family will be un-able to provide the degree of support forolder people that it once did. Apart fromhigh levels of migration, the trend tosmaller families and more women in thepaid workforce means that there will befewer family members to provide for thehealth care of older people.While traditional systems in which fami-

lies are the foundation of care for olderpeople are being weakened by the forces ofmodernization, poverty and economic con-straints at the government level mean thatthere is no strong safety net to compensatefor the weakening role of families.

Modernization has not only weakenedthe traditional support systems on whicholder people relied, it has also led to lifestyleand environmental changes that have re-sulted in different types of health needs.While the health policies of many develop-ing countries have for many years focusedon controlling communicable diseases, such

as malaria, countries are now facing a changein the type of health problems experiencedby an older population in an urbanizingworld. Because of lifestyle changes, povertyand environmental changes, many of thediseases and disabilities of older people arenow chronic diseases. These diseases take along time to develop and become disablingbut also have lasting effects if not managedproperly.

As the population ages these noncom-municable lifestyle-related and environment-based diseases become an increasinglyimportant component of the health needs ofthe population. Accordingly, health policiesmust shift to accommodate such health con-cerns. n

Key points1. Economic transformations and the

demographic ageing in the developingnations of the Western Pacific Region willlead to an increasing burden of noncom-municable disease and disability.

2. Health services and policies will need tobe oriented towards meeting the epi-demic in noncommunicable diseases.

3. Urban migration, HIV/AIDS and changesin family structures have dislocatedkinship networks and reduced thecapacity of relatives to provide for theneeds of older family members.

4. Accordingly, the health care needs ofolder people cannot always be adequatelymet by other family members.

5. Strategies to meet the health needs ofolder people must recognize the limitedresources of governments to provide ahealth and welfare safety net for theirelderly.

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Ageing and Health 7

To promote healthy ageing it is important tobe clear about what is meant by the term‘ageing’.

Chronological ageand health ageAge normally refers to chronological age -the number of years a person has been alive.In health research however, chronologicalage is a misleading measure of a person’shealth age. When considering ways of pro-moting healthy ageing, it is important toavoid the stereotype that older people aretypically ill and frail. While many diseasesand disabilities are more common amongolder people, it is also true that:n People of the same age vary greatly in

terms of their health. While some 70-year-olds have many diseases and dis-abilities, many remain healthy.

n While some senses such as hearing andsight deteriorate with age, the rate andextent to which they do so varies widely.We cannot conclude anything about aperson’s health simply by knowing howold they are.

n While some physical changes and healthproblems are more common at someages than others, this does not mean thatthe majority of people in a particular agegroup suffer from any particular condi-tion.

n Ill-health is not an inevitable conse-quence of reaching any particular age.When considering health promotion and

interventions to encourage healthy ageing,older people must not be treated as thoughthey are a uniform group. Like any other age

group, the older population is diverse. Itincludes those who are often called the‘young old’ and the ‘old old’; those who arehealthy and those who are frail; those fromadvantaged backgrounds and those living inpoverty; those who live alone and those withclose family connections. Also, the ageingexperience of older women is different fromthat of older men.6 Because of this diversity,health promotion should be specific, sincethe effectiveness of different forms of healthpromotion will depend on which group ofolder people are being targeted.7

Not only are older people a diverse popu-lation, they also have an assorted range ofhealth needs. The reasons for this diversityin health profiles among older people in-clude:

Genetic characteristics: Some diseaseshave a genetic component, which means thatthey tend to run in families or are found moreamong some races and ethnic groups thanothers. For example, there are clear geneticpredispositions towards contracting someforms of cancer, arthritis, heart disease andsome eye conditions.

Gender: Some conditions and diseasesare more characteristic of women than menor vice versa. Some gender differences willbe due to biological differences (e.g. breastcancer), while some may be linked with thedifferent lifestyles of men and women (e.g.higher male rates of tobacco use). Genderalso makes a difference to the extent to which

What Is Ageing?

6 Arber S., Ginn J. Gender and later life . London, Sage,1992.

7 Victor C., Howse K. Promoting the health of older people.London, Health Education Authority, 2000.

8 Ageing and Health

Table 3: Total fertility rates and life expectancy in the Western Pacific Region( in order of life expectancy).

Life Future lifeTotal expectancy expectancy

Country fertility (at birth) at age 60 Populationrate (‘000s)

Male Female Male Female

Japan 1.3 77.9 84.0 17.6 21.4 126 686Hong Kong 1.0 77.2 82.4 na na 6797Australia 1.8 76.2 81.8 17.0 19.5 19 157Singapore 1.5 75.6 79.6 14.5 16.2 4018Guam 3.9 75.4 80.2 na na 155Macao, China 1.2 75.0 80.0 na na 438New Zealand 2.0 74.1 79.7 16.7 18.8 3862Mariana Islands 2.0 72.7 79.0 na na 69American Samoa 4.5 72.0 na na 64Republic of Korea 1.4 71.0 78.6 11.1 12.1 47 275Malaysia 3.1 70.2 75.0 10.6 12.7 23 260Niue 3.0 70.0 na na 2Tonga 3.3 70.0 71.0 11.6 13.6 100Brunei Darussalam 2.7 70.0 76.0 13.3 15.1 331New Caledonia 2.5 69.8 75.8 na na 208China 1.4 68.7 73.0 11.8 14.3 1 259 000Cook Islands 2.6 68.4 71.5 11.4 13.0 19French Polynesia 2.6 68.2 75.4 na na 228Tokelau 4.8 68.0 70.0 na na 2Wallis and Fortuna 4.4 66.7 70.8 na na 14Philippines 3.3 66.6 71.9 11.5 13.6 77 926Micronesia, Federated

States of 4.4 66.6 67.7 11.0 12.0 107Marshall Islands 5.7 65.7 69.4 10.4 12.3 51Fiji3.3 65.5 68.7 11.2 12.7 825Samoa 4.5 65.4 71.9 12.3 12.7 169Solomon Islands 5.4 65.0 11.2 12.4 409Vanuatu 4.4 65.0 69.0 10.9 11.7 200Viet Nam 2.3 65.0 70.0 11.4 12.3 77 686Palau 2.6 64.5 70.8 na na 19Tuvalu 3.2 64.0 70.0 9.9 11.6 10Mongolia 2.3 62.6 67.6 10.8 12.7 2446Kiribati 4.5 58.5 64.7 10.7 11.4 85Papua New Guinea 4.8 54.6 53.5 9.2 10.5 5104Cambodia 5.3 54.4 58.3 9.0 10.1 11 440Nauru 3.7 54.4 68.2 7.9 10.5 12Lao People’s Democratic

Republic 5.6 52.0 54.0 9.6 10.6 4582

Source: WHO, Western Pacific Region Country Health Profiles http://www.wpro.who.int/info_source.aspSource for life expectancy at age 60: World health report 2000. Geneva, World Health Organiza-tion, 2000

individuals have access to resources, includ-ing money and good nutrition (see below fora fuller discussion of gender). Appendix Breports the prevalence rates and age of on-set of a range of different later-life diseasesfor men and women.

8 Brown G. W., Harris T. The social origins of depression.London, Tavistock, 1978.

9 Burchell B. The effects of labour market position, jobinsecurity, and unemployment on psychological health.In: Gallie D. et al. Social change and the experience of un-employment. Oxford, Oxford University Press, 1994: 188–212.

10 Wilkinson R.G. Unhealthy societies: the afflictions ofinequality. London, Routledge, 1996.

11 Blane D. Disease etiology and materialist explanationsof socioeconomic mortality differentials. European jour-nal of public health, 1997, 7: 385–391.

12 Van Doorslaer E. et al. Income-related inequalities inhealth: some international comparisons. Journal of healtheconomics, 1997, 16: 93–112.

13 Wilkinson R., Marmot M., Eds. Social determinants ofhealth - The solid facts. Geneva, World Health Organiza-tion, 1998.

14 Kim, J.Y. et al., Eds. Dying for growth: global inequalityand the health of the poor, Common Courage Press, 1999.

15 Bosma H. et al. Low job control and risk of coronaryheart disease in Whitehall II (prospective cohort) study.British medical journal, 1997, 314: 558–565.

Social class: The better off people arefinancially the better their health and thelonger they will live. 8 9 10 11 12 13 14 Thislink between health and social class is be-cause of class differences in:n lifestyle;n exposure to risk factors (especially work-

related factors that lead to ill-health atall ages)15 ;

n financial resources that allow health-pro-moting types of behaviour (e.g. diet, pur-chase of medicines, health care support);

n quality of housing.Poverty: As well as being linked with so-

cial class, poverty is also associated with thecountry in which a person lives. In the de-veloping countries of the Western PacificRegion high levels of poverty are associatedwith poorer health and early ageing. A 50-year-old in a poor country who has lived alife in poverty and in harsh circumstanceswill appear to be much older than their 50-year-old counterpart in an affluent country.The figures in Appendix B show that formany diseases the average age of onset isearlier in developing regions than in the es-tablished market economies.

Culture: Cultural differences mean thatpeople of the same age have different healthprofiles in different countries. Cultural prac-

Ageing and Health 9

that these diseases are either a natural oran inevitable part of ageing. Diseases anddisabilities are linked to getting older forone of three reasons.

Intrinsic ageing: This occurs when healthdecline occurs as a natural and inevitablepart of ageing. Scientists debate about ex-actly what conditions are due to natural, bio-logical components of growing older. Asresearch advances, we are learning that moreand more of the health conditions we oncethought were part and parcel of growingolder are due to disease and can, in prin-ciple, be prevented.16

Extrinsic ageing: Health decline amongolder people is often not caused by age it-self. Many diseases are concentrated amongolder people because they reflect the cumu-lative effect of a lifetime’s exposure to thefactors that cause the disease. For example,it is estimated that, although the rate of can-cer is directly linked with age, approximately70% of cancer cases are due to the cumula-

tices include diet, beliefs about health andeffective methods of care, lifestyle (includ-ing patterns of smoking, alcohol consump-tion and drug use) and the roles of men andwomen. These cultural differences lead todifferent types of behaviour, which meansthat the disease pattern of older people inone culture can be very different from thatin another culture.

Environment: Some older people live inhealthier environments than others. Bettersanitation, access to safe drinking water,clean air and warm housing will mean that,despite belonging to a similar age group,older people have very different health pro-files.

Is disease and ill-health anatural part of ageing?Many of the disabilities and diseases sufferedby older people are not a natural part ofgrowing older. It is true that some diseasesare far more common among older peoplethan among younger people and that the riskof developing these diseases and disabilitiesincreases as people grow older (see figuresin Appendix B). However, this does not mean

16 Williams T.F. Current status of biomedical andbehavioural research in aging. In: Hogness J. Health carefor an aging society. New York, Churchill Livingstone, 1989:123-137.

ActionsDirected towards decision-makers1. Encourage policy-makers and

programme developers to avoid assum-ing that all people of a given age areequally healthy or unhealthy.

2. Educate decision-makers to avoid simplyrelying on age-based criteria for screen-ing, health promotion targeting orprogramme eligibility.

3. Promote interventions that are targeteddifferently for particular groups of olderpeople.

Key points1. The older population is diverse2. Health promotion strategies, therefore,

also need to be diverse to cater for thisdiverse population

ActionDirected towards decision-makersAdvocate for research that identifies:n which diseases of later life are preventable;n the point of the life course at which

interventions are most likely to have thegreatest benefit and have the greatestchance of being adopted.

Key Points1. Age itself is not a good guide to a

person’s state of health.2. The older population is a diverse

population.3. Health promotion interventions need to

be shaped by this diversity rather than besimply directed to ‘the elderly’.

4. Disease and disability is not an inevitablepart of ageing

10 Ageing and Health

tive effect of exposure to environmental car-cinogens.17

The combination of intrinsic and extrin-sic factors: Health decline in later life can bedue to the combined effect of intrinsic andextrinsic causes. Natural decline can be ac-celerated by the cumulative effects of lifestyleand environmental factors over a lifetime.For example, the decline in heart and lungefficiency over a lifetime may be due partlyto natural decline in muscles and cells overtime as well as to the accumulated effects ofsmoking.

For practical purposes the most impor-tant thing is not whether a disease is causedby intrinsic or extrinsic ageing but whethera health condition is preventable, or at leasttreatable. Health promotion and disease pre-vention programmes can only be directed atpreventable conditions. It is the role of re-search scientists to discover the causes ofdiseases and whether or not they can betreated or prevented. n

17 Health of the elderly. Geneva, World Health Organiza-tion, 1989

Ageing and Health 11

Defining healthThe World Health Organization defineshealth as:

“a state of complete physical, mentaland social well-being and not merelythe absence of disease or infirmity” 18

This definition has three importanthealth promotion implications:

Health is more than physical health. Thethree components of health – physical, men-tal and social – cannot usefully be separatedfrom each other. Physical well-being affectspsychological health. Psychological health af-fects physical well-being, as the research onsomatic disorders demonstrates. Social well-being (e.g. social integration, friendships, val-ued roles, etc.) has a preventative effect onboth physical and psychological ill-health.

The emphasis on well-being rather thanjust the ‘absence of disease or infirmity’ em-phases the qualitative dimension of health.This means that any strategy for healthy age-ing should aim to improve on the quality oflife, not just the quantity – it should aim toextend ‘health expectancy’ rather than just‘life expectancy’ (see pages 25, 59). Friesargued that, as we approach the biologicallimits of extending life expectancy, the roleof health polices will be the ‘compression ofmorbidity’ – reducing the period when indi-viduals suffer from disease or infirmity be-fore death.19 This distinction between lifeexpectancy and health expectancy is criticalin framing any health strategy. Any strategymust to be clear about its primary goal – is itlife expectancy or health expectancy?

Good health has a subjective dimension.Well-being has no fixed meaning. The mean-ing of well-being will vary between cultures,social classes and individuals. This means

18 Preamble to the Constitution of the World Health Orga-nization. Official records of the World Health Organiza-tion, no. 2: 100. Geneva, World Health Organization, 1946.

19 Fries J. Aging, natural death and the compression ofmorbidity. New England journal of medicine, 1980, 303:130-135.

What is Health?

ActionsDirected towards decision-makers1. Advocate health interventions that extend

beyond the treatment and prevention ofphysical disease and disability.

2. Advocate for interventions that protectthe quality of life and do not just extendlife expectancy.

3. Develop health interventions thatpromote a person’s subjective sense ofwell-being. This will involve knowingwhat a person’s health goals are.

Key PointAvoid sharp distinctions between physical,mental and social health. These threedimensions of health affect each other. Thisimplies a more holistic approach to healthpromotion and disease prevention thanclinical interventions imply. It means thatphysical health problems might be effec-tively tackled by addressing mental or socialhealth matters rather than by a directmedical intervention.


that health interventions should take ac-count of the health goals of the people be-ing targeted. Not only will this lead to bettertargeting of well-being, but it will also pro-duce a better fit between interventions andindividual motivations.

Physical healthIt is useful to make a number of distinctionsregarding physical health.

Communicable andnoncommunicable diseasesIn the past, infectious diseases have been themain health problem in developing coun-tries. Public health programmes, such asimmunization, safe water and better sanita-tion projects, have been successful in con-taining many of these communicablediseases. The challenge of addressing suchinfectious as HIV/AIDS and malaria remains,but the disease burden of the future will bethe noncommunicable diseases that stemfrom the accumulated effects of lifestyle anddeterioration associated with ageing.

The trend from communicable to non-communicable disease has been called an‘epidemiological revolution’. The promi-nence of noncommunicable disease is partlydue to the success in reducing infectious dis-

eases. However, it is also due to populationageing and the lifestyle changes that haveaccompanied globalization, industrializationand urbanization.

Population ageing will require that heathsystems be reoriented towards the differenthealth needs of ageing populations. An agedpopulation has far more chronic or long-termdisease, more people with long-term disabili-ties, and more noncommunicable diseasethan infectious disease. Figure 2 illustrateshow projected ageing will change the bal-ance of the types of disease in the develop-ing world.

Lifestyle, disease and disabilityAmong the noncommunicable health prob-lems, the distinction between disease anddisability is important. This distinction re-flects the difference between the lifestyle-related diseases that reflect extrinsic ageingand the disabilities and infirmities associatedwith intrinsic ageing (see page 13). Somechanges are the inevitable result of growingolder. Hormonal changes in women, changesin the rate at which cells divide and repro-duce and other cellular changes are examplesof normal ageing which can affect health.

Diseases such as diabetes, heart disease,osteoporosis and stoke afflict only some olderpeople and are much more common amongthose with an unhealthy lifestyle that hasaccompanied modernization and urbaniza-tion. The main lifestyle elements that havebeen shown to contribute to many later lifediseases are:n poor nutrition and diet;n being overweight;n getting too little exercise;n tobacco use; andn high alcohol consumption.

These lifestyle characteristics are particu-larly damaging for health because they havemultiple health consequences. For example,poor diet is implicated in diabetes, heart dis-ease, osteoporosis, stokes, high blood pres-sure, etc. Tobacco is linked to almost all thediseases of later life. The good news is thatthis means that, if lifestyle behaviour can bechanged, it will lead to a whole range ofhealth improvements at one time.

Figure 2: Burden of disease 1990-2020


Disability, health and contextSimply having a disorder does not mean thatthe disorder or disease will be disabling. Tosome extent, the degree to which a disorderbecomes disabling depends on the contextin which a person must live with the disor-der. That is, the environment, rather than theparticular condition from which a person suf-fers, may be disabling. For example, a personwho has become unsteady on their feet willbe less or more disabled depending on theextent to which their environment turns thecondition into a disability. Steep paths, un-even surfaces and the absence of handrailswill all make it much more difficult for sucha person to get around and remain relativelyindependent. This means that the best wayof responding to some health problems is notto directly treat the physical problem (it maynot be treatable), but to treat the environ-ment in which a person lives. In this way thehealth problem need not become so dis-

abling. The way of helping with some healthproblems is to adapt the environment.

Common physical healthproblems among older peopleThe health problems encountered among theageing populations within the Western Pa-cific Region vary somewhat between coun-tries. Furthermore, the age at whichage-related health problems develop variesconsiderably both within and between coun-tries – this is especially so with those dis-eases closely related to lifestyle (see page 11)and poverty. Nevertheless, it is useful to notethe ‘typical’ health problems that emerge atdifferent ages. Table 4 lists the main physi-cal disorders. These are discussed more fullyin the section on common health problems(see page 11) and the details about preva-lence, age of onset and duration are providedin Appendix B.

Key Points1. The health burden of the future will be from noncommunicable

diseases and disorders.2. The noncommunicable diseases of later life reflect the cumulative

effect of lifestyle and environmental influences over many years.3. The environment contributes to the extent to which a disease or

disorder becomes disabling. This means that part of the way ofresponding to noncommunicable diseases and disorders is to modifythe environment.

ActionsDirected towards decision-makers1. Urge interventions that minimize the extent to which health

conditions in later life become disabling. These interventions mustmodify the environments in which older people live so that theirdisorders do not become incapacitating.

2. Advocate research that identifies the lifestyle factors that contributeto later-life diseases.

Directed towards individuals1. Increase understanding among younger people of the long-term

effects of their lifestyle2. Increase understanding among older people regarding the way in

which current lifestyle change can still reduce their risk of diseaseand disability or minimize the effects of current disordersTable 4: Common physical disorders among

older people

Class of healthproblem Specific type

Heart disease and Congestive heartstroke disease

Hypertension (highblood pressure)

Coronary vasculardisease (CVD)

Cancers BreastBowelCervical and relatedProstateLung

Musculoskeletal General damageOsteoarthritisOsteoporosis

Sensory CataractsGlaucomaMacular degenerationHearing lossParkinson’s disease

Other DiabetesUrinary incontinenceChronic obstructive

pulmonary disease


Mental health and cognitivefunctioningThe distinction between mental and physi-cal health can be somewhat artificial. Manymental disorders have a physical component.For example, depression has a neurologicalcomponent. Dementia, as far as it is under-stood, is primarily an organic impairment,although it has mental and cognitive effects.Conditions such as anxiety and alcohol de-pendence both include important physiologi-cal elements. Many physical diseases lead topsychological disorders. For example, heartdisease, stroke, diabetes, cancer, thyroid andendocrine problems are frequently associatedwith depression in older adults.

The main mental and cognitive function-ing problems (see page 29 for more details)among the elderly are:n dementia;n depression;n alcohol dependence; andn suicide.

Social healthSocial health is an aspect of health that in-cludes social relationships as part of thebroader concept of health.20 It has two ele-ments: individual and societal.

At the individual level social healthrefers to the way in which individuals inter-act with the wider society. This form of so-cial health includes:n social participation;n avoiding marginalization;n a sense of worth;n feelings of belonging;n a sense of control and empowerment

over one’s life;n avoiding undue dependence on others;n being treated with dignity.

Social health, in this sense, has implica-tions for both physical and mental health.The less isolated, the greater the sense ofcontrol and empowerment, and the moresocially integrated a person is, the less theysuffer from a range of physical and mentaldisorders.21 22 23 This means that one wayin which some physical and mental disor-

ders can be prevented is by improving aperson’s social well-being.

At the societal level social health re-fers to broad social characteristics such as:n low levels of social conflict;n minimal poverty;n social cohesion;n minimal crime;n tolerance of difference; andn levels of social capital (trust, social in-

teraction and social connections).Social health is an important component

of individual physical and mental health.The role of social health and a positive so-cial environment is an important compo-nent of the health promotion strategiesadopted by WHO.

The Regional framework for health pro-motion in the Western Pacific Region 2002-2005 stresses the role of social capital inhealth promotion.24 A focus on social capi-tal emphasizes the importance of generat-ing trust, goodwill and cooperation amongindividuals and groups as a means of mobi-lizing resources and encouraging collabora-tion between different sectors. Through thishealthier and richer social environment itis easier to create the circumstances inwhich individuals can make healthier deci-sions, and limited resources can be directedtowards the best health outcomes. Theframework document argues that:

“Social capital has been an importantfactor for improving health evenwhere economic capital is low. Thishas many implications for poverty-stricken areas in the Region where a

20 Donald C.A. et al. Conceptualization and measurementof health for adults in the health insurance study, Vol 4:Social health. Santa Monica, CA, Rand Corporation, 1978.

21 Caplan G. Support systems and community mental health.New York, Behavioral Publications, 1974.

22 Cassel J. The contribution of social environment to hostresistance. American journal of epidemiology, 1976, 104:107-23.

23 Greenblatt M.Y. et al. Social networks and mental health:an overview. American journal of psychiarty, 1982, 139:977-84.

24 Regional framework for health promotion 2002-2005.Manila, WHO Western Pacific Regional Office, 2002.


Key Points1. Mental health problems are an important,

but frequently ignored aspect of healthamong older people.

2. Social health involves people having goodsocial networks that are supportive andempowering.

3. Health is more than the absence ofdisease or simply about living longer.Healthy ageing must pay attention to thequality of life and not just the quantity.

high value is placed on interpersonalrelationships, family ties andcommunity identity. When acommunity is energized to worktoward health goals despite eco-nomic limitations, a potent socialforce is unleashed. This force shapeshealthy behaviour, attitudes andlifestyles of individuals, and the cycleof empowerment goes on.”25

Quantity vs quality of life(or mortality vs morbidity)Frequently health is equated with livinglonger. Thus the success of a health inter-vention may be measured in terms of howmuch it extends a person’s life. This is a le-gitimate measure of the success of healthinterventions and is frequently used as ameasure of national progress in achieving ahealthy society. However, the gerontologicaland health promotion literature stresses theimportance of the quality of life. While ex-tending the length of a person’s life is seenas desirable, the quality of that life is alsoseen to be a key measure of the effective-ness of any health promotion strategy.

The distinction between a focus on mor-tality (quantity) and morbidity (quality) canbe illustrated by considering the health ofmen and women in later life. In all nationsin the Western Pacific Region, women livelonger than men and by this measure arehealthier. However, women are much moreprone than men to chronic diseases and dis-abilities that affect the quality of their longer

life. Women in all Western Pacific Regioncountries live a larger percentage of theirlife with a chronic disease or disability thanmen do (see Table 3).

The effectiveness of health promotionstrategies will depend partly on the way inwhich effectiveness is measured.26 A par-ticular health promotion intervention maynot extend a person’s life but may improvethe quality of that life. Does this mean thatthe health promotion activity has failed?

The Active Ageing strategy of WHO isemphatic in its answer. 27 It identifies activeageing as the basic framework of the WHOpolicy on ageing. It defines active ageing as:

“…the process of optimizing oppor-tunities for health, participation andsecurity in order to enhancequality of life as people age.”

ActionsDirected towards decision-makers1. Increase awareness of health policy-makers and policy-makers in

non-health sectors that physical and mental health are affected bythe social environment in which a person lives.

2. Advocate for policies and actions that promote a sense of empow-erment, personal control and responsibility for health among olderpeople.

3. Advocate on behalf of older people to ensure that they are treatedwith dignity and respect.

4. Promote actions that build the stock of social capital within thecommunity.

Directed towards individuals1. Involve individuals in health promotion programmes.2. Urge individuals to take actions on their own behalf to improve

their health, both by improving their lifestyle and by advocating fora health-promoting environment.

3. Encourage social participation by older people and help them tobecome integrated into the community, and provide the opportu-nity for older people to make a meaningful contribution to the livesof others in the community.

4. Increase the health literacy of older people so that they are able totake actions for their own health.

5. Enable older people to get into the community by improvingtransport and safety in public places.

25 Ibid.26 Victor C. and Howse K.. Op cit. Ref 7.27 WHO. Op cit. Ref 4.



Physical healthHeart disease and strokeCongestive heart failure (CHF): Although CHFcurrently occurs at a lower rate in the devel-oping countries in the Western Pacific Re-gion than in developed countries, the ratesare increasing. Prevalence is much higheramong those aged over 60 than in youngerage groups and is much higher among menthan women. CHD develops as a result oflongstanding heart disease, hypertension orfollowing a heart attack. (Appendix B)

Hypertension (high blood pressure): Hy-pertension can occur at any age, but the riskincreases with age. Rates vary by gender andrace. The incidence of hypertension increasesmost sharply around the mid-forties andsteadily thereafter. Until the age of about 55males are more likely than females to sufferfrom hypertension. Thereafter, women havehigher rates than men. Among people in theirmid-fifties to mid-sixties the rates vary be-tween 40% to 60%, depending on race andgender. Among those in their mid-sixties tomid-seventies hypertension rates vary from50% to 75%, and among older people be-tween 60% to 75% suffer from hypertension.

Coronary vascular disease (CVD): Vascu-lar heart disease stems from blockage of theblood vessels taking blood to the heart. Theaccumulation of fatty deposits (plaque) thatblock the arteries can begin in the teenageyears and continues throughout life. By theages of 45 to 50, many people have devel-oped atherosclerosis (blockage of the arter-ies), which puts them at risk for coronaryheart disease. The rates of CVD increasesteadily from the mid-forties. On average,

men tend to suffer from CVD at about 10years younger than women.

Cerebrovascular disease (stroke): Al-though individuals of any age can suffer astroke, older people have a higher risk. Forevery decade after the age of 55, the risk ofstroke doubles, and two-thirds of all strokesoccur in people over 65. People over 65 areseven times more likely to die from a strokethan the general population. The rate ofstroke varies by ethnic and racial back-ground, as well as lifestyle factors, and ishigher among men aged over 60 than amongwomen aged over 60. Although stroke-re-lated mortality rates are declining in devel-oped countries, they are increasing indeveloping countries. (Appendix B)

CancerCancer deaths increased from about 6% to9% of all deaths in developing countries from1985-1997, and have remained stable ataround 21% in developed countries.28

Breast cancer: Most breast cancers occurin women aged over 50. Although detectedrates of breast cancer are much lower in thedeveloping countries in the Western PacificRegion than in developed countries (Appen-dix B), breast cancer occurs earlier in thedeveloping countries – on average at about53 years of age.

Colonic cancer: While the chances of co-lonic cancer progressively increase from age50, the average age of the onset of coloncancer in the developing countries in theWestern Pacific Region is closer to 60. Therates are much lower in the developing coun-

Common HealthProblems amongOlder People

28 WHO Op cit. Ref 3


tries in the Region than among developedcountries. Among those aged over 60, menare a little more prone to colonic and relatedcancers. (Appendix B)

Prostate cancer: Most (75%) prostatecancer is diagnosed in men aged over 65,with just 7% of cases found in men youngerthan 60. By age 75, three-quarters of mendisplay some cancerous changes, but mostof these remain latent and do not representa serious threat to health. Detected rates ofprostate cancer are much lower in the de-veloping countries of the Region than in de-veloped economies (Appendix B).

Cervical and related cancers: Cervical andrelated cancers occur at a higher rate in thedeveloping countries in the Region thanamong women in developed economies (Ap-pendix B). The average age at which womendevelop these cancers is around 55.

Lung cancer is the most common form ofcancer among men. The average age of on-set is around 62 years. Developing countriesare projected to have increasing mortalityrates. For example, China reported about152000 deaths in 1990, but expects over half amillion by 2020. 29

Musculoskeletal problemsBy later life, many older people have sufferedsome form of general damage to their bonesor joints. This may be due to injuries or theexcessive demands of physical labourthroughout life. Joint damage, especially inthe neck and back, are common problems.In addition to these general musculoskeletaldifficulties, the following specific conditionsare much more likely to occur among olderthan younger people.

Osteoarthritis is a disease that causespain and inflammation in the joints and isassociated with the breakdown of cartilagein joints. As the disease develops, movementcan become very painful and difficult. Preva-lence rates are lower in developing countriesthan in developed economies, but are rising(Appendix B). The incidence of osteoarthri-tis, the most common form of age-relatedarthritis, increases with age and most com-monly develops after the age of 45. The in-cidence increases sharply among those aged

60 and over and is more common amongwomen than men. On average, men andwomen suffer from this disease for about 12years.

Rheumatoid arthritis is a disease that re-sults in inflammation in the lining of thejoints. This inflammation can make move-ment in the affected joints both painful anddifficult. This form of arthritis increases withage and is more common among womenthan men. The average age of onset is rela-tively young in China (between 50 and 55)but about 10 years later in other developingcountries in the Region. On average, menand women suffer from this disease for aboutseven years (Appendix B)

Osteoporosis is the thinning and weak-ening of bone and results in bone fracturesresulting from slight knocks. This disease ismuch more common among women thanmen after the age of 50. One out of twowomen and one in eight men over the ageof 50 will experience an osteoporosis frac-ture.

Sensory impairmentCataract is a disease of the eye that can leadto blindness. Cataracts can develop amongpeople in their forties and fifties, but thesecataracts are usually small and do not leadto loss of sight. Cataracts that lead to visionloss usually occur after about the age of 60.Approximately 90% of people with cataractslive in developing countries and 60% of themare elderly. (Appendix B).

Glaucoma is a disease of the eye which,if untreated, can cause blindness. It is one ofthe main causes of blindness among olderpeople. Glaucoma is a much more commonproblem in the developing countries in theWestern Pacific Region than in developedeconomies and is about twice as commonamong women than men. On average, suf-ferers have glaucoma for between 9 to 12years. Its incidence increases with age, so thatabout 8% of those over the age of 70 haveglaucoma symptoms (Appendix B).

29 Murray C.J.L., Lopez A.D. Global health statistics : acompendium of incidence, prevalence, and mortality esti-mates for over 200 conditions. Boston, WHO and HarvardUniversity Press, 1990.


Macular degeneration is an eye diseasewhich damages the part of the eye that en-ables people to see straight ahead and to seefine detail. The symptoms can appear amongpeople in their forties but is more commonamong those aged 50 or over. The risk ofmacular degeneration dramatically increasesafter age 60.

Hearing loss is progressive from youngadulthood onwards. It affects the daily liv-ing of many older people, especially thoseaged over 65. About 30-35% of adults be-tween the ages of 65 and 75 years have ahearing loss and half of those aged over 85suffer significant hearing loss.

Parkinson’s disease is a disease that af-fects the part of the brain that controls move-ment. Although about 10% of sufferers areunder the age of 40, the average age of on-set in the developing countries in the West-ern Pacific Region is about 65. Rates rise withage and peak among those in their seventiesand eighties. The prevalence of Parkinson’sdisease is considerably lower in the devel-oping countries of the Region compared withthe rates in developed economies. The riskof Parkinson’s disease is similar for men andwomen (see Appendix B).

Other significant age-relateddisordersAlthough older people can suffer from dis-orders other than those described above onlythree further diseases or disorders will bementioned here.

Urinary incontinence can occur at any agebut is much more common among olderpeople – especially older women, for whomfrequent childbirth and inadequate treatmentof urinary tract infections can cause long-term damage. At least 1 in 10 people age 65or older suffers from incontinence. A signifi-cant effect of incontinence is that it can leadolder people to become socially isolated.

Diabetes mellitus (Type 2 diabetes): Ratesof diabetes are rising sharply in the WesternPacific Region, especially in many Asian andPacific Island states, where rates are verysimilar to the very high levels evident in thedeveloped economies (see Appendix B). Theprevalence of diabetes increases with age.

The rates for those over the age of 60 aremore than double those for 45-59-year-olds.The risk of this form of diabetes is much thesame for men and women. It develops, onaverage, when people are in their late fiftiesand sufferers have the disease for an aver-age of about 15 years.

Chronic obstructive pulmonary disease isa disease that affects the lungs and createsbreathing difficulties. The average onset oc-curs when people are in their early sixtiesand sufferers typically have the disease forabout eight years. Men are slightly moreprone to this disease. Rates of chronic ob-structive pulmonary disease are especiallyhigh in China (see Appendix B).

Mental healthMental health is an increasingly importanthealth problem in both the developed anddeveloping world. Levels of detected disor-ders are higher in developed countries butare, nevertheless, also high in developingcountries and appear to be increasing withurbanization and increasing substance abuse.Statistics are available in some countries/areas for the levels of mental disordersamong older people in the Western PacificRegion. Mental health is a significant healthissue in the Region.

Among the affluent countries in the Re-gion, mental and neurological disorders ac-count for 27% of the total disease burdenand 30% of the noncommunicable diseaseburden. In the Region’s developing countries,about 15% of the total disease burden and25% of the noncommunicable disease bur-den is due to mental disorders. The lowerfigures in the developing countries may bedue to lower levels of detection, but are alsodue to the higher rates of communicable dis-eases.30

Despite the levels of mental diseases anddisorders, there is a low level of awarenessof the burden of mental disease in the West-ern Pacific Region. In half of the countries inthe Western Pacific Region less than 1% ofthe health budget is spent on mental and

30World health report 2000. Geneva, World Health Orga-nization, 2000.


neurological disorders and many countriesdo not even have a mental health policy. 31

DementiaDespite being largely restricted to olderpeople, dementia is not a natural part ofageing. The two most common forms of de-mentia found among older people are:n Alzheimer’s disease (approximately 50%

of all dementias); andn Vascular dementia (approximately 20%

of all dementias).There are no reliable data on the rates

of dementia in developing countries, duepartly to the lack of culturally relevant mea-sures.32 In developed countries, Alzheimer’sdisease occurs in about 3% of adults aged65-74. Those over the age of 85 have a 25%chance of contracting Alzheimer’s disease.The best estimates of diagnosed dementiaamong older men and women in the devel-oping countries in the Western Pacific Re-gion indicate rates that are about two-thirdsthe levels in the developed countries. In thedeveloping countries dementias begin, onaverage, when people are in their early sev-enties and persist until death – about eightyears later. Rates are slightly higher amongwomen (see Appendix B).

The nature of dementia differs accord-ing to the type of dementia, but all are asso-ciated with neurological damage. Dementiasaffect memory, language, ability to commu-nicate, personality, mood and other charac-teristics on which normal social life depends.They can have major effects on the qualityof life of elderly sufferers and their carers.

The cause of Alzheimer’s damage is notfully understood, while multi-infarct demen-tia is the result of the cumulative effects of anumber of mini strokes. Since the causes ofmany dementias are not yet known, effectiveprevention strategies are not an option at thisstage. No cure is available for Alzheimer’s dis-ease (the most common form of dementia),but medication and behavioural strategies canassist with its management.

DepressionDepression is common among the elderly,although the actual levels in developing

countries are not known precisely. Obtain-ing good information on rates of depressionamong older men and women in developingcountries would require age- and culture-relevant measures of depression. However,the evidence is that depression often occurstogether with other diseases such as demen-tia, heart disease, stroke, diabetes, cancerand endocrine diseases. Apart from the dis-tress caused by depression, it can, if un-treated, worsen the effects of these otherconditions and make their treatment moredifficult.

Depression is underdiagnosed among theelderly both because of a lack of expertiseamong health practitioners and due to themistaken belief that the symptoms of depres-sion are a normal part of ageing. It has beenestimated that in developed countries ap-proximately 1%-3% of people aged over 65suffer from severe depression, with a further10% to 15% suffering milder forms.33 De-pression is often confused with the other dis-eases with which it is frequently associatedand is, therefore, left untreated. High sui-cide rates among the elderly are associatedwith high, but undiagnosed rates of depres-sion.

Alcohol dependenceAlcohol dependence is a mental health dis-order which has many physical conse-quences. High alcohol consumption isstrongly implicated in depression, strokes,high blood pressure (hypertension), urinaryincontinence, osteoporosis, coronary heartdisease, gout, oral cancer, congestive heartfailure and many other ailments.

Alcohol dependence among the elderlycan be one of two types. Some alcohol prob-lems are longstanding and by later life thisdependence has created many other physi-cal problems. Longstanding alcohol depen-dence is very difficult to treat successfully in

31 WHO. Op cit. Ref 24.

32 Bonita R. Women, ageing and health: Achieving healthacross the life span. Geneva, World Health Organization,1998.

33 Mental health: new understanding, new hope. Geneva,World Health Organization, 2001.


later life. Other alcohol problems may bemuch more recent and begin when otherdiseases create pain or depression, or follow-ing the grief and loneliness from losing apartner or close family member. Short-termalcohol abuse is more amenable to treat-ment.

SuicideThe underdiagnosed levels of depressionamong older people contribute to the rela-tively high suicide rates of older citizens. El-der suicide is normally linked to undiagnosedmental disorders and is very common insome countries.34 Suicide attempts amongolder people are better planned and moresuccessful than among younger people.35

Current research indicates that mood disor-ders (e.g. depression), a history of suicidalbehaviour, hopelessness, personality style(e.g. shy, timid, hostile, fiercely independent,or neurotic) physical disorders and func-tional impairment should be the focus ofsuicide prevention measures.36

Suicide rates increase as people growolder. For example, in China the male sui-cide rate in 1990 was 38 per 100 000 amongmen aged 45-59, but was 104 for those aged60 and over. Among other countries in theRegion the suicide rates are lower, but stillincrease with age. In the area containingmost of the developing countries in the West-ern Pacific Region, the male suicide rate of18 per 100 000 among men aged 45-59jumps to 28 for those aged 60 or over (seeAppendix B)

ActionsDirected towards decision-makers1. Advocate for the development of mental health strategies at

national, regional and local levels.2. Increase decision-makers’ awareness of the importance of mental

health problems among some older populations.3. Urge a greater proportion of health budgets to be directed towards

mental health programmes among the elderly.4. Increase the awareness and understanding of doctors, health

visitors and other health workers of the risks of depression andsuicide among older people.

5. Improve training of health workers so that there is an increasedunderstanding of the interdependence of physical, mental and socialhealth.

6. Integrate mental health provision into other health deliveryprogrammes.

7. Develop improved methods for detection of depression amongolder people and train health workers and other communityworkers to detect depression and make use of the effectivetreatments that are available.

8. Increase public understanding of mental health and dispel the stigmaattached to mental health problems.

9. Develop community-based suicide prevention programmes de-signed especially for older people and to assist families and healthworkers in understanding the risk of elder suicide and the associ-ated risk factors.

Directed towards individuals1. Increase knowledge of symptoms of depression.2. Increase understanding of risks of suicide.3. Encourage older people with symptoms of mental health problems

to seek help.

34 Conwell Y. Suicide in later life: A review and recommen-dations for prevention. Suicide & life-threatening behav-ior, 2001: 32-47.

35 Conwell Y., Brent D. Suicide and aging 1: Patterns ofpsychiatric diagnosis. International psychogeriatrics, 1995,7: 149-164.

36 Conwell Y. Management of suicidal behavior in the eld-erly. Psychiatric clinics, 1997, 20(3): 667-683.



The major health problems of older peopleare chronic, noncommunicable diseases anddisabilities. Any strategy designed to improvethe health of older people requires a firmunderstanding of the factors that contributeto the development of these diseases. Thissection outlines the broad range of factorsthat contribute to these chronic health prob-lems. Rather than focusing on just the medi-cal determinants of chronic disease anddisabilities, this section seeks to place thediseases of ageing in developing countrieswithin a broad social, cultural and economiccontext.

Figure 3 summarizes many of the fac-tors that affect health outcomes. Within theinner circle are six classes of health determi-nants. The way in which these determinantsaffect health depends on the cultural andgender context within which they operate.The effect of all these is, in turn, dependenton a person’s particular life history and stagein the life course.

Cultural determinantsA person’s health is affected by theirbehaviour and by the wider environment inwhich they live. Values, beliefs and traditionsplay a central role in the health behaviour ofolder people and in the opportunities avail-able to them to adopt healthy modes ofbehaviour. These cultural elements affect theways in which a society:n views growing older;n values older people and their contribu-

tions;n enables older people to participate in the

society;

Why Do Older peopleSuffer from ChronicDiseases and Disabilities?

n understands diseases and disabilities inlater life 37.Values and traditions also affect the ex-

tent to which families play a part in support-ing older people and the extent to whichcoresidency is acceptable to both the elderlyand their families. The health needs of a per-son who has a family nearby who can providecare and housing will be quite different fromthose where the family has moved away andthe older person is isolated and without theday-to-day support a family can provide.

The extent to which the culture sanctionshealthy and unhealthy behaviour also playsa central role in the levels of health in any

Figure 3: Determi-nants of health.

37 For example, where disabilities are thought to be aninevitable and natural part of ageing, older people andthose around them may do little to manage or avoid theseproblems.


society. For example, a culture in whichsmoking is regarded as a sign of sophistica-tion and alcohol consumption as a sign ofvirility will produce unhealthy lifestyles. Anyattempt to promote health must be framedwithin the context of these cultural beliefsand will involve challenging them.

Similarly, a culture will regard certaintypes of behaviour as appropriate or inap-propriate for particular age groups. Whereexercise and activity are seen to be inappro-priate for older people, diseases and disabili-ties related to inactivity are likely toincrease.38 To tackle inactivity among olderpeople will first involve challenging the cul-tural belief about exercise and activity amongthe elderly.

Economic and socialdeterminantsHealth also has a social context. Health andill-health are socially distributed – the higherin the social hierarchy people are, the healthierthey tend to be. The more socially disadvan-taged people are, the more likely they are tosuffer from disease and disabilities and theyounger they will die. 39 40 41 42 43 44 45

Social position affects health for twomain reasons: poverty and disempowerment.Poverty is a strong predictor of poor health:the poorer people are, the more likely theyare to suffer from ill-health – at any stage inthe life course, including later life. It has beenshown that older people in poverty have amuch lower level of functioning than thosewho are financially well off.46 Poverty hasespecially important implications for healthin later life. Poverty throughout the lifecourse has a cumulative effect, wherebymany of the impacts are especially evidentin later life. Furthermore, poverty is morecommon among older people and this meansthat the capacity of older people to deal withhealth problems is more pronounced thanamong younger age groups.

Social position also affects health be-cause it is linked with social isolation,disempowerment and a loss of control overone’s life. The less people feel in control oftheir own life and future, the less likely they

are to engage in health-promoting behaviour(see pages 37, 82).

These two factors, poverty anddisempowerment, affect health through avariety of means, some of which are dis-cussed below.

NutritionGood nutrition plays a role in disease pre-vention throughout life – including later life.Poor nutrition is implicated in a wide rangeof later-life diseases including heart disease,hypertension, diabetes, osteoporosis, stroke,incontinence and a range of different can-cers. 47 48 49 50

Poor diet is associated with social posi-tion. In general people lower on the socialladder eat less nutritious food and moreharmful food. Part of the reason for this ap-pears to be that the better, fresher and morenutritious food is often more expensive. Theeffect of poor diet compounds over a life-time and this means that the effect of social

38 Finch H. Physical activity at our age . London, HealthEducation Authority, 1997.

39 Brown G.W. and Harris T.. Op cit. Ref 8.

40 Wilkinson R.G. Op cit. Ref 10.

41 Wunch G. Socioeconomic differences in mortality: a lifecourse approach. European journal of population, 1996,12: 167–185.

42 Bartley M. et al. Health and the life course: why safetynets matter. British medical journal, 1997, 314: 1194–1196.

43 Van Doorslaer E. et al. Op cit. Ref 12.

44 Wilkinson R. and Marmot M., Eds. Op cit. Ref 13.

45 Bloom D., Canning D. The health and wealth of nations.London, Department for International Development /World Health Organization, 1999.

46 Gunatilake G. Poverty and health in developing coun-tries: and the potential role of technical cooperation amongdeveloping countries (TCDC) for the poverty alleviationand health development. Geneva, World Health Organi-zation, 1995.

47 World Health Organization. Diet, nutrition, and the pre-vention of chronic diseases. Geneva, WHO, 1990.

48 Blane D. Op cit. Ref 11.

49 World Cancer Fund. Food, nutrition and the preventionof cancer: a global perspective. Washington, DC, AmericanInstitute for Cancer Research, 1997.

50 World Health Organization and Tufts University Schoolof Nutrition and Policy. Keep fit for life: meeting the nutri-tional needs of older persons. Geneva, WHO, 2002.


position on health will be especially markedin later life.

Affordability and access to healthcareAnother factor associated with good healthis the ability to purchase good health careonce illness strikes. Access to good doctorsand ability to afford medicines and treat-ments affect recovery rates, the duration ofillnesses and mortality. Where surgery is re-quired or health appliances would help (e.g.hearing aid), money is essential. Thewealthier members of any society are moreable to take advantage of medical advancesto manage diseases.

Housing and neighbourhoodenvironmentHousing quality is also related to health inlater life.51 Poor heating, dampness and poorsanitation will aggravate diseases and dis-abilities and make recovery more difficult.Inappropriate housing increases the risk offalls, reduces mobility and can make it moredifficult for a person to get out into the com-munity. The capacity to obtain suitable hous-ing or to modify a house to the needs of anolder person is linked to financial resources.

The location of housing is also impor-tant. Housing near industrial areas with dan-gerous pollutants, in poorly drained areas,or subject to high noise levels will have anongoing and cumulative effect on health.Living in an unsafe neighbourhood can makean elderly person anxious and reluctant toget out into the community or to exercise.In addition, neighbourhoods that are not el-der-friendly because of poor lighting, steep-ness, lack of footpaths, steps and poortransport will make it difficult for olderpeople to participate in the community andbenefit from a sense of belonging. The so-cial isolation and lack of sense of control thatcan stem from a neighbourhood that is notelder-friendly will result in poorer health out-comes (see page 37).

Given the importance of families in mostdeveloping countries, it is important thatsuitable housing is available near familymembers and friends. Where family mem-

bers have migrated to cities, the isolationof older people in rural areas is an increas-ing problem that has negative health con-sequences. Providing housing options closeto families or supportive friends can helpalleviate the social isolation to which someolder people can be prone.

StressStress and anxiety are an important sourceof ill-health.52 Stress releases adrenalinwhich is a biological response to help dealwith fear. The effects of stress are cumula-tive. The hormones released under stressaffect the heart and the immune system,which, if they are continually subject to thesehormones, can be more vulnerable to dis-ease. While helpful in the short term, con-tinual stress and anxiety can lead to medicaldisorders such as depression, high bloodpressure, heart disease, a weakened immunesystem and stroke.

Social factors can contribute to stress andanxiety. Financial insecurity can contributeto stress, as can concerns about future health.Where older people are financially or sociallyvulnerable and their health and financialfuture are uncertain, the resulting stress canincrease susceptibility to disease. For manyolder people, the damage of stress occursearlier in life but reveals itself in the diseasesof later life.

In the developing world, the rapid ratesof urbanization and poor conditions in manyof the rapidly expanding urban areas is likelyto have had a negative impact on mental,physical and social health. In the WesternPacific Region, the level of urbanization hasincreased from 17% living in urban areas in1950 to 37% in 1995, and this is expectedto rise to more than 50% by 2015.53 Over-crowding, pollution, poverty, dependence onan uncertain cash economy, high levels ofviolence and the disruption of social support

51 Regneir V., Pynoos J. Housing the aged. New York,Elsevier, 1987.

52 Marmot M.G. Does stress cause heart attacks? Post-graduate medical journal, 1986, 62: 683–686.



networks will add to stress and affect men-tal and physical health.54

Migration to cities has also had negativeeffects on mental, physical and social healthfor those remaining in rural areas. Not onlyare older people in rural areas more isolated,there is also typically very little by way ofmental health services in rural areas. Onerecent study reported that, in Hunan prov-ince in rural China, the suicide rate was 88.3per 100 000 compared to 24.4 per 100 000in urban areas.55 Other studies have reportedmuch higher rates of depression amongwomen in rural areas than in the populationat large. 56

Mental health disorders are associatedwith living conditions and with poverty. Pov-erty, low education and unemployment allincrease the chance of suffering from a men-tal disorder. In turn, these disorders worsena person’s economic and social resources,which in turn makes it more difficult to main-tain good health or recover from illness.

Social isolation and exclusionSocial networks, family and friendships area protective factor against ill-health. 57 58 59

60 61 62 People who are socially isolated andmarginalized are more susceptible to a rangeof diseases and are at greater risk of depres-sion and suicide. Lack of social support alsomakes it more difficult to deal with and re-cover from ill-health.

Feeling valued is also an important pro-tective factor against ill-health.63 64 In somesocieties, older people are marginalized.Rapid change has meant that their skills areless valued and retirement may mean thatthey are no longer economically productive.Where ageing is regarded as something toavoid and where older people feel unwantedrather than valued, they are more likely tosuffer ill-health. Where ageing is also asso-ciated with loss of control, dependence anda sense of powerlessness it is associated withill-health.65 66

Education and illiteracyIlliteracy can be a powerful barrier exclud-ing older people from active participation ina modernizing society. Illiteracy can create a

sense of powerlessness and loss of self es-teem in a rapidly changing society where tra-ditional skills and knowledge are devalued.By encouraging literacy, the opportunities towork and participate in the society are in-creased and this in turn can improve aperson’s economic circumstances and socialwell-being. This can encourage indepen-dence as people grow older and enable olderpeople to actively participate in better healthbehaviour.

WorkAlthough many older people may no longerbe working, their health can show the accu-mulated effects of a lifetime of work. Olderpeople who have worked in jobs that havebeen physically demanding, unsafe or in-volved exposure to harmful products anddamaging work practices will show the ac-cumulated effects more than those who havehad a more advantaged employment.

54 Desjarlais R. et al. World mental health: problems andpriorities in low-income countries. New York, Oxford Uni-versity Press, 1995.

55 Xu et al, 2000


57 House J.S. et al. Social relationships and health. Sci-ence, 1988, 241: 540-545.

58 Chappell N.L. The role of family and friends in qualityof life. In: Birren E., Ed. The concept and measurement ofquality of life in the frail elderly. New York, Academic Press,1991.


60 Van Doorslaer E. et al. Op cit. Ref 12.

61 Martire L.M. et al. Stability and change in older adults’social contact and social support: the CardiovascularHealth Study. Journals of gerontology: Series B: Psychologi-cal and social sciences, 1999, 54B: S302-S311.

62 Lubben J.E., Gironda M.W. Social support networks.In:Brummel-Smith K. Comprehensive geriatric assessment: aguide for healthcare providers. New York, McGraw-Hill,2000.


64 Wilkinson R. and Marmot M, eds. Op cit. Ref 13.

65 Wallerstein, N. Powerlessness, empowerment andhealth: implications for health promotion programmes.American journal of health promotion, 1992 6(3): 197-205.

66 Marmot M.G. et al. Contribution of job control and otherrisk factors to social variations in coronary heart disease.Lancet, 1997, 350: 235–239.


Employment that provides little say indecisions and little control over the way workis done is associated with greater depression,more back pain and heart disease.67 Em-ployment requiring constant use of fine mo-tor movements is associated with arthritis inlater life.

Physical environmentdeterminantsPhysical environment plays an importantpart in health. While the physical environ-ment in which older people live cannot beseparated from their social and economicenvironment, it is nevertheless worth high-lighting two key aspects of the physical en-vironment that have an impact on health inlater life.

Neighbourhood safety: Where environ-mental hazards, such as dangerous roads,unsafe footpaths, difficult steps, poor light-ing, etc, make it difficult for older people toget out of their homes, the risks of ill-healthfrom social isolation and lack of exercise in-crease.

Environmental pollution: Air, noise andwater pollution are three important elementsof the physical environment that affecthealth. Air and noise pollution are especiallyimportant in the development of noncom-municable diseases that emerge in later life.Hearing problems and lung disease (e.g.chronic obstructive pulmonary disease) thatemerge in later life are the result of a life-time of exposure to damaging environmen-tal factors.

The roles of these aspects of the physi-cal environment are becoming increasinglyimportant determinants of health in theWestern Pacific Region as the level of urban-ization increases rapidly (see pages 7, 37,70, 78). Urban violence and crime have alsoincreased significantly. 68

Health systems and services asdeterminantsThe nature of health services in any countryand region will affect the level of noncom-municable disease. Where diseases are pre-

ventable, the extent to which health systemsadopt a preventative or a curative approachto health will affect the levels of these dis-eases in later life. Many, but not all non-communicable diseases of later life caneither be prevented, delayed or made lessdisabling if steps are taken earlier in the lifecourse to ensure healthy behaviour and ahealth-promoting environment. However,the ‘find it and fix it’ emphasis in manyhealth systems means that insufficient at-tention is given to preventing disease anddisability in the first place.

Health systems that are not integratedwith other sectors will tend to focus on the‘find it and fix it’ approach of curative medi-67 Ibid.


Key points1. Health is affected by a person’s social and economic environment.2. Social inequality and poverty are key aspects of the social and

economic environment that lead to poor health outcomes in laterlife.

3. Social and economic inequality lead to poor health outcomesbecause they are linked to factors such as social isolation, a sense ofdisempowerment, high levels of stress, poor housing and poornutrition.

4. To improve the health of older people it is important to change thesocial and economic environment that contributes to the ill-healthof those most affected by poverty.

ActionsDirected towards decision-makers1. Advocate at the local, regional and national levels for regulations to

reduce air, water and noise pollution.2. Urge initiatives at the local level to develop safe, barrier-free public

spaces where older people can go easily for both exercise andsocial interaction. Improving footpaths, installing rails on steps,making lifts available, having traffic lights that take account of poorsight or hearing, and providing good lighting will make public placessafer for older people.

Directed towards individuals1. Increase awareness of the ways in which the worst effects of noise,

air and water pollution can be controlled.2. Provide individuals with tips as to how to move about the local

neighbourhood with the least risk of falls etc.


cine. A health-promotion approach will en-courage the cooperation of the health sectorwith other sectors. Thus a health-promotionmodel of health services encourages othersectors such as agriculture, transport, edu-cation, industry, housing, etc., to developpolicies that encourage better health (seepages 67, 82).

As well as focusing on curative medicine,most health systems concentrate on physi-cal health and neglect mental health.69 Inthe countries of the Western Pacific Region,although mental disorders account for about15% of the total disease burden, less than1% of the health budget is spent on mentalhealth.

Behavioural determinantsWhile the context in which people live is cru-cial to health in later life, the way in which

Table 5: Lifestyle and noncommunicable diseases

Behaviour Associated with:

Smoking Lung disease; lung cancer; diabetes;cataract; congestive heart failure;coronary heart disease; high bloodpressure; vascular dementia; stroke;emphysema; chronic obstructivepulmonary disease.

Diet Overweight; heart disease; congestiveheart failure; coronary heart disease;diabetes; high blood pressure;osteoporosis; stroke.

Obesity Heart disease; stroke and the mini-strokes involved in vascular demen-tia; diabetes; high blood pressure;arthritis – especially in the knees;foot problems; breast cancer; highblood pressure; osteoarthritis; stroke.

Insufficient exercise Obesity; reduced emotional well-beingand failure to relieve stress; poorblood circulation; reduced energy;poor sleeping; osteoporosis;osteoarthritis; increased bloodpressure, coronary heart disease;reduced flexibility; poorer balance,poorer bone density and strength;diabetes; stroke.

Excess alcohol consumption Liver disease; stomach ulcers; gout;depression; osteoporosis; heartdisease; breast cancer; diabetes; highblood pressure.

individuals live within that context also af-fects their health. The Active Ageing frame-work of WHO highlights the role of healthylifestyles in healthy ageing. It states:

“The adoption of healthy lifestylesand actively participating in one’sown care are important at all stagesof the life course. One of the mythsof ageing is that it is too late toadopt such lifestyles in the lateryears. On the contrary, engaging inappropriate physical activity, healthyeating, not smoking and usingalcohol and medications wisely inolder age can prevent disease andfunctional decline, extend longevityand enhance one’s quality of life.”70

Table 5 summarizes the main noncom-municable diseases of later life associatedwith each lifestyle behaviour.

Whether or not people engage in healthyor unhealthy behaviour involves individualchoice. Individuals, therefore, need to beencouraged to make choices that will havepositive health outcomes. However, encour-aging health-promoting choices is no simplematter. Essentially it involves a twofold ap-proach that targets both individuals and thesocial and cultural environment in whichthey make their decisions (see Figure 4).

At the individual level two things arerequired:n knowledge about the health conse-

quences of behaviour; andn motivation to adopt health-promoting

behaviour (see page 78).At the social and cultural level it is im-

portant to create an environment that bothencourages and enables individuals to makehealthy choices. Developing an environmentin which ‘hea l thy cho i ces a re easychoices ’ can involve significant socialchange (e.g. reducing poverty so that thereis greater access to nutritious food), legisla-tive change (e.g. outlawing tobacco adver-tising) or changing the physical




infrastructure to encourage exercise and re-duce social isolation.

Biological determinantsGeneticsIt is difficult to say precisely how much ofany disease or disability is due to geneticfactors. However, we know that some chronicdiseases such as heart disease, various can-cers and arthritis do run in families. It hasbeen estimated that about half of the varia-tion in life span is due to factors that arefixed relatively early in life – by the timepeople are aged 30. However, only about halfof this is thought to be due to genetic fac-tors.71

This means that, if we want to increasethe life span of the population, we cannotjust wait until people get old and then inter-vene to overcome the illnesses that developlater in life. Interventions early in the lifecourse will be important in contributing tolife towards the later part of the life course.It also means that there is no basis on whichto be fatalistic – to think that health in laterlife is fixed by a person’s genetic make up.

AgeingWhile some physical changes are a naturalpart of growing older (e.g. menopause inwomen, changes in cellular division, dietaryneeds, etc.), most changes associated withlater life are neither universal nor ordained

to occur at a set age (see page 11). The envi-ronment in which older people live and thelifestyle behaviour they adopt can play a sig-nificant part in their risk of developing a dis-ease, the age at which it occurs, its rate ofprogress and the extent to which it disablesthem from leading an active later life.

GenderGender is an important determinant of healthin later life. Women are more subject to somediseases and disabilities than men, while menare more prone than women to other dis-eases. While some of the gender differencesin health in later life are related to biologi-Figure 4: A model of behavioural choice


Table 6: Years of health life lost to disease and disability bygender for selected Western Pacific Region countries

% of total life expectancy lostto ill-health/disability

Males Females

Australia 9.1 10.7Brunei Darussalam 13.1 16.2Cambodia 14.7 16.8China 11.6 13.2Cook Islands 12.0 15.3Fiji 12.3 15.1Japan 8.1 9.9Kiribati 12.6 15.7Lao People’s Democratic Republic 16.4 18.5Malaysia 12.6 14.5Marshall Islands 12.7 15.3Micronesia, Federated States of 12.5 15.2Mongolia 17.8 18.5Nauru 14.1 16.7New Zealand 8.5 11.0Niue 12.6 15.6Papua New Guinea 15.4 18.1Philippines 11.9 14.3Republic of Korea 10.3 12.1Samoa 12.7 15.6Singapore 11.4 14.1Solomon Islands 12.9 15.9Tonga 12.0 14.9Tuvalu 11.3 14.8Vanuatu 12.8 15.8Viet Nam 12.7 15.9

Source: Men, ageing and health: achieving health across the life span. Geneva, World HealthOrganization, 2001


Table 7: Gender differences in selected diseases and disabilitiesin later life in Western Pacific Region countries, 1990

Prevalence is higher for Age at onsetCondition men or women? is earlier for

Diabetes mellitus Similar SimilarCongestive heart disease Much higher for men MenColon cancer Men MenCervical cancer Exclusive to womenProstate cancer Exclusive to menDementia Women MenParkinson’s disease Men in some places SimilarGlaucoma Much higher for women WomenCataract Women MenHeart attack Men MenAngina MenStroke Men MenChronic obstructive pulmonary

disease Men MenRheumatoid arthritis Much higher for women WomenOsteoarthritis (hip) Much higher for men MenOsteoarthritis (knee) Much higher for women WomenSuicide Men Men

Source: Murray C.J.L., Lopez A.D. Global health statistics : a compendium of incidence, preva-lence, and mortality estimates for over 200 conditions. Boston, WHO and Harvard University Press,1990.

cal differences, there are also important so-cial and cultural factors at play.

In all countries in the Western PacificRegion women live longer than men (seeTable 3). However, in all these same coun-tries women spend a greater proportion oftheir life suffering from disabilities and ill-health (Table 6). In other words, whilewomen life longer, their extra years tend tobe spent in poorer health and greater dis-ability. This means that health promotiondirected to older men and women needs tobe shaped somewhat differently by the dif-ferent health experiences and health profilesof older men and women. Some strategieswill need to be targeted much more specifi-cally towards men and others towardswomen.

The graphs in Appendix B provide de-tails about the extent of gender differencein the health problems commonly foundamong older people. Table 7 below summa-rizes the main differences.

In understanding and targeting thegendered patterns of disease and disabilityin later life, it is crucial that the social and

cultural components of health, rather thanjust the biological components, are ad-dressed.

Differences such as prostate, breast andcervical cancers are clearly biological. Butgender is much more than biology .Gender differences in health also relate to:n the different activities of men and

women;n their different access to resources;n discrimination in access to health ser-

vices;n their different capacity to make their own

decisions; andn their different capacity to participate in

community-based decisions and activi-ties.Furthermore, the greater longevity of

women means that more women will livewithout a partner for at least some of theirlater life. This means that the experience oflater life and the context in which older womenlive is quite different to that of most older men.Most older men have a partner, while manyolder women spend some of their later yearswithout a partner.

This means that as well as being atten-tive to the different diseases and disabilitiesthat stem largely from biological differences,any health strategy must attend to the posi-tion of men and women and tackle somehealth problems by addressing the positionof men and women in their particular soci-eties.

WomenIn many societies women are second-classcitizens and suffer systematic discriminationin many areas of life. Greater poverty, poorereducation, lower literacy, poorer access tohealth services, exclusion from meaningfulwork, caring responsibilities and the greaterchance of living alone in later life all meanthat women live more of their later life inpoor health and suffer disabilities (see Table3 and Table 6).

The WHO Active Ageing framework hasobserved that:

“These cumulative disadvantagesmean that women are more likelythan men to be poor and to suffer


disabilities in older age. Because oftheir second-class status, the healthof older women is often neglected orignored. In addition, many womenhave low or no incomes because ofyears spent in unpaid caregivingroles. The provision of family care isoften achieved at the detriment offemale caregivers’ economic securityand good health in later life.”72

Bonita observed that, because most devel-oping countries do not have publicly-fundedsocial security schemes, ageing women in thesecountries must rely on the family for securityand shelter. 73 However, rapid urbanizationand the movement of younger people to thecities means that older women may be leftwithout their family to provide for them. This,she argues, is contributing to the deteriora-tion of living conditions for older women. Poorhealth services in rural areas and the absenceof family members means that these women(who may often be widowed) are left withinadequate support, which is often made worseby their poverty. Those who move to the citiesfind that they have no place in the urban fam-ily structures.

In those countries where poverty andpoor nutrition are widespread, the positionof ageing women is often worse than in thepopulation at large. Years of childbearing andtaking care of the nutritional needs of theirfamilies at the expense of their own needsmeans that by later life many older womensuffer the consequences in the form ofanaemia and osteoporosis. 74

The death of a partner has a particularimpact on women. Older women are farmore likely than older men to live alone. InChina, in 1990, approximately two-thirds ofwomen over the age of 65 were widows. 75 Thismeans that older women are more prone toboth the poor health outcomes associatedwith social isolation and the poverty associ-ated with widowhood.

Finally the low social status of womenwill affect their sense of self efficacy – theirsense that they can do things that make adifference. Health-promotion strategies seekto empower individuals to actively partici-

pate in their own health. To the extent thatwomen have a lower sense of self-efficacy,health-promotion strategies targeted at olderwomen will need to be directed at empow-ering women to advocate and act on theirown behalf.

MenAspects of being male also contribute to poorhealth among men The recent analysis byWHO, Men, ageing and health, concludesthat:

“The battle will be against compla-cency, against established attitudes,towards a culture in which menwould recognize the importance oflooking after themselves, a culture ofself-care, as opposed to the currentcommon belief of men who regardthemselves as ‘indestructible ma-chines’.” 76

In all countries in the Western PacificRegion, men have a shorter life expectancythan women. Table 7 also documents thediseases and disabilities of later life wheremen have a higher risk. While some of thesedifferences can be attributed partly to thebiological differences between men andwomen, they are also linked to differencesin male and female behaviour. Higher ratesof smoking and alcohol consumption areassociated with many of the diseases towhich older men are more prone. Anotherfactor is the extent to which men neglecttheir health throughout life. Gendered selfidentities in which men are encouraged tothink of themselves as ‘indestructible ma-chines’ means that men are less likely thanwomen to engage in preventive behaviourthroughout their life.

The work demands on many men canalso contribute to disabilities in later life.Unsafe working environments, noise pollu-


73 Bonita R. Op cit. Ref 32.

74 Ibid.

75 Ibid.

76 WHO. Op cit Ref 3.


tion and the physical demands required inmany labouring jobs in developing countrieswill have a long-term effect on the health ofmen in later life.

The centrality of paid work for men alsoposes health risks. Many work places andwork tasks assume a young, healthy person.As a man ages and his body makes it moredifficult to perform as well in some worktasks the demands on his body increase orthe risk of job loss increases.

As men age and stop work they suffer,not only the economic cost of retirement, butalso the social and psychological losses as-

ActionsDirected towards decision-makers1. Target health promotion strategies to the particular needs and

disabilities for which men and women are at risk.2. Work towards greater gender equality where the needs of women

are not ignored.3. Introduce programmes that enable women to control fertility.4. Initiate programmes that encourage men to take better care of their

health.5. Encourage men to reduce their alcohol and tobacco consumption.6. Challenge the ‘indestructible machine’ image of men so that men

are more open to adopting health-promoting behaviour.7. Develop programmes that encourage a sense of self-efficacy among

women. Develop initiatives that will assist the many women wholive much of their later life alone and in poverty following the deathof their husbands.

Directed towards individuals1. Increase knowledge of and capacity to control fertility.2. Encourage greater gender equity within households.

sociated with it. Where the workplace hasbeen the source of social networks and of asense of personal worth, the losses due toretirement can be particularly severe formen. These losses have implications for thesocial, physical and mental health of men,as is evident from the higher suicide anddepression rates among older men.

Lifelong factors: health from alife-course perspective

“Health and activity in older age are… a summary of the living circum-stances and actions of an individualduring the whole life span.” 77

Health in earlier life provides the foun-dations on which health in later life is built.Most of the determinants of health discussedearlier highlight the fact that health in laterlife is affected by factors that operate overthe course of a person’s life. This is particu-larly true of noncommunicable diseases anddisabilities, where the appearance of diseasesymptoms in later life reflects the cumula-tive impact of factors that have operated overmany years. Nutrition and diet, smoking andalcohol consumption can take many yearsto show their effects. This means that im-proving the health of older people may meanfirst improving the health, lifestyle and en-vironment of people well before they reachold age.

Scientists have identified different mod-els of the way in which earlier life affectshealth in later life.

The critical periods model: This approachhighlights the importance of particular lifestages (e.g. in utero, infancy, adolescence)in growth and development.78 Events atthese critical stages can have lifelong conse-quences, which may only show up in laterlife. For example, low birth weight, whichfrequently reflects undernourishment during

Key points1. Gender is a key determinant of health.2. Gender differences are much more than just biological differences.3. While some of the links between gender and health are due to

biological differences, many are associated with the position of menand women in society.

4. The second-class status of women in many societies makes themmore vulnerable to many diseases and disorders in later life.

5. The self image of men can make them more vulnerable to certainhealth problems.

6. Improving the health of older people will require addressing genderinequities.

77 Stein C., Moritz I. A life course perspective of maintain-ing independence in older age . Geneva, World Health Or-ganization, 1999.

78 Sayer A. et al. Are rates of ageing determined in utero?Age ageing, 1998, 27: 579-83.


pregnancy, increases the risk of heart dis-ease, obesity, stroke and diabetes in laterlife.79 80 Adolescence is the time when mostpeople begin to smoke and is, therefore,critical for later life health. This emphasison critical periods means that the best, oronly time to prevent some health problemsis to intervene at these critical stages andprevent the trigger that has largely irrevers-ible, lifelong consequences.

The accumulation model: As people gothrough life they are exposed to more andmore risk factors, which accumulate. It isonly in later life that people have had enoughexposure to the risks to actually show thesymptoms of a disease. For example, clog-ging up blood vessels begins during adoles-cence because of too much fat andcholesterol in the diet. This has no visibleeffect in early adulthood because not enoughfat has built up. However, if people continueto eat fatty food for 20 or 30 years, enoughfat will build up in the blood vessels to causeheart disease. This means that the best wayto prevent later-life health problems is toprevent the exposure to risk factors acrossthe life course – not just in later life.

The multiplier accumulation model: Thisapproach emphasizes that risk accumulationis not random. Exposure to one risk factorcan increase the exposure to other risks. Forexample, a child born to poor parents is morelikely to be low-birth-weight. The same childis also more likely to have a poor diet. To-gether, these two factors increase the chanceof illness.81 Similarly, being protected fromone risk can help avoid exposure to otherrisks. n

79 Barker D. J. P. Mothers, babies and health in later life.London, Churchill Livingston, 1998.

80 Stein C. and Moritz I. Op cit. Ref 77.

81 Hertzman C., Wiens M. Child development and long-term outcomes: a population health perspective and sum-mary of successful interventions. Social science and medi-cine, 1996, 43: 1083.

ActionsDirected towards decision-makers1. Promote healthy behavior among younger, as well as older people.2. Make policy-makers and decision-makers aware of the long-term

consequences of policies and environmental factors on health inlater life.

3. Advocate for better health education in schools.4. Advocate for research as to the life-course stages that are most

critical for later-life health and the establishment of good healthbehaviour so that interventions can be directed to the most strate-gic points in the life course.

Directed towards individuals1. Increase the awareness that many heath problems in later life are

due to controllable types of behaviour earlier in life.

Key points1. Health in later life is the outcome of a complex set of individual,

societal and cultural factors.2. Individual factors that affect later life health include biology (genet-

ics and gender) and lifestyle.3. Many noncommunicable diseases of later life are, in principle,

preventible.4. Prevention methods require the encouragement of individual

behaviour and social change that will result in healthier outcomes.5. Societal determinants of later-life health include social inequality,

poverty, gender inequality, environmental health and the structureof health systems.

6. Cultural determinants of health include values regarding health andageing.

7. Individual modes of behaviour over the life course, not just in laterlife, are key determinants of health in later life.



A health promotion approach to better healthin ageing societies involves two main com-ponents:n assisting individuals to make decisions

that lead to better health outcomes (e.g.healthier lifestyles); and

n creating social, economic and environ-mental conditions that are favourable togood health (healthy settings).Underlying this second element is the

recognition that “Health conditions in devel-oping countries must be viewed in a widersocioeconomic context where nearly a thou-sand million people are trapped in a viciouscycle of poverty, malnutrition, disease anddespair.” 82

WHO defines health promotion as:

“…a comprehensive social andpolitical process, {which} not onlyembraces actions directed atstrengthening the skills and capabili-ties of individuals, but also actiondirected towards changing social,environmental and economic condi-tions so as to alleviate their impacton public and individual health.Health promotion is the process ofenabling people to increase controlover the determinants of health andthereby improve their health.Participation is essential to sustainhealth promotion action.” 83

This dual target of health promotion (i.e.individual behaviour and the settings inwhich the behaviour takes place) is spelledout in the Ottawa Charter of 1986 (http://w w w . w h o . i n t / h p r / a r c h i v e / d o c s /

ottawa.html ), which sets out five core strat-egies for promoting health:n building healthy public policies;n creating supportive environments;n strengthening community action;n reorienting health services; andn developing personal skills.

Mittelmark has identified four definingelements of health promotion: health impactassessment; local community focus; primaryprevention; and empowerment of individu-als.84

Health impact assessment: This involvesestablishing systems for systematically evalu-ating all public policies and programmes, fromnational to local levels, for their positive, neu-tral and negative impacts on health. 85

Local community focus: By strengtheningand mobilizing local communities and re-sources, health promotion seeks to achievepositive health change by transformingneighbourhoods and key institutions, suchas homes, schools, hospitals and workplaces,into health-promoting environments. Bystrengthening the local community capacityto build healthy settings and promote healthy

What is aHealth-PromotionApproach

82 Dhillon H.S., Philip L. Health promotion and communityaction in developing countries. Geneva, World Health Or-ganization, 1994.

83 World Health Organization. Health promotion glossary.Geneva, WHO, 1998.

84 Mittelmark M.B. What is health promotion? Equity inhealth: health promotion, its effectiveness and its perti-nence to health. University of Bergen, Norway, 2000.

85 Mittelmark M.B. Promoting social responsibility for health:health impact assessment and healthy public policy at thecommunity level. Fifth Global Conference for Health Pro-motion: Health Promotion: Bridging the Equity Gap,Mexico, 2000.


behaviour, the health-promotion approachseeks to avoid relying on uncertain externalsupport.

Primary prevention: Health promotionfocuses on primary prevention (see page 56),health education and improving the qualityof informal care provided by family mem-bers. It also includes systems for maintain-ing health-promotion infrastructure withinlocal health care systems and for traininghealth care professionals on ways to involvepatients in developing their own treatmentplans.

Empowerment of individuals: Assistingpeople to take control over and improve theirown health by adopting health promotingbehaviour and making better use of healthcare and preventive services.

“Health promotion is in fact enlight-ened health activism; it is a processof activating communities, policymakers, professionals and the publicin favour of health supportivepolicies, systems and ways of living.It is carried out through acts ofadvocacy, empowerment of peopleand building social support systemsthat enable people to make healthychoices and live healthy lives.” 86

By targeting both the individual andpublic levels, the goal of health promotionis to ‘make healthy choices easy, early andexciting, everywhere’ .87

Empowerment andparticipationIn addition to improving health by directingefforts towards both individuals and thestructures in which individuals live, the othercentral component of health promotion is to“enable individuals and communities to takecharge of conditions and circumstances thatcontribute to ill-health”. 88

In other words, health promotion in-volves mobilizing individuals and commu-nities both to take responsibility for betterhealth outcomes and to use the resources ofindividuals and communities in buildinghealth-promoting environments (settings).

Health promotion emphasizes the impor-tance of empowerment of individuals andcommunities in producing better health. Thisinvolves:n individuals and communities taking re-

sponsibility for healthier lifestyles andsettings and;

n enabling individuals and communities tocreate health settings and behave inhealthier ways.

Health promotion at differentlevels of careHealth promotion can be targeted at any ofthree levels of care – primary, secondary ortertiary.

Primary: These strategies aim to reducerisks, maintain wellbeing and prevent dis-eases and disabilities from developing in thefirst place and will target both individualmodes of behaviour and the broader social,economic and environmental context inwhich people live. By changing this context(e.g. banning tobacco advertising, improv-ing food quality, making good food afford-able) the goal is to reduce the risks toill-health.

Secondary: Since primary prevention andpromotion strategies will never eliminatedisease and disability, a second line of de-fence is to intervene in health problems be-fore they progress and become eitherdisabling or incurable. At the individual levelthis may involve greater access to informa-tion and services for health screening to de-tect problems before they becomesymptomatic. At the broader level, second-ary prevention and promotion may involvepreventing health problems becoming worseor becoming disabling. This may involve pro-viding better housing, improving access tohealth workers or creating a safer environ-ment. It also involves social mobilization and

86 Dhillon H.S. and Philip L. Op cit. Ref 82:9.

87 WHO Regional Office for the Western Pacific. Op cit.Ref 24.



advocacy for secondary preventionprogrammes such as screening for cervicalcancer or deafness, adult immunization, oremployee compensation for exposure to en-vironmental hazards.

Tertiary: Where a disease or disabilityadvances, its effects will require management.This is the task of tertiary prevention. In can-cers this may involve therapies or pain man-agement. With Alzheimer’s disease orParkinson’s disease it will involve assisting thesufferer with the tasks of daily living or pro-viding symptomatic relief. For post open heartsurgery patients, this may involve patient edu-cation on appropriate diet, physical and sexualactivity and stress management.

Medical versus healthpromotion modelsMany health strategies are tertiary-level strat-egies – they have adopted the ‘find it and fixit’ model which focuses on curing diseasesrather than preventing them.

The dilemma faced in many developingcountries is how to allocate the very limitedresources available for health. The medicalmodel is one where resources are directedprimarily to curative services, where the needfor interventions is urgent and visible. Whilethe needs of ill people cannot be ignored,the problem with the medical approach isthat failure to attend to health promotionsimply creates more sick people.

Developing countries face the particu-larly difficult problem of very limited eco-nomic resources on the one hand and facingthe ‘double burden’ of disease on the other:infectious diseases have not been adequatelycontrolled, yet, at the same time the ageing ofthe population and social changes have pro-duced a rise in degenerative, noncommuni-cable diseases. HIV/AIDS, together withurbanization, the need for rapid economicdevelopment and widespread poverty, allmean that there are large and growing de-mands for health-related expenditure but verylimited resources to meet these demands.

The challenge faced by developing coun-tries is:n how to direct health expenditures in the

ActionsDirected towards decision-makers1. Advocate for the redirection of resources towards primary and

secondary disease and disability prevention.2. Initiate programmes that release community-based resources that

enhance primary and secondary disease and disability prevention.3. Encourage health service providers to build in primary and second-

ary disease and disability prevention opportunities and educationwhen delivering tertiary-level services.

Directed towards individuals1. Increase individual awareness of disease and disability prevention

actions that individuals can take.2. Encourage individuals to have check-ups and to use health screen-

ing opportunities.

most efficient and effective ways; andn how to draw on other community and

individual resources to help meet thehealth challenges they face.The health promotion strategy in devel-

oping countries needs to be based on a recog-nition that the economic resources availablefrom governments and donors will be insuffi-cient to meet emerging health needs. There-fore, health promotion strategies will need to:n respond to major health problems affect-

ing older persons and demostrate effec-tiveness in reducing risks, mortality andmorbidity;

n increase the yield and sources of fundsfor health promotion to include fundsfrom local governments, corporations,social security funds, social health insur-ance, “sin” taxes;

n improve organizational practices andperformance of the public sector andensure that quality improvementprogrammes are applied to services forolder persons;

n Define the role of the state in relation toother stakeholders such as the privatesector, civil society, the community andthe family.

Settings, populationsand lifestylesThe focus of health promotion on context andempowerment has led the Western Pacific


Region Regional Health Promotion Frame-work to emphasize three ways of achievinghealthy outcomes: by promoting healthy set-tings, healthy populations and healthylifestyles.

Healthy settings: This approach involvestargeting the environment in which peoplelive and has led to the Healthy Cities, HealthyIslands, and Healthy Hospitals initiatives. Forexample, the Healthy Cities initiative has ledto action to promote smoke-free environ-ments, safer spaces, better housing and openspaces where exercise is encouraged.

Healthy populations: This approach in-volves targeting life stages and groups. Sincethe health needs of people vary according totheir stage in the life cycle or their gender,the populations approach encourages initia-tives that focus on the health needs and con-tributions of people at particular life stages.An example of such an initiative is the at-tention that is now being paid to the healthof older people.

Healthy lifestyles: This approach focusesmore on the behaviour of individuals andhow their decisions and actions can lead tohealthier outcomes. Health education, socialmobilization and advocacy programmes thathave tried to impart information about theimportance of not smoking, better nutritionand exercise are examples of the healthy-lifestyles approach.

The goal of health promotionfor an ageing population:active ageingThe concept of active ageing emphasizes theimportance of improving the quality ratherthan just the quantity of life among older

Key pointThe important part of health promotion is that all three approachesare part of a package – simply attending to one aspect of healthpromotion (e.g. healthy lifestyles) is insufficient. The conjunction ofthe three approaches is seen to be the most effective way of promot-ing health: creating an environment that enables and encouragespeople in specific life-stage groups to engage in healthy types ofbehaviour is seen to be the approach with the best potential topromote better health.

people (see page 25). It seeks to add ‘lifeinto the years’ and not just add ‘years ontolife’. The WHO Active Ageing frameworkdefines active ageing as:

“…the process of optimizing oppor-tunities for health, participation andsecurity in order to enhance qualityof life as people age.” 89

An emphasis on active ageing allowspeople to:n realize their potential for physical, so-

cial, mental well-being throughout thelife course;

n participate in society according to theirneeds, desires and capacities; and

n receive adequate protection, security andcare when required.

89 World Health Organization. Op cit. Ref 4.

Key points1. Health promotion must be directed

towards individuals and the wider socialand physical environment in which theylive.

2. Health promotion needs to target thesettings and lifestyles of targeted popula-tions (e.g. gender and life stage).

3. Individually targeted health promotionneeds to be directed to behaviour such asdiet, smoking, exercise and alcohol use.

4. A lifelong approach to healthy behaviourneeds to be adopted.

5. Individually directed health promotionneeds to be targeted for different types ofindividuals, depending on such factors asgender and stage in the life cycle.

6. Environmentally targeted health promo-tion need to be directed to (a) makinghealthier choices/behaviour by individualseasier (b) removing unhealthy elements inthe wider settings in which individuals live.

7. Rather than relying on central govern-ments to make all the changes needed forhealthier ageing, health promotionstrategies should seek to enable andempower individuals and communities tobring about health improvements.


Consistent with the general health pro-motion approach, the Active Ageing frame-work promotes a balance betweenindividual, family, and community contribu-tions. The WHO framework encourages per-sonal responsibility (self-care), age-friendlyenvironments and intergenerational solidar-

ity. This approach also adopts a life-courseperspective. The best way for older peopleto remain active and to retain the capacityto participate in their own health is to:n plan and prepare for older age; andn adopt positive personal health practices

at all stages of life. n



The discussion so far has argued that healthpromotion must be multipronged. It shouldincorporate a life-course perspective thatrecognizes that many of the diseases anddisabilities of later life reflect the cumula-tive effect of factors that have operated overmany years. It should also recognize that theenvironment and settings in which people

Approaches toHealth Promotion forOlder People

live have a direct impact on health and en-able or limit the capacity of individuals tomake healthy choices. Finally, it should seekto encourage and enable individuals to makethe choices that lead to better health.

Within this broad framework, we candistinguish between five approaches. Theseare approaches designed to improve health

Figure 5:Approaches tohealth promotionfor older people.


by: cultural change; social structural change;mobilizing community resources; supportingfamilies to promote healthy, active ageing;and encouraging and enabling individualsto adopt healthy behaviour.

The cultural change approachOne way of enabling individuals to makehealthier choices is to make the culture (val-ues, traditions, beliefs etc) one in whichhealth-promoting behaviour is seen as de-sirable behaviour. Cultural approaches topromoting lifestyle changes recognize thatinformation is processed within a culturalcontext.90 It is one thing to communicatethe facts about the harmful effects of alifestyle (e.g. diet, tobacco use) but thesefacts will be weighed against the culturallydesirable aspects of this lifestyle. Whilepeople might accept that smoking is harm-ful to health, the possibility of harm some-time in the distant future will be put againstthe cultural benefits that smoking bestowsin the here and now.

In any culture, certain behaviour is val-ued and other behaviour is frowned upon.Particular behaviour is seen to be appropriatefor some age groups but not for others. Theculture sanctions different behaviour for menand women. For example, where tobacco useand alcohol consumption are seen as signs ofyouth, vitality, masculinity and sophistication,or eating western style foods is regarded asbeing ‘modern’, health promotion messagesthat simply try to communicate factual, healthinformation will be ineffective.

A cultural approach to promotinglifestyle change will be directed at cultural(values) change in the first instance, with thehope that in the longer term individual changewill follow. Such strategies require accurateinformation about cultural norms and values.Where appropriate, the intervention should tryto change these norms, values and culturalimages. For example, a strategy designed toreduce smoking might learn that smoking isregarded as a sign of sophistication. This in-formation would enable a health promotioncampaign to try to change this image to onewhere smoking is regarded as dirty and dis-

tinctly unsophisticated.Since many of the chronic diseases of

later life are the result of the cumulative ef-fect of unhealthy behaviour – often over a life-time, health promotion approaches directedat cultural or values change need to targetyounger groups, where lifestyle decisions aremade. For example, most people who smoketobacco begin to do so in their early adult yearswhen smoking is seen as a behaviour thatbestows an adult and masculine status. Healthpromotion strategies directed to culturalchange that alters the way in which smokingis regarded need to be targeted at this par-ticular point in the life course.

Cultural change can also includechanges directed at altering the ways inwhich particular age groups are regarded,or towards altering what is considered ap-propriate, age-related behaviour. Alteringthe way in which ageing is regarded can playan important part in improving healthamong older people. Where older people areregarded as passive, inactive and dependent,their behaviour will come to reflect thoseexpectations. If ageing is portrayed in a posi-tive way and is regarded as a time duringwhich people can and are expected to beactive and contributing members of the so-ciety, then behaviour will reflect these morepositive expectations.

A cultural approach to health promotionmay also involve resisting particular culturalchanges and strengthening elements of a tra-ditional culture. For example, many of thelifestyle changes that are so damaging tohealth are the result of the adoption of west-ern behaviour (smoking, diet etc). Culturalchanges in many Western Pacific Regioncountries are reducing the extent to whichextended families can support older familymembers in ways that enable active ageing.While the forces of modernization and ur-banization are unlikely to be stopped, healthpromotion strategies may be directed to-wards ways of strengthening those elementsof the traditional culture that promote ac-tive ageing.

90 Airhihenbuwa O. C. Health and culture: beyond the West-ern paradigm. Thousand Oaks, Sage Publications, 1995.


The structural changeapproachLifestyle is not simply a matter of individualchoice. Choices are unevenly distributed insociety. Typically wealth brings greater choice– especially where the choices are affectedby financial resources. Health choices and

behaviour are associated with financial re-sources. 91 92 93 Diet is an example of ahealth-related choice that is affected by fi-nancial resources. In many places, povertyprevents people having sufficient or nutri-tious food. Purchasing good low-fat, low-salt,fresh food is often expensive and an ongo-ing good diet will be out of the financial reachof many citizens. Housing has a bearing onhealth, but poverty denies many people thecapacity to have safe, warm housing.

A sense of control and self-efficacyenables individuals to change.94 The beliefthat one’s own actions can actually make adifference is influenced by a person’s posi-tion in the social hierarchy. If people lowerdown the social ladder are to be motivatedto change their behaviour, they must have asense that their own actions can actuallymake a difference. Addressing people’s senseof powerlessness of may be a prerequisitefor getting them to change their lifestyle.95

Encouraging a sense among older people thatthey can do something about their healthwill be an important part of encouraginglifestyle change – especially in societies inwhich older people are marginalized.

Taking action to improve health requiresthat a person values good health. Butwhether or not they value good health candepend on their self esteem and senseof worth . Disadvantaged and sociallymarginalized groups will often lack this selfbelief and thus engage in damaging, self-destructive behaviour. 96 97

Structural approaches to lifestyle changemay require political action - challenging thepower of those whose interests are not inhealth promotion. For example, cancer rates,heart disease and respiratory disease have

Key points1. Behaviour is influenced by the culture

(values, priorities and beliefs) in which aperson lives.

2. Where these factors produce unhealthybehaviour, cultural values, priorities andbeliefs will need to be challenged beforebehavioural change will occur.

3. Cultural change is an important elementof health promotion.

4. In many cases, changing cultural valueswill involve challenging the valuespromoted by modernization andstrengthening traditional values.

ActionsDirected towards decision-makers1. Obtain accurate information regarding

the way in which unhealthy behaviour isregarded in different population groups.

2. Target campaigns for value change atspecific groups.

3. Encourage campaigns that challengenegative images of ageing.

4. Advocate against policies thatdisempower, marginalize and stereotypeolder people.

5. Encourage public campaigns that chal-lenge the positive images attached tomany unhealthy types of behaviour.

6. Regulate the promotion of images ofunhealthy behaviour as being healthy andglamorous (e.g. tobacco advertising,alcohol consumption, eating fatty take-away food).

Directed towards individuals1. Encourage older individuals to develop

positive views about what they can do.2. Increase awareness of the harmful effects

of much behaviour that is regarded asglamorous.


92 Bartley M. et al. Op cit. Ref 42.

93 Wilkinson R. and Marmot M, eds. Op cit. Ref 13.

94 O’Leary A. Self-efficacy and health. Behavioural researchand therapy, 1985, 23(4): 437-451.

95 Wallerstein N. Op cit. Ref 65.


97 Blane D. Op cit. Ref 11.


will increase. However, tobacco control willrequire legislation that challenges the powerof tobacco companies to undermine healthpromotion initiatives.

Within the health sector, implementingprevention strategies requires structuralchanges. It requires refocusing the sectorfrom clinical interventions to preventive andpromotion strategies.

Interventions directed at the structurallevel will try to initiate environmental changesuch as reducing air, water and noise pollu-tion, or improving workplace safety. Intro-ducing such changes is likely to meetresistance from industry and other interests,since they are likely to involve financial costs.However, there is limited value in convinc-ing people to eat healthy food, exercise moreand smoke less if their environment andworkplace continues to damage their health.

In many countries, older people are dis-proportionately poor. Poverty is a barrier togood health, so effective health promotionfor the elderly will involve tackling poverty.Poverty reduction, tackling illiteracy andimproving education will create a context inwhich people can make better health choices.Without tackling poverty, health promotionstrategies directed at individual change may

ActionsDirected towards decision-makers1. Advocate for policies and reforms that reduce poverty. This may

include advocating for changes in social structures that producepoverty (e.g. poor education, low wages, industrial conditions, highfertility).

2. Advocate policies that alleviate the effects of poverty. For example,literacy programmes, mean- tested access to health care, work-based pension schemes, subsidized housing, health care and medicalsupplies can help alleviate some of the financial ill-effects of poverty.

3. Foster social networks for ageing people by supporting communitygroups run by older people.

4. Advocate for better public transport and safe communities so thatolder people can avoid social isolation.

5. Develop outreach activities so that isolated older people canparticipate in groups and have the opportunity to be part of thecommunity.

6. Urge improved access to education and literacy skills early in lifeand provide opportunities for ongoing education throughout life.

7. As a means of improving the economic well-being and sense ofvalue of older people, encourage opportunities for older people toparticipate in the paid workforce. Opportunities for voluntary workshould also be encouraged.

8. Advocate for the development of housing options that allow olderpeople to remain connected to their families.

9. Campaign for improved occupational health and safety. Since a greatdeal of a person’s life is spent working, the conditions in theworkplace will have a cumulative and long-term impact on health.Ergonomics, repetitive injuries and workplace carcinogens are justsome of the workplace factors that affect health status long afterleaving the workforce.

Directed towards individuals1. Encourage actions that help address the social consequences of

poverty. Encourage social participation by marginalized groups, andpromote a sense of dignity and empowerment among those that aredisadvantaged. Challenge dependency among those who havelearned to be dependent and provide the means by which peoplefeel able to take some responsibility for their own health.

2. Encourage and enable older people to get out of their home andjoin groups and mix with family and friends.

3. Encourage older people to continue to work in the paid or volun-tary work sectors.

Key points1. The ability to make healthy choices is

constrained by a person’s access to socialand economic resources.

2. This access is unevenly distributed acrosssociety.

3. Enabling people to take action toimprove their health and adopt healthierbehaviour will require improving theaccess of poor people to society’s socialand economic resources.

4. Reducing social, economic and genderinequalities will lead to improvements inhealth as the health behaviour andenvironments of the most disadvantagedare improved.

5. Enabling people to adopt healthybehaviour involves convincing them thattheir actions can make a difference.

accompanied the growth in tobacco use indeveloping countries. In Cambodia, Chinaand the Republic of Korea, about two-thirdsof males now smoke. One in four tobaccodeaths worldwide occurs in the Western Pa-cific Region. Until tobacco consumption iscontrolled, tobacco-related health problems


only be effective among the moreadvantaged sectors of society and in the moredeveloped countries.

The link between gender and ill-healthis a further example of ways in which struc-tural changes will be required to producehealthier outcomes. The second-class statusof women in many societies contributes to agreater proportion being affected by chronicdisease and disability (Table 7). Structuralchanges which improve the position ofwomen in developing societies will be re-quired before the health disadvantage ofwomen can be reduced.

Intersectoral approachesTraditionally, health has been the businessof the ‘health sector’ – doctors, nurses andhospitals. The focus has been on curing ill-nesses and helping people to live with theirdisabilities.

Because many of the determinants ofhealth are not under the direct control ofhealth services, health-promotion modelssee health as the business of all sectors ofgovernment, the non-government sector,community groups, families, churches etc.Indeed, to leave health to the health sectoris to marginalize health. The health-promo-tion approach is to promote health as theconcern of all sectors. This means, for ex-ample, that health can be promoted by theeducation sector by improving health literacyand reducing illiteracy generally (Health-promoting Schools). The agricultural sectorcan play a role through the production ofnutritious foods; the communication sectorcan assist with health education for all ages;the housing sector can encourage age-appro-priate housing that is safe and reduces so-cial isolation; the public works sector canensure better planning and infrastructure,help avoid overcrowding and provide safeneighbourhoods; and the transportation sec-tor can help by providing public transportso that older people are not so prone to so-cial isolation. In other words, rather thanfocusing on health care or even a publichealth policy, the focus of health promotionis to promote healthy policy – where poli-

Key points1. Health should not be the concern of just

the health sector.2. Better health will be the result of healthy

public policy.3. This means that policies across all sectors

have a health dimension. The challenge isto ensure that the health dimension of allpublic policies is health-enhancing.

4. Encouraging non-health sectors tobecome more health-oriented willrequire a lot of bridge-building work andthe development of social capital toensure intersectoral cooperation ratherthan competition.

cies across all government and non-govern-ment sectors include a health dimension.98

One goal of health-promotion strategies isto include health-impact assessments inpolicy development across all sectors.99

In practice, achieving a health orienta-tion across all sectors can be very difficult.The interests of health are not always seento be compatible with other priorities. Thepressure for rapid economic development inthe developing world can lead to a disregardfor the environmental consequences of in-dustrial development; the financial difficul-ties governments face can make somegovernments reluctant to curb the activitiesof tobacco companies; economic pressuresmean that governments are unable to fundincome-support measures etc. The challengeof health-promotion strategies is to convincegovernment and others that good health isan economic imperative and a foundationof economic development.

A true intersectoral approach requirescooperation rather than competition be-tween sectors. The Western Pacific RegionRegional framework for health promotionplaces special emphasis on developingintersectoral cooperation by building the

98 Hancock T. Beyond health care: from public healthpolicy to healthy public policy. Canadian journal of pub-lic health, 1985, 76: 9-11.

99 Mittelmark M.B. Op cit. Ref 84.


social capital in each country. 100 This frame-work recognizes that economic capital is bothunavailable and insufficient on its own tocope with the looming health needs of age-ing societies.

Community-based approachesStructural change will be largely dependenton the actions of central and regional gov-ernments. However, a great deal can beachieved at the local community level. A corestrategy of health promotion is to strengthenlocal community capacity to build healthysettings and promote healthy behaviour. Thisemphasis on the local community seeks bothto avoid relying on uncertain external sup-port and to empower individuals in achiev-ing better health outcomes.

“The world community sometimesacts slowly. People at the local levelcan influence their situation moredirectly and often more swiftly.Empowering individuals, localauthorities and groups is crucial.Health is not only, and perhaps noteven primarily, the concern ofdoctors and nurses. It is political, aquestion of influence, power andresources.”

“Change won’t come easy. Advocat-ing community participation meansinitiating a process of decentraliza-tion. Such a process will be a funda-

mental challenge in the face of thesteady concentration of political andeconomic power in the hands ofsmall elites.” . 101

Local governmentRapid urbanization has meant that a greatdeal of growth in urban centres has beenunplanned. This has resulted in severe over-crowding, inadequate housing, serious traf-fic problems and environmental degradationand pollution. Apart from the general healthconsequences of these developments, olderpeople can be especially affected. Air pollu-tion can make the consequences of lungproblems (e.g. chronic pulmonary obstruc-tive disease) very serious; noise can makehearing problems worse; and congestion,poor public transport, and crowded, unsafewalkways can all make urban environmentsunfriendly and unsafe for older people. Lo-cal governments can play an important partin trying to plan and regulate urban growth.Greater regulatory control at the local levelcan make new cities healthier cities.

Using community-based resourcesIt has been argued that developing societiesface particularly demanding health chal-lenges and do not have the economic re-sources to face these challenges using the‘find it and fix it’ curative approaches. If acurative approach is adopted to the exclu-sion of effective health promotion, peoplewill become ill at a faster rate than they canbe ‘cured’. If developing countries are to beable to address the health challenges of age-ing societies they need to:n prevent as many people as possible from

becoming ill;n delay the onset of diseases and disabili-

ties so that the proportion of life forwhich older people are afflicted by dis-eases and disabilities is reduced; and


101 Haglund B.J.A. Creating healthy environments. A Sym-posium on the effectiveness of health promotion: Cana-dian and international perspectives, University of Toronto,1996.

ActionsDirected towards decision-makers1. Advocate at the national, regional and local levels for the introduc-

tion of health-impact statements as a routine part of all policyinitiatives.

2. Make people outside of the health sector more aware of the healthimplications of their policies.

3. Develop opportunities where key individuals from outside thehealth sector can meet with those working in the health sector andin health promotion in particular.

4. Encourage greater trust and cooperation between health workersprimarily in the medical area and those in the community-develop-ment and health-promotion areas. Develop ways in which theknowledge and expertise of all health-related workers can be used.


n draw on underutilized resources to en-able active and health ageing.This last action points to the importance

of mobilizing the resources potentially avail-able in local communities and families. Mo-bilizing community, family and personalresources to promote better health will bemore cost-efficient than the purely medicalmodel and will make use of a much widerrange of disease prevention strategies andresources than are available to the hospital-based clinician. In many places, geographicalisolation and a lack of physical infrastructure(e.g. good roads) mean that community-basedcare is the only type of heath care available.

In developing countries, the local com-munity can play a central role in a person’shealth. It can damage their health or it canimprove it.

Economic development has had majorconsequences for the nature of communities.Industrialization has led to rapid movementfrom rural communities to large urban cen-tres. The rate of urbanization has been sorapid in many places that there remains aserious shortage of appropriate housing andadequate infrastructure in cities. Equallyimportant, however, is that, with urbaniza-tion, old community ties and support systemshave been dislocated without alternative in-formal systems replacing them.

Urbanization has affected social relation-ships and support systems at two levels. Ur-ban environments are much moreanonymous than the smaller rural commu-nities from which many people have moved.While a variety of informal support systemswere available in the rural communities, al-ternatives to these are lacking in many ur-ban centres. In rural centres too, the oldsupport networks have been disrupted by ur-ban migration. In particular, extended familynetworks have suffered. This is particularly im-portant for the health and well-being of olderpeople. On the whole, older family membershave remained in rural areas or have returnedto rural areas after retiring. In countries whereelder care has been the responsibility of fami-lies rather than the state, the disruption of fam-ily ties has had serious consequences (seepages 7, 70, 77, 89).

As well as playing an important role insocial health, the nature of the local commu-nity affects whether older people can engagein healthy lifestyles. Urban living will meanthat individuals are unable to produce theirown healthy food. Over time, this can changedietary habits and have long-term conse-quences for later-life health. The localneighbourhood can encourage or discourageexercise – a known factor in the prevention ofmany chronic diseases. A neighbourhood thatencourages exercise and makes exercise anormal part of everyday life will be morehealth-promoting than one in which exerciseis difficult. Older people need exercise-friendlyneighbourhoods if they are to be expected toexercise regularly. This requires safe places inwhich to walk, good footpaths and well de-signed, barrier-free neighbourhoods and cit-ies. Neighbourhoods need to cater for olderpeople so that they can walk without the dan-ger of debilitating falls. This involves atten-tion to stairs, use of rails, good footpaths andtransport systems that take account of themore limited mobility of some older people.102

The community can also promote healthby preventing social isolation among olderpeople. Where older people become isolatedeither because of ill-health, death of a spouseor the migration of family members, chronichealth problems can be made worse. Depres-sion frequently follows isolation. Poor dietand lack of exercise are associated with iso-lation, as are problems with alcohol. Whilethe social forces that produce this isolationand the disruption of supportive family tiesare unlikely to be reversed quickly, local com-munities can help reduce social isolationamong the elderly. While visiting programmesare one way of doing this, a more effectiveway is to enable older people to participatein community life. This may involve assis-tance with transport, mobility aids or orga-nizing group activities.103

102 Leveille S.G. et al. Preventing disability and managingchronic illness in frail older adults: A randomized trial ofa community-based partnership with primary care. Jour-nal of the American Geriatrics Society, 1998, 46: 1191-1198.

103 Stuck A.E. et al. Risk factors for the functional statusdecline in community-living elderly people: A systematicliterature review. Social science and medicine, 1999, 48:445-469.


Health visitors and communityhealth workersHealth visitors and community health work-ers are an important community resource forhealth promotion and disease prevention.They provide a means of promoting goodhealth in the community and mobilizingcommunity resources.

Health visiting has been used in manycountries for maternal and child welfare andhas been extended to health and welfaresupport for older people. Health visiting andcommunity health work is based on the phi-losophy that good health promotion andcare must be shaped by and integratedwith the context in which people live.The promotion and prevention roles of com-munity health workers include:1. Health education: With suitable train-

ing, health visitors should be able to pro-vide good preventive health advice toolder people and their families. Train-ing and good materials are required toenable health workers to fulfil this re-sponsibility effectively. Health-visitor-based health education allowsinformation to be tailored and selectedto suit the cultural context and the par-ticular situation in which an older per-son is living. In this way,community-based health educationavoids the ‘one size fits all’ approach ofmass health promotion campaigns.Health literacy and linguistic compe-tence in community languages can as-sist in developing healthier behaviourand can provide individuals with themeans to take control of their health.

2. Health screening: By visiting older peoplerather than waiting for them to visit aclinic, the goal is to screen for healthproblems among populations where theprobability of illness is high. This allowsfor highly targeted screening with thegoal of detecting diseases before theybecome symptomatic. Early diagnosisincreases the chance of effective treat-ment. 104

3. Health management: When a person hasdeveloped a disease, community healthworkers help manage the symptoms and

assist carers. Knowledge of the particu-lar circumstances in which an older per-son lives helps the health workerpropose realistic management strate-gies. The health worker can locatesources of care assistance and coordi-nate care needs. Good community-based care helps avoid the unnecessaryuse of institutional care.

4. Network building: Social networks and asense of belonging improve health.105 106

107 108 Community health workers linkolder people to other people, health pro-viders and community groups. These so-cial networks make better use ofcommunity resources and help integrateolder people into the life of the commu-nity.

5. Advocacy: Community health workerscan give a voice to those parts of the com-munity that are otherwise unheard. Byhighlighting the needs of the elderly –especially those living in poverty - healthworkers may be able to harness morecommunity resources for their healthneeds and create a more supportivehealth environment. Lobbying decision-makers on matters ranging from extend-ing a local bus service to implementinglegislation banning tobacco advertisingwill also be an important part of build-ing a health-supportive environment.

6. Process: An important element of thecommunity health worker’s role is theway in which health promotionprogrammes are implemented. The gen-eral philosophy of community-based in-terventions is to involve individuals intheir own health, increase their sense ofresponsibility and efficacy for their

104 Bloom,H. G. Preventive medicine: When to screen fordisease in older patients. Geriatrics, 2001, 56(4): 41-45.

105 House J.S. et al. Op cit. Ref 57.

106 Chappell N.L. Op cit. Ref 58.

107 Oxman T.E. et al. Social support and depressive symp-toms in the elderly. American journal of epidemiology, 1992,135: 356–368.

108 Gironda M.W. et al. Social support networks of elderswithout children. Journal of gerontological social work ,1998, 27: 63-84.


health and provide opportunities for cli-ent input into their own health strate-gies. The approach is designed to reducethe sense of powerlessness that manypeople feel. The goal is to provide indi-viduals and families with the means bywhich they can help themselves and con-tribute to their own health care, ratherthan just waiting to be told what to door to have things done to them. 109 110

Community careThere has been ongoing debate aboutwhether community care or institutional careis the best way of meeting the health andcare needs of the elderly. It is important, inthe context of this debate, to stress that themajority of older people do not require in-stitutional care and are quite healthy andindependent for most of their old age.

The developed countries in the WesternPacific Region have higher rates of institu-tional care for older people than the devel-oping countries. However, even in thedeveloped countries, only a very small pro-portion of the population aged over 65 arein or ever use institutional care. Both devel-oping and developed nations in the WesternPacific Region are seeking to use communitycare as much as possible for older people.

The basic philosophy of community careis to enable older people to ‘age in place’. Itrespects the preference of most older people,who value their independence and prefer toremain in their own homes and local com-munity. The community-care model alsobuilds on the desire of families to care forolder family members as far as possible.Community care has also been developed asa way in which the health needs of ageingpopulations can be met without a massivediversion of public resources away from otherexpenditure priorities.111 The objective ofcommunity-care models is to promotehealthy ageing in a way that is consistentwith community values and is affordable.

Community care includes both formaland informal care.112 Damron-Rodriguezand Lubben provide an excellent account ofthe community-care model for agedhealth.113 At the formal care level, commu-

nity-care systems provide services that en-able older people to continue to live in thecommunity. The type of support providedwill vary greatly depending on the local con-text but may include:n modifying the immediate context in

which people live in order to minimizethe disabling effect of any disorder;

n community nursing;n paramedical services;n meals;n home help;n personal care;n home modification and maintenance;n transport;n community-based respite care (mostly

day care);n education and/or training for service

providers and consumers;n assessment and/or referral services;n information and advocacy services;n social (including neighbour aid) support;

andn carer support.

The informal element of community careis the support provided by family, neighboursand friends. Overall, the informal elementof community care is far more substantialthan the formal component. Within the in-formal component, family-based support re-mains the most important element in bothdeveloped and developing countries. Themajority of family care is provided by femalefamily members.

The particular form of community carewill depend on the nature of local commu-nities, the types of resources available andthe needs and preferences of those in the

109 Levin L., Idler E. Self-care in health. Annual review ofpublic health, 1983, 4: 181-201.

110 O’Leary A. Op cit. Ref 94.

111 Lubben J.E. Models for delivering long term care. Homehealth care services quarterly,1987,8:5-22.

112 Litwin H., Lightman E. The development of commu-nity care policy for the elderly: A comparative perspec-tive. International journal of health services, 1996, 26: 691-708.

113 Damron-Rodriguez J., Lubben J.E. A framework forunderstanding community health care in ageing societies.International Meeting on Community Health Care in Age-ing Societies. WHO Kobe Centre, 2000.


community. Damron-Rodriguez and Lubbendescribe four main models of communitycare. 114 These are:1. Communal care model;2. Marketplace model;3. Case management model;4. Managed care organization model.

These four models differ according tohow the following aspects of care are dealtwith:n Elder’s role: How involved is the older

person in care arrangements?n Self-care: How is self-care treated in care

planning?n Social network: Are family, friends and

neighbours integrated into the care plan?n Agency care: Do community agencies

compete or coordinate?n Payment source: Do payment sources

coordinate funding of services?

Table 8: Models of community care

Model of care

Communal care Marketplace care Case management Managed care

Elder’s role: How involved Older person remains Older person maintains Case manager Case manager moderatesis the older person in in the community extensive discretion moderates older person’scare arrangements? on care older person’s discretion

discretionSelf-care: How is self-care Receives instruction in May purchase instruction Case manager Case manager strongly

treated in care planning? community support and support from encourages and encourages andmarket place facilitates facilitates

Social network: Are family, Mostly uncoordinated No formal coordination Case manager Case manager stronglyfriends and neighbours encourages and encourages andintegrated into the care helps coordinate helps coordinateplan?

Agency care: do community A web of volunteer Autonomous agencies, Mostly autonomous Extensive coordination ofagencies compete or community-based generally in agencies, formal partnershipscoordinate? services competition but some

collaborationPayment source: Do Free Uncoordinated payment Often some Robust coordination

payment sources sources coordination of payment sourcescoordinate funding of paymentservices? sources

Payment type: What form Little or none Fee for service Fee for service Pre-paid capitation forof payment is rendered majority of carefor delivered services?

Coordination: Is there a Generally nonexistent Generally nonexistent, Semi-formalized Formalized with strongformalized attempt to ad hoc if at all authority given tocoordinate care care managerprovisions?

Source: Based on Damron-Rodriguez J. and Lubben J.E. Op cit. Ref 113.

n Payment type: What form of payment isrendered for delivered services?

n Coordination: Is there a formalized at-tempt to coordinate care provisions?The characteristics of each of these mod-

els are summarized in Table 8.1. Communal care model. The commu-

nal care model relies mainly on volunteer orfree care services provided in the commu-nity. These free services might be providedby local agencies, the government, religiousgroups, charities or other community orga-nizations.

In most communities, some level of com-munal care is available, but this often needsto be supplemented by other forms of com-munity care. Since this care is free it has tobe rationed to those most in need or least

114 Ibid.


able to purchase services. In China, the‘three nos’ test (no family, no source of in-come and no ability to work) is applied. Theprototype of this model is the Chinese sys-tem where the work-unit-based collective(to which the older person once belongedas a worker) is responsible for providingcommunal care services .115

2. Marketplace model. The marketplacemodel is based on older people and/or theirfamilies locating and paying for the servicesthey want. In effect, the older person or theirfamily decide what they need and coordi-nate the services themselves. Access to ser-vices depends on the capacity of the olderperson or their family to pay for services.

3. Case management model. The casemanagement model of community care pro-vides for a much more coordinated and in-tegrated system of care.116 The case manageris heavily involved in identifying care needsand locating appropriate services. The casemanager draws on whatever suitable re-sources are available – family, local networksand the purchase of specific care and healthservices. Health visitors and communityhealth workers may perform this coordinat-ing role.

4. Managed care organization model. Thismodel of care has been developed more inthe United States of America than in devel-oping countries. It is a development of thecase management model that is aimed atcontaining the costs of care. A case managercoordinates all care and has considerableauthority in decisions about what care willbe provided, by whom and for how long.117

These care managers negotiate the bestprices with care providers and specify thetype of care to be provided. The managedcare is the most highly formalized of the fourmodels and in important respects approachesthe institutional care end of the care spec-trum.118

Each model relies on as much self careand family support as possible. The phi-losophy of community health modelsis to augment, rather than replace,self and family care. By supporting selfand family care, the goal is to ensure ad-equate care, avoid unsustainable demands

on families, fill the gaps that are created bydifferent family circumstances and reducethe level of demand on institutional care.

Family-based approachesIn all countries in the Region, family mem-bers are the major source of care and sup-port for older people. However, indeveloping countries there is a greater reli-ance on family members as a means of sup-

Key points1. Central governments have limited resources to direct towards

health.2. Therefore, community-based strategies are fundamental to good

health promotion.3. Planning, regulating and facilitating at the local government level can

have significant effects on the environment in which individuals liveand, as such, can make important contributions to better health.

4. Local communities represent a potentially enormous resource forthe promotion of better health among older people.

5. Community-based housing can contribute to healthier ageing.6. Community care of the elderly is a desirable way of caring for older

people.7. Community involvement represents a way of empowering older

people.8. Community-based delivery of health services is a desirable model of

health care delivery.9. Community health workers have a key role to play in health

promotion at the community level by:a. lobbying local and other authorities for actions that lead tobetter health;b. being proactive in detecting diseases;c. assisting older people by reducing isolation and using the socialresources available in the community; andd. involving individuals in their own health actions.

10.The role of community health models is to augment, rather thanreplace, self and family care.

115 Leung J., Wong Y.C. Community-based service for thefrail elderly of China. Journal of international social work,(in press).

116 Applebaum R., Mayberry P. Long-term care case man-agement: A look at alternative models. Gerontologist, 1996,36: 701-705.

117 Abrahams R. et al. Variations in care planning practicein the Social/HMO: An exploratory study. Gerontologist,1989, 29: 725-736.

118 Hanson J.C. Practical lessons for delivering integratedservices in a changing environment. Generations, 1999,23: 22-28.


porting active ageing among older people.More developed health systems and govern-ment-based income support systems meanthat in developed countries older people arenot as reliant on families. In developingcountries, both cultural values and the ab-sence of government-based support systemsmean that older people are more reliant onfamily members for housing and other formsof support.

Urbanization and population changehave major implications for the role of fam-ily members in health promotion in later life.Urban migration can mean that older peopleare left behind in rural locations withoutadequate financial, health or social re-sources. Those who move to cities with theirchildren can suffer the social dislocation in-volved in such a move and the consequencesof overcrowding, inadequate housing andenvironments that may not be conducive toactive ageing.

Rapidly declining fertility will havelonger-term consequences for men andwomen in later life. The fewer children aperson has, the greater the chances that theolder person will be left without family sup-port in later life. Changing roles of womenwill also have implications for the extent towhich women are willing and able to pro-vide high levels of care and support for olderfamily members.

The pressures on families in the face ofrapid social change mean that health-pro-motion strategies need to take this declin-ing family role into account. Strategies alsoneed to be developed to enable families toprovide support to older family members.Imaginative ways of enabling families tobalance the demands of modern urban soci-ety and traditional demands are required.

The individual approachThe lifestyle choices of individuals contrib-ute to their risk of contracting chronic dis-eases and disabilities. These choices areshaped, but not determined, by the cultureand social structure in which a person lives.Individuals still make choices. The goal ofstructural and cultural change is to make the

healthy choices easier. Nevertheless, the in-dividual still has to make those choices.

People who practice preventive healthbehaviour live longer and have lower mor-bidity than those who do not.119 120 121 Indi-vidual-based strategies of health promotionare designed to persuade individuals tochange their lifestyle – to eat healthier foods,exercise appropriately, stop smoking and re-duce alcohol consumption.

The individually oriented approach is aneducational model that seeks to convinceindividuals to change their health-relatedbehaviour. It assumes that providing accu-rate information will cause individuals to seethe light and adopt healthier lifestyles. Themain challenge for individually oriented in-terventions is to get the information topeople in clear and persuasive ways. Ex-amples of this approach are informationcampaigns that focus on the harmful effectsof smoking, the danger of a high-fat diet andthe consequences of insufficient exercise.The content of information campaigns vary.Some outline the dangers of particularbehaviour, others describe healthy behaviour,some provide tips to assist with behaviouralchange, while others use fear campaigns.

At one level it is difficult to fault thisapproach. Individuals do have to changetheir behaviour. These programmes try topromote individual responsibility and a senseof control over life and this, in itself, can havepositive health outcomes. The question iswhether information-based approaches areeffective in the long run. Human behaviouris not simply a rational response to informa-tion. Even where behaviour is rational in thatit achieves an individual’s goals, it cannotbe assumed that the individual’s goals matchthose of public health campaigns. It maymake sense to get more exercise, smoke lessand eat healthier food if you want to live along and healthy life, but longevity is not

119 Belloc N. B., Breslow L. Relationship of physical healthstatus and health practices. Preventive medicine, 1972, 1:409-421.

120 Krause N. Illness behavior in later life. In: George L.K.Handbook of aging and social sciences. San Diego, Aca-demic Press, 1990.

121 Stuck A.E. et al. Op cit. Ref 103.


Key points1. Community care models need to be

designed to support, rather than replacefamily and individual efforts to care forolder people.

2. While family-based strategies for care ofolder family members will continue to beimportant, changes to family structuresthat accompany modernization will meanthat family supports will need to besupplemented by other ways of assistingolder people with health problems.

3. Individual older people are a key part ofensuring they have good health in laterlife. They need to be enabled andencouraged to make changes and takeresponsibility for their own health.

4. Changes to a person’s environment willbe part of the process of enabling andempowering that individual to behave in ahealth-promoting way.

5. Health education and literacy is morethan making information available.Individuals must be convinced that thechanges implied by the information arebelievable and worthwhile.

necessarily a goal of all people. Health maynot be a priority.

Individuals process information ratherthan simply absorbing it. This process in-cludes judgements about whether:

The information is believable: Believabil-ity is influenced by the source of the infor-mation. This means that good informationmust come from a credible source.122 Anypromotion campaign based on providing in-formation must ensure that the informationsources are credible to the target audience.

Figure 6: A model of the links between information and action

ActionsDirected towards decision-makers1. Advocate for policies that create an environment that makes it

easier for individuals to adopt healthy modes of behaviour.2. Advocate for greater regulation of food quality, better food

labelling requirements, banning of tobacco advertising, increasingtaxes on tobacco.

3. Work for the creation of safe, exercise-friendly public spaces.4. Develop initiatives to increase access to healthy food at an afford-

able price.

Directed towards individuals1. Increase awareness of individuals regarding the benefits of lifestyle

changes for health in both the short and long terms.2. Help individuals understand that many later-life diseases and

disabilities are either preventable or modifiable by factors that arewithin their own control.

3. Assist individuals in making healthy changes by ways such asteaching them to deal with nicotine addiction, reduce stress andcontrol alcohol consumption, and how to build exercise into theirdaily routines.

4. Provide information about how to change diet, how to cook withdifferent (healthy) foods, and how to make healthy foods enjoyable.

5. Teach older people how to build safe levels of exercise into theirdaily routines.

Lifestyle change is worthwhile: Individu-als weigh up the costs and benefits ofbehaviour change. These assessments willbe based on many more considerations thanthe simple health outcomes. The particularelements of an individual’s cost-benefitsanalysis will vary widely but will probablyinclude matters such as:n the financial cost of change;n the time required to change;n an assessment of how much benefit the

122 O’Leary A. Op cit. Ref94.


change would bring;n how much they value their health;n the extent to which the bad health

behaviour is pleasurable;n the effort required to change.

The effectiveness of information cam-paigns depends on how much a person thinksthat the effort required and the likely ben-efits outweigh these personal costs. Changethat requires considerable immediate costswith the promise of distant gains is likely tobe less attractive than change that bringsimmediate benefits.

This does not mean that good health in-formation should not be developed or thathealth literacy is not important. It does mean,however, that health information and healthliteracy will not be sufficient on their own toproduce the required changes. The type ofinformation that is provided and the way itis framed are important. Providing informa-tion without addressing cultural and struc-tural factors will be of limited value.

Methods of implementinghealth-promotion approachesIt is one thing to argue that effective healthpromotion needs to be directed towards cul-tural, social, community, family and indi-vidual levels, but quite another to know howto go about this targeting. The WHO call foraction in 1990 identified three main prin-ciples when designing and implementinghealth-promotion strategies: advocacy, socialsupport and empowerment.123

AdvocacyHealth is simply one of the competing de-mands facing governments and other deci-sion-makers. In many cases, health,especially that of older people, may be a rela-tively low priority. In order to promote thepolicy-level changes that are required as partof the package of improving the health ofolder people, decision-makers and otheropinion-makers must be aware of both theimportance of health and ways in whichhealthy ageing can be encouraged.

A core part of health promotion is to pro-mote health by ensuring that health remains

high on the public agenda. This means thatdecision-makers and those who influenceopinions need to be convinced of the im-portance of health as a national priority. Thiswill involve lobbying such people to act insupport of health-promoting policies.

Advocacy needs to convince decision-makers that health, including that of the eld-erly, has economic and political benefits. Suchadvocacy is normally directed at convincingdecision-makers to develop policies and en-vironments that enable individuals to makegood health choices.

Advocacy can be directed to health pro-fessionals and service providers to develop abetter balance between health promotion anddisease prevention on the one hand, and cura-tive approaches on the other.

Academics and researchers are also goodtargets for health advocacy. Good quality re-search is required to test and demonstratethe most effective ways of preventing diseasesand disabilities in later life. If academics canbe encouraged to explore the most effectiveways of supporting good health, this evidencecan be used to advocate for better healthpolicies.

Social SupportSince health occurs within a social and cul-tural context (see pages 34, 34) a key part ofpromoting better health is to encouragehealth-supporting social settings. WHO hasadvocated a ‘settings’ approach to health pro-motion that aims to promote health by tar-geting:n community organizations and institu-

tions (e.g. hospitals, schools, workplaces)to foster healthy behaviour and promotecommunity action for better health; and

n infrastructure that has an influence onhealth.

EmpowermentHealth-promotion strategies cannot rely ongovernment resources to achieve betterhealth outcomes. An important element ofhealth promotion in developing countries is

123 Dhillon H.S. and Philip L. Op cit. Ref 82.


to mobilize communities and individuals toachieve better health outcomes.

Mobilizing individuals can take twoforms:n encouraging individuals to behave in

healthier ways; andn preparing individuals for community ac-

tion to work for better health settings.A key part of mobilizing individuals is to

convince them that:n they can do something; andn that doing something can make a differ-

ence.Both these can pose challenges in health

promotion among older people. Where olderpeople are marginalized, feel disempoweredor have become dependent on others (includ-ing experts), it can be difficult to convince themthat they have the capacity to make decisionsand behaviour changes that would make anydifference. A sense of disempowerment comesfrom many sources, including cultural expec-tations of older people, illiteracy, gender, pov-erty and social isolation.

The second challenge is to convince olderpeople that anything they do might make adifference. The message that can empowerindividuals to lifestyle change is that reduc-ing risk factors (e.g. smoking, poor diet) andincreasing protective factors (e.g. good diet,exercise) have health benefits at any age.

A further element of empowering olderpeople is to enable them to self-manage their

Key points1. Health promotion is more than health

education2. Health promotion consists of three main

methods:a. advocacy to decision-makers to createthe conditions for better health and tomake the individual’s healthy choiceseasier choices;b. developing settings that support health;andc. empowerment of individuals andcommunities to act for better health.

24 Lorig K. et al. Arthritis self-management: a study of theeffectivness of patient education in the elderly. Gerontolo-gist, 1984, 24: 455-7.

125 Lorig K. et al. Arthritis patient education: a review ofthe literature. Patient education and counselling, 1987, 10:

126 Clark N. M. et al. Impact of self management educa-tion on the functional health status of older adults withheart disease. Gerontologist, 1992, 32: 438-43.

127 Clark N. M. et al. Self management of heart disease byolder adults: assesment of an intervention based on cog-nitive theory. Research on aging, 1997, 19: 362-82.

health. This may involve prevention of ill-ness and disabilities or self-management ofchronic disease and disabilities if they de-velop. Recent research has concluded thathelping people to self-manage chronic dis-ease has a positive impact on pain, depres-sion etc. The main reason for the beneficialeffects of self-management are associated



with a greater sense of self-efficacy. 124 125 126 127

Epidemiological approaches to health careinvolve:

“…the study of the distribution anddeterminants of health states orevents in specified populations, andthe application of this study to thecontrol of health problems.” 128

Epidemiological approaches are an essen-tial tool in health promotion and health plan-ning.

Social, spatial and age-relatedhealth patternsEpidemiological methods are based on thecollection of systematic evidence about thecharacteristics of people who suffer fromparticular diseases and disabilities. As wellas collecting information about the disease,these data collections also obtain informa-tion about the frequency with which diseasesappear in particular counties and regions,among different social groups, among menand women, in different age groups, patternsat different times of the year and so forth.

Epidemiological analysis provides a mapof the distribution of health and ill-health.This map can show where and among whomparticular diseases are most common, andgroups where the same disease is rare. Thesehealth maps serve many purposes. One im-portant function is to pinpoint where andamong which types of people needs are great-est. This information assists in establishingpreventative health priorities and in ensur-ing that health support services and interven-

Epidemiology andHealth Promotion

tions are directed to areas of greatest need.As far as community-based health promo-tion is concerned, this assists with commu-nity planning.

One of the problems encountered inmany countries, especially many developingnations, is that good quality statistical infor-mation is unavailable and good statisticalcollection systems have not been established.

Identifying trendsIn addition to mapping the distribution ofdiseases, epidemiological analysis trackschanges over time. Careful tracking helpsspot emerging health problems and helpsdetect those that are declining, thus enablingthe deployment of limited resources to ar-eas of greatest need. By anticipating areasof need through trend analysis, epidemio-logical analysis can lead to early interven-tions and prevent health problems fromescalating out of control.

Discovering correlatesand causesIn the process of mapping the distributionof diseases and disease trends, epidemiologi-cal analysis plays an important role in find-ing likely causes of ill-health. Whileepidemiology cannot locate causes with themethodological rigour of clinically controlledtrials, they can, nevertheless, highlight thetypes of factors which, if modified, shouldlead to better health outcomes. Even where

128 World Health Organization. Op cit. Ref 83.


ActionsDirected towards decision-makers1. Advocate for routine health reporting

mechanisms so that epidemiological datacan be collected in a standardized andregular manner.

2. Argue for training to be made available tohealth workers so that epidemiologicaldata can be interpreted and appliedaccurately.

3. Use epidemiological data for planning atthe community level. This will helpensure that community-based planningand programme development is based ona sound statistical base.

4. Where available, use epidemiological datato provide a baseline against which toevaluate the effectiveness of healthpromotion and disease preventioninterventions.

Key points1. Health promotion requires good research

regarding the distribution and determi-nants of health and illness

2. Mapping the distribution of health andillness helps:a. target interventions and promotions

more effectively;b. identify trends in diseases and disabili

ties;c. identify factors associated with diseases

and thus point to possible interventionstrategies; and

d. identify populations in which targetedhealth screening may be warranted.

the causal mechanisms are not revealed byepidemiological methods, they can still iden-tify effective interventions. For example,even before the precise mechanism by whichtobacco had its damaging effects wasknown, it was clear that tobacco controlwould reduce the incidence of certain dis-eases.

Targeted screeningBy helping identify the most at-risk groups,epidemiological research provides a basis fortargeted screening for diseases as part of dis-ease prevention. While universal vaccinationprogrammes have been effective in control-

ling many infectious diseases, universalscreening is not feasible, necessary or ef-fective when detecting non-symptomaticdiseases. Such universal screening strate-gies, such as for breast cancer, prostate can-cer or diabetes, are very expensive and arenot necessarily cost-effective. Knowing theepidemiology of any disease will contrib-ute greatly to more effective screening strat-

129 Bloom H.G. Op cit. Ref 104.


egies and conserve scarce health funds fortreatments and targeted interventions.129

The purpose of this document is to outlinethe factors that need to be incorporated intoa health-promotion approach for achievinghealthy ageing among the developing coun-tries in the Western Pacific Region of WHO.It has been argued that there is no alterna-tive to health promotion as a way of respond-ing to the rapidly emerging epidemic ofnoncommunicable diseases and disabilitiesin the developing countries of the Region.

However, the task of health promotionwill not be easy.

Life course challengesMany of the chronic diseases and disabili-ties that emerge in later life are the result ofthe cumulative effect of a lifetime of risk fac-tors. To reduce the risk of chronic disease inlater life, the lifestyles of people will need tobe tackled much earlier in the life course,when the advantages of such behaviouralchange are not so evident.

PovertyThe health of older people in developingcountries must be seen as part of the widercontext in which millions of people are partof a vicious cycle of poverty, illiteracy, mal-nutrition, disempowerment and despair. 130

Poverty and the poor living conditions (e.g.poor nutrition, poor housing, environmen-tal degradation) associated with poverty area major impediment to improving the healthof older people in developing countries. Un-less fundamental changes are made to this

wider context it will be difficult to makemajor advances in improving the health con-ditions of older people. The challenge of re-ducing poverty in the short or intermediateterm cannot be underestimated.

Economic prioritiesTypically, developing countries are seekingto achieve rapid economic gains and devel-opment. The normal way in which they seekto achieve this is by industrialization andfood production that gives priority to foreignmarkets and earning foreign exchange. 131

This can mean that insufficient attention isgiven to the needs of local citizens. This canresult in low wages and poverty, poor nutri-tion and environmental degradation, all ofwhich have serious health consequences.

Most developing countries have limitedresources and many competing demands forthese resources. International donors tendto encourage activities that promote eco-nomic development and have quick and vis-ible outcomes.132 In this context, thechallenge is to convince policy-makers andothers that expenditure on the health of olderpeople (many of whom may no longer beeconomically productive) is more importantthan other expenditure demands.

The challenge for health promotion is toconvince policy-makers that good health isan economic asset rather than a cost – thathealth is an essential component of socialand economic development.

The Challenges ofHealth Promotion inDeveloping Countries

130 Dhillon H.S. and Philips L. Op cit. Ref 82.131 Dhillon H.S. and Philips L. Op cit. Ref 82.132 Dhillon H.S. and Philips L. Op cit. Ref 82.


EducationLow levels of literacy and health literacy pro-vide particular challenges for a health-pro-motion approach. This can be a specialproblem when trying to promote betterhealth behaviour among older people,where there may be poor levels of knowl-edge about the factors that contribute tothe noncommunicable diseases of later life.

The same type of problem can be an is-sue when advocating at government levelsfor a health-promotion approach across allsectors of government. In developing coun-tries (and other countries for that matter),decision-makers are not always fully awareof the health implications of public policydecisions in other sectors.

Political stabilityWhere there is political instability, internalconflict and war, it is extremely difficult todevelop health-promoting environments.Not only are the economic resources andpriorities of governments directed elsewhere,the regulatory environment to create health-supportive settings is lacking.

Intersectoral cooperationHealth promotion requires a reorienting ofhealth systems from tertiary or curative pre-vention strategies to primary and secondaryprevention models. This reorientation willoften be resisted by those whose experienceis limited to curative medicine and who haveinterests in maintaining the current empha-sis on the ‘find it and fix it’ approach. Thisapproach may be advocated by doctors, butalso by pharmaceutical companies and thosewho have an interest in the institutions ofcurative health (hospitals etc.).

As well as reorienting the health system,a health-promotion approach requires thatall sectors place a much greater focus on thehealth implications of public policies in ar-eas that appear to be only indirectly relatedto health. Not only may decision-makers inother sectors be unaware of the health im-plications of their policies, their competingpriorities may lead them to disregard thehealth implications of their decisions.

Commercial interestsSome businesses do not necessarily have thehealth of citizens of developing countriesuppermost in their priorities. The desire tomarket products will often result in poorhealth outcomes. The role of tobacco com-panies in marketing tobacco in developingcountries is the most obvious example of thischallenge to public health. However, themarketing of western food products that arehigh in fat and sugar, and the aggressivemarketing of alcohol, are all examples ofcommercial interests that represent a toughchallenge for health promotion. Commercialpromotion of unhealthy products andlifestyles can make it particularly difficult tomake healthy choices the easy or attractivechoices. Regulation of the activities of somecommercial interests is required, but politi-cal will is not necessarily sufficient to intro-duce useful levels of regulation or thepolicing of regulations. The taxes gainedfrom unhealthy products can be an impor-tant source of government funds, and im-poverished governments can find it difficultto resist this source of revenue.

The double burden of diseaseOne of the particular challenges that facedeveloping countries is that the epidemic ofnoncommunicable disease is developing be-fore the burden of infectious disease has beendealt with. The increasing challenge posedby HIV/AIDS simply makes the burden ofdisease worse. The difficulty faced by devel-oping nations is to deal with these dualsources of disease without adequate eco-nomic resources to do so.

The speed of changePopulations in the developing world will ageat a much faster rate than countries in thedeveloped world have (see page 7 ). It ismuch easier for countries to adjust to gradualpopulation transitions than to these rapidchanges. It is doubly difficult to respond tosuch rapid changes when the adjustmentsmust be made before a country has devel-oped a level of affluence that allows for theexpenditure required to meet the new chal-lenges.


Economic development is occurring ata rapid rate and this has led to rapid urban-ization. This has taken place at such a ratethat family and social policy systems havenot kept pace. Urbanization has, in manycases, disrupted kinship networks and madeit much more difficult for them to providethe support for older people that they oncedid. At the same time, governments have notdeveloped the welfare safety net that is pro-vided in developed countries. The speed ofthe transition and the economic cost hasmade it next to impossible for governmentsto provide for the needs of older citizens.

Empowerment and controlThe evidence indicates that health promo-tion is most effective when individuals andcommunities are empowered and able to ex-ercise choice and control over their lives. En-abling individuals and communities to actto improve their health is less easy to achievein some societies. It is especially challeng-ing when working with groups and commu-nities that have been disempowered and who

do not have the sense of self-efficacy to takecharge of their own health behaviour. n


The ageing of developing countries in theWestern Pacific Region and the subsequentepidemic of noncommunicable diseasesposes a major health challenge. This chal-lenge must be met by countries with limitedeconomic resources and, in many cases, be-fore the problem of communicable diseasesis under control. It has been argued that theonly way in which the challenge can be metis by adopting health-promotion strategies,rather than relying on the tertiary preven-tion strategies of curative medicine.

Decision-makers and health workers, aswell as individuals themselves, will need toaddress the lifestyle factors and healthbehaviour that are contributing to the explo-sion of noncommunicable disease amongolder people. However, simply encouragingindividuals to behave in healthy ways willnot solve the problem. The settings/environ-ments in which individuals live must also betransformed so that they promote the healthof individuals and enable them to makehealthy choices.

Summary

Health promotion must always be a two-pronged strategy. It must encourage indi-viduals to behave in healthy ways and buildan environment which both enables healthybehaviour and ensures that the environmen-tal determinants of health are set correctly.

Creating health-promoting environ-ments and enabling individuals to behavein healthy ways can mean that substantialsocial and economic changes are required.These changes will often be necessary in or-der to empower individuals to act for healthchange and to ensure that the health-dam-aging impacts of social, economic and gen-der inequalities are alleviated.

Ultimately, healthier outcomes will re-sult when many different elements of a so-ciety are working towards healthieroutcomes. This means that health promo-tion will seek to achieve better healththrough cultural, social and economicchange, as well as by health systems reform.Better health will also require that the localcommunity is directed towards achievinghealth-supporting settings for older peopleand supporting families and individuals tobehave in ways that result in better physi-cal, mental and social health for the grow-


Appendices

The most up-to-date and comprehensive reviewof the evidence of the effectiveness of healthpromotion is provided in:

The evidence of health promotion effective-ness: shaping public health in a new Europe

This is a report for the European Commis-sion by the International Union for HealthPromotion and Education, assessing 20 yearsevidence of the health, social, economic andpolitical impacts of health promotion and rec-ommendations for action. Part One: Core docu-ment. Part Two: Evidence book. Details can befound at: http://www.iuhpe.nyu.edu/pubs/index.html

Other useful references regarding evi-dence of the effectiveness of health promo-tion are:Arblaster L. et al. Review of the research on the

effectiveness of health service interventions toreduce variations in health. CRD Report 3,York University, U.K. NHS Centre for Re-views & Dissemination, 1995.

Baum F. The new public health: an Australianperspective. University Press, 1998.

Cattan M, White X. Developing evidence-basedhealth promotion for older people: a sys-tematic review and survey of health promo-tion interventions targeting social isolationand loneliness among older people. InternetJournal of Health Promotion 1998; http://www.monash.edu.au/health/IJHP/1998/13 .

Doyle N. The effectiveness of policy in healthpromotion. Paper at Second InternationalSymposium On The Effectiveness Of HealthPromotion. University of Toronto, May 28-30, 2001. http://www.utoronto.ca/chp/doyle.doc

Freimuth VS, Kraus Taylor M. Are mass medi-ated health campaigns effective? A review ofthe empirical evidence. University of Mary-land, 1995.

Harris MA et al. Preventative healthprogrammes for the elderly: a critical re-view. Australian Journal of Ageing, 1996,15: 148-54

Hodgson R, Abbasi T, Clarkson J. Effectivemental health promotion: a literature re-view. Health Education Journal, 1996, vol.55: 55-74.

Hyndman B. Does self help help: a review ofthe literature on the effectiveness of self-help programs. ParticipACTION. Fall,1996.Mittelmark MB et al. Realistic out-comes: lessons from community-basedresearch and demonstration programs forthe prevention of cardiovascular diseases.Journal of Public Health Policy, 1993, Vol14, No. 4 : 437-462.

Nutbeam D, Harris E. Theory in a nutshell: aguide to health. Sydney, McGraw Hill, 1999.

Patterson C, Chambers L. Preventive healthcare. The Lancet, 1995, 345:1611-15.

Raeburn J, Sidaway A. Effectiveness of mentalhealth promotion: a review. Department ofBehavioural Science, University ofAuckland, April 1995.

Victor C, Howse K. Promoting health of olderpeople: setting a research agenda, London,Health Education Aurthority, 2000.

Windsor R, Baranowski T, Clark N. Evaluationof health promotion, health education anddisease prevention programs with PowerWeb,Second Edition. Mountain View, McGraw-Hill Publishing Company, 1994.

Appendix A: Selected resources on the evidence for the effectiveness ofhealth promotion


Appendix B: Prevalence rates, age of onset and duration by gender for selected diseases of laterlife in countries in the Western Pacific Region

The statistics below are based on those provided by Murray and Lopez (Murray and Lopez, 1990). While statistics are not specificallyavailable for the Western Pacific Region, most Western Pacific Region countries (bold in lists below) are included in one of the three groupsof countries in the prevalence charts.

Established Market economies Other Asia and Islands

Andorra American SamoaAustralia BangladashAustria BhutanBelgium Brunei DarussalamBermuda CambodiaCanada Cook IslandsChannel Islands Micronesia, Federated States ofDenmark FijiFaeroe Islands French PolynesiaFinland GuamFrance Hong Kong, ChinaGermany IndonesiaGibraltar Johnston IslandGreece KiribatiGreenland Korea, Democratic Peoples RepublicHoly See Korea, Republic ofIceland Lao People’s Democratic RepublicIreland Macao, ChinaIsle of Man MalaysiaItaly MaldivesJapan Marshall IslandsLiechenstein MauritiusLuxembourg MongoliaMonaco MyanmarNetherlands NauruNew Zealand NepalNorway New CaledoniaPortugal Northern Mariana IslandsSan Marino PalauSt Pierre and Miquelon Papua New GuineaSweden PhilippinesSwitzerland Pitcairn IslandsUnited Kingdom ReunionUnited States Seychelles

SingaporeSolomon IslandsSri LankaThailandTokelauTongaVanuatuViet NamWake IslandWallis and Futuna(Western) Samoa

Acute myocardial infarction (heart attack)


Angina

Breast cancer

Cataracts

Cerebrovascular disease (1st stroke)


Cervical and related cancer

Colon cancer

Congestive heart disease

Chronic obstructive pulmonary disease


Dementia

Diabetes

Glaucoma

Lung cancer


Osteoarthritis (hip)

Osteoarthritis (knee)

Parkinson’s disease

Prostate cancer


Rheumatoid athritis Suicide


Advocacy for healthA combination of individual and social actionsdesigned to gain political commitment, policysupport, social acceptance and systems supportfor a particular health goal or programme.

CommunityA specific group of people, often living in adefined geographical area, who share a com-mon culture, values and norms, and are ar-ranged in a social structure according torelationships which the community has devel-oped over a period of time. Members of a com-munity gain their personal and social identityby sharing common beliefs, values and normswhich have been developed by the communityin the past and may be modified in the future.They exhibit some awareness of their identityas a group, and share common needs and acommitment to meeting them.

Empowerment for healthIn health promotion, empowerment is a pro-cess through which people gain greater controlover decisions and actions affecting theirhealth.

Empowerment may be a social, cultural,psychological or political process throughwhich individuals and social groups are able toexpress their needs, present their concerns,devise strategies for involvement in decision-making, and achieve political, social and cul-tural action to meet those needs. Through sucha process, people see a closer correspondencebetween their goals in life and a sense of howto achieve them, and a relationship betweentheir efforts and life outcomes. Health promo-tion encompasses actions, not only directed atstrengthening the basic life skills and capacitiesof individuals, but also at influencing underly-ing social and economic conditions and physi-cal environments which impact upon health. Inthis sense, health promotion is directed at creat-ing the conditions which offer a better chanceof there being a relationship between the ef-forts of individuals and groups, and subsequenthealth outcomes in the way described above.

A distinction is made between individualand community empowerment. Individualempowerment refers primarily to the

individual’s ability to make decisions and havecontrol over their personal life. Communityempowerment involves individuals acting col-lectively to gain greater influence and controlover the determinants of health and the qualityof life in their community, and is an importantgoal in community action for health.

EpidemiologyEpidemiology is the study of the distributionand determinants of health-states or events inspecified populations, and the application ofthis study to the control of health problems.

Health behaviourAny activity undertaken by an individual, re-gardless of actual or perceived health status, forthe purpose of promoting, protecting or main-taining health, whether or not such behaviouris objectively effective towards that end.

Health expectancyHealth expectancy is a population-based mea-sure of the proportion of expected life spanestimated to be healthful and fulfilling, or freeof illness, disease and disability, according tosocial norms and perceptions and professionalstandards.

Health literacyHealth literacy represents the cognitive andsocial skills which determine the motivationand ability of individuals to gain access to,understand and use information in ways whichpromote and maintain good health.

Health literacy implies the achievement ofa level of knowledge, personal skills and confi-dence to take action to improve personal andcommunity health by changing personallifestyles and living conditions. Thus, healthliteracy means more than being able to readpamphlets and make appointments. By improv-ing people’s access to health information, andtheir capacity to use it effectively, health lit-eracy is critical to empowerment. Health literacyis itself dependent upon more general levels ofliteracy. Poor literacy can affect people’s healthdirectly by limiting their personal, social andcultural development, as well as hindering thedevelopment of health literacy.

Appendix C: Glossary(WHO definitions as provided in the WHO Health Promotions Glossary http://www.who.int/hpr/backgroundhp/glossary/glossary.pdf)


Health-promoting hospitalsA health-promoting hospital, not only provideshigh quality comprehensive medical and nurs-ing services, but also develops a corporateidentity that embraces the aims of health pro-motion; develops a health-promoting organiza-tional structure and culture, including active,participatory roles for patients and all membersof staff; develops itself into a health-promotingphysical environment; and actively cooperateswith its community.

Health sectorThe health sector consists of organized publicand private health services (including healthpromotion, disease prevention, diagnostic, treat-ment and care services), the policies and activi-ties of health departments and ministries,health-related nongovernmental organizationsand community groups, and professional asso-ciations.

Healthy citiesA healthy city is one that is continually creatingand improving those physical and social envi-ronments and expanding those communityresources which enable people to mutuallysupport each other in performing all the func-tions of life and in developing to their maxi-mum potential.

Healthy islandsA healthy island is one that is committed toand involved in a process of achieving betterhealth and quality of life for its people, andhealthier physical and social environments inthe context of sustainable development.

Healthy public policyHealthy public policy is characterized by anexplicit concern for health and equity in allareas of policy, and by an accountability forhealth impact. The main aim of healthy publicpolicy is to create a supportive environment toenable people to lead healthy lives. Such apolicy makes healthy choices possible or easierfor citizens. It makes social and physical envi-ronments health-enhancing.

Intersectoral collaborationA recognized relationship between part or partsof different sectors of society which has beenformed to take action on an issue to achievehealth outcomes or intermediate health out-comes in a way which is more effective, effi-cient or sustainable than might be achieved bythe health sector acting alone.

Settings for healthThe place or social context in which peopleengage in daily activities in which environmen-tal, organizational and personal factors interactto affect health and well-being.

Social capitalSocial capital represents the degree of socialcohesion which exists in communities. It refersto the processes between people which estab-lish networks, norms, and social trust, andfacilitate coordination and cooperation formutual benefit.

Social networksSocial relations and links between individualswhich may provide access to or mobilization ofsocial support for health.

Social supportThat assistance available to individuals andgroups from within communities which canprovide a buffer against adverse life events andliving conditions, and can provide a positiveresource for enhancing the quality of life.

AgeingandHealth

AgeingandHealthA HEALTH PROMOTIONAPPROACH FORDEVELOPING COUNTRIES

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HEALTH PROMOTION APPROACH FOR DEVELOPING COUNTRIES

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