Who - Active Ageing 'A Policy Framework'

ACTIVE AGEING: A POLICY FRAMEWORK
WHO/ NMH/ NPH/ 02.8

DISTR.: GENERAL
ORIG.: ENGLISH
Acti ve Agei ng
A Poli cy Framework
World Health Organization
Noncommunicable Diseases and Mental Health Cluster
Noncommunicable Disease Prevention and Health Promotion Department
Ageing and Life Course
PAGE 2
Thi s Poli cy Framework i s i ntended to i nform
di scussi on and the formulati on of acti on plans
that promote healthy and acti ve agei ng. I t was
developed by WHO s Agei ng and Li fe Course
Programme as a contri buti on to the Second
Uni ted Nati ons World Assembly on Agei ng,
held i n Apri l 2002, i n Madri d, Spai n. The
preli mi nary versi on, publi shed i n 2001 enti tled
Health and Ageing: A Discussion Paper, was
translated i nto French and Spani sh and wi dely
ci rculated for feedback throughout 2001
( i ncludi ng at speci al workshops held i n Brazi l,
Canada, the Netherlands, Spai n and the Uni ted
K i ngdom) . I n January 2002, an expert group
meeti ng was convened at the WHO Centre for
Health Development ( WK C) i n K obe, Japan,
wi th 29 parti ci pants from 21 countri es. De-
tai led comments and recommendati ons from
thi s meeti ng, as well as those recei ved through
the previ ous consultati on process, were com-
pi led to complete thi s nal versi on.
A complementary monograph enti tled
Active Ageing: From Evidence to Action i s
bei ng prepared i n collaborati on wi th the I nter-
nati onal Associ ati on of Gerontology ( I AG) and
wi ll be avai lable at http://www.who.i nt/hpr/
agei ng where more i nformati on about agei ng
from a li fe course perspecti ve i s also provi ded.
A contribution of the World Health Organization to the
Second United Nations World Assembly on Ageing,
Madrid, Spain, April 2002.
PAGE 3
Contents
Introduction 5
1. Global Ageing: A Triumph and a Challenge 6
The Demographi c Revoluti on 6
Rapi d Populati on Agei ng i n Developi ng Countri es 9
2. Active Ageing: The Concept and Rationale 12
What i s Acti ve Agei ng? 12
A Li fe Course Approach to Acti ve Agei ng 14
Acti ve Agei ng Poli ci es and Programmes 16
3. The Determinants of Active Ageing: Understanding the Evidence 19
Cross-Cutti ng Determi nants: Culture and Gender 20
Determi nants Related to Health and Soci al Servi ce Systems 21
Behavi oural Determi nants 22
Determi nants Related to Personal Factors 26
Determi nants Related to the Physi cal Envi ronment 27
Determi nants Related to the Soci al Envi ronment 28
Economi c Determi nants 30
4. Challenges of an Ageing Population 33
Challenge 1: The Double Burden of Di sease 33
Challenge 2: I ncreased Ri sk of Di sabi li ty 34
Challenge 3: Provi di ng Care for Agei ng Populati ons 37
Challenge 4: The Femi ni zati on of Agei ng 39
Challenge 5: Ethi cs and I nequi ti es 40
Challenge 6: The Economi cs of an Agei ng Populati on 42
Challenge 7: Forgi ng a New Paradi gm 43
5. The Policy Response 45
I ntersectoral Acti on 46
K ey Poli cy Proposals 46
1. Health 47
2. Parti ci pati on 51
3. Securi ty 52
WHO and Agei ng 54
I nternati onal Collaborati on 55
Conclusi on 55
6. References 57
PAGE 4
This booklet uses t he Unit ed Nat ions st andard of age 60 t o describe older people. This may
seem young in t he developed world and in t hose developing count ries where maj or gains in
life expect ancy have already occurred. However, what ever age is used wit hin different con-
t ext s, it is import ant t o acknowledge t hat chronological age is not a precise marker for t he
changes t hat accompany ageing. There are dramat ic variat ions in healt h st at us, part icipat ion
and levels of independence among older people of t he same age. Decision-makers need t o
t ake t his int o account when designing policies and programmes for t heir older populat ions.
Enact ing broad social policies based on chronological age alone can be discriminat ory and
count erproduct ive t o well being in older age.
How Old is Older?
The hands you see i n the background desi gn of thi s paper are celebrati ng the worldwi de
tri umph of populati on agei ng. I f you fan the pages qui ckly, you wi ll see them applaudi ng the
i mportant contri buti on that older people make to our soci eti es, as well as the cri ti cal gai ns i n
publi c health and standards of li vi ng that have allowed people to li ve longer i n almost all parts
of the world.
Thi s text and the preli mi nary versi on of the paper were drafted by Peggy Edwards, a Health
Canada consultant based for si x months at WHO , under the gui dance of WHO s Agei ng and Li fe
Course Programme. The support from Health Canada at all phases of the project i s gratefully
acknowledged.
PAGE 5
I ntroducti on
Populati on agei ng rai ses many fundamental
questi ons for poli cy-makers. How do we help
people remai n i ndependent and acti ve as they
age?How can we strengthen health promo-
ti on and preventi on poli ci es, especi ally those
di rected to older people?As people are li vi ng
longer, how can the quali ty of li fe i n old age
be i mproved?Wi ll large numbers of older
people bankrupt our health care and soci al
securi ty systems?How do we best balance the
role of the fami ly and the state when i t comes
to cari ng for people who need assi stance, as
they grow older?How do we acknowledge
and support the major role that people play as
they age i n cari ng for others?
Thi s paper i s desi gned to address these ques-
ti ons and other concerns about populati on
agei ng. I t targets government deci si on-mak-
ers at all levels, the nongovernmental sec-
tor and the pri vate sector, all of whom are
responsi ble for the formulati on of poli ci es and
programmes on agei ng. I t approaches health
from a broad perspecti ve and acknowledges
the fact that health can only be created and
sustai ned through the parti ci pati on of multi ple
sectors. I t suggests that health provi ders and
professi onals must take a lead i f we are to
achi eve the goal that healthy older persons re-
main a resource to their families, communities
and economies, as stated i n the WHO Brasi li a
Declarati on on Agei ng and Health i n 1996.
Part 1 descri bes the rapi d worldwi de
growth of the populati on over age 60, espe-
ci ally i n developi ng countri es.
Part 2 explores the concept and rati onale
for acti ve agei ng as a goal for poli cy and
programme formulati on.
Part 3 summari zes the evi dence about
the factors that determi ne whether or not
i ndi vi duals and populati ons wi ll enjoy a
posi ti ve quali ty of li fe as they age.
Part 4 di scusses seven key challenges as-
soci ated wi th an agei ng populati on for gov-
ernments, the nongovernmental, academi c
and pri vate sectors.
Part 5 provi des a poli cy framework for
acti ve agei ng and concrete suggesti ons for
key poli cy proposals. These are i ntended
to serve as a baseli ne for the development
of more speci c acti on steps at regi onal,
nati onal and local levels i n keepi ng wi th
the acti on plan adopted by the 2002 Second
Uni ted Nati ons World Assembly on Agei ng.
PAGE 6
1. Global Agei ng:
A Tri umph and a Challenge
Populati on agei ng i s one of humani tys
greatest tri umphs. I t i s also one of our great-
est challenges. As we enter the 21st century,
global agei ng wi ll put i ncreased economi c
and soci al demands on all countri es. At the
same ti me, older people are a preci ous, often-
i gnored resource that makes an i mportant
contri buti on to the fabri c of our soci eti es.
The World Health O rgani zati on argues that
countri es can afford to get old i f governments,
i nternati onal organi zati ons and ci vi l soci ety
enact acti ve agei ng poli ci es and programmes
that enhance the health, parti ci pati on and
securi ty of older ci ti zens. The ti me to plan and
to act i s now.
In all countries, and in developing
countries in particular, measures to
help older people remain healthy
and active are a necessity, not a
luxury.
These poli ci es and programmes should be
based on the ri ghts, needs, preferences and
capaci ti es of older people. They also need to
embrace a li fe course perspecti ve that recog-
ni zes the i mportant i nuence of earli er li fe
experi ences on the way i ndi vi duals age.
The Demographic Revolution
Worldwi de, the proporti on of people age
60 and over i s growi ng faster than any other
age group. Between 1970 and 2025, a growth
i n older persons of some 694 mi lli on or
223 percent i s expected. I n 2025, there wi ll be
a total of about 1.2 bi lli on people over the age
of 60. By 2050 there wi ll be 2 bi lli on wi th
80 percent of them li vi ng i n developi ng
countri es.
Age composi ti on that i s, the proporti onate
numbers of chi ldren, young adults, mi ddle-
aged adults and older adults i n any gi ven
country i s an i mportant element for poli cy-
makers to take i nto account. Populati on
agei ng refers to a decli ne i n the proporti on of
chi ldren and young people and an i ncrease
i n the proporti on of people age 60 and over.
As populati ons age, the tri angular populati on
pyrami d of 2002 wi ll be replaced wi th a more
cyli nder-li ke structure i n 2025 ( see Fi gure 1) .
Population ageing is rst and foremost a success story for public health policies
as well as social and economic development.
Gro Harlem Brundtland, Di rector-General, World Health O rgani zati on, 1999
PAGE 7
Decreasi ng ferti li ty rates and i ncreasi ng
longevi ty wi ll ensure the conti nued greyi ng
of the worlds populati on, despi te setbacks
i n li fe expectancy i n some Afri can countri es
( due to AI DS) and i n some newly i ndepen-
dent states ( due to i ncreased deaths caused
by cardi ovascular di sease and vi olence) . Sharp
decreases i n ferti li ty rates are bei ng observed
throughout the world. I t i s esti mated that by
2025, 120 countri es wi ll have reached total
ferti li ty rates below replacement level ( aver-
age ferti li ty rate of 2.1 chi ldren per woman) , a
substanti al i ncrease compared to 1975, when
just 22 countri es had a total ferti li ty rate below
or equal to the replacement level. The current
gure i s 70 countri es.
Unti l now, populati on agei ng has been mostly
associ ated wi th the more developed regi ons
of the world. For example, currently ni ne of
the ten countri es wi th more than ten mi lli on
i nhabi tants and the largest proporti on of older
people are i n Europe ( see Table 1) . Li ttle
change i n the ranki ng i s expected by 2025
when people age 60 and over wi ll make up
about one-thi rd of the populati on i n countri es
li ke Japan, Germany and I taly, closely fol-
lowed by other European countri es
( see Table 1) .
As t he propor t i on of chi l dren and young peopl e decl i nes and t he propor t i on of peopl e age 60 and over i ncreases, t he
t ri angul ar popul at i on pyrami d of 2002 w i l l be repl aced w i t h a more cyl i nder- l i ke st ruct ure i n 2025.
PAGE 8
Table 1. Count ries wit h more t han 10 million inhabit ant s (in 2002) wit h t he
highest proport ion of persons above age 60
2002 2025
It aly 24.5% Japan 35.1%
Japan 24.3% It aly 34.0%
Germany 24.0% Germany 33.2%
Greece 23.9% Greece 31.6%
Belgium 22.3% Spain 31.4%
Spain 22.1% Belgium 31.2%
Port ugal 21.1% Unit ed Kingdom 29.4%
Unit ed Kingdom 20.8% Net herlands 29.4%
Ukraine 20.7% France 28.7%
France 20.5% Canada 27.9%
Source: UN, 2001
What i s less known i s the speed and si gni -
cance of populati on agei ng i n less developed
regi ons. Already, most older people around
70 percent li ve i n developi ng countri es ( see
Table 2) . These numbers wi ll conti nue to ri se
at a rapi d pace.
Table 2. Absolute numbers of persons (in millions) above 60 years of age in count ries
wit h a tot al populat ion approaching or above 100 million inhabit ant s (in 2002)
2002 2025
China 134.2 China 287.5
India 81.0 India 168.5
Unit ed St at es of America 46.9 Unit ed St at es of America 86.1
Japan 31.0 Japan 43.5
Russian Federat ion 26.2 Indonesia 35.0
Indonesia 17.1 Brazil 33.4
Brazil 14.1 Russian Federat ion 32.7
Pakist an 8.6 Pakist an 18.3
Mexico 7.3 Bangladesh 17.7
Bangladesh 7.2 Mexico 17.6
Nigeria 5.7 Nigeria 11.4
Source: UN, 2001
I n all countri es, especi ally i n developed ones,
the older populati on i tself i s also agei ng.
People over the age of 80 currently number
some 69 mi lli on, the majori ty of whom li ve
i n more developed regi ons. Although people
over the age of 80 make up about one percent
PAGE 9
of the worlds populati on and three percent of
the populati on i n developed regi ons, thi s age
group i s the fastest growi ng segment of the
older populati on.
I n both developed and developi ng countri es,
the agei ng of the populati on rai ses concerns
about whether or not a shri nki ng labour
force wi ll be able to support that part of the
populati on who are commonly beli eved to be
dependent on others ( i .e., chi ldren and older
people) .
The old-age dependency rati o ( i .e., the total
populati on age 60 and over di vi ded by the
populati on age 15 to 60 see Table 3) i s pri -
mari ly used by economi sts and actuari es who
forecast the nanci al i mpli cati ons of pensi on
poli ci es. However, i t i s also useful for those
concerned wi th the management and planni ng
of cari ng servi ces.
Old-age dependency ratios are
changing quickly throughout the
world. I n J apan for example, there
are currently 39 people over
age 60 for every 100 in the age
group 15 60. I n 2025 this number
will increase to 66.
However, most of the older people i n all
countri es conti nue to be a vi tal resource to
thei r fami li es and communi ti es. Many con-
ti nue to work i n both the formal and i nfor-
mal labour sectors. Thus, as an i ndi cator for
forecasti ng populati on needs, the dependency
rati o i s of li mi ted use. More sophi sti cated
i ndi ces are needed to more accurately reect
dependency, rather than falsely categori zi ng
i ndi vi duals that conti nue to be fully able and
i ndependent.
At the same ti me, acti ve agei ng poli ci es and
programmes are needed to enable people to
conti nue to work accordi ng to thei r capaci -
ti es and preferences as they grow older, and
to prevent or delay di sabi li ti es and chroni c
di seases that are costly to i ndi vi duals, fami li es
and the health care system. Thi s i s di scussed
further i n the secti on on work ( page 31) and
i n Challenge 2: I ncreased Ri sk of Di sabi li ty
( page 34) and Challenge 6: the Economi cs of
an Agei ng Populati on ( page 42) .
Table 3. Old age dependency rat io for selected
count ries / regions
2002 2025
Japan 0.39 Japan 0.66
Nort h America 0.26 Nort h America 0.44
European
Union
0.36 European
Union
0.56
Source: UN, 2001
Rapid Population Ageing in
Developing Countries
I n 2002, almost 400 mi lli on people aged 60
and over li ved i n the developi ng world. By
2025, thi s wi ll have i ncreased to approxi mately
840 mi lli on representi ng 70 percent of all older
people worldwi de. ( see Fi gure 2) . I n terms of
regi ons, over half of the worlds older people
li ve i n Asi a. Asi as share of the worlds old-
est people wi ll conti nue to i ncrease the most
whi le Europes share as a proporti on of the
global older populati on wi ll decrease the most
over the next two decades ( see Fi gure 3) .
PAGE 10
PAGE 11
Compared to the developed world, soci o-
economi c development i n developi ng coun-
tri es has often not kept pace wi th the rapi d
speed of populati on agei ng. For example,
whi le i t took 115 years for the proporti on of
older people i n France to double from 7 to
14 percent, i t wi ll take Chi na only 27 years
to achi eve the same i ncrease. I n most of the
developed world, populati on agei ng was a
gradual process followi ng steady soci o-eco-
nomi c growth over several decades and gener-
ati ons. I n developi ng countri es, the process i s
bei ng compressed i nto two or three decades.
Thus, whi le developed countri es grew afuent
before they became old, developi ng countri es
are getti ng old before a substanti al i ncrease i n
wealth occurs ( K alache and K eller, 2000) .
Rapi d agei ng i n developi ng countri es i s
accompani ed by dramati c changes i n fam-
i ly structures and roles, as well as i n labour
patterns and mi grati on. Urbani zati on, the
mi grati on of young people to ci ti es i n search
of jobs, smaller fami li es and more women
enteri ng the formal workforce mean that fewer
people are avai lable to care for older people
when they need assi stance.
PAGE 12
2. Acti ve Agei ng:
The Concept and Rati onale
I f agei ng i s to be a posi ti ve experi ence,
longer li fe must be accompani ed by conti nu-
i ng opportuni ti es for health, parti ci pati on and
securi ty. The World Health O rgani zati on has
adopted the term acti ve agei ng to express
the process for achi evi ng thi s vi si on.
What is Active Ageing?
Active ageing is the process of
optimizing opportunities for health,
participation and security in order
to enhance quality of life as people
age.
Acti ve agei ng appli es to both i ndi vi duals and
populati on groups. I t allows people to reali ze
thei r potenti al for physi cal, soci al, and mental
well bei ng throughout the li fe course and to
parti ci pate i n soci ety accordi ng to thei r needs,
desi res and capaci ti es, whi le provi di ng them
wi th adequate protecti on, securi ty and care
when they requi re assi stance.
The word acti ve refers to conti nui ng parti ci -
pati on i n soci al, economi c, cultural, spi ri tual
and ci vi c affai rs, not just the abi li ty to be
physi cally acti ve or to parti ci pate i n the labour
force. O lder people who reti re from work
and those who are i ll or li ve wi th di sabi li ti es
can remai n acti ve contri butors to thei r fami -
li es, peers, communi ti es and nati ons. Acti ve
agei ng ai ms to extend healthy li fe expectancy
and quali ty of li fe for all people as they age,
i ncludi ng those who are frai l, di sabled and i n
need of care.
Health refers to physi cal, mental and soci al
well bei ng as expressed i n the WHO de ni ti on
of health. Thus, i n an acti ve agei ng frame-
work, poli ci es and programmes that promote
mental health and soci al connecti ons are
as i mportant as those that i mprove physi cal
health status.
Mai ntai ni ng autonomy and i ndependence as
one grows older i s a key goal for both i ndi -
vi duals and poli cy makers ( see box on de ni -
ti ons) . Moreover, agei ng takes place wi thi n
the context of others fri ends, work associ -
ates, nei ghbours and fami ly members. Thi s i s
why i nterdependence as well as i ntergenera-
ti onal soli dari ty ( two-way gi vi ng and recei v-
i ng between i ndi vi duals as well as older and
younger generati ons) are i mportant tenets of
acti ve agei ng. Yesterdays chi ld i s todays adult
and tomorrows grandmother or grandfather.
The quali ty of li fe they wi ll enjoy as grandpar-
ents depends on the ri sks and opportuni ti es
they experi enced throughout the li fe course,
as well as the manner i n whi ch succeedi ng
generati ons provi de mutual ai d and support
when needed.
PAGE 13
Some key denit ions
Autonomy is t he perceived abilit y t o cont rol, cope wit h and make personal decisions
about how one lives on a day-t o-day basis, according t o ones own rules and prefer-
ences.
Independence is commonly underst ood as t he abilit y t o perform funct ions relat ed t o
daily living i.e. t he capacit y of living independent ly in t he communit y wit h no and/ or
lit t le help from ot hers.
Qualit y of life is an individuals percept ion of his or her posit ion in life in t he cont ext
of t he cult ure and value syst em where t hey live, and in relat ion t o t heir goals, expect a-
t ions, st andards and concerns. It is a broad ranging concept , incorporat ing in a com-
plex way a persons physical healt h, psychological st at e, level of independence, social
relat ionships, personal beliefs and relat ionship t o salient feat ures in t he environment .
(WHO, 1994). As people age, t heir qualit y of life is largely det ermined by t heir abilit y t o
maint ain aut onomy and independence.
Healt hy life expect ancy is commonly used as a synonym for disabilit y-free life expec-
t ancy. While life expect ancy at birt h remains an import ant measure of populat ion
ageing, how long people can expect t o live wit hout disabilit ies is especially import ant
t o an ageing populat ion.
Wit h t he except ion of aut onomy which is not oriously difcult t o measure, all of t he
above concept s have been elaborat ed by at t empt s t o measure t he degree of dif-
cult y an older person has in performing act ivit ies relat ed t o daily living (ADLs) and
inst rument al act ivit ies of daily living (IADLs). ADLs include, for example, bat hing, eat ing,
using t he t oilet and walking across t he room. IADLs include act ivit ies such as shop-
ping, housework and meal preparat ion. Recent ly, a number of validat ed, more holist ic
measures of healt h-relat ed qualit y of life have been developed. These indices need t o
be shared and adapt ed for use in a variet y of cult ures and set t ings.
The term acti ve agei ng was adopted by the
World Health O rgani zati on i n the late 1990s. I t
i s meant to convey a more i nclusi ve message
than healthy agei ng and to recogni ze the fac-
tors i n addi ti on to health care that affect how
i ndi vi duals and populati ons age ( K alache and
K i ckbusch, 1997) .
The acti ve agei ng approach i s based on the
recogni ti on of the human ri ghts of older
people and the Uni ted Nati ons Pri nci ples of
i ndependence, parti ci pati on, di gni ty, care and
self-ful llment. I t shi fts strategi c planni ng away
from a needs-based approach ( whi ch as-
sumes that older people are passi ve targets) to
a ri ghts- based approach that recogni zes the
ri ghts of people to equali ty of opportuni ty and
treatment i n all aspects of li fe as they grow
older. I t supports thei r responsi bi li ty to exer-
ci se thei r parti ci pati on i n the poli ti cal process
and other aspects of communi ty li fe.
PAGE 14
A Life Course Approach to Active
Ageing
A li fe course perspecti ve on agei ng recogni zes
that older people are not one homogeneous
group and that i ndi vi dual di versi ty tends to
i ncrease wi th age. I nterventi ons that create
supporti ve envi ronments and foster healthy
choi ces are i mportant at all stages of li fe ( see
Fi gure 4) .
As i ndi vi duals age, noncommuni cable di seases
( NCDs) become the leadi ng causes of morbi d-
i ty, di sabi li ty and mortali ty i n all regi ons of
the world, i ncludi ng i n developi ng countri es,
as shown i n Fi gures 5 and 6. NCDs, whi ch
are essenti ally di seases of later li fe, are costly
to i ndi vi duals, fami li es and the publi c purse.
But many NCDs are preventable or can be
postponed. Fai li ng to prevent or manage the
growth of NCDs appropri ately wi ll result i n
enormous human and soci al costs that wi ll ab-
sorb a di sproporti onate amount of resources,
whi ch could have been used to address the
health problems of other age groups.
* Changes in t he environment can lower t he disabilit y t hreshold, t hus decreasing t he number of disabled people in a given com-
munit y.
Funct ional capacit y (such as vent ilat or y capacit y, muscular st rengt h, and cardiovascular out put ) increases in childhood and
peaks in early adult hood, event ually followed by a decline.The rat e of decline, however, is largely det ermined by fact ors relat ed t o
adult lifest yle such as smoking, alcohol consumpt ion, levels of physical act ivit y and diet as well as ext ernal and environmen-
t al fact ors.The gradient of decline may become so st eep as t o result in premat ure disabilit y. However, t he accelerat ion in decline
can be inuenced and may be reversible at any age t hrough individual and public policy measures.
PAGE 15
PAGE 16
Major chronic condit ions affect ing
older people worldwide
Cardiovascular diseases
(such as coronary heart disease)
Hypert ension
St roke
Diabet es
Cancer
Chronic obst ruct ive pulmonary
disease
Musculoskelet al condit ions
(such as art hrit is and ost eoporosis)
Ment al healt h condit ions
(most ly dement ia and depression)
Blindness and visual impairment
Not e:The causes of disabilit y in older age are similar for
women and men alt hough women are more likely t o report
musculoskelet al problems.
Source:WHO, 1998a
I n the early years, communi cable di seases,
maternal and peri natal condi ti ons and nu-
tri ti onal de ci enci es are the major causes of
death and di sease. I n later chi ldhood, ado-
lescence and young adulthood, i njuri es and
noncommuni cable condi ti ons begi n to assume
a much greater role. By mi dli fe ( age 45) and
i n the later years, NCDs are responsi ble for
the vast majori ty of deaths and di seases ( see
Fi gures 5 and 6) . Research i s i ncreasi ngly
showi ng that the ori gi ns of ri sk for chroni c
condi ti ons, such as di abetes and heart di sease,
begi n i n early chi ldhood or even earli er. Thi s
ri sk i s subsequently shaped and modi ed by
factors, such as soci o-economi c status and
experi ences across the whole li fe span. The
ri sk of developi ng NCDs conti nues to i ncrease
as i ndi vi duals age. But i t i s tobacco use, lack
of physi cal acti vi ty, i nadequate di et and other
establi shed adult ri sk factors whi ch wi ll put
i ndi vi duals at relati vely greater ri sk of develop-
i ng NCDs at older ages ( see Fi gure 7) . Thus,
i t i s i mportant to address the ri sks of noncom-
muni cable di sease from early li fe to late li fe,
i .e. throughout the li fe course.
Active Ageing Policies and
Programmes
An acti ve agei ng approach to poli cy and
programme development has the potenti al to
address many of the challenges of both i ndi -
vi dual and populati on agei ng. When health,
labour market, employment, educati on and
soci al poli ci es support acti ve agei ng there wi ll
potenti ally be:
fewer premature deaths i n the hi ghly pro-
ducti ve stages of li fe
fewer di sabi li ti es associ ated wi th chroni c
di seases i n older age
more people enjoyi ng a posi ti ve quali ty of
li fe as they grow older
more people parti ci pati ng acti vely as they
age i n the soci al, cultural, economi c and
poli ti cal aspects of soci ety, i n pai d and
unpai d roles and i n domesti c, fami ly and
communi ty li fe
lower costs related to medi cal treatment
and care servi ces.
PAGE 17
Acti ve agei ng poli ci es and programmes rec-
ogni ze the need to encourage and balance
personal responsi bi li ty ( self-care) , age-fri endly
envi ronments and i ntergenerati onal soli dari ty.
I ndi vi duals and fami li es need to plan and pre-
pare for older age, and make personal efforts
to adopt posi ti ve personal health practi ces at
all stages of li fe. At the same ti me support-
i ve envi ronments are requi red to make the
healthy choi ces the easy choi ces.
There are good economi c reasons for enacti ng
poli ci es and programmes that promote acti ve
agei ng i n terms of i ncreased parti ci pati on and
reduced costs i n care. People who remai n
healthy as they age face fewer i mpedi ments
to conti nued work. The current trend toward
early reti rement i n i ndustri ali sed countri es i s
largely the result of publi c poli ci es that have
encouraged early wi thdrawal from the labour
force. As populati ons age, there wi ll be
i ncreasi ng pressures for such poli ci es to
change parti cularly i f more and more i ndi -
vi duals reach old age i n good health, i .e. are
t for work. Thi s would help to offset the
ri si ng costs i n pensi ons and i ncome securi ty
schemes as well as those related to medi cal
and soci al care costs.
Wi th regard to ri si ng publi c expendi tures
for medi cal care, avai lable data i ncreasi ngly
i ndi cate that old age i tself i s not associ ated
wi th i ncreased medi cal spendi ng. Rather, i t i s
di sabi li ty and poor health often associ ated
wi th old age that are costly. As people age
i n better health, medi cal spendi ng may not
i ncrease as rapi dly.
PAGE 18
Poli cymakers need to look at the full pi cture
and consi der the savi ngs achi eved by decli nes
i n di sabi li ty rates. I n the USA for example,
such decli nes mi ght lower medi cal spendi ng
by about 20 percent over the next 50 years
( Cutler, 2001) . Between 1982 and 1994, i n the
USA, the savi ngs i n nursi ng home costs alone
were esti mated to exceed $17 bi lli on ( Si nger
and Manton, 1998) . Moreover, i f i ncreased
numbers of healthy older people were to
extend thei r parti ci pati on i n the work force
( through ei ther full or part-ti me employment) ,
thei r contri buti on to publi c revenues would
conti nuously i ncrease. Fi nally, i t i s often less
costly to prevent di sease than to treat i t. For
example, i t has been esti mated that a one-dol-
lar i nvestment i n measures to encourage mod-
erate physi cal acti vi ty leads to a cost savi ng of
$3.2 i n medi cal costs ( U.S. Centers for Di sease
Control, 1999) .
PAGE 19
Acti ve agei ng depends on a vari ety of i nu-
ences or determi nants that surround i ndi vi d-
uals, fami li es and nati ons. Understandi ng the
evi dence we have about these determi nants
helps us desi gn poli ci es and programmes that
work.
The followi ng secti on summari zes what we
know about how the broad determi nants of
health affect the process of agei ng. These
determi nants apply to the health of all age
groups, although the emphasi s here i s on the
health and quali ty of li fe of older persons. At
thi s poi nt, i t i s not possi ble to attri bute di rect
causati on to any one determi nant; however,
the substanti al body of evi dence on what
determi nes health suggests that all of these
factors ( and the i nterplay between them) are
good predi ctors of how well both i ndi vi duals
and populati ons age. More research i s needed
to clari fy and speci fy the role of each deter-
mi nant, as well as the i nteracti on between
determi nants, i n the acti ve agei ng process. We
also need to better understand the pathways
that explai n how these broad determi nants
actually affect health and well bei ng.
Moreover, i t i s helpful to consi der the i nu-
ence of vari ous determi nants over the li fe
course so as to take advantage of transi ti ons
and wi ndows of opportuni ty for enhanci ng
health, parti ci pati on and securi ty at di fferent
stages. For example, there i s evi dence that
sti mulati on and secure attachments i n i nfancy
i nuence an i ndi vi duals abi li ty to learn and
3. The Determi nants of Acti ve Agei ng:
Understandi ng the Evi dence
PAGE 20
get along wi th others throughout all of the
later stages of li fe. Employment, whi ch i s a
determi nant throughout adult li fe greatly i nu-
ences ones nanci al readi ness for old age. Ac-
cess to hi gh quali ty, di gni ed long-term care i s
parti cularly i mportant i n later li fe. O ften, as i s
the case wi th exposure to polluti on, the young
and the old are the most vulnerable popula-
ti on groups.
Cross-Cutting Determinants: Culture
and Gender
Culture i sa cross-cutti ng determi nant wi thi n the
framework for understandi ng acti ve agei ng.
Culture, which surrounds all indi-
viduals and populations, shapes the
way in which we age because it inu-
ences all of the other determinants
of active ageing.
Cultural values and tradi ti ons determi ne to a
large extent how a gi ven soci ety vi ews older
people and the agei ng process. When soci eti es
are more li kely to attri bute symptoms of di s-
ease to the agei ng process, they are less li kely
to provi de preventi on, early detecti on and
appropri ate treatment servi ces. Culture i s a
key factor i n whether or not co-resi dency wi th
younger generati ons i s the preferred way of
li vi ng. For example, i n most Asi an countri es,
the cultural norm i s to value extended fami -
li es and to li ve together i n multi generati onal
households. Cultural factors also i nuence
health-seeki ng behavi ours. For example, at-
ti tudes toward smoki ng are gradually changi ng
i n a range of countri es.
There i s enormous cultural di versi ty and com-
plexi ty wi thi n countri es and among countri es
and regi ons of the world. For example, di verse
ethni ci ti es bri ng a vari ety of values, atti tudes
and tradi ti ons to the mai nstream culture wi thi n
a country. Poli ci es and programmes need to
respect current cultures and tradi ti ons whi le
de-bunki ng outdated stereotypes and mi si nfor-
mati on. Moreover, there are cri ti cal uni versal
values that transcend culture, such as ethi cs
and human ri ghts.
Gender is a lens through which to
consider the appropriateness of vari-
ous policy options and how they will
affect the well being of both men
and women.
I n many soci eti es, gi rls and women have
lower soci al status and less access to nutri -
ti ous foods, educati on, meani ngful work and
health servi ces. Womens tradi ti onal role as
fami ly caregi vers may also contri bute to thei r
i ncreased poverty and i ll health i n older age.
Some women are forced to gi ve up pai d em-
ployment to carry out thei r caregi vi ng respon-
si bi li ti es. O thers never have access to pai d
employment because they work full-ti me i n
unpai d caregi vi ng roles, looki ng after chi ldren,
older parents, spouses who are i ll and grand-
chi ldren. At the same ti me, boys and men are
more li kely to suffer debi li tati ng i njuri es or
death due to vi olence, occupati onal hazards,
and sui ci de. They also engage i n more ri sk-
taki ng behavi ours such as smoki ng, alcohol
and drug consumpti on and unnecessary expo-
sure to the ri sk of i njury.
PAGE 21
Determinants Related to Health and
Social Service Systems
To promote active ageing, health
systems need to take a life course
perspective that focuses on health
promotion, disease prevention and
equitable access to quality primary
health care and long-term care.
Health and soci al servi ces need to be i nte-
grated, coordi nated and cost-effecti ve. There
must be no age di scri mi nati on i n the provi si on
of servi ces and servi ce provi ders need to treat
people of all ages wi th di gni ty and respect.
Health Promotion and Disease Prevention
Health promoti on i s the process of enabli ng
people to take control over and to i mprove
thei r health. Di sease preventi on i ncludes the
preventi on and management of the condi ti ons
that are parti cularly common as i ndi vi duals
age: noncommuni cable di seases and i njuri es.
Preventi on refers both to pri mary preven-
ti on ( e.g. avoi dance of tobacco use) as well
as secondary preventi on ( e.g. screeni ng for
the early detecti on of chroni c di seases) , or
terti ary preventi on, e.g. appropri ate cli ni -
cal management of di seases. All contri bute to
reduci ng the ri sk of di sabi li ti es. Di sease pre-
venti on strategi es whi ch may also address
i nfecti ous di seases save money at any age.
For example, vacci nati ng older adults agai nst
i nuenza saves an esti mated $30 to $60 i n
treatment costs per $1 spent on vacci nes ( U.S.
Department of Health and Human Servi ces,
1999) .
Curative Services
Despi te best efforts i n health promoti on and
di sease preventi on, people are at i ncreasi ng
ri sk of developi ng di seases as they age. Thus
access to curati ve servi ces becomes i ndi spens-
able. As the vast majori ty of older persons
i n any gi ven country li ve i n the communi ty,
most curati ve servi ces must be offered by the
pri mary health care sector. Thi s sector i s best
equi pped to. make referrals to the secondary
and terti ary levels of care where most acute
and emergency care i s also provi ded.
Ulti mately, the worldwi de shi ft i n the global
burden of di sease toward chroni c di seases
requi res a shi ft from a nd i t and x i t model
to a coordi nated and comprehensi ve conti n-
uum of care. Thi s wi ll requi re a reori entati on
i n health systems that are currently organi zed
around acute, epi sodi c experi ences of di s-
ease. The present acute care models of health
servi ce deli very are i nadequate to address the
health needs of rapi dly agei ng populati ons
( WHO , 2001) .
As the populati on ages, the demand wi ll con-
ti nue to ri se for medi cati ons that are used to
delay and treat chroni c di seases, allevi ate pai n
and i mprove quali ty of li fe. Thi s calls for a
renewed effort to i ncrease affordable access to
essenti al safe medi cati ons and to better ensure
the appropri ate, cost-effecti ve use of current
and new drugs. Partners i n thi s effort need to
i nclude governments, health professi onals, the
pharmaceuti cal i ndustry, tradi ti onal healers,
employers and organi zati ons representi ng
older people.
PAGE 22
Long-term care
Long-term care i s de ned by WHO as the
system of acti vi ti es undertaken by i nformal
caregi vers ( fami ly, fri ends and/or nei ghbours)
and/or professi onals ( health and soci al ser-
vi ces) to ensure that a person who i s not fully
capable of self-care can mai ntai n the hi ghest
possi ble quali ty of li fe, accordi ng to hi s or
her i ndi vi dual preferences, wi th the greatest
possi ble degree of i ndependence, autonomy,
parti ci pati on, personal ful llment and human
di gni ty ( WHO , 2000b) .
Thus, long-term care i ncludes both i nformal
and formal support systems. The latter may
i nclude a broad range of communi ty servi ces
( e.g., publi c health, pri mary care, home care,
rehabi li tati on servi ces and palli ati ve care) as
well as i nsti tuti onal care i n nursi ng homes and
hospi ces. I t also refers to treatments that halt
or reverse the course of di sease and di sabi li ty.
Mental Health Services
Mental health servi ces, whi ch play a cruci al
role i n acti ve agei ng, should be an i ntegral
part of long-term care. Parti cular attenti on
needs to be pai d to the under-di agnosi s of
mental i llness ( especi ally depressi on) and
to sui ci de rates among older people ( WHO ,
2001a) .
Behavioural Determinants
The adoption of healthy lifestyles
and actively participating in ones
own care are important at all stages
of the life course. One of the myths
of ageing is that it is too late to adopt
such lifestyles in the later years. On
the contrary, engaging in appropri-
ate physical activity, healthy eating,
not smoking and using alcohol and
medications wisely in older age can
prevent disease and functional de-
cline, extend longevity and enhance
ones quality of life.
Tobacco Use
Smoki ng i s the most i mportant modi able
ri sk factor for NCDs for young and old ali ke
and a major preventable cause of premature
death. Smoki ng not only i ncreases the ri sk
for di seases such as lung cancer, i t i s also
negati vely related to factors that may lead
to i mportant losses i n functi onal capaci ty.
For example, smoki ng accelerates the rate of
decli ne of bone densi ty, muscular strength and
respi ratory functi on. Research on the effects
of smoki ng revealed not just that smoki ng i s a
ri sk factor for a large and i ncreasi ng number
of di seases but also that i ts i ll effects are cu-
mulati ve and long lasti ng. The ri sk of contract-
i ng at least one of the di seases associ ated wi th
smoki ng i ncreases wi th the durati on and the
amount of exposure.
PAGE 23
A cri ti cal message for young people should
always be I f you want to grow older, dont
smoke. Moreover, i f you want to grow older
and to i ncrease your chance to age well, agai n
dont smoke.
The bene ts of qui tti ng are wi de-rangi ng
and apply to any age group. I t i s never too
late to qui t smoki ng. For i nstance, stroke ri sk
decreases after two years of absti nence from
ci garette smoki ng and, after ve years, i t
becomes the same as that for i ndi vi duals who
have never smoked. For other di seases, e.g.
lung cancer and obstructi ve pulmonary di s-
ease, qui tti ng decreases the ri sk but only very
slowly. Thus, current exposure i s not a very
good i ndi cator of current and future ri sks and
past exposure should be taken i nto account
as well; the effects of smoki ng are cumulati ve
and long standi ng ( Doll, 1999) .
Smoki ng may i nterfere wi th the effect of
needed medi cati ons. Exposure to second-hand
smoke can also have a negati ve effect on older
peoples health, especi ally i f they suffer from
asthma or other respi ratory problems.
Most smokers start young and are qui ckly
addi cted to the ni coti ne i n tobacco. Therefore,
efforts to prevent chi ldren and youth from
starti ng to smoke must be a pri mary strategy i n
tobacco control. At the same ti me, i t i s i mpor-
tant to reduce the demand for tobacco among
adults ( through comprehensi ve acti ons such
as taxati on and restri cti ons on adverti si ng) and
to help adults of all ages to qui t. Studi es have
shown that tobacco control i s hi ghly cost-ef-
fecti ve i n low- and mi ddle-i ncome countri es.
I n Chi na, for example, conservati ve esti mates
suggest that a 10 percent i ncrease i n tobacco
taxes would reduce consumpti on by ve
percent and i ncrease overall revenue by ve
percent. Thi s i ncreased revenue would be suf-
ci ent to nance a package of essenti al health
care servi ces for one-thi rd of Chi nas poorest
ci ti zens ( World Bank, 1999) .
Physical Activity
Parti ci pati on i n regular, moderate physi cal
acti vi ty can delay functi onal decli nes. I t can
reduce the onset of chroni c di seases i n both
healthy and chroni cally i ll older people. For
example, regular moderate physi cal acti vi ty
reduces the ri sk of cardi ac death by 20 to 25
percent among people wi th establi shed heart
di sease ( Merz and Forrester, 1997) . I t can also
substanti ally reduce the severi ty of di sabi li -
ti es associ ated wi th heart di sease and other
chroni c i llnesses ( U.S Preventi ve Servi ces Task
Force, 1996) . Acti ve li vi ng i mproves mental
health and often promotes soci al contacts.
Bei ng acti ve can help older people remai n as
i ndependent as possi ble for the longest peri od
of ti me. I t can also reduce the ri sk of falls.
There are thus i mportant economi c bene ts
when older people are physi cally acti ve.
Medi cal costs are substanti ally lower for older
people who are acti ve ( WHO , 1998) .
Despi te all of these bene ts, hi gh proporti ons
of older people i n most countri es lead seden-
tary li ves. Populati ons wi th low i ncomes, eth-
ni c mi nori ti es and older people wi th di sabi li -
ti es are the most li kely to be i nacti ve. Poli ci es
and programmes should encourage i nacti ve
people to become more acti ve as they age and
to provi de them wi th opportuni ti es to do so. I t
i s parti cularly i mportant to provi de safe areas
for walki ng and to support culturally-appropri -
ate communi ty acti vi ti es that sti mulate physi cal
PAGE 24
acti vi ty and are organi zed and led by older
people themselves. Professi onal advi ce to go
from doi ng nothi ng to doi ng somethi ng and
physi cal rehabi li tati on programmes that help
older people recover from mobi li ty problems
are both effecti ve and cost-ef ci ent.
I n the least developed countri es, the oppo-
si te problem may occur. I n these countri es,
i ndi vi duals are often engaged i n strenuous
physi cal work and chores that may hasten
di sabi li ti es, cause i njuri es and aggravate previ -
ous condi ti ons, especi ally as they approach
old age. Thi s may i nclude heavy caregi vi ng
responsi bi li ti es for i ll and dyi ng relati ves.
Health promoti on efforts i n these areas should
be di rected at provi di ng reli ef from repeti ti ve,
strenuous tasks and maki ng adjustments to
unsafe physi cal movements at work that wi ll
decrease i njuri es and pai n. O lder people who
regularly engage i n vi gorous physi cal work
need opportuni ti es for rest and recreati on.
Healthy Eating
Eati ng and food securi ty problems at all ages
i nclude both under-nutri ti on ( mostly, but not
exclusi vely, i n the least developed countri es)
and excess energy i ntake. I n older people,
malnutri ti on can be caused by li mi ted access
to food, soci oeconomi c hardshi ps, a lack of
i nformati on and knowledge about nutri ti on,
poor food choi ces ( e.g., eati ng hi gh fat foods) ,
di sease and the use of medi cati ons, tooth loss,
soci al i solati on, cogni ti ve or physi cal di sabi li -
ti es that i nhi bi t ones abi li ty to buy foods and
prepare them, emergency si tuati ons and a lack
of physi cal acti vi ty.
Excess energy i ntake greatly i ncreases the ri sk
for obesi ty, chroni c di seases and di sabi li ti es as
people grow older.
Diets high in (saturated) fat and
salt, low in fruits and vegetables and
providing insufcient amounts of
bre and vitamins combined with
sedentarism, are major risks factors
for chronic conditions like diabetes,
cardiovascular disease, high blood
pressure, obesity, arthritis and some
cancers.
I nsuf ci ent calci um and vi tami n D i s associ -
ated wi th a loss of bone densi ty i n older age
and consequently an i ncrease i n pai nful, costly
and debi li tati ng bone fractures, especi ally i n
older women. I n populati ons wi th hi gh frac-
ture i nci dence, ri sk can be decreased through
ensuri ng adequate calci um and vi tami n D
i ntake.
Oral Health
Poor oral health pri mari ly dental cari es,
peri odontal di seases, tooth loss and oral can-
cer cause other systemi c health problems.
They create a nanci al burden for i ndi vi duals
and soci ety and can reduce self-con dence
and quali ty of li fe. Studi es show that poor
oral health i s associ ated wi th malnutri ti on and
therefore i ncreased ri sks for vari ous noncom-
muni cable di seases. O ral health promoti on
and cavi ty preventi on programmes desi gned
to encourage people to keep thei r natural
teeth need to begi n early i n li fe and conti nue
over the li fe course. Because of the pai n and
reduced quali ty of li fe associ ated wi th oral
health problems, basi c dental treatment servi c-
es and accessi bi li ty to dentures are requi red.
PAGE 25
Alcohol
Whi le older people tend to dri nk less than
younger people, metaboli sm changes that
accompany agei ng i ncrease thei r suscepti -
bi li ty to alcohol-related di seases, i ncludi ng
malnutri ti on and li ver, gastri c and pancreati c
di seases. O lder people also have greater ri sks
for alcohol-related falls and i njuri es, as well as
the potenti al hazards associ ated wi th mi xi ng
alcohol and medi cati ons. Treatment servi ces
for alcohol problems should be avai lable to
older people as well as younger people.
Accordi ng to a recent WHO revi ew of the
li terature, there i s evi dence that alcohol use at
very low levels ( up to one dri nk a day) may
offer some form of protecti on agai nst coronary
heart di sease and stroke for people age 45 and
over. However, i n terms of overall excess mor-
tali ty, the adverse effects of dri nki ng outwei gh
any protecti on agai nst coronary heart di sease,
even i n hi gh ri sk populati ons ( Jerni gan et al.,
2000) .
Medications
Because older people often have chroni c
health problems, they are more li kely than
younger people to need and use medi cati ons
tradi ti onal, over-the-counter and prescri bed.
I n most countri es, older people wi th low
i ncomes have li ttle or no access to i nsurance
for medi cati ons. As a result, many go wi thout
or spend an i nappropri ately large part of thei r
meager i ncomes on drugs.
I n contrast, medi cati ons are someti mes over-
prescri bed to older people ( especi ally to older
women) who have i nsurance or the means
to pay for these drugs. Adverse drug-related
reacti ons and falls associ ated wi th medi cati on
use ( especi ally sleepi ng pi lls and tranqui li zers)
are si gni cant causes of personal sufferi ng and
costly preventable hospi tal admi ssi ons ( Gur-
wi tz and Avorn, 1991) .
I atrogenesis health problems that are
i nduced by di agnoses or treatments caused
by the use of drugs i s common i n old age,
due to the i nteracti on of drugs, i nadequate
dosages and a hi gher frequency of unpredi ct-
able reacti ons through unknown mechani sms.
Wi th the advent of many new therapi es, there
i s an i ncreasi ng need to establi sh systems for
preventi ng adverse drug reacti ons and for
i nformi ng both health professi onals and the
agei ng publi c about the ri sks and bene ts of
modern therapi es.
Adherence
Access to needed medi cati ons i s i nsuf ci ent i n
i tself unless adherence to long-term therapy
for agei ng-related chroni c i llnesses i s hi gh.
Adherence i ncludes the adopti on and mai n-
tenance of a wi de range of behavi ours ( e.g.,
healthy di et, physi cal acti vi ty, not smoki ng) ,
as well as taki ng medi cati ons as di rected by
a health professi onal. I t i s esti mated that i n
developed countri es adherence to long-term
therapy averages only 50 percent. I n develop-
i ng countri es the rates are even lower. Such
poor adherence severely compromi ses the
effecti veness of treatments and has dramati c
quali ty of li fe and economi c i mpli cati ons for
publi c health. Populati on health outcomes pre-
di cted by treatment ef cacy data can only be
achi eved i f adherence i nformati on i s provi ded
to all health professi onals and planners. Wi th-
out a system that addresses the i nuences on
adherence, advances i n bi omedi cal technol-
PAGE 26
ogy wi ll fai l to reali ze thei r potenti al to reduce
the burden of chroni c di sease ( Di polli na and
Sabate, 2002) .
Determinants Related to Personal
Factors
Biology and Genetics
Bi ology and geneti cs greatly i nuence how a
person ages. Agei ng i s a set of bi ologi cal pro-
cesses that are geneti cally determi ned. Agei ng
can be de ned as a progressi ve, generali zed
i mpai rment of functi on resulti ng i n a loss of
adaptati ve response to a stress and i n a grow-
i ng ri sk of age-associ ated di sease ( K i rkwood,
1996) . I n other words, the mai n reason why
older persons get si ck more frequently than
younger persons i s that, due to thei r longer
li ves, they have been exposed to external,
behavi oural, and envi ronmental factors that
cause di sease for a longer ti me than thei r
younger counterparts ( Gray, 1996) .
While genes may be involved in the
causation of disease, for many
diseases the cause is environmental
and external to a greater degree
than it is genetic and internal.
I t should also be noted that there i s evi dence
i n human populati ons that longevi ty tends
to run i n fami li es. But, all thi ngs consi dered,
there i s general agreement that the li felong
trajectory of health and di sease for an i ndi -
vi dual i s the result of a combi nati on of genet-
i cs, envi ronment, li festyle, nutri ti on, and to an
i mportant extent, chance ( K i rkwood, 1996) .
Therefore, the i nuence of geneti cs on the
development of chroni c condi ti ons such as
di abetes, heart di sease, Alzhei mers Di sease
and certai n cancers vari es greatly among i ndi -
vi duals. For many people, li festyle behavi ours
such as not smoki ng, personal copi ng ski lls
and a network of close ki n and fri ends can
effecti vely modi fy the i nuence of heredi ty on
functi onal decli ne and the onset of di sease.
Psychological Factors
Psychologi cal factors i ncludi ng i ntelli gence
and cogni ti ve capaci ty ( for example, the abi li ty
to solve problems and adapt to change and
loss) are strong predi ctors of acti ve agei ng and
longevi ty ( Smi ts et al., 1999) . Duri ng normal
agei ng, some cogni ti ve capaci ti es ( i ncludi ng
learni ng speed and memory) naturally de-
cli ne wi th age. However, these losses can be
compensated by gai ns i n wi sdom, knowledge
and experi ence. O ften, decli nes i n cogni ti ve
functi oni ng are tri ggered by di suse ( lack of
practi ce) , i llness ( such as depressi on) , behav-
i oural factors ( such as the use of alcohol and
medi cati ons) , psychologi cal factors ( such as
lack of moti vati on, low expectati ons and lack
of con dence) , and soci al factors ( such as
loneli ness and i solati on) , rather than agei ng
per se.
O ther psychologi cal factors that are acqui red
across the li fe course greatly i nuence the
way i n whi ch people age. Self-ef cacy ( the
beli ef people have i n thei r capaci ty to exert
control over thei r li ves) i s li nked to personal
behavi our choi ces as one ages and to prepara-
ti on for reti rement. Copi ng styles determi ne
how well people adapt to the transi ti ons ( such
as reti rement) and cri ses of agei ng ( such as
bereavement and the onset of i llness) .
PAGE 27
Men and women who prepare for old age and
are adaptable to change make a better adjust-
ment to li fe after age 60. Most people remai n
resi li ent as they age and, on the whole, older
people do not vary si gni cantly from younger
people i n thei r abi li ty to cope.
Determinants Related to the Physical
Environment
Physical Environments
Physi cal envi ronments that are age fri endly
can mak e the di fference between i ndepen-
dence and dependence for all i ndi vi duals but
are of parti cular i mportance for those grow-
i ng older. For example, older people who
li ve i n an unsafe envi ronment or areas wi th
multi ple physi cal barri ers are less li k ely to get
out and therefore more prone to i solati on,
depressi on, reduced tness and i ncreased
mobi li ty problems.
Speci c attenti on must be gi ven to older peo-
ple who li ve i n rural areas ( some 60 percent
worldwi de) where di sease patterns may be
di fferent due to envi ronmental condi ti ons and
a lack of avai lable support servi ces. Urbani za-
ti on and the mi grati on of younger people i n
search of jobs may leave older people i solated
i n rural areas wi th li ttle means of support and
li ttle or no access to health and soci al servi ces.
Accessi ble and affordable publi c transporta-
ti on servi ces are needed i n both rural and
urban areas so that people of all ages can fully
parti ci pate i n fami ly and communi ty li fe. Thi s
i s especi ally i mportant for older persons who
have mobi li ty problems.
Hazards i n the physi cal envi ronment can lead
to debi li tati ng and pai nful i njuri es among
older people. I njuri es from falls, res and traf-
c colli si ons are the most common.
Safe Housing
Safe, adequate housi ng and nei ghbourhoods
are essenti al to the well bei ng of young and
old. For older people, locati on, i ncludi ng
proxi mi ty to fami ly members, servi ces and
transportati on can mean the di fference be-
tween posi ti ve soci al i nteracti on and i solati on.
Bui ldi ng codes need to take the health and
safety needs of older people i nto account.
Household hazards that i ncrease the ri sk of
falli ng need to be remedi ed or removed.
Worldwi de, there i s an i ncreasi ng trend for
older people to li ve alone especi ally unat-
tached older women who are mai nly wi dows
and are often poor, even i n developed coun-
tri es. O thers may be forced to li ve i n arrange-
ments that are not of thei r choi ce, such as wi th
relati ves i n already crowded households. I n
many developi ng countri es, the proporti on of
older people li vi ng i n slums and shanty towns
i s ri si ng qui ckly as many, who moved to the
ci ti es long ago, have become long-term slum-
dwellers, whi le other older people mi grate to
ci ti es to joi n younger fami ly members who
have already moved there. O lder people li vi ng
i n these settlements are at hi gh ri sk for soci al
i solati on and poor health.
I n ti mes of cri si s and coni ct, di splaced older
people are parti cularly vulnerable. O ften they
are unable to walk to refugee camps. Even
i f they make i t to camps, i t may be hard to
obtai n shelter and food, especi ally for older
women and older persons wi th di sabi li ti es
who experi ence low soci al status and multi ple
other barri ers.
PAGE 28
Falls
Falls among older people are a large and
i ncreasi ng cause of i njury, treatment costs and
death. Envi ronmental hazards that i ncrease
the ri sks of falli ng i nclude poor li ghti ng, sli p-
pery or i rregular walki ng surfaces and a lack
of supporti ve handrai ls. Most often, these
falls occur i n the home envi ronment and are
preventable.
The consequences of i njuri es sustai ned i n old-
er age are more severe than among younger
people. For i njuri es of the same severi ty, older
people experi ence more di sabi li ty, longer hos-
pi tal stays, extended peri ods of rehabi li tati on,
a hi gher ri sk of subsequent dependency and a
hi gher ri sk of dyi ng.
The great majority of injuries are
preventable; however, the traditional
view of injuries as accidents has
resulted in historical neglect of this
area in public health.
Clean Water, Clean Air and Safe Foods
Clean water, clean ai r and access to safe foods
are parti cularly i mportant for the most vulner-
able populati on groups, i .e. chi ldren and older
persons, and for those who have chroni c i ll-
nesses and compromi sed i mmune systems.
Determinants Related to the Social
Environment
Soci al support, opportuni ti es for educati on
and li felong learni ng, peace, and protecti on
from vi olence and abuse are key factors i n
the soci al envi ronment that enhance health,
parti ci pati on and securi ty as people age. Lone-
li ness, soci al i solati on, i lli teracy and a lack
of educati on, abuse and exposure to coni ct
si tuati ons greatly i ncrease older peoples ri sks
for di sabi li ti es and early death.
Social Support
I nadequate soci al support i s associ ated not
only wi th an i ncrease i n mortali ty, morbi di ty
and psychologi cal di stress but a decrease i n
overall general health and well bei ng. Di srup-
ti on of personal ti es, loneli ness and coni ctual
i nteracti ons are major sources of stress, whi le
supporti ve soci al connecti ons and i nti mate re-
lati ons are vi tal sources of emoti onal strength
( Gi ronda and Lubben, i n press) . I n Japan, for
example, older people who reported a lack
of soci al contact were 1.5 ti mes more li kely
to di e i n the next three years than were those
wi th hi gher soci al support ( Sugi swawa et al,
1994) .
O lder people are more li kely to lose fami ly
members and fri ends and to be more vulner-
able to loneli ness, soci al i solati on and the
avai labi li ty of a smaller soci al pool. Soci al
i solati on and loneli ness i n old age are li nked
to a decli ne i n both physi cal and mental
well bei ng. I n most soci eti es, men are less
li kely than women to have supporti ve soci al
networks. However, i n some cultures, older
women who are wi dowed are systemati cally
excluded from mai nstream soci ety or even
rejected by thei r communi ty.
Deci si on-makers, nongovernmental organi za-
ti ons, pri vate i ndustry and health and soci al
servi ce professi onals can help foster soci al
networks for agei ng people by supporti ng tra-
di ti onal soci eti es and communi ty groups run
by older people, voluntari sm, nei ghbourhood
helpi ng, peer mentori ng and vi si ti ng, fami ly
caregi vers, i ntergenerati onal programmes and
outreach servi ces.
PAGE 29
Violence and Abuse
O lder people who are frai l or li ve alone may
feel parti cularly vulnerable to cri mes such as
theft and assault. A common form of vi olence
agai nst older people ( especi ally agai nst older
women) i s elder abuse commi tted by fami ly
members and i nsti tuti onal caregi vers who
are well known to the vi cti ms. Elder abuse
occurs i n fami li es at all economi c levels. I t
i s li kely to escalate i n soci eti es experi enci ng
economi c upheaval and soci al di sorgani zati on
when overall cri me and exploi tati on tends to
i ncrease.
According to the I nternational
Network for the Prevention of Elder
Abuse, elder abuse is a single or
repeated act, or lack of appropriate
action occurring within any rela-
tionship where there is an expecta-
tion of trust which causes harm or
distress to an older person (Action
on Elder Abuse 1995).
Elder abuse i ncludes physi cal, sexual, psycho-
logi cal and nanci al abuse as well as neglect.
O lder people themselves percei ve abuse as
i ncludi ng the followi ng soci etal factors: neglect
( soci al exclusi on and abandonment) , vi olati on
( human, legal and medi cal ri ghts) and depri va-
ti on ( choi ces, deci si ons, status, nances and
respect) ( WHO /I NPEA 2002) . Elder abuse i s
a vi olati on of human ri ghts and a si gni cant
cause of i njury, i llness, lost producti vi ty, i sola-
ti on and despai r. T ypi cally, i t i s underreported
i n all cultures.
Confronti ng and reduci ng elder abuse requi res
a multi sectoral, multi di sci pli nary approach i n-
volvi ng justi ce of ci als, law enforcement of -
cers, health and soci al servi ce workers, labour
leaders, spi ri tual leaders, fai th i nsti tuti ons,
advocacy organi zati ons and older people
themselves. Sustai ned efforts to i ncrease publi c
awareness of the problem and to shi ft values
that perpetuate gender i nequi ti es and agei st
atti tudes are also requi red.
Education and Literacy
Low levels of educati on and i lli teracy are as-
soci ated wi th i ncreased ri sks for di sabi li ty and
death among people as they age, as well as
wi th hi gher rates of unemployment. Educati on
i n early li fe combi ned wi th opportuni ti es for
li felong learni ng can help people develop the
ski lls and con dence they need to adapt and
stay i ndependent, as they grow older.
Studi es have shown that employment prob-
lems of older workers are often rooted i n thei r
relati vely low li teracy ski lls, not i n agei ng per
se. I f people are to remai n engaged i n mean-
i ngful and producti ve acti vi ti es as they grow
older, there i s a need for conti nuous trai ni ng
i n the workplace and li felong learni ng oppor-
tuni ti es i n the communi ty ( O ECD, 1998) .
Li ke younger people, older ci ti zens need trai n-
i ng i n new technologi es, especi ally i n agri cul-
ture and electroni c communi cati on. Self-di rect-
ed learni ng, i ncreased practi ce and physi cal
adjustments ( such as the use of large pri nt)
can compensate for reducti ons i n vi sual acui ty,
heari ng and short-term memory. O lder people
can and do remai n creati ve and exi ble. I nter-
generati onal learni ng bri dges age di fferences,
enhances the transmi ssi on of cultural values
and promotes the worth of all ages. Studi es
have shown that young people who learn wi th
PAGE 30
older people have more posi ti ve and reali sti c
atti tudes about the older generati on.
Unfortunately, there conti nue to be stri ki ng
di spari ti es i n li teracy rates between men and
women. I n 1995 i n the least developed coun-
tri es, 31 percent of adult women were i lli terate
compared to 20 percent of adult men ( WHO ,
1998a) .
Economic Determinants
Three aspects of the economi c envi ronment
have a parti cularly si gni cant effect on acti ve
agei ng: i ncome, work and soci al protecti on.
I ncome
Acti ve agei ng poli ci es need to i ntersect wi th
broader schemes to reduce poverty at all ages.
Whi le poor people of all ages face an i n-
creased ri sk of i ll health and di sabi li ti es, older
people are parti cularly vulnerable. Many older
people especi ally those who are female, li ve
alone or i n rural areas do not have reli able or
suf ci ent i ncomes. Thi s seri ously affects thei r
access to nutri ti ous foods, adequate housi ng
and health care. I n fact, studi es have shown
that older people wi th low i ncomes are one-
thi rd as li kely to have hi gh levels of functi on-
i ng as those wi th hi gh i ncomes ( Guralni ck and
K aplan, 1989) .
The most vulnerable are older women and
men who have no assets, li ttle or no savi ngs,
no pensi ons or soci al securi ty payments or
who are part of fami li es wi th low or uncertai n
i ncomes. Parti cularly, those wi thout chi ldren
or fami ly members often face an uncertai n
future and are at hi gh ri sk for homelessness
and desti tuti on.
Social Protection
I n all countri es of the world, fami li es provi de
the majori ty of support for older people who
requi re help. However, as soci eti es develop
and the tradi ti on of generati ons li vi ng together
begi ns to decli ne, countri es are i ncreasi ngly
called on to develop mechani sms that pro-
vi de soci al protecti on for older people who
are unable to earn a li vi ng and are alone and
vulnerable. I n developi ng countri es, older
people who need assi stance tend to rely on
fami ly support, i nformal servi ce transfers and
personal savi ngs. Soci al i nsurance programmes
i n these setti ngs are mi ni mal and i n some
cases redi stri bute i ncome to mi nori ti es i n the
populati on who are less i n need. However, i n
countri es such as South Afri ca and Nami bi a,
whi ch have a nati onal old age pensi on, these
bene ts are a major source of i ncome for
many poor fami li es as well as the older adults
who li ve i n these fami li es. The money from
these small pensi ons i s used to purchase food
for the household, to send chi ldren to school,
to i nvest i n farmi ng technologi es and to en-
sure survi val for many urban poor fami li es.
I n developed countri es, soci al securi ty
measures can i nclude old-age pensi ons,
occupati onal pensi on schemes, voluntary
savi ngs i ncenti ves, compulsory savi ngs funds
and i nsurance programmes for di sabi li ty,
si ckness, long-term care and unemployment.
I n recent years, poli cy reforms have favoured
a multi -pi llared approach that mi xes state
and pri vate support for old age securi ty and
encourages worki ng longer and gradual
reti rement ( O ECD, 1998) .
PAGE 31
Work
Throughout the world, i f more people
would enjoy opportuni ti es for di gni ed
work ( properly remunerated, i n adequate
envi ronments, protected agai nst the hazards)
earli er i n li fe, people would reach old age
able to parti ci pate i n the workforce. Thus, the
whole soci ety would bene t. I n all parts of the
world, there i s an i ncreasi ng recogni ti on of
the need to support the acti ve and producti ve
contri buti on that older people can and do
make i n formal work, i nformal work, unpai d
acti vi ti es i n the home and i n voluntary
occupati ons.
I n developed countri es, the potenti al gai n
of encouragi ng older people to work
longer i s not bei ng fully reali zed. But when
unemployment i s hi gh, there i s often a
tendency to see reduci ng the number of older
workers as a way to create jobs for younger
people. However, experi ence has shown that
the use of early reti rement to free up new jobs
for the unemployed has not been an effecti ve
soluti on ( O ECD, 1998) .
I n lessdeveloped countri es, older people are
by necessi ty more li kely to remai n economi cally
acti ve i nto old age ( see Fi gure 9) . However,
i ndustri ali zati on, adopti on of new technologi es
and labour market mobi li ty i sthreateni ng
much of the tradi ti onal work of older people,
parti cularly i n rural areas. Development projects
need to ensure that older people are eli gi ble for
credi t schemesand full parti ci pati on i n i ncome-
generati ng opportuni ti es.
PAGE 32
Concentrating only on work in the
formal labour market tends to ig-
nore the valuable contribution that
older people make in work in the
informal sector (e.g., small scale,
self-employed activities and domes-
tic work) and unpaid work in the
home.
I n both developi ng and developed coun-
tri es, older people often tak e pri me respon-
si bi li ty for household management and
chi ldcare so that younger adults can work
outsi de the home.
I n all countri es, ski lled and experi enced older
people act as volunteers i n schools, commu-
ni ti es, reli gi ous i nsti tuti ons, busi nesses and
health and poli ti cal organi zati ons. Voluntary
work bene ts older people by i ncreasi ng
soci al contacts and psychologi cal well bei ng
whi le maki ng a si gni cant contri buti on to thei r
communi ti es and nati ons.
PAGE 33
The challenges of populati on agei ng are
global, nati onal and local. Meeti ng these chal-
lenges wi ll requi re i nnovati ve planni ng and
substanti ve poli cy reforms i n developed coun-
tri es and i n countri es i n transi ti on. Develop-
i ng countri es, most of whom do not yet have
comprehensi ve poli ci es on agei ng, face the
bi ggest challenges.
Challenge 1: The Double Burden
of Disease
As nati ons i ndustri ali ze, changi ng patterns of
li vi ng and worki ng are i nevi tably accompani ed
by a shi ft i n di sease patterns. These changes
i mpact developi ng countri es most. Even as
these countri es conti nue to struggle wi th i nfec-
ti ous di seases, malnutri ti on and compli cati ons
from chi ldbi rth, they are faced wi th the rapi d
growth of noncommuni cable di seases ( NCDs) .
Thi s double burden of di sease strai ns already
scarce resources to the li mi t.
The shi ft from communi cable to NCDs i s fast
occurri ng i n most of the developi ng world,
where chroni c i llnesses such as heart di sease,
cancer and depressi on are qui ckly becomi ng
the leadi ng causes of morbi di ty and di sabi l-
i ty. Thi s trend wi ll escalate over the next few
decades. I n 1990, 51 percent of the global
burden of di sease i n developi ng and newly
i ndustri ali zed countri es was caused by NCDs,
mental health di sorders and i njuri es. By 2020,
the burden of these di seases wi ll ri se to ap-
proxi mately 78 percent ( See Fi gure 10) .
By 2020, over 70 percent of t he global burden of disease in developing and newly indust rialized count ries will be caused by
noncommunicable diseases, ment al healt h disorders and injuries.
4. Challenges of an Agei ng Populati on
PAGE 34
There i s no questi on that poli cy makers and
donors must conti nue to put resources to-
ward the control and eradi cati on of i nfecti ous
di seases. But i t i s also cri ti cal to put poli ci es,
programmes and i ntersectoral partnershi ps
i nto place that can help to halt the massi ve
expansi on of chroni c NCDs. Whi le not neces-
sari ly easy to i mplement, those that focus on
communi ty development, health promoti on,
di sease preventi on and i ncreasi ng parti ci pa-
ti on are often the most effecti ve i n control-
li ng the burden of di sease. Furthermore other
long-term poli ci es that target malnutri ti on and
poverty wi ll help to reduce both chroni c com-
muni cable and noncommuni cable di seases.
Support for relevant research i s most
urgently needed for less developed countri es.
Currently, low and mi ddle-i ncome countri es
have 85 percent of the worlds populati on and
92 percent of the di sease burden, but only
10 percent of the worlds health research
spendi ng ( WHO , 2000) .
HIV/ AIDS and older people
In Africa and ot her developing regions, HIV/ AIDS has had mult iple impact s on older
people, in t erms of living wit h t he disease t hemselves, caring for ot hers who are infect -
ed and t aking on t he parent ing role wit h orphans of AIDS. This impact has been largely
ignored t o dat e. In fact , most dat a on HIV and AIDS infect ion rat es are only compiled
up t o age 49. Improved dat a collect ion (wit hout age limit at ions) t hat helps us bet t er
underst and t he impact of HIV/ AIDS on older people is urgent ly needed. HIV/ AIDS infor-
mat ion, educat ion and prevent ion act ivit ies as well as t reat ment services should apply
t o all ages.
Numerous st udies have found t hat most adult children wit h AIDS ret urn home t o die.
Wives, mot hers, aunt s, sist ers, sist ers-in-law and grandmot hers t ake on t he bulk of t he
care. Then, in many cases, t hese women t ake on t he care of t he orphaned children.
Government s, nongovernment al organizat ions and privat e indust ry need t o address
t he nancial, social and t raining needs of older people who care for family members
and neighbours who are infect ed and raise child survivors, some of whom t hemselves
are also infect ed (WHO, 2002).
Challenge 2: Increased Risk of
Disability
I n both developi ng and developed countri es,
chroni c di seasesare si gni cant and costly
causesof di sabi li ty and reduced quali ty of li fe.
An older personsi ndependence i sthreatened
when physi cal or mental di sabi li ti esmake i t di f-
cult to carry out the acti vi ti esof dai ly li vi ng.
As they grow older, people wi th di sabi li ti es
are li kely to encounter addi ti onal barri ers relat-
ed to the agei ng process. For example, mobi l-
i ty problems due to poli omyeli ti s i n chi ldhood
may be consi derably aggravated later i n li fe.
Now that many young people wi th i ntellectual
di sabi li ti es survi ve at much older ages and li ve
beyond thei r parents, thi s speci al group also
requi res careful attenti on from poli cy makers.
Many people develop di sabi li ti es i n later li fe
related to the wear and tear of agei ng ( e.g.,
arthri ti s) or the onset of a chroni c di sease,
PAGE 35
whi ch could have been prevented i n the rst
place ( e.g., lung cancer, di abetes and peri ph-
eral vascular di sease) or a degenerati ve i llness
( e.g., dementi a) . The li keli hood of experi enc-
i ng seri ous cogni ti ve and physi cal di sabi li ti es
dramati cally i ncreases i n very old age. Si gni -
cantly, adults over the age of 80 are the fastest
growi ng age group worldwi de.
But di sabi li ti es associ ated wi th agei ng and the
onset of chroni c di sease can be prevented
or delayed. For example, as menti oned on
page 18, there has been a si gni cant decli ne
over the last 20 years i n age-speci c di sabi li ty
rates i n the U.S.A ( see Fi gure 11) , England,
Sweden and other developed countri es.
Fi gure 10 shows the actual decli ne i n di sabi li -
ti es among older Ameri cans between 1982
and 1999 compared to the projected numbers
i f rates of di sabi li ty had remai ned stable over
that ti me peri od.
Some of thi s decli ne i s li kely due to i ncreased
educati on levels, i mproved standards of li v-
i ng and better health i n the early years. The
adopti on of posi ti ve li festyle behavi ours i s
also a factor. As already menti oned, choosi ng
not to smoke and maki ng modest i ncreases i n
physi cal acti vi ty levels can si gni cantly reduce
ones ri sk for heart di sease and other i llnesses.
Supporti ve changes i n the communi ty are
also i mportant, both i n terms of preventi ng
di sabi li ti es and reduci ng the restri cti ons that
people wi th di sabi li ti es often face. I n addi ti on,
i mpressi ve progress i n the management of
chroni c condi ti ons has been observed, i nclud-
i ng new techni ques for early di agnosi s and
treatment, as well as long-term management
of chroni c di seases, such as hypertensi on and
arthri ti s. Recent studi es have also emphasi zed
that the i ncreasi ng use of ai ds from si mple
personal ai ds, such as canes, walkers, hand-
rai ls, to technologi es ai med at the populati on
as a whole, such as telephones may reduce
PAGE 36
dependence among di sabled people. I n the
USA the use of such ai ds by dependent older
people i ncreased from 76 percent i n 1984 to
over 90 percent i n 1999 ( Cutler, 2001) .
Vision and Hearing
O ther common age-related di sabi li ti es i nclude
vi si on and heari ng losses. Worldwi de, there
are currently 180 mi lli on people wi th vi sual
di sabi li ty, up to 45 mi lli on of whom are bli nd.
Most of these are older people, as vi sual i m-
pai rment and bli ndness i ncrease sharply wi th
age. O verall, approxi mately four percent of
persons aged 60 years and above are thought
to be bli nd, and 60 percent of them li ve i n
Sub-Saharan Afri ca, Chi na and I ndi a. The ma-
jor age-related causes of bli ndness and vi sual
di sabi li ty i nclude cataracts ( nearly 50 percent
of all bli ndness) , glaucoma, macular degenera-
ti on and di abeti c reti nopathy ( WHO , 1997) .
There i s an urgent need for poli ci es and pro-
grammes desi gned to prevent vi sual i mpai r-
ment and to i ncrease appropri ate eye care
servi ces, parti cularly i n developi ng countri es.
I n all countri es, correcti ve lenses and cataract
surgery should be accessi ble and affordable
for older people who need them.
Heari ng i mpai rment leads to one of the most
wi despread di sabi li ti es, parti cularly i n older
people. I t i s esti mated that worldwi de over
50 percent of people aged 65 years and over
have some degree of heari ng loss ( WHO ,
2002a) . Heari ng loss can cause di f culti es wi th
communi cati on. Thi s, i n turn can lead to frus-
trati on, low self-esteem, wi thdrawal and soci al
i solati on ( Pal, 1974, Wi lson, 1999) .
Poli ci es and programmes need to be i n place
to reduce and eventually eli mi nate avoi dable
heari ng i mpai rment and to help people wi th
heari ng loss obtai n heari ng ai ds. Heari ng loss
may be prevented by avoi di ng exposure to
excessi ve noi se and the use of potenti ally
damagi ng drugs and by early treatment of di s-
eases leadi ng to heari ng loss, such as mi ddle
ear i nfecti ons, di abetes and possi bly hyperten-
si on. Heari ng loss can someti mes be treated,
especi ally i f the cause i s i n the ear canal or
mi ddle ear. Most often, however, the di sabi li ty
i s reduced by ampli cati on of sounds, usually
by usi ng a heari ng ai d.
An Enabling Environment
As populati ons around the world li ve longer,
poli ci es and programmes that help prevent
and reduce the burden of di sabi li ty i n old
age are urgently needed i n both developi ng
and developed countri es. O ne useful way to
look at deci si on-maki ng i n thi s area i s to thi nk
about enablement i nstead of di sablement. Di s-
abli ng processes i ncrease the needs of older
people and lead to i solati on and dependence.
Enabli ng processes restore functi on and
expand the parti ci pati on of older people i n all
aspects of soci ety.
A vari ety of sectors can enact age-fri endly
poli ci es that prevent di sabi li ty and enable
those who have di sabi li ti es to fully parti ci pate
i n communi ty li fe. Here are some examples of
enabli ng programmes, envi ronments and poli -
ci es i n a vari ety of sectors:
barri er-free workplaces, exi ble work
hours, modi ed work envi ronments and
part-ti me work for people who experi ence
di sabi li ti es as they age or are requi red to
care for others wi th di sabi li ti es ( pri vate
i ndustry and employers)
PAGE 37
well-li t streets for safe walki ng, accessi ble
publi c toi lets and traf c li ghts that gi ve
people more ti me to cross the street ( local
governments)
exerci se programmes that help older
people mai ntai n thei r mobi li ty or recover
the leg strength they need to be mobi le
( recreati on servi ces and nongovernmental
agenci es)
li fe-long learni ng and li teracy programmes
( educati on sector and nongovernmental
organi zati ons)
heari ng ai ds or i nstructi on i n si gn language
that enables older people who are hard of
heari ng to conti nue to communi cate wi th
others ( soci al servi ces and nongovernmen-
tal organi zati ons)
barri er-free access to health centres, reha-
bi li tati on programmes and cost-effecti ve
procedures such as cataract surgery and hi p
replacements ( health sector)
credi t schemes and access to small busi -
ness and development opportuni ti es so that
older people can conti nue to earn a li vi ng
( governments and i nternati onal agenci es) .
Changi ng the atti tudes of health and soci al
servi ce provi ders i s paramount to ensuri ng that
thei r practi ces enable and empower i ndi vi du-
als to remai n as autonomous and i ndependent
as possi ble for as long as possi ble. Professi on-
al caregi vers need to respect older peoples
di gni ty at all ti mes and to be careful to avoi d
premature i nterventi ons that may uni ntenti on-
ally i nduce the loss of i ndependence.
Researchers need to better de ne and stan-
dardi ze the tools used to assess abi li ty and
di sabi li ty and to provi de poli cy makers wi th
addi ti onal evi dence on key enabli ng processes
i n the broader envi ronment, as well as i n med-
i ci ne and health. Careful attenti on needs to be
pai d to gender di fferences i n these analyses.
Challenge 3: Providing Care for
Ageing Populations
As populati ons age, one of the greatest chal-
lenges i n health poli cy i s to stri ke a balance
among support for self-care ( people look-
i ng after themselves) , i nformal support ( care
from fami ly members and fri ends) and formal
care ( health and soci al servi ces) . Formal care
i ncludes both pri mary health care ( deli vered
mostly at the communi ty level) and i nsti tuti on-
al care ( ei ther i n hospi tals or nursi ng homes) .
Whi le i t i s clear that most of the care i ndi vi du-
als need i s provi ded by themselves or thei r
i nformal caregi vers, most countri es allot thei r
nanci al resources i nversely, i .e., the greatest
share of expendi ture i s on i nsti tuti onal care.
All over the world, fami ly members, fri ends
and nei ghbours ( most of whom are women)
provi de the bulk of support and care to older
adults that need assi stance. Some poli cy mak-
ers fear that provi di ng more formal care ser-
vi ces wi ll lessen the i nvolvement of fami li es.
Studi es show that thi s i s not the case. When
appropri ate formal servi ces are provi ded,
i nformal care remai ns the key partner ( WHO ,
2000c) . O f concern though are recent demo-
graphi c trends i n a large number of countri es
i ndi cati ng the i ncrease i n the proporti on of
chi ldless women, changes i n di vorce and mar-
ri age patterns and the overall much smaller
number of chi ldren of future cohorts of older
people, all contri buti ng to a shri nki ng pool of
fami ly support ( Wolf, 2001) .
PAGE 38
Formal care through health and soci al servi ce
systems needs to be equally accessi ble to all.
I n many countri es older people who are poor
and who li ve i n rural areas have li mi ted or
no access to needed health care. A decli ne i n
publi c support for pri mary health care servi ces
i n many areas has put i ncreased nanci al and
i ntergenerati onal strai n on older people and
thei r fami li es.
Most older persons i n need of care prefer to
be cared for i n thei r own homes. But care-
gi vers ( who are often older people) must be
supported i f they are to conti nue to provi de
care wi thout becomi ng i ll themselves. Above
all, they need to be well i nformed about the
condi ti on they are faced wi th and how i t i s
li kely to progress, and about how to obtai n
the support servi ces that are avai lable. Vi si ti ng
nurses, home care, peer support programmes,
rehabi li tati on servi ces, the provi si on of
assi sti ve devi ces ( rangi ng from basi c devi ces
such as a heari ng ai d to more sophi sti cated
ones, such as an electroni c alarm system) ,
respi te care and adult day care are all i mpor-
tant servi ces that enable i nformal caregi vers to
conti nue to provi de care to i ndi vi duals who
requi re help, whatever thei r age. O ther forms
of support i nclude trai ni ng, i ncome securi ty
( e.g., soci al securi ty coverage and pensi ons) ,
help wi th housi ng adjustments that enable
fami li es to look after people who are di sabled
and di sbursements to help cover cari ng costs.
As the proporti on of older people i ncreases i n
all countri es, li vi ng at home i nto very old age
wi th help from fami ly members wi ll become
i ncreasi ngly common. Home care and com-
muni ty servi ces to assi st i nformal caregi vers
need to be avai lable to all, not just to those
who know about them or can afford to pay
for them.
Sex rat i os f or popul at i ons age 60 and over re ect t he l arger propor t i on of women t han men i n al l regi ons of t he worl d,
par t i cul arl y i n t he more devel oped regi ons.
PAGE 39
Professi onal caregi vers also need trai ni ng
and practi ce i n enabli ng models of care that
recogni ze older peoples strengths and em-
power them to mai ntai n even small measures
of i ndependence when they are i ll or frai l.
Paternali sti c or di srespectful atti tudes by pro-
fessi onals can have a devastati ng effect on the
self-esteem and i ndependence of older people
who requi re servi ces.
I nformati on and educati on about acti ve age-
i ng needs to be i ncorporated i nto curri cula
and trai ni ng programmes for all health, soci al
servi ce and recreati on workers as well as ci ty
planners and archi tects. Basi c pri nci ples and
approaches i n old-age care should be manda-
tory i n the trai ni ng of all medi cal and nursi ng
students as well as other health professi ons.
Challenge 4: The Feminization of
Ageing
Women li ve longer than men almost every-
where. Thi s i s reected i n the hi gher rati o of
women versus men i n older age groups. For
example, i n 2002, there were 678 men for
every 1, 000 women aged 60 plus i n Europe.
I n less developed regi ons, there were 879 men
per 1, 000 women ( See Fi gure 12) . Women
make up approxi mately two-thi rds of the
populati on over age 75 i n countri es such as
Brazi l and South Afri ca. Whi le women have
the advantage i n length of li fe, they are more
li kely than men to experi ence domesti c vi o-
lence and di scri mi nati on i n access to educa-
ti on, i ncome, food, meani ngful work, health
care, i nheri tances, soci al securi ty measures and
poli ti cal power. These cumulati ve di sadvan-
tages mean that women are more li kely than
In cont rast t o t he pyrami d f orm, t he Japanese popul at i on st ruct ure has changed due t o popul at i on agei ng t owards a cone
shape. By 2025, t he shape w i l l be si mi l ar t o an up- si de- dow n pyrami d, w i t h persons age 80 and over account i ng f or t he l arg-
est popul at i on group. The f emi ni zat i on of ol d age i s hi ghl y vi si bl e.
PAGE 40
men to be poor and to suffer di sabi li ti es i n
older age. Because of thei r second-class status,
the health of older women i s often neglected
or i gnored. I n addi ti on, many women have
low or no i ncomes because of years spent i n
unpai d caregi vi ng roles. The provi si on of fam-
i ly care i s often achi eved at the detri ment of
female caregi vers economi c securi ty and good
health i n later li fe.
Women are also more li kely than men to li ve
to very old age when di sabi li ti es and multi ple
health problems are more common. At age
80 and over, the world average i s below 600
men for every 1, 000 women. I n the more
developed regi ons women age 80 and over
outnumber men by more than two to one ( see
the example of Japan i n Fi gure 13) .
Because of womens longer li fe expectancy
and the tendency of men to marry younger
women and to remarry i f thei r spouses di e,
female wi dows dramati cally outnumber male
wi dowers i n all countri es. For example, i n the
Eastern European countri es i n economi c tran-
si ti on over 70 percent of women age 70 and
over are wi dows ( Botev, 1999) .
O lder women who are alone are hi ghly
vulnerable to poverty and soci al i solati on. I n
some cultures, degradi ng and destructi ve at-
ti tudes and practi ces around buri al ri ghts and
i nheri tance may rob wi dows of thei r property
and possessi ons, thei r health and i ndepen-
dence and, i n some cases, thei r very li ves.
Challenge 5: Ethics and Inequities
As populati ons age, a range of ethi cal con-
si derati ons comes to the fore. They are often
li nked to age di scri mi nati on i n resource al-
locati on, i ssues related to the end of li fe and a
host of di lemmas li nked to long-term care and
the human ri ghts of poor and di sabled older
ci ti zens. Sci enti c advancements and modern
medi ci ne have led to many ethi cal questi ons
related to geneti c research and mani pulati on,
bi otechnology, stem cell research and the use
of technology to sustai n li fe whi le compromi s-
i ng quali ty of li fe. I n all cultures, consumers
need to be fully i nformed about false clai ms
of anti -agei ng products and programmes that
are i neffecti ve or harmful. They need protec-
ti on from fraudulent marketi ng and nanci ng
schemes, especi ally as they grow older.
Soci eti es that value soci al justi ce must stri ve to
ensure that all poli ci es and practi ces uphold
and guarantee the ri ghts of all people, re-
gardless of age. Advocacy and ethi cal deci -
si on-maki ng must be central strategi es i n all
programmes, practi ces, poli ci es and research
on agei ng.
O lder age often exacerbates other pre-exi sti ng
i nequali ti es based on race, ethni ci ty or gender.
Whi le women are uni versally di sadvantaged
i n terms of poverty, men have shorter li fe
expectanci es i n most countri es. The exclusi on
and i mpoveri shment of older women and men
i s often a product of structural i nequi ti es i n
both developi ng and developed countri es. I n-
equali ti es experi enced i n earli er li fe i n access
to educati on, employment and health care, as
well as those based on gender and race have
a cri ti cal beari ng on status and well bei ng i n
old age. For older people who are poor, the
consequences of these earli er experi ences
PAGE 41
are worsened through further exclusi on from
health servi ces, credi t schemes, i ncome-gener-
ati ng acti vi ti es and deci si on-maki ng. I nequi ti es
i n care occur when small and comparati vely
well off porti ons of the agei ng populati on,
parti cularly those i n developi ng countri es,
consume a di sproporti onately hi gh amount of
publi c resources for thei r care.
I n many cases, the means for older people to
achi eve di gni ty and i ndependence, recei ve
care and parti ci pate i n ci vi c affai rs are very
li mi ted. These condi ti ons are often worse for
older people li vi ng i n rural areas, i n countri es
i n transi ti on and i n si tuati ons of coni ct or
humani tari an di sasters.
I n all regi ons of the world, relati ve wealth and
poverty, gender, ownershi p of assets, access to
work and control of resources are key factors
i n soci oeconomi c status. Recent World Bank
data reveal that i n many developi ng countri es
well over half of the populati on li ves on less
than two purchasi ng power pari ty ( PPP) dol-
lars per day ( see Table 4) .
I t i s well known that soci oeconomi c status
and health are i nti mately related. Wi th each
step up the soci oeconomi c ladder, people li ve
longer, healthi er li ves ( Wi lki nson, 1996) . I n re-
cent years, the gap between ri ch and poor and
subsequent i nequali ti es i n health status has
been i ncreasi ng i n countri es i n all parts of the
world ( Lynch et al, 2000) . Fai lure to address
thi s problem wi ll have seri ous consequences
for the global economy and soci al order, as
well as for i ndi vi dual soci eti es and people of
all ages.
Table 4. Percent age of t he populat ion below internat ional povert y lines in count ries
wit h a populat ion approaching or above 100 million in t he year 2000
Count ries Populat ion
(millions)#
Percent age wit h
<1dollar/ day*
Percent age wit h
<2dollar/ day*
China 1.275 18.5 53.7
India 1.008 44.2 86.2
Indonesia 212 7.7 55.3
Brazil 170 9.0 25.4
Russian Federat ion 145 7.1 25.1
Pakist an 141 31.0 84.7
Bangladesh 137 29.1 77.8
Nigeria 113 70.2 90.8
Mexico 98 12.2 34.8
*adjust ed for purchasing power
Source:World Bank, 2001, #Source: UN, 2001
PAGE 42
Challenge 6: The Economics of an
Ageing Population
Perhaps more than anythi ng else, poli cy mak-
ers fear that rapi d populati on agei ng wi ll lead
to an unmanageable explosi on i n health care
and soci al securi ty costs. Whi le there i s no
doubt that agei ng populati ons wi ll i ncrease
demands i n these areas, there i s also evi dence
that i nnovati on, cooperati on from all sectors,
planni ng ahead and maki ng evi dence-based,
culturally-appropri ate poli cy choi ces wi ll
enable countri es to successfully manage the
economi cs of an agei ng populati on.
Research i n countri es wi th aged populati ons
has shown that agei ng per se i s not li kely to
lead to health care costs that are spi rali ng out
of control, for two reasons.
Fi rst, accordi ng to O ECD data, the major
causes of escalati ng health care costs are
related to ci rcumstances that are unrelated to
the demographi c agei ng of a gi ven populati on.
I nef ci enci es i n care deli very, bui ldi ng too
many hospi tals, payment systems that encour-
age long hospi tal stays, excessi ve numbers
of medi cal i nterventi ons and the i nappropri -
ate use of hi gh cost technologi es are the key
factors i n escalati ons i n health care costs. For
example, i n the Uni ted States and other O ECD
countri es, new technologi es were someti mes
rapi dly i ntroduced and used where alternati ve
and less expensi ve procedures already exi sted,
and for whi ch the margi nal effecti veness was
relati vely low ( Jacobzone and O xley, 2002) .
There appears to be consi derable scope for
poli cy makers to address these i ssues and
i mprove the effecti veness of health care.
Second, the costs of long-term care can be
managed i f poli ci es and programmes address
preventi on and the role of i nformal care. Poli -
ci es and health promoti on programmes that
prevent chroni c di seases and lessen the degree
of di sabi li ty among older ci ti zens enable
them to li ve i ndependently longer. Another
major factor i s the capaci ty and wi lli ngness
of fami li es to provi de care and support for
older fami ly members. Thi s wi ll depend to a
large extent on the rates of female parti ci pa-
ti on i n the labour force and on workplace and
publi c poli ci es that recogni ze and support the
caregi vi ng role.
I n many countri es, the bulk of spendi ng i son
curati ve medi ci ne. Care for chroni c condi ti ons
leadsto an i mproved quali ty of li fe; however,
i t i salwayspreferable i f those condi ti onscould
be prevented or delayed unti l very late i n li fe.
Deci si on makersneed to evaluate whether such
outcomescan be achi eved through poli ci esthat
addressthe broad determi nantsof acti ve age-
i ng, such asi nterventi onsto prevent i njuri es,
i mprove di etsand physi cal acti vi ty, i ncrease
li teracy or i ncrease employment.
Ulti mately, the level of fundi ng allocated to
the health system i s a soci al and poli ti cal
choi ce wi th no uni versally appli cable answer.
However, the WHO suggests that i t i s better
to make pre-payments on health care as much
as possi ble, whether i n the form of i nsurance,
taxes or soci al securi ty. The pri nci ple of fai r
nanci ng ensures equi ty of access regardless
of age, sex or ethni ci ty and that the nanci al
burden i s shared i n a fai r way ( WHO , 2000a) .
PAGE 43
A second major concern to poli cy-makers i s
the demand that an agei ng populati on may
put on soci al securi ty systems. Alarmi sts poi nt
to the growi ng proporti on of the dependent
populati on that has reti red from the formal la-
bour force. The i dea that everyone over age 60
i s dependent i s, however, a false assumpti on.
Many people conti nue to work i n the formal
labour market i n later li fe or would choose to
do so i f the opportuni ty exi sted. Many oth-
ers conti nue to contri bute to the economy
through i nformal work and voluntary acti vi ti es,
as well as i ntergenerati onal exchanges of cash
and fami ly support. For example, older people
who look after grandchi ldren allow younger
adults to parti ci pate i n the labour market.
An agei ng populati on provi des other advan-
tages to the overall economy. Nati ons wi th
decli ni ng worki ng-age populati ons wi ll be
able to draw on older experi enced workers
and i ndustri es wi ll be able to grow as they
serve the needs of older consumers.
Global agei ng does requi re governments and
the pri vate sector to address the challenges to
soci al securi ty and pensi on systems. A bal-
anced approach to the provi si on of soci al
protecti on and economi c goals suggests that
soci eti es who are wi lli ng to plan can afford to
grow old. Labour market poli ci es ( for exam-
ple, i ncenti ves for early reti rement and manda-
tory reti rement practi ces) have a more dramat-
i c i mpact on a nati ons abi li ty to provi de soci al
protecti on i n old age than demographi c agei ng
per se. The goal must be to ensure adequate
li vi ng standards for people as they grow older,
whi le recogni zi ng and harnessi ng thei r ski lls
and experi ence and encouragi ng harmoni ous
i ntergenerati onal transfers.
Challenge 7: Forging a New Paradigm
Tradi ti onally, old age has been associ ated wi th
reti rement, i llness and dependency. Poli ci es
and programmes that are stuck i n thi s out-
dated paradi gm do not reect reali ty. I ndeed,
most people remai n i ndependent i nto very old
age. Especi ally i n developi ng countri es, many
people over age 60 conti nue to parti ci pate
i n the labour force. O lder people are acti ve
i n the i nformal work sector ( e.g., domesti c
work and small scale, self-employed acti vi -
ti es) although thi s i s often not recogni zed i n
labour market stati sti cs. O lder peoples unpai d
contri buti ons i n the home ( such as looki ng
after chi ldren and people who are i ll) allow
younger fami ly members to engage i n pai d
labour. I n all countri es, the voluntary acti vi ti es
of older people provi de an i mportant econom-
i c and soci al contri buti on to soci ety.
I t is time for a new paradigm, one
that views older people as active
participants in an age-integrated
society and as active contributors as
well as beneciaries of development.
Thi s i ncludes recogni ti on of the contri buti ons
of older people who are i ll, frai l and vulner-
able and champi oni ng thei r ri ghts to care and
securi ty.
Thi s paradi gm takes an i ntergenerati onal
approach that recogni zes the i mportance of
relati onshi ps and support among and between
fami ly members and generati ons. I t rei nforces
a soci ety for all ages the central focus of
the 1999 Uni ted Nati ons I nternati onal Year of
O lder Persons.
PAGE 44
The new paradi gm also challenges the tra-
di ti onal vi ew that learni ng i s the busi ness of
chi ldren and youth, work i s the busi ness of
mi dli fe and reti rement i s the busi ness of old
age. The new paradi gm calls for programmes
that support learni ng at all ages and allow
people to enter or leave the labour market i n
order to assume caregi vi ng roles at di fferent
ti mes over the li fe course. Thi s approach sup-
ports i ntergenerati onal soli dari ty and provi des
i ncreased securi ty for chi ldren, parents and
people i n thei r old age.
O lder people themselves and the medi a must
take the lead i n forgi ng a new, more posi ti ve
i mage of agei ng. Poli ti cal and soci al recogni -
ti on of the contri buti ons that older people
make and the i nclusi on of older men and
women i n leadershi p roles wi ll support thi s
new i mage and help de-bunk negati ve stereo-
types. Educati ng young people about agei ng
and payi ng careful attenti on to upholdi ng the
ri ghts of older people wi ll help to reduce and
eli mi nate di scri mi nati on and abuse.
PAGE 45
The agei ng of the populati on i s a global phe-
nomenon that demands i nternati onal, nati onal,
regi onal and local acti on. I n an i ncreasi ngly
i nter-connected world, fai lure to deal wi th the
demographi c i mperati ve and rapi d changes i n
di sease patterns i n a rati onal way i n any part
of the world wi ll have soci oeconomi c and
poli ti cal consequences everywhere.
Ultimately, a collective approach to
ageing and older people will deter-
mine how we, our children and our
grandchildren will experience life in
later years.
The poli cy framework for acti ve agei ng shown
below i s gui ded by the United Nations Prin-
ciples for Older People( the outer ci rcle) . These
are i ndependence, parti ci pati on, care, self-ful-
llment and di gni ty. Deci si ons are based on
an understandi ng of how the determinants of
active ageing i nuence the way that i ndi vi du-
als and populati ons age.
The poli cy framework requi res acti on on three
basi c pi llars:
Health. When the ri sk factors ( both envi ron-
mental and behavi oural) for chroni c di seases
and functi onal decli ne are kept low whi le the
protecti ve factors are kept hi gh, people wi ll
enjoy both a longer quanti ty and quali ty of
5. The Poli cy Response
PAGE 46
li fe; they wi ll remai n healthy and able to man-
age thei r own li ves as they grow older; fewer
older adults wi ll need costly medi cal treatment
and care servi ces.
For those who do need care, they should have
access to the enti re range of health and soci al
servi ces that address the needs and ri ghts of
women and men as they age.
Participation. When labour market, employ-
ment, educati on, health and soci al poli ci es and
programmes support thei r full parti ci pati on i n
soci oeconomi c, cultural and spi ri tual acti vi -
ti es, accordi ng to thei r basi c human ri ghts,
capaci ti es, needs and preferences, people wi ll
conti nue to make a producti ve contri buti on to
soci ety i n both pai d and unpai d acti vi ti es as
they age.
Security. When poli ci es and programmes ad-
dress the soci al, nanci al and physi cal securi ty
needs and ri ghts of people as they age, older
people are ensured of protecti on, di gni ty and
care i n the event that they are no longer able
to support and protect themselves. Fami li es
and communi ti es are supported i n efforts to
care for thei r older members.
Intersectoral Action
Attai ni ng the goal of acti ve agei ng wi ll requi re
acti on i n a vari ety of sectors i n addi ti on to
health and soci al servi ces, i ncludi ng educa-
ti on, employment and labour, nance, soci al
securi ty, housi ng, transportati on, justi ce and
rural and urban development. Whi le i t i s clear
that the health sector does not have di rect
responsi bi li ty for poli ci es i n all of these other
sectors, they belong i n the broadest sense
wi thi n the scope of publi c health because they
support the goals of i mproved health through
i ntersectoral acti on. Thi s ki nd of an approach
stresses the i mportance of the numerous di f-
ferent publi c health partners and rei nforces the
role of the health sector as a catalyst for acti on
( Yach, 1996) .
Furthermore, all poli ci es need to support i n-
tergenerati onal soli dari ty and i nclude speci c
targets to reduce i nequi ti es between women
and men and among di fferent subgroups
wi thi n the older populati on. Parti cular atten-
ti on needs to be pai d to older people who are
poor and margi nali zed, and who li ve i n rural
areas.
An acti ve agei ng approach seeks to eli mi nate
age di scri mi nati on and recogni ze the di versi ty
of older populati ons. O lder people and thei r
caregi vers need to be acti vely i nvolved i n the
planni ng, i mplementati on and evaluati on of
poli ci es, programmes and knowledge develop-
ment acti vi ti es related to acti ve agei ng.
Key Policy Proposals
The followi ng poli cy proposals are desi gned
to address the three pi llars of acti ve age-
i ng: health, parti ci pati on and securi ty. Some
are broad and encompass all age groups
whi le others are targeted speci cally to those
approachi ng old age and/or older people
themselves.
PAGE 47
1. Health
1.1 Prevent and reduce the burden of
excess disabilities, chronic disease and
premature mortality.
Goals and targets. Set gender-speci c,
measurable targets for i mprovements i n
health status among older people and i n
the reducti on of chroni c di seases, di sabi li -
ti es and premature mortali ty as people age.
Economic inuences on health. Enact
poli ci es and programmes that address the
economi c factors that contri bute to the
onset of di sease and di sabi li ti es i n later li fe
( i .e., poverty, i ncome i nequi ti es and soci al
exclusi on, low li teracy levels, lack of educa-
ti on) . Gi ve pri ori ty to i mprovi ng the health
status of poor and margi nali zed populati on
groups.
Prevention and effective treatments.
Make screeni ng servi ces that are proven
to be effecti ve, avai lable and affordable to
women and men as they age. Make effec-
ti ve, cost-ef ci ent treatments that reduce
di sabi li ti es ( such as cataract removal and
hi p replacements) more accessi ble to older
people wi th low i ncomes.
Age-friendly, safe environments. Cre-
ate age-fri endly health care centres and
standards that help prevent the onset or
worseni ng of di sabi li ti es. Prevent i njuri es
by protecti ng older pedestri ans i n traf c,
maki ng walki ng safe, i mplementi ng fall pre-
venti on programmes, eli mi nati ng hazards
i n the home and provi di ng safety advi ce.
Stri ngently enforce occupati onal safety
standards that protect older workers from
i njury. Modi fy formal and i nformal work
envi ronments so that people can conti nue
to work producti vely and safely as they
age.
Hearing and vision. Reduce avoi dable
heari ng i mpai rment through appropri ate
preventi on measures and support access
to heari ng ai ds for older people who have
heari ng loss. Ai m to reduce and eli mi nate
avoi dable bli ndness by 2020 ( WHO , 1997) .
Provi de appropri ate eye care servi ces for
people wi th age-related vi sual di sabi li ti es.
Reduce i nequi ti es i n access to correcti ve
glasses for agei ng women and men.
Barrier-free living. Develop barri er-free
housi ng opti ons for agei ng people wi th
di sabi li ti es. Work to make publi c bui ldi ngs
and transportati on accessi ble for all people
wi th di sabi li ti es. Provi de accessi ble toi lets
i n publi c places and workplaces.
Quality of life. Enact poli ci es and pro-
grammes that i mprove the quali ty of li fe
of people wi th di sabi li ti es and chroni c
i llnesses. Support thei r conti nui ng i ndepen-
dence and i nterdependence by assi sti ng
wi th changes i n the envi ronment, provi di ng
rehabi li tati on servi ces and communi ty sup-
port for fami li es, and i ncreasi ng affordable
access to effecti ve assi sti ve devi ces ( e.g.,
correcti ve eyeglasses, walkers) .
PAGE 48
Social support. Reduce ri sks for loneli -
ness and soci al i solati on by supporti ng
communi ty groups run by older people,
tradi ti onal soci eti es, self-help and mutual
ai d groups, peer and professi onal outreach
programmes, nei ghbourhood vi si ti ng,
telephone support programmes, and fami ly
caregi vers. Support i ntergenerati onal con-
tact and provi de housi ng i n communi ti es
that encourage dai ly soci al i nteracti on and
i nterdependence among young and old.
HI V and AI DS. Remove the age li mi tati on
on data collecti on related to HI V/AI DS.
Assess and address the i mpact of HI V/AI DS
on older people, i ncludi ng those who
are i nfected and those who are cari ng for
others who are i nfected and/or for AI DS
orphans.
Mental health. Promote posi ti ve mental
health throughout the li fe course by provi d-
i ng i nformati on and challengi ng stereotypi -
cal beli efs about mental health problems
and mental i llness.
Clean environments. Put poli ci es and
programmes i n place that ensure equal
access for all to clean water, safe food and
clean ai r. Mi ni mi ze exposure to polluti on
throughout the li fe course, parti cularly i n
chi ldhood and old age.
1.2 Reduce risk factors associated with
major diseases and increase factors
that protect health throughout the life
course.
Tobacco. Take comprehensi ve acti on at
local, nati onal and i nternati onal levels to
control the marketi ng and use of tobacco
products. Provi de older people wi th help to
qui t smoki ng.
Physical activity. Develop culturally
appropri ate, populati on-based i nforma-
ti on and gui deli nes on physi cal acti vi ty for
older men and women. Provi de accessi ble,
pleasant and affordable opportuni ti es to be
acti ve ( e.g., safe walki ng areas and parks) .
Support peer leaders and groups that
promote regular, moderate physi cal acti vi ty
for people as they age. I nform and educate
people and professi onals about the i mpor-
tance of stayi ng acti ve as one grows older.
Nutrition. Ensure adequate nutri ti on
throughout the li fe course, parti cularly i n
chi ldhood and among women i n the repro-
ducti ve years. Ensure that nati onal nutri ti on
poli ci es and acti on plans recogni ze older
persons as a potenti ally vulnerable group.
I nclude speci al measures to prevent malnu-
tri ti on and ensure food securi ty and safety
as people age.
Healthy eating. Develop culturally ap-
propri ate, populati on-based gui deli nes for
healthy eati ng for men and women as they
age. Support i mproved di ets and healthy
wei ghts i n older age through the provi si on
of i nformati on ( i ncludi ng i nformati on spe-
ci c to the nutri ti on needs of older people) ,
educati on about nutri ti on at all ages, and
food poli ci es that enable women, men and
fami li es to make healthy food choi ces.
Oral health. Promote oral health among
older people and encourage women and
men to retai n thei r natural teeth for as long
as possi ble. Set culturally appropri ate poli cy
goals for oral health and provi de appropri -
ate oral health promoti on programmes and
treatment servi ces duri ng the li fe course.
PAGE 49
Psychological factors. Encourage and
enable people to bui ld self-ef cacy, cogni -
ti ve ski lls such as problem-solvi ng, pro-
soci al behavi our and effecti ve copi ng ski lls
throughout the li fe course. Recogni ze and
capi tali ze on the experi ence and strengths
of older people whi le helpi ng them i m-
prove thei r psychologi cal well bei ng.
Alcohol and drugs. Determi ne the extent
of the use of alcohol and drugs by people
as they age and put practi ces and poli ci es
i n place to reduce mi suse and abuse.
Medications. I ncrease affordable access
to essenti al safe medi cati ons among older
people who need them but cannot afford
them. Put practi ces and poli ci es i n place to
reduce i nappropri ate prescri bi ng by health
professi onals and other health advi sors.
I nform and educate people about the wi se
use of medi cati ons.
Adherence. Undertake comprehensi ve
measuresto better understand and correct
poor adherence to therapi es, whi ch severely
compromi se treatment effecti veness, parti cu-
larly i n relati on to long-term therapi es.
1.3. Develop a continuum of affordable,
accessible, high quality and age-
friendly health and social services that
address the needs and rights of women
and men as they age.
A continuum of care throughout the
life course. Taki ng i nto consi derati on thei r
opi ni ons and preferences, provi de a con-
ti nuum of care for women and men as they
grow older. Re-ori ent current systems that
are organi zed around acute care to provi de
a seamless conti nuum of care that i ncludes
health promoti on, di sease preventi on, the
appropri ate treatment of chroni c di seases,
the equi table provi si on of communi ty sup-
port and di gni ed long-term and palli ati ve
care through all the stages of li fe.
Affordable, equitable access. Ensure
affordable equi table access to quali ty
pri mary health care ( both acute and
chroni c) , as well as long-term care servi ces
for all.
I nformal caregivers. Recogni ze and
address gender di fferences i n the burden
of caregi vi ng and make a speci al effort to
support caregi vers, most of whom are older
women who care for partners, chi ldren,
grandchi ldren and others who are si ck
or di sabled. Support i nformal caregi vers
through i ni ti ati ves such as respi te care,
pensi on credi ts, nanci al subsi di es, trai ni ng
and home care nursi ng servi ces. Recogni ze
that older caregi vers may become soci ally
i solated, nanci ally di sadvantaged and si ck
themselves, and attend to thei r needs.
Formal caregivers. Provi de pai d caregi v-
ers wi th adequate worki ng condi ti ons and
remunerati on, wi th speci al attenti on to
those who are unski lled and have low so-
ci al and professi onal status ( most of whom
are women) .
PAGE 50
Mental health services. Provi de compre-
hensi ve mental health servi ces for men and
women as they age, rangi ng from mental
health promoti on to treatment servi ces for
mental i llness, rehabi li tati on and re-i ntegra-
ti on i nto the communi ty as requi red. Pay
speci al attenti on to i ncreased depressi on
and sui ci dal tendenci es due to loss and so-
ci al i solati on. Provi de quali ty care for older
people wi th dementi a and other neurologi -
cal and cogni ti ve problems i n thei r homes
and i n resi denti al faci li ti es when appropri -
ate. Pay speci al attenti on to agei ng people
wi th long-term i ntellectual di sabi li ti es.
Coordinated ethical systems of care.
Eli mi nate age di scri mi nati on i n health
and soci al servi ce systems. I mprove the
coordi nati on of health and soci al servi ces
and i ntegrate these systems when feasi ble.
Set and mai ntai n appropri ate standards of
care for agei ng persons through regulatory
mechani sms, gui deli nes, educati on, consul-
tati on and collaborati on.
I atrogenesis. Prevent i atrogenesi s ( di sease
and di sabi li ty that i s i nduced by the process
of di agnosi s or treatment) . Establi sh ad-
equate systems for preventi ng adverse drug
reacti ons wi th a speci al focus on old age.
Rai se awareness of the relati ve ri sks and
bene ts of modern therapi es among health
professi onals and the publi c at large.
Ageing at home and in the community.
Provi de poli ci es, programmes and servi ces
that enable people to remai n i n thei r homes
as they grow older, wi th or wi thout other
fami ly members accordi ng to thei r ci rcum-
stances and preferences. Support fami li es
that i nclude older people who need care i n
thei r households. Provi de help wi th meals
and home mai ntenance, and at-home nurs-
i ng support when i t i s requi red.
Partnerships and quality care. Provi de
a comprehensi ve approach to long-term
care ( by i nformal and formal caregi vers)
that sti mulates collaborati on between the
publi c and pri vate sectors and i nvolves all
levels of government, ci vi l soci ety and the
not-for-pro t sector. Ensure hi gh quali ty
standards and sti mulati ng envi ronments
i n resi denti al care faci li ti es for men and
women who requi re thi s care, as they grow
older.
1.4 Provide training and education to
caregivers.
I nformal caregivers. Provi de fam-
i ly members, peer counsellors and other
i nformal caregi vers wi th i nformati on and
trai ni ng on how to care for people as they
grow older. Support older healers who
are knowledgeable about tradi ti onal and
complementary medi ci nes whi le also as-
sessi ng thei r trai ni ng needs.
Formal caregivers. Educate health and
soci al servi ce workers i n enabli ng models
of pri mary health care and long-term care
that recogni ze the strengths and contri bu-
ti ons of older people. I ncorporate modules
on acti ve agei ng i n medi cal and health
curri cula at all levels. Provi de speci ali st
educati on i n gerontology and geri atri cs for
medi cal, health and soci al servi ce profes-
si onals.
I nform all health and soci al servi ce profes-
si onals about the process of agei ng and
PAGE 51
ways to opti mi ze acti ve agei ng among
i ndi vi duals, communi ti es and populati on
groups. Provi de i ncenti ves and trai ni ng
for health and soci al servi ce professi onals
to support self-care and counsel healthy
li festyle practi ces among men and women
as they age. I ncrease the awareness and
sensi ti vi ty of all health professi onals and
communi ty workers of the i mportance of
soci al networks for well bei ng i n old age.
Trai n health promoti on workers to i denti fy
older people who are at ri sk for loneli ness
and soci al i solati on.
2. Participation
2.1 Provide education and learning op-
portunities throughout the life course.
Basic education and health literacy.
Make basi c educati on avai lable to all across
the li fe course. Ai m to achi eve li teracy for
all. Promote health li teracy by provi di ng
health educati on throughout the li fe course.
Teach people how to care for themselves
and each other as they get older. Educate
and empower older people on how to ef-
fecti vely select and use health and commu-
ni ty servi ces.
Lifelong learning. Enable the full par-
ti ci pati on of older people by provi di ng
poli ci es and programmes i n educati on and
trai ni ng that support li felong learni ng for
women and men as they age. Provi de older
people wi th opportuni ti es to develop new
ski lls, parti cularly i n areas such as i nfor-
mati on technologi es and new agri cultural
techni ques.
2.2 Recognize and enable the active par-
ticipation of people in economic devel-
opment activities, formal and informal
work and voluntary activities as they
age, according to their individual
needs, preferences and capacities.
Poverty reduction and income genera-
tion. I nclude older people i n the planni ng,
i mplementati on and evaluati on of soci al de-
velopment i ni ti ati ves and efforts to reduce
poverty. Ensure that older people have
the same access to development grants,
i ncome-generati on projects and credi t as
younger people do.
Formal work. Enact labour market and
employment poli ci es and programmes that
enable the parti ci pati on of people i n mean-
i ngful work as they grow older, accordi ng
to thei r i ndi vi dual needs, preferences and
capaci ti es ( e.g., the eli mi nati on of age
di scri mi nati on i n the hi ri ng and retenti on
of older workers) . Support pensi on reforms
that encourage producti vi ty, a di verse sys-
tem of pensi on schemes and more exi ble
reti rement opti ons ( e.g., gradual or parti al
reti rement) .
I nformal work. Enact poli ci es and pro-
grammes that recogni ze and support the
contri buti on that older women and men
make i n unpai d work i n the i nformal sector
and i n caregi vi ng i n the home.
Voluntary activities. Recogni ze the value
of volunteeri ng and expand opportuni -
ti es to parti ci pate i n meani ngful volunteer
acti vi ti es as people age, especi ally those
who want to volunteer but cannot because
of health, i ncome, or transportati on restri c-
ti ons.
PAGE 52
2.3 Encourage people to participate fully
in family community life, as they grow
older.
Transportation. Provi de accessi ble, af-
fordable publi c transportati on servi ces i n
rural and urban areas so that older people
( especi ally those wi th compromi sed mobi l-
i ty) can parti ci pate fully i n fami ly and com-
muni ty li fe.
Leadership. I nvolve older people i n
poli ti cal processes that affect thei r ri ghts.
I nclude older women and men i n the
planni ng, i mplementati on and evaluati on
of locally based health and soci al servi ce
and recreati on programmes. I nclude older
people i n preventi on and educati on efforts
to reduce the spread of HI V/AI DS. I nvolve
older people i n efforts to develop research
agendas on acti ve agei ng, both as advi sors
and as i nvesti gators.
A society for all ages. Provi de greater
exi bi li ty i n peri ods devoted to educa-
ti on, work and caregi vi ng responsi bi li ti es
throughout the li fe course. Develop a range
of housi ng opti ons for older people that
eli mi nate barri ers to i ndependence and
i nterdependence wi th fami ly members, and
encourage full parti ci pati on i n communi ty
and fami ly li fe. Provi de i ntergenerati onal
acti vi ti es i n schools and communi ti es.
Encourage older people to become role
models for acti ve agei ng and to mentor
young people. Recogni ze and support
the i mportant role and responsi bi li ti es of
grandparents. Foster collaborati on among
nongovernmental organi zati ons that work
wi th chi ldren, youth and older people.
A positive image of ageing. Work wi th
groups representi ng older people and the
medi a to provi de reali sti c and posi ti ve i m-
ages of acti ve agei ng, as well as educati onal
i nformati on on acti ve agei ng. Confront
negati ve stereotypes and agei sm.
Reduce inequities in participation
by women. Recogni ze and support the
i mportant contri buti on that older women
make to fami li es and communi ti es through
caregi vi ng and parti ci pati on i n the i nformal
economy. Enable the full parti ci pati on of
women i n poli ti cal li fe and deci si on-mak-
i ng posi ti ons as they age. Provi de educa-
ti on and li felong learni ng opportuni ti es to
women as they age, i n the same way that
they are provi ded to men.
Support organizations representing
older people. Provi de i n-ki nd and nanci al
support and trai ni ng for members of these
organi zati ons so that they can advocate,
promote and enhance the health, securi ty
and full parti ci pati on of older women and
men i n all aspects of communi ty li fe.
3. Security
3.1 Ensure the protection, safety and dig-
nity of older people by addressing the
social, nancial and physical security
rights and needs of people as they age.
Social security. Support the provi si on of
a soci al safety net for older people who are
poor and alone, as well as soci al securi ty
i ni ti ati ves that provi de a steady and ad-
equate stream of i ncome duri ng old age.
Encourage young adults to prepare for
old age i n thei r health, soci al and nanci al
practi ces.
PAGE 53
HI V/ AI DS. Support the soci al, economi c
and psychologi cal well bei ng of older
people who care for people wi th HI V/AI DS
and take on surrogate parenti ng roles for
orphans of AI DS. Provi de i n-ki nd sup-
port, affordable health care and loans to
older people to help them meet the needs
of chi ldren and grandchi ldren affected by
HI V/AI DS.
Consumer protection. Protect consumers
from unsafe medi cati ons and treatments,
and unscrupulous marketi ng practi ces,
parti cularly i n older age.
Social justice. Ensure that deci si ons be-
i ng made concerni ng care i n older age
are based on the ri ghts of older people
and gui ded by the UN Pri nci ples for O lder
Persons. Uphold older persons ri ghts to
mai ntai n i ndependence and autonomy for
the longest peri od of ti me possi ble.
Shelter. Expli ci tly recogni ze older peoples
ri ght to and need for secure, appropri ate
shelter, especi ally i n ti mes of coni ct and
cri si s. Provi de housi ng assi stance for older
people and thei r fami li es when requi red
( payi ng speci al attenti on to the ci rcum-
stances of those who li ve alone) through
rent subsi di es, cooperati ve housi ng i ni ti a-
ti ves, support for housi ng renovati ons, etc.
Crises. Uphold the ri ghts of older people
duri ng coni ct. Speci cally recogni ze and
act on the need to protect older people i n
emergency si tuati ons ( e.g., by provi di ng
transportati on to reli ef centres to those who
cannot walk there) . Recogni ze the contri bu-
ti on that older people can make to recovery
efforts i n the aftermath of an emergency
and i nclude them i n recovery i ni ti ati ves.
Elder abuse. Recogni ze elder abuse ( phys-
i cal, sexual, psychologi cal, nanci al and
neglect) and encourage the prosecuti on of
offenders. Trai n law enforcement of cers,
health and soci al servi ce provi ders, spi ri tual
leaders, advocacy organi zati ons and groups
of older people to recogni ze and deal
wi th elder abuse. I ncrease awareness of
the i njusti ce of elder abuse through publi c
i nformati on and awareness campai gns. I n-
volve the medi a and young people, as well
as older people i n these efforts.
3.2 Reduce inequities in the security
rights and needs of older women.
Enact legi slati on and enforce laws that
protect wi dows from the theft of property
and possessi ons and from harmful practi ces
such as health-threateni ng buri al ri tuals and
charges of wi tchcraft.
Enact legi slati on and enforce laws that pro-
tect women from domesti c and other forms
of vi olence as they age.
Provi de soci al securi ty ( i ncome support)
for older women who have no pensi ons or
meager reti rement i ncomes because they
have worked all or most of thei r li ves i n the
home or i nformal sector.
PAGE 54
WHO and Ageing
In 1995 when WHO renamed it s Healt h of t he Elderly Programme t o Ageing and
Healt h, it signaled an import ant change in orient at ion. Rat her t han compart ment alizing
older people, t he new name embraced a life course perspect ive: we are all ageing and
t he best way t o ensure good healt h for fut ure cohort s of older people is by prevent ing
diseases and promot ing healt h t hroughout t he life course. Conversely, t he healt h of
t hose now in older age can only be fully underst ood if t he life event s t hey have gone
t hrough are t aken int o considerat ion.
The aim of t he Ageing and Healt h Programme has been t o develop policies t hat ensure
t he at t ainment of t he best possible qualit y of life for as long as possible, for t he largest
possible number of people. For t his t o be achieved, WHO is required t o advance t he
knowledge base of geront ology and geriat ric medicine t hrough research and t raining
effort s. Emphasis is needed on fost ering int erdisciplinary and int ersect oral init iat ives,
part icularly t hose direct ed at developing count ries faced wit h unprecedent ed rapid
rat es of populat ion ageing wit hin a cont ext of prevailing povert y and unsolved infra-
st ruct ure problems. In addit ion t he Programme highlight ed t he import ance of :
adopt ing communit y-based approaches by emphasizing t he communit y as a key
set t ing for int ervent ions
respect ing cult ural cont ext s and inuences
recognizing t he import ance of gender differences
st rengt hening int ergenerat ional links
respect ing and underst anding et hical issues relat ed t o healt h and well being in old
age.
The Int ernat ional Year of Older Persons (1999) was a landmark in t he evolut ion of
t he WHOs work on ageing and healt h. That year, t he World Healt h Day t heme was
act ive ageing makes t he difference and t he Global Movement for Act ive Ageing was
launched by t he WHO Direct or-General, Dr Gro Harlem Brundt land. At t his occasion,
Dr Brundt land st at ed: Maint aining healt h and qualit y of life across t he lifespan will do
much t owards building fullled lives, a harmonious int ergenerat ional communit y and a
dynamic economy. WHO is commit t ed t o promot ing Act ive Ageing as an indispensable
component of all development programmes.
In 2000, t he name of t he WHO programme was changed again t o Ageing and Life
Course t o reect t he import ance of t he life-course perspect ive. The mult i-focus of t he
previous programme and t he emphasis on developing act ivit ies wit h mult iple part ners
from all sect ors and several disciplines have been maint ained. A furt her renement of
t he act ive ageing concept has been added and t ranslat ed int o all t he programme ac-
t ivit ies, including research and t raining, informat ion disseminat ion, advocacy and policy
development .
In addit ion t o t he Ageing and Life Course Programme at WHO Headquart ers, each of
t he six WHO Regional Ofces have t heir own Adviser on Ageing in order t o address
specic issues from a regional perspect ive.
PAGE 55
International Collaboration
Wi th the launch of the I nternati onal Plan of
Acti on on Agei ng, the 2002 World Assembly
on Agei ng marks a turni ng poi nt i n addressi ng
the challenges and celebrati ng the tri umphs
of an agei ng world. As we embark on the
i mplementati on phase, cross-nati onal, regi onal
and global shari ng of research and poli cy
opti ons wi ll be cri ti cal. I ncreasi ngly, mem-
ber states, nongovernmental organi zati ons,
academi c i nsti tuti ons and the pri vate sector
wi ll be called upon to develop age-sensi ti ve
soluti ons to the challenges of an agei ng world.
They wi ll need to take i nto consi derati on the
consequences of the epi demi ologi cal transi -
ti on, rapi d changes i n the health sector, global-
i zati on, urbani zati on, changi ng fami ly patterns
and envi ronmental degradati on, as well as
persi stent i nequali ti es and poverty, parti cularly
i n developi ng countri es where the majori ty of
older persons are already li vi ng.
To advance the movement for acti ve age-
i ng, all stakeholders wi ll need to clari fy and
populari ze the term acti ve agei ng through
di alogue, di scussi on and debate i n the poli ti cal
arena, the educati on sector, publi c fora and
medi a such as radi o and televi si on program-
mi ng.
Acti on on all three pi llars of acti ve agei ng
needs to be supported by knowledge develop-
ment acti vi ti es i ncludi ng evaluati on, research
and survei llance and the di ssemi nati on of
research ndi ngs. The results of research need
to be shared i n clear language and accessi ble
and practi cal formats wi th poli cy makers,
nongovernmental organi zati ons representi ng
older people, the pri vate sector and the publi c
at large.
I nternati onal agenci es, countri es and regi ons
wi ll need to work collaborati vely to develop a
relevant research agenda for acti ve agei ng.
WHO is committed to work in col-
laboration with other intergovern-
mental organizations, NGOs and the
academic sector for the development
of a global framework for research
on ageing. Such a framework should
reect the priorities expressed in
the I nternational Plan of Action on
Ageing 2002 and those in this docu-
ment.
Conclusion
I n thi s document, WHO offers a framework
for acti on for poli cymakers. Together wi th the
newly-adopted UN Plan of Acti on on Age-
i ng, thi s framework provi des a roadmap for
desi gni ng multi sectoral acti ve agei ng poli ci es
whi ch wi ll enhance health and parti ci pati on
among agei ng populati ons whi le ensuri ng that
older people have adequate securi ty, protec-
ti on and care when they requi re assi stance.
WHO recogni zes that publi c health i nvolves
a wi de range of acti ons to i mprove the health
of the populati on and that health goes be-
yond the provi si on of basi c health servi ces.
Therefore, i t i s commi tted to work i n coopera-
ti on wi th other i nternati onal agenci es and the
Uni ted Nati ons i tself to encourage the i mple-
mentati on of acti ve agei ng poli ci es at global,
regi onal and nati onal levels. Due to the spe-
ci ali st nature of i ts work, WHO wi ll provi de
PAGE 56
techni cal advi ce and play a catalyti c role for
health development. However, thi s can only
be done as a joi nt effort. Together, we must
provi de the evi dence and demonstrate the
effecti veness of the vari ous proposed courses
of acti on. Ulti mately, however, i t wi ll be up
to nati ons and local communi ti es to develop
culturally sensi ti ve, gender-speci c, reali sti c
goals and targets, and i mplement poli ci es and
programmes tai lored to thei r uni que ci rcum-
stances.
The acti ve agei ng approach provi des a frame-
work for the development of global, nati onal
and local strategi es on populati on agei ng. By
pulli ng together the three pi llars for acti on of
health, parti ci pati on and securi ty, i t offers a
platform for consensus bui ldi ng that addresses
the concerns of multi ple sectors and all re-
gi ons. Poli cy proposals and recommendati ons
are of li ttle use unless follow-up acti ons are
put i n place. The ti me to act i s now.
PAGE 57
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PAGE 59
We gratefully acknowledge the support provi ded by Health Canada. UNFPA contri buted to the pri nti ng of
the brochure through the Geneva I nternati onal Network on Agei ng ( GI NA) .
Graphi c Desi gn: Mari lyn Langfeld
Copyri ght World Health O rgani zati on, 2002
Thi s document i s not a formal publi cati on of the World Health O rgani zati on ( WHO ) , and all ri ghts are
reserved by the O rgani zati on. The paper may, however, be freely revi ewed, abstracted, reproduced and
translated, i n part or i n whole, but not for sale nor for use i n conjuncti on wi th commerci al purposes.
The vi ews expressed i n documents by named authors are solely the responsi bi li ty of these authors.

World Health O rgani zati on
Noncommuni cable Di sease Preventi on and Health Promoti on
Agei ng and Li fe Course
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Fax: +41-22-791 4839 Emai l: acti veagei ng@who.i nt

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