Handbook of Active Ageing and Quality of Life: From Concepts to Applications (International Handbooks of Quality-of-Life) 303058030X, 9783030580308

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International Handbooks of Quality-of-Life Series Editor: Graciela Tonon

Fermina Rojo-Pérez Gloria Fernández-Mayoralas  Editors

Handbook of Active Ageing and Quality of Life From Concepts to Applications

International Handbooks of Quality-of-Life Series Editor Graciela Tonon, Universidad Nacional de Lomas de Zamora and Universidad de Palermo, Ciudad Autonoma de Buenos Aires, Argentina Editorial Board Alex Michalos, University of Northern British Columbia, Canada Rhonda Phillips, Purude University, USA Don Rahtz, College of William & Mary, USA Dave Webb, University of Western Australia, Australia Wolfgang Glatzer, Goethe University, Germany Dong Jin Lee, Yonsei University, Korea Laura Camfield, University of East Anglia, UK

Aims and Scope The International Handbooks of Quality of Life Research offer extensive bibliographic resources. They present literature reviews of the many sub-disciplines and areas of study within the growing field of quality of life research. Handbooks in the series focus on capturing and reviewing the quality of life research literature in specific life domains, on specific populations, or in relation to specific disciplines or sectors of industry. In addition, the Handbooks cover measures of quality of life and well-being, providing annotated bibliographies of well-established measures, methods, and scales.

More information about this series at http://www.springer.com/series/8365

Fermina Rojo-Pérez  Gloria Fernández-Mayoralas Editors

Handbook of Active Ageing and Quality of Life From Concepts to Applications

Editors Fermina Rojo-Pérez Institute of Economics, Geography and Demography (IEGD) Spanish National Research Council (CSIC), Research Group on Ageing (GIE-CSIC), Ageing Network of the Latin American Population Association (ALAP) Madrid, Spain

Gloria Fernández-Mayoralas Institute of Economics, Geography and Demography (IEGD) Spanish National Research Council (CSIC), Research Group on Ageing (GIE-CSIC) Madrid, Spain

ISSN 2468-7227 ISSN 2468-7235 (electronic) International Handbooks of Quality-of-Life ISBN 978-3-030-58030-8 ISBN 978-3-030-58031-5 (eBook) https://doi.org/10.1007/978-3-030-58031-5 # Springer Nature Switzerland AG 2021 Chapter 5 is licensed under the terms of the Creative Commons Attribution 4.0 International License (http://creativecommons.org/licenses/by/4.0/). For further details see licence information in the chapter. This work is subject to copyright. All rights are reserved by the Publisher, whether the whole or part of the material is concerned, specifically the rights of translation, reprinting, reuse of illustrations, recitation, broadcasting, reproduction on microfilms or in any other physical way, and transmission or information storage and retrieval, electronic adaptation, computer software, or by similar or dissimilar methodology now known or hereafter developed. The use of general descriptive names, registered names, trademarks, service marks, etc. in this publication does not imply, even in the absence of a specific statement, that such names are exempt from the relevant protective laws and regulations and therefore free for general use. The publisher, the authors, and the editors are safe to assume that the advice and information in this book are believed to be true and accurate at the date of publication. Neither the publisher nor the authors or the editors give a warranty, expressed or implied, with respect to the material contained herein or for any errors or omissions that may have been made. The publisher remains neutral with regard to jurisdictional claims in published maps and institutional affiliations. This Springer imprint is published by the registered company Springer Nature Switzerland AG. The registered company address is: Gewerbestrasse 11, 6330 Cham, Switzerland

Throughout our research career, we have been fortunate to be accompanied by academics and researchers specialising in ageing, active ageing and quality of life. We would like to dedicate this book to them. First, we wish to mention Antonio Abellán García and Vicente Rodríguez-Rodríguez, the friends and colleagues with whom we co-founded the Research Group on Ageing (GIE-CSIC) in 1988 at the Institute of Economics, Geography and Demography, Spanish National Research Council (IEGD, CSIC). Additionally and as members of the Spanish Research Group on Quality of Life and Ageing, we also wish to dedicate a mention here to Pablo Martinez Martín, recently retired from the National Centre of Epidemiology, Carlos III Institute of Health (CNE, ISCIII). They have all performed immense scientific work in their respective fields, and we have shared knowledge, research time and fine professional moments with them, for which we feel grateful. In the context of the International Society for Quality of Life Studies (ISQOLS), we recall our first participation in the ISQOLS conferences. This was at the seventh such conference, held in July 2006 at Rhodes University, Grahamstown, South Africa, and organised by Valerie Møller and Denis Huschka. It is a source of pride to be a part of this association, sharing our interest in quality of life studies with members from all parts of the world.

In a special way, we thank Valerie for dedicating her expertise to drafting the preface that crowns this book. Our profound thanks also to Graciela Tonon, editor of the Springer book series on International Handbooks of Quality-of-Life, for inviting and encouraging us to coordinate this edited book. Our utmost gratitude extends to all the authors of the different chapters of the book; they are responsible for its quality, thanks to their preparedness to selflessly transmit their knowledge. It is an honour for us, the editors, to collaborate in the dissemination of knowledge in the field of active ageing and quality of life. We hope to be able to contribute to improving the lives of the ageing population. To all those older adults who think that we are writing about them: yes, we are writing both about you and for you. —Fermina Rojo-Pérez and Gloria Fernández-Mayoralas I also dedicate this book to my parents, Vita ({) and María, who worked assiduously with love and by way of example to secure the education and well-being of their children from their humble rural origins. To José Manuel, with whom I share my life, and to my brothers and sisters, for their love, support and understanding of my work. —Fermina Rojo-Pérez To my mother (Josefina ({)), who in spite of leaving us so soon, has been my role model for becoming the woman I wish to be. To my father (Ángel ({)), who spoke of me with pride. To Lorenzo, my partner of 40 years, with whom I can also discuss research and science. And to my child, Gloria, for whom I too aspire to serve as a role model. —Gloria Fernández-Mayoralas

Foreword

A Place and a Time for a Handbook on Active Ageing and Quality of Life There will always be a place and a time for novel ways of thinking and doing things. The Handbook on Active Ageing and Quality of Life represents such a new initiative. It will introduce fresh ideas and inject new energy into the study of ageing and applied gerontology in the twenty-first century. The preface title, referring to ‘a place and a time’, is borrowed from one that featured in the editorial of a new regional journal of gerontology in 1993. The editors considered the time had arrived when scholars, practitioners and policymakers in the southern African region could learn from gerontologists in other parts of the world. They hoped that the new journal would provide access to knowledge and practical and policy lessons learnt, which might find new regional applications (Møller and Ferreira 1993). Three decades later, this Handbook on Active Ageing and Quality of Life has a similar role to play, but its mission is a more urgent one. The handbook will be addressing a global readership looking for information to equip them to face the new challenge of the demographic revolution. For the first time in history, the twenty-first century will see the proportion of people aged 60 years and over growing faster than any other age group worldwide.

New Agendas Since the 1990s, there has been a new way of thinking about what some contributors to this handbook refer to as ‘positive’ ageing and ‘positive’ wellbeing in the twenty-first century. The handbook takes as starting point the new agendas set by the 2002 Madrid Plan of Action on Ageing and the World Health Organization’s 2002 Policy Framework on Active Ageing. The agendas represent a major turning point in finding solutions to meeting the challenges of population ageing:

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The Madrid Plan of Action1 adopted at the Second World Assembly on Ageing in April 2002 offers a bold new agenda for society to focus on the priority areas of older people and development, advancing health and well-being into old age and ensuring enabling and supportive environments. Noteworthy is that the agenda links questions of ageing to other frameworks for social and economic development and human rights. Global ageing is a success story according to the World Health Organization (WHO). The WHO Policy Framework on Active Ageing declares global ageing as ‘a triumph and a challenge’ (WHO 2002, p. 6). Active ageing aims to optimise opportunities for health, participation and security in order to enhance quality of life as people age, so that people can realise their full potential for well-being throughout the life course. Importantly, active ageing applies to both individuals and population groups. The agenda for the twenty-first century’s pursuit of happiness has also undergone revision. The commission set up by French President Nicolas Sarkozy in 2008 produced the Stiglitz et al.’s (2009) report that recommended consideration of other than economic measures, such as GDP, to assess social progress. The report spurred the Beyond GDP movement that assesses social progress with comprehensive measures of prosperity and well-being such as happiness metrics. Taken together, the Madrid Plan of Action, the WHO Active Ageing Framework and the Beyond GDP movement have provided a blueprint for achieving greater quality of life for all in the twenty-first century—a plan that envisages a new, more inclusive social contract that enhances well-being across the generations.

Active Ageing and Quality of Life in the Twenty-First Century Active ageing might be seen as a new hashtag for ageing in the twenty-first century. Contributors to the Handbook on Ageing and Quality of Life share with their readers the many ways in which caring societies and older people themselves, as active members of society, are responding to the challenges of the demographic revolution. The handbook invites readers to appreciate the many advances in gerontological scholarship, research and practice. Richly nuanced descriptors of active ageing, such as ‘healthy’, ‘productive’, ‘successful’ and ‘positive’ ageing, feature in the handbook. Authors speak of ‘enhanced’ well-being and ‘positive’ quality of life. Their scholarly discussions examine the history of these two key concepts and the linkage between them: Are active ageing and quality of life identical or fraternal twins? Is this distinction important or not? The scope of the handbook is broad and addresses a readership made up of scholars, practitioners and policymakers as well as the interested public. 1

https://www.un.org/development/desa/ageing/madrid-plan-of-action-and-its-implementa tion.html

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Divided into four sections, the handbook firstly covers advances in theoretical knowledge in the field of gerontology and the tools of the trade—how we can measure active ageing and quality of life among older people in various settings. Further sections of the handbook present outcomes of projects and policies that make it possible for older people to age in place, to develop agency and to live in dignified and secure environments. Authors share their experience of the many lessons learnt from the application of a wide range of practical projects and new policies. Buen Vivir. A number of chapters in the handbook showcase the Latin American experience of applying active ageing to enhance the well-being of older people in society. This may not be fortuitous. Latin American countries are known as leaders in promoting quality of life for their people. Buen Vivir (Spanish for ‘living well’) is a leitmotiv for achieving collective well-being in society. The exceptionally high levels of happiness among Latin American people, compared to their more modest standards of living, have been attributed to the priority given to family life: ‘Latin Americans value human relations, and they can count on family and friendship networks to live a fulfilling life’ (Rojas 2017, p. 239). A golden thread running through the handbook is the importance of social networks, family support and social integration in community life. Lifelong learning, meaningful occupations and volunteering can be synonymous with or recipes for active ageing. Different chapters elaborate on how health, participation and security – the pillars of active ageing – can be achieved in many different settings, ones that provide age-friendly and enabling environments and ones that cater for independent living as well as assisted living and in care homes. We learn social support is essential for active ageing and the empowerment of the older generation. A sense of urgency is detected when the authors share with readers tips on best practice that will enhance not only the lived experience of older members of society but also the lives of their families and caregivers. Drawing on research and practice from different world regions, the handbook provides guidelines for promoting active ageing and enhanced well-being in diverse domains of life. Noteworthy is that the pillars of active ageing – health, participation, security and lifelong learning – are also compatible with the Sustainable Development Goals for the twenty-first century.

Active Ageing and the New Generational Contract ‘Becoming modern’. On a personal note, this writer came across a work written by a social scientist in the 1980s, who argued the price society must pay for ‘becoming modern’ was that older people’s knowledge and wisdom would necessarily become obsolete and be devalued. This notion came as a shock and gave an incentive to turn to gerontology to learn whether social progress would inevitably lead to older people being sidelined. In future, would the generational contract based on mutual respect and support be overturned? Would younger generations, who had been nurtured by and learnt

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from their elders, no longer feel any obligation to listen to and care for their ageing parents? The ‘grandmother hypothesis’ and longevity. It may be true that, in the past, many roles in society were defined by age. According to the ‘grandmother hypothesis’, the earliest grandmothers lived to an age beyond their reproductive years, so they could look after their grandchildren, which gave their daughters the freedom to forage for food for their offspring. Providing support and sustenance to their offspring could extend to the wider community and thereby benefit a larger group (Hawkes 2004; Wikipedia 2020). In short, grandmothering is critical for longevity and for the survival of grandchildren who will become future active agers. Contemporary grandmothers will continue to look after and spend time with their grandchildren, if not in person then at a distance, including as ‘Skype’ or now ‘Zoom’ grandmothers. Overlooked active agers. There will always have been some active agers, who were ahead of their times, even before the label was coined. The twentyfirst century offers new options for older people to achieve a better quality of life for themselves and their families and communities, given the greater support for active ageing and recognition for active agers. The past century witnessed some of the most dramatic advances in public health, sciences and technology. The cohorts who lived in the past century experienced the most rapid change that the world has ever seen. Many of our parents and grandparents not only witnessed but also participated in these developments. However, many of their contributions to society and social progress, particularly those by women, are being recognised only now. Sharing between the generations. In contemporary society, there is greater leeway for defining the terms of mutual support and respect between generations compared to the dictates of filial piety. It may be true that some roles in society have been reversed in the process of ‘becoming modern’. The digital natives of the twenty-first century, the ‘Thumbelinas’ (Howles 2015; Serres 2015), who nimbly call up information on their mobile phones rather than store knowledge in their heads, are often the ones to pass on knowledge to the older generation. However, many active agers have welcomed the opportunity to learn from their grandchildren of the benefits of the digital age, which is likely to dominate our lives in future. Noteworthy is that the coronavirus, which took the world by surprise in early 2020, appears to have prompted millennials to consult the history of their grandparents and greatgrandparents to learn how they coped with crises in the past century, such as the 1918 influenza and the two World Wars. Thus, there may be continuation of mutual exchange of expertise and experience between the generations in the years to come.

Active Ageing and Quality of Life: Outlook for the Future The Covid-19 global public health pandemic that swept across the globe in 2020 has put older people most at risk. The ancient adage that societies will be

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judged by how they care for and cherish the older people in their midst became relevant once more. The International Longevity Centre Global Alliance (ILC-GA), an organisation with a focus on the self-actualisation and well-being of older people, expressed its concern for the impact of the pandemic on older people, their families and communities. The Global Alliance’s Position Statement on COVID-19 (ILC-GA 2020), among others, denounced ageism and stressed the importance of dignity for older people in the time of the coronavirus, while acknowledging the contribution of older people to family and community. The statement also advocates that measures taken to manage the health crisis should be relevant to and respectful of older people’s lived experience. Importantly, the alliance notes that the pandemic has brought to the fore the many social inequalities in society: ‘the world must stand united’ to pool knowledge and resources equitably in the concerted fight against COVID-19. It is common knowledge that the pandemic will pass. However, life may never be the same again in the post-COVID-19 era. As alluded to in the Global Alliance statement, the most positive scenarios for the future see the new era as both a challenge and an opportunity to do things differently on a grander scale. There are hopes that the public health crisis has focused our minds on building a more co-operative and compassionate global order for tomorrow. A world that will succeed in achieving equal opportunities and well-being for people of all ages and social backgrounds. Surely, now must be the right time to produce a Handbook on Active Ageing and Quality of Life that can serve as a guide on how to achieve the world we should all like to live in. Emeritus Professor, Quality of Life Studies, Rhodes University, Grahamstown, South Africa

Valerie Møller

References Hawkes, K. (2004). Human longevity: The grandmother effect. Nature, 428 (6979), 128–129. Howles, T. (2015). Thumbelina: The culture and technology of millennials (Review). Critical Research on Religion, 3, 326–329. International Longevity Centre Global Alliance (ILC-GA). (2020). Position Statement on COVID-19. Accessed May 22, 2020 from https://www.ilcalliance.org/wp-content/uploads/2020/05/ILC-GA-position-onCOVID19-7-May-2020-1.pdf Møller, V., & Ferreira, M. (1993). A place and a time for a gerontology journal. Southern African Journal of Gerontology, 2(1), 1–2. https://doi. org/10.21504/sajg.v2i1.16 Rojas, M. (2017). Well-being in Latin America. In: R.J. Estes & M.J. Sirgy (Eds.), The pursuit of human well-being: The untold global history, International Handbooks of Quality-of-Life Research (pp. 217–255). Cham: Springer. Serres, M. (2015). Thumbelina: The culture and technology of millennials. (Transl. Daniel W. Smith). Lanham, MD: Rowman & Littlefield.

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Stiglitz, J. E., Sen, A., & Fitoussi, J.-P. (2009). Report by the Commission on the Measurement of Economic Performance and Social Progress. Paris. http://www.stiglitzsen-fitoussi.fr/en/index.htm WHO-World Health Organisation. (2002). Active ageing: A policy framework. Geneva: World Health Organisation. https://apps.who.int/iris/han dle/10665/67215 Wikipedia. Grandmother hypothesis. Accessed May 25, 2020 from https://en. wikipedia.org/wiki/Grandmother_hypothesis

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Contents

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Introduction: Methodological and Empirical Advances in Active Ageing and Quality of Life . . . . . . . . . . . . . . . . . . . Gloria Fernández-Mayoralas and Fermina Rojo-Pérez

Part I

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Theoretical and Conceptual Perspectives

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Active Aging and Quality of Life . . . . . . . . . . . . . . . . . . . . . . Rocío Fernández-Ballesteros, Macarena Sánchez-Izquierdo, and Marta Santacreu

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3

Active Aging and the Longevity Revolution . . . . . . . . . . . . . . Alexandre Kalache, Ina Voelcher, and Marilia Louvison

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4

Active Ageing and Quality of Life: A Systematized Literature Review . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Fermina Rojo-Pérez, Gloria Fernández-Mayoralas, and Vicente Rodríguez-Rodríguez

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The Life Course Construction of Inequalities in Health and Wealth in Old Age . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Michel Oris, Marie Baeriswyl, and Andreas Ihle

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Lifelong Learning and Quality of Life . . . . . . . . . . . . . . . . . . 111 Mª Ángeles Molina and Rocío Schettini

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Aging at a Developmental Crossroad . . . . . . . . . . . . . . . . . . . 121 Feliciano Villar and Rodrigo Serrat

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Quality of Life of Older People with Dementia . . . . . . . . . . . . 135 Beatriz León-Salas, Maria João Forjaz, Carmen Rodríguez-Blázquez, and Pablo Martínez-Martín

Part II

Social Policy Issues and Research Agenda

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Developmental Social Policy and Active Aging with High Quality of Life . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 149 Christian Aspalter

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“Active Ageing”: Its Relevance from an Historical Perspective . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 171 Julio Pérez Díaz and Antonio Abellán García xiii

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Transnational Aging and Quality of Life . . . . . . . . . . . . . . . . 185 Vincent Horn

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What Should Guarantee Pensions Systems Designed with a Human Rights Approach? . . . . . . . . . . . . . . . . . . . . . . . . . . 201 Sol Minoldo and Enrique Peláez

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Civil Society Organizations’ Discourse and Interventions to Promote Active Ageing in Relation with the Quality of Life in Latin-America . . . . . . . . . . . . . . . . . . . . . . . . . . . . 217 Vicente Rodríguez-Rodríguez, Verónica Montes de Oca Zavala, Mariana Paredes, and Sagrario Garay-Villegas

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Outdoor Green Spaces and Active Ageing from the Perspective of Environmental Gerontology . . . . . . . . . . . . . . . . . . . . . . . . 235 Diego Sánchez-González and Carmen Egea-Jiménez

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Active Ageing and Quality of Life . . . . . . . . . . . . . . . . . . . . . 253 Alan Walker

Part III

Methods, Measurement Instruments-Scales, Evaluations

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Active Ageing and Quality of Life . . . . . . . . . . . . . . . . . . . . . 273 Carmen Rodríguez-Blázquez and Maria João Forjaz

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Measuring the Impact of Active and Assisted Living (AAL) Solutions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 285 Birgit Aigner-Walder, Albert Luger, and Julia Himmelsbach

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Quality of Later Life in Europe . . . . . . . . . . . . . . . . . . . . . . . 299 Noelia Somarriba Arechavala, Pilar Zarzosa Espina, and Patricia Gómez-Costilla

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Proposals for Better Caring and Ageing . . . . . . . . . . . . . . . . . 319 Mª Silveria Agulló-Tomás, Vanessa Zorrilla-Muñoz, Mª Victoria Gómez-García, and Marian Blanco-Ruíz

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Preventing Loneliness . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 337 José Buz, Jenny de Jong Gierveld, and Daniel Perlman

Part IV

Applications (Domains, Geographical Contexts)

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Gender Differences in Active Aging in Canada . . . . . . . . . . . 357 María Victoria Zunzunegui and Emmanuelle Belanger

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Health and the Built Environment . . . . . . . . . . . . . . . . . . . . . 369 Marcia G. Ory, Chanam Lee, and Aya Yoshikawa

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Cuba: Active Ageing and Quality of Life of Older Persons . . . 395 Alina C. Alfonso León and Rolando García Quiñones

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Active Ageing for Quality of Later Life in Mexico. The Role of Physical and Social Environments . . . . . . . . . . . . . . . . . . . . . 409 Sagrario Garay-Villegas and Verónica Montes de Oca Zavala

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Happiness as a Quality of Life Component for Active Ageing in Colombia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 427 Doris Cardona-Arango, Alejandra Segura-Cardona, Diana Isabel Muñoz-Rodríguez, and Ángela Segura-Cardona

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Satisfaction with Quality of Life among Ex-combatants During the Reintegration Process. Colombia . . . . . . . . . . . . . . . . . . . 441 Carlos Robledo Marín and Doris Cardona-Arango

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Successful Aging and Quality of Life: A Cross-Ethnic Comparison in Chile . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 451 Esteban Sánchez-Moreno, Lorena Gallardo-Peralta, Vicente Rodríguez-Rodríguez, and Abel Soto Higuera

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Growing Older with Dignity: The Nature and Determinants of Quality of Life Among Older People in South Africa . . . . . 467 Pranitha Maharaj and Benjamin Roberts

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Staying Engaged . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 485 Jacki Liddle and Nancy A. Pachana

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Age-Friendly Environments and Active Aging for Community-based Older People Living in Beijing, China . . . 509 Yang Cheng, Jing Xi, and Mark Rosenberg

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Successful Aging and Active Aging in Taiwan: From Concept to Application: Micro and Macro Perspectives . . . . . . . . . . . . 521 Hui-Chuan Hsu

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Social Participation, Occupational Activities and Quality of Life in Older Europeans: A Focus on the Oldest Old . . . . . 537 Lia Araújo, Laetitia Teixeira, Oscar Ribeiro, and Constança Paul

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Quality of Life of Older Swedes . . . . . . . . . . . . . . . . . . . . . . . 549 Deborah Finkel and Gerdt Sundström

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Active Ageing as Framework for a Quality of Life Enabling Environment in Nursing Homes in Flanders, Belgium . . . . . . 559 Ellen Gorus, Patricia De Vriendt, and Lien Van Malderen

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Activities to Address Quality of Life Between Urban and Rural Ageing People in the Czech Republic . . . . . . . . . . . . . . . . . . . 573 Marcela Petrová Kafková

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Active Ageing: Conceptual Developments, International Experiences and Recent Policy Strategies in Italy . . . . . . . . . . 593 Claudia Di Matteo, Giovanni Lamura, and Andrea Principi

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Multimorbidity, Social Networks and Health-Related Wellbeing at the End of the Life Course . . . . . . . . . . . . . . . . . 609 Dolores Puga, Celia Fernández-Carro, and Hermenegildo Fernández-Abascal

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Care and Active Ageing . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 629 María Teresa Martín Palomo, María Pía Venturiello, Gloria Fernández-Mayoralas, and María Eugenia Prieto-Flores

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Residential Environment and Active Ageing: The Role of Physical Barriers in Leisure Participation . . . . . . . . . . . . . . . 643 María-Eugenia Prieto-Flores, Raúl Lardiés-Bosque, and Fermina Rojo-Pérez

Contributors

Antonio Abellán García Institute of Economics, Geography and Demography (IEGD), Spanish National Research Council (CSIC), Madrid, Spain Mª Silveria Agulló-Tomás Department of Social Analysis, Institute of Gender Studies, Carlos III University of Madrid, Getafe, Madrid, Spain Birgit Aigner-Walder Carinthia University of Applied Sciences, Institute for Applied Research on Ageing, Villach, Austria Alina C. Alfonso León Centre of Demographic Studies (CEDEM), University of Havana, Havana, Cuba Lia Araújo Polytechnic Institute of Viseu and CINTESIS (Center for Health Technology and Services Research), Porto, Portugal Christian Aspalter Social Work and Social Administration Programme, BNU-HKBU United International College, Zhuhai, China Marie Baeriswyl Swiss National Centre of Competence in Research LIVES – Overcoming Vulnerability: Life Course Perspectives, University of Geneva, Geneva, Switzerland Centre for the Interdisciplinary Study of Gerontology and Vulnerability, University of Geneva, Geneva, Switzerland Emmanuelle Belanger Center for Gerontology and Health Care Practice, School of Public Health, Brown University, Providence, RI, USA Marian Blanco-Ruíz Institute of Gender Studies, Carlos III University of Madrid, Getafe, Madrid, Spain Department of Communication and Sociology, Rey Juan Carlos University, Fuenlabrada, Madrid, Spain José Buz Faculty of Education, University of Salamanca, Salamanca, Spain Doris Cardona-Arango Public Health Observatory Research Group, Universidad CES, Medellín, Colombia Yang Cheng Faculty of Geographical Science, Beijing Normal University, Beijing, China

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Jenny de Jong Gierveld The Hague & Faculty of Social Sciences, Netherlands Interdisciplinary Demographic Institute (NIDI), Vrije Universiteit Amsterdam, Amsterdam, Netherlands Patricia De Vriendt Department of Gerontology (GERO) and Frailty in Ageing Research Group (FRIA), Vrije Universiteit Brussel, Brussels, Belgium Department of Occupational Therapy, Artevelde University College Ghent, Ghent, Belgium Department of Rehabilitation Sciences, Occupational Therapy Department, Ghent University, Ghent, Belgium Claudia Di Matteo Centre for Socio-Economic Research on Ageing, National Institute of Health and Science on Ageing—IRCCS INRCA, Ancona, Italy Carmen Egea-Jiménez University of Granada, Granada, Spain Hermenegildo Fernández-Abascal Faculty of Economics and Business, Department of Applied Economy, University of Valladolid, Valladolid, Spain Rocío Fernández-Ballesteros Autonomous University of Madrid, Madrid, Spain Celia Fernández-Carro Faculty of Political Science and Sociology, Department of Sociology III, UNED, Madrid, Spain Gloria Fernández-Mayoralas Institute of Economics, Geography and Demography (IEGD), Spanish National Research Council (CSIC), Research Group on Ageing (GIE-CSIC), Madrid, Spain Deborah Finkel Department of Psychology, Indiana University Southeast, Indiana, USA School of Health and Welfare, Jönköping University, Jönköping, Sweden Maria João Forjaz National Centre of Epidemiology and REDISSEC, Carlos III Institute of Health, Madrid, Spain Lorena Gallardo-Peralta School of Social Work, University of Tarapacá, Arica, Chile Faculty of Social Work, Universidad Complutense, Madrid, Spain Sagrario Garay-Villegas Faculty of Social Work, Autonomous University of Nuevo León (UANL), San Nicolás de los Garza, Mexico Rolando García Quiñones Academic Unit of Social Sciences, Autonomous University of Zacatecas, Zacatecas, Mexico Patricia Gómez-Costilla Economic Analysis Department, Valladolid University, Valladolid, Spain Mª Victoria Gómez-García Department of Social Analysis, Institute of Gender Studies, Carlos III University of Madrid, Getafe, Madrid, Spain

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Ellen Gorus Department of Gerontology (GERO) and Frailty in Ageing Research Group (FRIA), Vrije Universiteit Brussel, Brussels, Belgium Department of Geriatrics, Universitair Ziekenhuis Brussel, Brussels, Belgium Julia Himmelsbach AIT Austrian Institute for Technology GmbH, Center for Technology Experience, Vienna, Austria Vincent Horn Institute of Education, Johannes Gutenberg University Mainz, Mainz, Germany Hui-Chuan Hsu School of Public Health, Taipei Medical University, Taipei, Taiwan Andreas Ihle Swiss National Centre of Competence in Research LIVES – Overcoming Vulnerability: Life Course Perspectives, University of Geneva, Geneva, Switzerland Centre for the Interdisciplinary Study of Gerontology and Vulnerability, University of Geneva, Geneva, Switzerland Cognitive Aging Lab, University of Geneva, Geneva, Switzerland Alexandre Kalache International Longevity Centre Brazil, Rio de Janeiro, Brazil Giovanni Lamura Centre for Socio-Economic Research on Ageing, National Institute of Health and Science on Ageing—IRCCS INRCA, Ancona, Italy Raúl Lardiés-Bosque Department of Geography and Regional Planning, Study Group for Spatial Planning (GEOT), The Institute of Research into Environmental Sciences (IUCA), Universidad de Zaragoza, Zaragoza, Spain Chanam Lee Landscape Architecture and Urban Planning, College of Architecture, Texas A&M University, College Station, TX, USA Beatriz León Salas Canarian Foundation Institute of Health Research of Canary Islands (FIISC) and REDISSEC, El Rosario, Tenerife, Spain Jacki Liddle School of Information Technology and Electrical Engineering, The University of Queensland, Brisbane, QLD, Australia School of Psychology, The University of Queensland, Brisbane, QLD, Australia Marilia Louvison International Longevity Centre Brazil, Rio de Janeiro, Brazil Albert Luger Carinthia University of Applied Sciences, Institute for Applied Research on Ageing, Villach, Austria Pranitha Maharaj School of Built Environment and Development Studies, University of KwaZulu-Natal (UKZN), Durban, South Africa María Teresa Martín Palomo Almeria University, Almería, Spain Pablo Martínez-Martín National Centre of Epidemiology and CIBERNED, Carlos III Institute of Health, Madrid, Spain

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Sol Minoldo Centre for Research and Studies on Culture and Society, National Council for Scientific and Technical Research (CIECS-CONICET) (UBA), Cordoba, Argentina Mª Ángeles Molina Francisco de Vitoria University, Madrid, Spain Verónica Montes de Oca Zavala Institute of Social Research, National Autonomous University of Mexico (UNAM), Ciudad de México, Mexico Diana Isabel Muñoz-Rodríguez Epidemiology and Biostatistics Research Group, Universidad CES, Medellín, Colombia Michel Oris Swiss National Centre of Competence in Research LIVES – Overcoming Vulnerability: Life Course Perspectives, University of Geneva, Geneva, Switzerland Centre for the Interdisciplinary Study of Gerontology and Vulnerability, University of Geneva, Geneva, Switzerland Institute of Demography and Socioeconomics, University of Geneva, Geneva, Switzerland Marcia G. Ory Center for Population Health and Aging, School of Public Health, Texas A&M University, College Station, TX, USA Nancy A. Pachana School of Psychology, The University of Queensland, Brisbane, QLD, Australia Mariana Paredes Interdisciplinary Aging Centre, University of the Republic, Montevideo, Uruguay Constança Paul Institute of Biomedical Sciences Abel Salazar and CINTESIS, University of Porto, Porto, Portugal Enrique Peláez Centre for Research and Studies on Culture and Society, National Council for Scientific and Technical Research (CIECS-CONICET) (UBA), Cordoba, Argentina Julio Pérez Díaz Institute of Economics, Geography and Demography (IEGD), Spanish National Research Council (CSIC), Madrid, Spain Daniel Perlman University of North Carolina at Greensboro, Greensboro, NC, USA Marcela Petrová Kafková Office for Population Studies, Faculty of Social Studies, Masaryk University, Brno, Czech Republic María Eugenia Prieto-Flores National Council of Scientific and Technical Research (CONICET), Institute of Geography, National University of La Pampa, Santa Rosa, Argentina Andrea Principi Centre for Socio-Economic Research on Ageing, National Institute of Health and Science on Ageing—IRCCS INRCA, Ancona, Italy Dolores Puga Institute of Economics, Geography and Demography (IEGD), Spanish National Research Council (CSIC), Madrid, Spain

Contributors

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Oscar Ribeiro Department of Education and Psychology and CINTESIS, University of Aveiro, Aveiro, Portugal Benjamin Roberts South African Social Attitudes Survey (SASAS), Developmental, Capable and Ethical State (DCES) Research Division, Human Sciences Research Council (HSRC), Durban, South Africa Carlos Robledo Marín Fundación Opción Colombia (FUNDACOL), Medellin, Colombia Carmen Rodríguez-Blázquez National Centre of Epidemiology and CIBERNED, Carlos III Institute of Health, Madrid, Spain Vicente Rodríguez-Rodríguez Institute of Economics, Geography and Demography (IEGD), Spanish National Research Council (CSIC), Research Group on Ageing (GIE-CSIC), Ageing Network of the Latin American Population Association (ALAP), Madrid, Spain Fermina Rojo-Pérez Institute of Economics, Geography and Demography (IEGD), Spanish National Research Council (CSIC), Research Group on Ageing (GIE-CSIC), Ageing Network of the Latin American Population Association (ALAP), Madrid, Spain Mark Rosenberg Department of Geography and Planning, Queen’s University, Kingston, ON, Canada Diego Sánchez-González Department of Geography, National Distance Education University (UNED), Madrid, Spain Macarena Sánchez-Izquierdo Universidad Pontificia Comillas, Madrid, Spain Esteban Sánchez-Moreno Department of Sociology: Methods and Theory, Research Institute for Development and Cooperation (IUDC), Universidad Complutense, Madrid, Spain Marta Santacreu European University of Madrid, Madrid, Spain Rocío Schettini Foundation of the Autonomous University of Madrid, Madrid, Spain Alejandra Segura-Cardona Psychology, Health and Society Research Group, Universidad CES, Medellin, Colombia Ángela Segura-Cardona Epidemiology and Biostatistics Research Group, Universidad CES, Medellín, Colombia Rodrigo Serrat Department of Cognition, Development, and Educational Psychology, University of Barcelona, Barcelona, Spain Noelia Somarriba Arechavala Applied Economics Department, Valladolid University, Valladolid, Spain Abel Soto Higuera Department of Social Work, Universidad de la Frontera, Temuco, Chile

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Gerdt Sundström School of Health and Welfare, Jönköping University, Jönköping, Sweden Laetitia Teixeira Institute of Biomedical Sciences Abel Salazar and CINTESIS, University of Porto, Porto, Portugal Lien Van Malderen Department of Gerontology (GERO) and Frailty in Ageing Research Group (FRIA), Vrije Universiteit Brussel, Brussels, Belgium María Pía Venturiello National Council of Scientific and Technical Research (CONICET), University of Buenos Aires, Buenos Aires, Argentina Feliciano Villar Department of Cognition, Development, and Educational Psychology, University of Barcelona, Barcelona, Spain Ina Voelcher International Longevity Centre Brazil, Rio de Janeiro, Brazil Alan Walker Department of Sociological Studies, University of Sheffield, Sheffield, UK Jing Xi Faculty of Geographical Science, Beijing Normal University, Beijing, China Aya Yoshikawa Center for Population Health and Aging, School of Public Health, Texas A&M University, College Station, TX, USA Pilar Zarzosa Espina Applied Economics Department, Valladolid University, Valladolid, Spain Vanessa Zorrilla-Muñoz Department of Mechanical Engineering, Carlos III University of Madrid, Leganés, Madrid, Spain Department of Social Analysis, Institute of Gender Studies, Carlos III University of Madrid, Getafe, Madrid, Spain María Victoria Zunzunegui School of Public Health, Université de Montréal, Montreal, QC, Canada

Contributors

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Introduction: Methodological and Empirical Advances in Active Ageing and Quality of Life Special Focuses of the Book Gloria Fernández-Mayoralas and Fermina Rojo-Pérez

1.1

Introduction

Demographic ageing is a widespread process affecting all societies and territories. The United Nations (2019) estimates that there are currently over one billion people worldwide aged 60 years and above, representing almost 14% of the global population, and the rapid growth of this age group means that by 2050 at least one quarter of the population of every region other than Africa will be members of this age group. Women make up a large part of older people, with a worldwide ratio of 85 men to each 100 women aged 60 or over and a more pronounced gender gap in the figures for developed countries. Population ageing, which in other times was considered a matter for the developed economies of Europe and North America, is today a global phenomenon that is reaching Latin America and is subject to only one notable exception, the region of Sub-Saharan Africa, which remains G. Fernández-Mayoralas (*) Institute of Economics, Geography and Demography (IEGD), Spanish National Research Council (CSIC), Research Group on Ageing (GIE-CSIC), Madrid, Spain e-mail: [email protected] F. Rojo-Pérez Institute of Economics, Geography and Demography (IEGD), Spanish National Research Council (CSIC), Research Group on Ageing (GIE-CSIC), Ageing Network of the Latin American Population Association (ALAP), Madrid, Spain e-mail: [email protected]

relatively youthful in demographic terms. As a result, the demographic story of the twentieth and twenty-first centuries has been and continues to be one of ageing, at the level of both individual and population (Leeson 2017). Together with falling fertility rates, the evolution of society has also entailed a reduction in mortality at advanced ages, giving rise to increased longevity among the population. In this sense, demographic ageing is an achievement and a mark of success for humanity; never before have whole generations been able to enjoy such high life expectancy and expect to live a longer old age, with the result of more generations coexisting at the same time. We are entering an era of longevity on a planet-wide scale, meaning that the twenty-first century is destined to be a century of centenarians (Leeson 2018). Considering the current situation, and the fact that population projections indicate a growing trend, ageing represents a challenge both for societies as a whole and for individuals. At the beginning of the century, the United Nations held its Second World Assembly on Ageing in Madrid, Spain, at which the term active ageing (AA) was used for the first time in the Madrid International Plan of Action on Ageing (MIPAA) (UN 2002). As a contribution to the Assembly on Ageing and its Political Declaration, the World Health Organization (WHO) adopted AA as a target for action and its seminal document “Active Ageing: A Policy Framework” (WHO 2002) started an agenda of policies and activities

# Springer Nature Switzerland AG 2021 F. Rojo-Pérez, G. Fernández-Mayoralas (eds.), Handbook of Active Ageing and Quality of Life, International Handbooks of Quality-of-Life, https://doi.org/10.1007/978-3-030-58031-5_1

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that were developed across many countries with the aim of promoting a new image of ageing and of older people. Other international institutions subsequently supported the study of this sociodemographic phenomenon based on this new and positive paradigm, including the European Commission (EUROSTAT/European Commission 2012), which labelled 2012 the European Year for Active Ageing and Solidarity between Generations. AA continues to provide a coherent and comprehensive framework for strategies on an individual, local, national and global scale in response to the longevity revolution (ILC-BR 2015). The WHO defined AA as “the process of optimizing opportunities for health, participation and security in order to enhance quality of life as people age” (WHO 2002, p. 12), and later added the pillar of lifelong learning (ILC-BR 2015). In addition to these four pillars for action, the WHO framework includes six AA determinants: behavioural determinants, personal factors, physical environment, social environment, economic determinants, and health and social services determinants; it also incorporates two crosscutting determinants, in gender and culture. The model is completed by the human rights perspective, underpinned by the United Nations Principles for Older Persons adopted by General Assembly resolution in 1991 (comprising independence, participation, care, self-fulfilment and dignity). In this multi-dimensional framework for action and promotion of AA, quality of life (QoL) appears as an outcome variable (Van Malderen et al. 2013), which can in turn be considered globally or measured as an outcome of each one or several of the AA domains. The QoL concept hence adjusts well to changes in living conditions that come about during the process of optimization of opportunities for positive ageing. Following the positive ageing paradigm, the WHO more recently presented its “World Report on Ageing and Health” (WHO 2015), which called attention to the existence of ageist stereotypes in policies and behaviours, making it necessary to fight age discrimination. Additionally and in line with the key principles and values providing a basis for the Sustainable

G. Fernández-Mayoralas and F. Rojo-Pérez

Development Goals, the WHO (2020a) has announced plans for a Decade of Healthy Ageing (2020–2030), involving an action plan with ten priorities focused on innovation, planning, up-todate data, promotion of research, organisation of health systems and support and care systems, integrated care in old age, combating ageism, designing sustainable, fair and efficient solutions, and adapting cities and communities for older people. The 73rd World Health Assembly (held from 17 to 21 May 2020) reviewed progress made on actions for the Decade of Healthy Ageing (2020–2030), focusing on four actions intended to help to optimize levels and distribution of healthy ageing within and across countries: changing how we think, feel and act towards age and ageing; developing communities in ways that foster the abilities of older people; delivering person-centred, integrated care and primary health services responsive to older people; and providing access to long-term care to older people who need it (WHO May 2020b).

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Methodological and Empirical Advancements in Active Ageing and Quality of Life

In this context of promotion of active and healthy ageing, understanding old age and ageing is key to the facilitation of demographic sustainability and to being able to face the social and economic challenges of the twenty-first century. As such, research into ageing must be approached from an interdisciplinary and multidisciplinary perspective, and understood as a challenge with social, economic and environmental implications, but also as an area that offers opportunities for the development of society as a whole (Dimitriadis 2019). The consequences of all facets of population ageing require scientific knowledge and the transmission of that knowledge to society, in order to properly implement the social policies that will promote and facilitate the living conditions and QoL of older people in their living settings. The challenge of AA places the emphasis on conditions acquired over the course of a lifetime that influence QoL in old age. Longitudinal

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Introduction: Methodological and Empirical Advances in Active Ageing and Quality of Life

approaches are hence required, together with perspectives that take into account both quantitative evidence and the depth and richness of qualitative methodology that takes into consideration people’s opinions and assessments. This complementariness helps to achieve an understanding of phenomena and to explain processes, as well as encouraging citizen participation in research. All of this is not to omit systematized reviews, with or without meta-analysis, examining the various aspects related to sociodemographic processes in order to identify what knowledge has been acquired. In relation to health, it is paramount to study the prevalence of chronic disorders leading to processes of fragility, disability and dependence, and particularly cognitive impairment and dementia. But it is also crucial to study the periodic eruption of health emergencies and crises such as COVID-19, with acute consequences for the health of the population in general and that of older people in particular (Shahid et al. 2020). Knowledge regarding social inequalities in health is also fundamental to provide a basis for the public provision of social and healthcare services. Conducting research into social participation includes having more and better knowledge about: (1) workplace integration of people aged 50 years and above, in suitable working conditions, as well as the retention and promotion of senior talent; (2) the development of new models for activity involving social, political, association-based, educational, cultural and knowledge-building activities; and (3) changes to family structures, informal care, solitude as opposed to loneliness, and new forms of co-living in collaborative environments emulating ageing in place. Security is another pillar for action; it also has a multidimensional and complex nature, incorporating aspects that define QoL related to health security (health coverage and dependence), financial resources (pension system), support networks (family and social), friendly residential settings that contribute to the security of residents, particularly the more vulnerable, and social protection in general (to guarantee a minimum level of social coverage so as to eliminate poverty and reduce inequality).

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The perspective of older people’s rights also opens up a key field of research, including elements that play a central role in the fight against age-based discrimination or ageism: choice as to retirement age, autonomy and control over decision-making, fair access to healthcare and dependence, prevention of and protection against violence and mistreatment (particularly in relation to the multiple discrimination suffered by older women), sexual orientation and sexuality in old age, and ethics in key areas such as living wills and euthanasia. The impacts of ageing therefore cover personal experience, the social image of old age, age-friendly and inclusive environments for all ages, the sustainability of the pension system, health and social services policies, long-term care, formal or informal care, the social and cultural context of ageing, and the digital gap and technological development. There is a need to evaluate the effects of sustainability policies in the context of an increasingly aged society, which must be more efficient in productive and reproductive terms. As a global phenomenon, ageing will generate—and is already generating—one of the most dynamic sectors of the economy over coming decades, based on the so-called grey economy, on the adaptation of the services sector for a more active and healthy older population, and on development policies for rural sustainability.

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Special Focuses of the Book

This book is part of the International Handbooks of Quality-of-Life collection. The series editor Graciela Tonon invited and encouraged us to act as editors. The seeds for this book were sown at the symposium of the same name that took place during the 15th Annual Conference of the International Society for Quality of Life Studies, “Quality of Life: Towards a Better Society”, held in Innsbruck, Austria (September 28–30, 2017). The president of the ISQOLS at the time was professor Mariano Rojas, and the chair of the local organizing committee was professor Stefan Höfer. The aim of the symposium was to

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demonstrate the wide-ranging and multidimensional research landscape relating to ageing and to disseminate knowledge from a theoretical and empirical perspective, as well as practical experiences of ageing well and QoL in old age across the world, with the intention of meeting the challenges of an aged and ageing population. The structure of the book underlines the commitment to engage in a more in-depth examination of theoretical and applied research, methods, domains and indicators and their interactions, in order to identify, analyse and investigate matters including which factors better explain how AA enhances QoL, the conceptualization of AA and its connection with other similar concepts (healthy, productive or successful ageing), which methods and indicators better fit existing knowledge of AA and QoL, analyses of essential components of AA and their relationships with QoL, and AA profiles and associated factors for better QoL. In order to honour this commitment, as editors of this handbook, we invited contributions from a number of noted international scholars and researchers, from diverse fields of enquiry and representing different countries. The idea was for each to submit a chapter addressing key issues related to multidimensional constructs including ageing, AA and QoL, from different disciplinary and interdisciplinary perspectives. These perspectives included social sciences, politics, geography, health sciences and geriatrics, psychology, economics, and engineering and other technologies. Almost 90s academics eventually collaborated, with representation from every populated continent in the world. The book is structured in four sections as follows: I. Theoretical and conceptual perspectives (7 chapters); II. Social policy issues and research agenda (7 chapters); III. Methods, measurement instruments-scales, evaluations (5 chapters); IV. Applications (domains, geographical contexts) (19 chapters). Immediately following this introductory chapter is Section I on theoretical and conceptual perspectives, beginning with an examination by Fernández-Ballesteros et al. in Chap. 2 of the history and definitions of the constructs of AA

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and QoL. They ask whether it is possible to distinguish between the two or if they are tautological, since the concepts are multidimensional and appear to have overlapping components, although the WHO includes QoL as an outcome of AA in its definition of the latter concept (something that has not yet been proven). The authors therefore propose longitudinal and experimental studies to systematically evaluate the two concepts and measure the direction of their relationship, as well as conceptualizing their respective singularity. Perhaps part of the answer comes from the purpose that each concept serves: an action framework, in the case of AA, or an outcome variable or measure, in the case of QoL. In Chap. 3, Kalache and Voelcher explain AA as a concept and a policy tool for coping with the demographic change implied by the so-called longevity revolution, which is being observed on a global scale and is demanding a reconsideration of the traditional understanding of ageing and old age. As director of the WHO’s global ageing programme (1995–2008), Kalache is recognised worldwide as the leader of the movement seeking a paradigm shift to a positive view of ageing. This involves going beyond a simple increase in physical activity or extending one’s working life to take into account diverse and changing geographical, political and cultural contexts, with an emphasis on continued participation in meaningful engagements (social, economic, cultural, spiritual and civic). The need to examine the relationship between the concepts of AA and QoL does not appear to have been a central aim of the research into ageing well over recent decades; the fact is that few studies have expressly analysed this relationship, as is clear from the results found in the systematized literature review performed by Rojo-Pérez et al. and reported in Chap. 4. AA and QoL are constructs that are rarely studied together. Their definitions are not made explicit and ad hoc indicators are not therefore used. Moreover, there is a prevalence of cross-sectional methodologies that make it difficult to establish the meaning of any relationship between the constructs. The importance to contemporary societies of developing knowledge of AA and

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Introduction: Methodological and Empirical Advances in Active Ageing and Quality of Life

QoL supports the argument that there is a need to encourage studies with this aim. In Chap. 5, Oris et al. explore how individual heterogeneity is constructed in the ageing process and in wellbeing during old age, based on perspective of the life course that shows how inequalities in the two paramount components of QoL, health and wealth, can become cumulative disadvantages that hinder AA. This approach uses the individual as a unit of analysis, but considers the macro context (time and space), the meso context (social network and linked lives) and the micro context (past experiences). The authors highlight the need for more longitudinal research, although they recognise the limitation of maintaining a sufficient sample at the most advanced ages. In Chap. 6, Molina Martínez and Schettini discuss the role of lifelong learning in AA, as well as its contribution to improving QoL as people age. Their perspective recognises lifelong learning as an instrument for improving economic productivity and efficiency at work, but they go further and propose a need to evaluate the effectiveness of programmes based on lifelong learning and to confirm benefits from a personal view, taking into account both participation and improvement of cognitive functioning. In Chap. 7, Villar and Serrat present the concept of generativity through Erikson’s influential developmental theory, associated with middleage and defined as a concern for caring for and guiding the next generation and for being productive and contributing to the wellbeing and improvement of families, communities and society as a whole. The authors apply this concept to older age groups, providing a conceptual framework that may enrich the concept of ‘ageing well’, as it is complementary to other similar concepts such as successful and active ageing. The first Section of the book draws to a close with Chap. 8, in which León-Salas et al. explore the impact of dementia in old age and the need to use specific QoL measurement instruments with sufferers, who experience problems related to understanding, communication, insight and interpretation. The authors undertake a narrative review of literature to investigate the concept,

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determinants and instruments of QoL according to the severity level of dementia. Section II contains a series of chapter in which AA and QoL are taken as basic concepts for social policy issues and the research agenda. Based on the theory of developmental social policy, in Chap. 9, Aspalter proposes making proper preparations for the onset of extremely aged societies, by means of supply-side social investment strategies in addition to the development of practical applications of behavioural preventative social policy. This might include using the method of social policy marketing (in particular health policy marketing). In relation to international health strategy, in Chap. 10, Pérez Díaz and Abellán García recognize the importance of the concept of AA as well as its consolidation as a general framework for national health policies, especially in Europe. However, they emphasise three points in respect of which the concept is facing obstacles: (1) in its definition for purposes of implementation; (2) in its limited adoption outside Europe; and (3) from the WHO itself, which appears to be ceasing to use it. Horn contributes Chap. 11 from the perspective of globalization and international mobility, noting how this has given rise to an increase in the transnationalization of older people’s geographical and social frameworks of reference. This must undoubtedly influence QoL in turn, above all in relation to its pillars of health, including dependence (care obligations do not disappear) and participation (different ways of “doing family”, changes in lifestyles and social roles, ICT-based communication). All of this opens up a new line of research for studies on ageing in place and QoL. From a rights perspective, in Chap. 12 Minoldo and Peláez ask whether the concurrence of social security traditions which arose simultaneously with the first human rights treaties remain valid and suitable for the current period, with treaties produced many decades later. Using a frame of reference that is both international and Inter-American, they apply a qualitative approach involving content analysis of the human rights instruments related to the economic and social

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rights of older people. This is a meaningful method used in understanding the lack of current alignment between the human rights approach and the priorities and criteria that guided the design and development of the social security of the past. The authors reflect on what this may mean for the extension of current protection systems. Also applying a qualitative analysis, to the documents produced by Civil Society Organizations (CSOs) in Latin America, Rodríguez-Rodríguez et al. reflect in Chap. 13 on the role of CSOs in promoting AA and QoL in Latin America and on their influence in the creation of public policies, with a limited impact on the final design of these policies owing to the dominant role played by government. CSOs’ documents can be examined to follow the implementation of the MIPAA and the parameters of AA, particularly the health of older people, as an individual right that allows people to live with autonomy (security) and facilitates social participation, as well as establishing social relationships in their living settings, but also financial security and participation in the labour market. In contrast, the authors note that the idea of QoL is not expressed powerfully enough in the CSOs’ documents to be able to follow its evolution over the last 20 years. In Chap. 14, Sánchez-González and EgeaJiménez present a literature review concerning the role of green outdoor spaces in promoting AA, applying a perspective from environmental gerontology. The authors propose a model for intervention in AA based on the optimum adaptation of the specific characteristics of outdoor green spaces to the capacities and preferences of elderly people, and to encourage the active participation of older persons in the design and planning of friendly cities, in which natural elements can promote lifelong healthy lifestyles. Walker closes Section II with Chap. 15, which focuses on the essential role of scientific research in the achievement of AA and enhancement of QoL in old age. After outlining the meaning of AA, the chapter examines how it could transform nature and QoL in old age, drawing on major recent European and UK research programmes.

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Walker previously directed the European Research Area in Ageing, and in this chapter key research priorities are listed according to the Road Map for European Ageing Research and the MIPAA, with an examination of what policymakers must do in order to make AA a reality. Section III: Methods, measurement instruments-scales, evaluations is opened by Rodríguez-Blázquez and Forjaz, who use Chap. 16 to review the characteristics of the main generic and specific instruments for assessing QoL in old age, as well as the use of QoL rating scales in AA studies. The authors perform a non-systematic search across two bibliographic databases (PubMed and Web of Science) and describe a significant association between QoL and the usual AA indicators. They note that the relationship between the concepts is probably bidirectional, with other variables acting as mediators or moderators and probably playing an important role in the relationship. Again, further research is needed to determine a causal model, using longitudinal designs and complex statistical models such as structural equation modelling. In Chap. 17, Aigner-Walder et al. focus on active and assisted living (AAL) solutions. They ask questions including the following: are these technologies really leading to reduced costs? Who pays for their development and use? Can AAL solutions contribute to higher quality of living for older adults? Can data security be guaranteed? What are the economic effects of such solutions? Finally, they ask how we can measure the overall impact of AAL solutions. The authors point out the various stakeholder groups involved in an insurance-based health care system, their partly conflicting interests in technical innovations on the market, and the large number of potential indicators in existence to assess the overall effects of AAL technologies and systems. An econometric perspective on QoL in old age in Europe is presented by Somarriba Arechavala et al. in Chap. 18. Based on the most recent available information from the Survey on Health, Ageing and Retirement in Europe (SHARE), the

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Introduction: Methodological and Empirical Advances in Active Ageing and Quality of Life

authors provide an alternative synthetic indicator of QoL to the CASP12 scale (Börsch-Supan et al. 2005 #16833; Wiggins et al. 2008 #2673) used in the aforementioned survey. This represents an interesting contribution given that the indicator does not assume homogeneity between individuals who have the same overall score but different partial scores. The authors then estimate several econometric models to find and analyse the most decisive factors in explaining QoL across 26 European countries. Results are presented on an individual and a country-based scale. A further methodological perspective relates to the evaluation of care programmes for older people, involving a qualitative methodology based on the testimonies of caregivers, mainly women, and heads of care programmes. This is the aim of Agulló Tomás et al. in Chap. 19, whose results offer specific proposals for care for the elderly and support programmes for carers in relation to care in the context of the health service, the psychosocial sphere, social and labour policies and transversal demands. Section III closes with Chap. 20, in which Buz et al. present a framework for preventing intense loneliness from a social intervention perspective. The framework is based on strategies aimed at actions to be implemented before loneliness occurs or during its earlier stages. The authors underline the importance of macro, meso and micro social factors for preventing loneliness and fostering AA, and the efforts of individuals as well as professionals, policymakers and institutions at local and state levels. Section IV comprises the meat of the book, with 19 contributions organized by geographical context and country. These chapters examine the applications of AA and QoL, or focus on domains of QoL or determinants for AA. Studies presented from a global perspective come from Cuba, Chile, Colombia, South Africa, Taiwan, Italy and Sweden. In Chap. 23, Alfonso León and García Quiñones address singularities of the ageing process in Cuba, a developing country with a socialist model, a centralized economy, advanced public policies but limited economic resources, where

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the population is ageing rapidly with more than 20% of people currently aged 60 years or over. This situation means that the new challenges and gaps have essentially been conditioned by the financial and economic difficulties involved in securing resources such as food, housing and favourable physical environments. This makes it necessary to develop legal instruments to enable older adults to fully exercise their rights and to provide an opportunity to extend the provision of elderly care services. In stark contrast to the Cuban case are the highly developed Scandinavian countries such as Sweden, for which Finkel and Sundström describe and analyse AA and QoL in Chap. 33. Material living conditions have improved vastly for older Swedish people in recent decades and their social life and family ties have expanded in important ways. Older people are increasingly involved in the labour market and family ties are stronger today than 30 years ago, with many more reporting that they have a partner and children, and more often children who live close. Also in the European context, in Chap. 36, Di Matteo et al. present the Italian case within the conceptual framework of AA, selecting European and international experiences regarding the construction and implementation of policy strategies inspired by mainstream programmatic documents (e.g. WHO 2002; MIPAA 2002). Recent efforts have been undertaken to develop a concerted national strategy in this field, as well as to define a useful analytical tool to understand the different territorial scenarios. This could help policymaking by promoting realistic change, respecting national and local cultural differences, and recognizing multiple, differentiated ways to achieve the goal of ageing well. Maharaj and Roberts describe a particular case in Chap. 28 relating to the nature and determinants of QoL among older people in South Africa. The authors use the South African Social Attitudes Survey, which introduces the racial diversity of South African society. They point out that the dominant predictors of wellbeing are socio-economic characteristics (such as education, employment status and self-rated poverty). As a result of inequities

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along racial lines, white South Africans enjoyed a very comfortable standard of living comparable to that of developed nations while the majority of black African adults lived in poverty, with inadequate access to resources like education and health. While some progress has been recorded, the legacy of social inequality continues and this is reflected in disparities in levels of wellbeing, which undoubtedly influences differences in AA according to racial population group. In Chap. 26, Robledo Marín and Cardona Arango study the specific case of AA and QoL among ex-combatants during the reintegration process in Colombia. Direct participation in the war has turned ex-combatants into subjects with high levels of vulnerability, requiring the attention of various actors in order to strengthen social networks and support, provide adequate healthcare and very possibly offer personal care in order to secure a dignified and healthy old age. Dissatisfaction was strongly associated with being over 65, female, without a partner, living with non-functional families and having functional dependence. Also in the case of Colombia, in Chap. 25, Cardona et al. explore how the concept of happiness as a component of QoL is associated with AA. Based on the results they obtain in their quantitative study, the authors conclude that wellbeing and happiness appear to have a natural affinity, and intangible or subjective aspects related to wellbeing must be taken into account for the material and objective aspects of living conditions to be satisfied. As part of this block of chapters analysing AA and QoL from a global perspective, two of them introduce the successful ageing (SA) approach. Chapter 31 involves Hsu highlighting the conceptual differences between (micro) SA and (macro) AA and applying them to Taiwan. In order to do soshe reports results from a qualitative study (micro approach) that illustrates an intervention program to improve SA among individuals as well as a longitudinal panel study (macro approach) based on the Taiwanese Active Ageing Index. The author concludes that SA and AA concepts can be planned and implemented to improve QoL in old age, and that strategies can

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be derived from both micro and macro perspectives. Also adopting a SA approach, in Chap. 27, Sánchez-Moreno et al. examine a model based on the domains of QoL (sensory abilities; autonomy; past, present and future activities; social participation; death and dying; and intimacy) and SA (functional performance mechanisms; intrapsychic factors; spirituality; gerotranscendence and life purpose/satisfaction) in a multi-ethnic sample of older Chilean adults. They report the main differences as being between the two groups of indigenous older adults (Aymara and Mapuche), on one hand, and the non-indigenous group, on the other, showing the importance of designing culturebased psychosocial intervention in the field of social gerontology. Together with culture, gender is another crosscutting determinant of AA. However, it is not common to find research that expressly examines its impact on AA, or more generally on ageing well. This is the aim of Zunzunegui and Belanger, who in Chap. 21 examine gender-related differences in AA in Canada, attributable to financial insecurity, psychological violence from partner and family, and lack of neighbourhood safety. For the authors, the provision of sufficient funds to cover basic needs and peaceful relationships and neighbourhood environments should be public policy targets towards both ageing well and the promotion of gender equality. Also from a gender perspective, in Chap. 38, Martín Palomo et al. focus on the paradigm of care and its contribution to the concept of AA. The authors adopt a qualitative approach to analyse the perceptions, experiences and values of older people with respect to the organization of responsibility for care, which is generally allocated to the family, essentially meaning women. The opinions of institutional managers and key members of CSOs are also taken into account. Self-care and self-determination are identified as being central to the process of advancing towards an expanded definition of AA, as well as considering the notion of vulnerability, lifelong interdependencies and functional diversity.

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Another significant group of chapters aims to examine issues including the relationship established between one or more dimensions of QoL and one or more pillars or determinants of AA. This is the case for two chapters focusing on health and wellbeing. The contribution from Puga et al. in Chap. 37 explores the role of social networks (SN) in the interplay between multimorbidity and self-rated health status among the ‘oldest old’ population (aged 80+) in Spain. The authors conclude that even with a high level of multimorbidity, the assessment by the oldest-old population of their health-related wellbeing was mediated by some facets of their SN. The second main conclusion is that the effect of SN as a mediating factor varies considerably by gender, having a greater impact on women’s wellbeing: it is among the female population that SN plays a mitigating role in the relationship between morbidity and wellbeing. In addition, having closer networks softens the effect of the lack of a partner on the perception of social isolation. In Chap. 22, Ory et al. examine the influence on health and wellbeing of the built environment and the significance of place, introducing the concept of healthy ageing (HA). The authors note that research frameworks often reflect siloed approaches and ageing issues are often neglected or treated stereotypically in environmental literature. In this regard, they highlight several popularly cited theoretical frameworks which reflect interdisciplinary approaches, noting in particular environmental gerontology as an example of an approach that marries environmental and ageing concerns. The chapter provides examples from the United States and other parts of the world for improving population health through environmental strategies and policies; these are examples of successful practice of the principle of active ageing, involving age-friendly and dementiafriendly communities. A further three chapters are focused on participation and its meaning for AA and QoL. In Chap. 28, Liddle and Pachana highlight diversity as a key factor in understanding the needs, experiences and preferences for ageing well in Australia. The authors studied three key groups:

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Aboriginal and Torres Strait Islander people, people from culturally and linguistically diverse backgrounds, and people living in rural and remote areas. They conclude that trends towards supporting continued community engagement are focusing on returning control to individuals and communities, places that support engagement and ways of enabling meaningful doing and connecting with others. From the European perspective, in Chap. 32 Araujo et al. identify being engaged in life through participation in activities as an important factor for QoL. Based on data from the Survey of Health, Ageing and Retirement in Europe (SHARE), they use a multilevel approach to explore the associations between different types of participation (productive, social, and leisure activities) in different age groups (50+ years old), considering interaction effects (age, educational level) and control variables (health, functionality, memory). The authors conclude that there is a global decrease in participation with the advancement of age. In addition, being enrolled in productive, social and leisure activities is associated with higher levels of QoL. The introduction of interactions between age and education proves that the effect of activities differs across educational level and age group. In relation to the domain of environment, in Chap. 35 Petrová Kafková also analyses the role of activity in QoL, in this case among urban and rural older people in the Czech Republic. Using mixed methods, the author concludes that neither environment brings about higher QoL in old age. Different determinants contribute to preserving QoL in both environments and both “urban” and “rural” lifestyles can preserve activity, whether involvement in clubs and sports or an ageing process filled with activities such as taking care of the home and garden. Both environments also pose many obstacles and challenges. Safety is reported as the most frequently mentioned problem among urban older adults, while rural older adults point to facing significant logistical demands in terms of ensuring access to healthcare.

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Physical and social environmental determinants for AA are the central objective of the four chapters dedicated to Mexico, China, Spain and Belgium. In Chap. 24, Garay Villegas and Montes de Oca Zavala analyse the physical and social dimensions of an environment as determinants of AA to enhance QoL in old age. The authors analyse data from the Survey on Living Conditions of Older People in Mexico (2016) and find that older people generally enjoy favourable environments, perhaps due to the fact that the survey was carried out in the States where the three largest cities of the country are located, and where infrastructure and access to services is more developed in comparison with other States of the Republic. They highlight the need for a longitudinal approach in accordance with the life course perspective of AA as a process, as well as more qualitative research to further examine relationships with neighbours, support given and received, and mistreatment within and beyond the family sphere. Chapter 29 by Cheng et al. focuses on three intertwined concepts: social support, AA and age-friendly community. These are illustrated through a case study of 30 people aged 60 years and over living in three different communities in Beijing, China. A qualitative analysis addressed several topics: (1) sense of community is highly related to the socio-cultural environment of the community and affects older people’s AA; (2) age-friendly communities provide more opportunities for older people to participate; (3) the significance of age-friendly communities in improving social support for AA among older people is tied to where they live. The results shed light on the significance of creating age-friendly communities in order to offer social support and AA opportunities, which eventually improves QoL for older people. Also from an age-friendly community approach, in Chap. 39 Prieto-Flores et al. analyse environment and participation, focusing in particular on the obstacles of the physical environment for the mobility of older people, as barriers to participation in leisure activities in the neighbourhood or place of residence, as well as the impact of physical environment on the QoL

G. Fernández-Mayoralas and F. Rojo-Pérez

indicators of satisfaction with free time and with life as a whole. Using the Pilot Survey of the Longitudinal Study on Ageing in Spain Project (ELES-EP Project) and structural equation models, the results indicate that obstacles relating to accessibility of housing or buildings might reduce the frequency with which older people participate in leisure activities in their community, negatively affecting satisfaction with free time and QoL in turn. Finally, Chap. 34 examines the particular residential setting of nursing homes. Gorus et al. adapted the AA framework for nursing homes (NHs) in Flanders, Belgium, with a comprehensive set of determinants on which NHs could focus to improve residents’ QoL, with participation acting as the central component. Two strategies were developed and implemented. First, participatory action research (PAR) was used to structurally involve residents in the organization of the NH, potentially leading to improved quality and empowerment. Second, the ‘because activities should be meaningful’ (BAM) strategy was developed to enhance meaningful activities. The authors conclude that by introducing AA as a framework, NHs can create a comprehensive and empowering environment for all residents. In conclusion, as editors we wish to express our gratitude and pride at having had the opportunity to collaborate with this extensive group of academics and researchers specializing in AA and QoL. We thank them for the work and effort they have put into in participating in this Handbook. Producing the chapters and editing this book has been a lengthy activity for everyone involved. We are sure that readers will appreciate its quality and coverage of conceptualization, methodology, countries studied, dimensions and factors analysed, all in relation to ageing well.

References Börsch-Supan, A., Brugiavini, A., Jürges, H., Mackenbach, J., Siegrist, J., & Weber, G. (Eds.). (2005). Health, ageing and retirement in Europe: First results from the survey of health, ageing and retirement in Europe. Mannheim: Mannheim Research

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Institute for the Economics of Aging (MEA). Retrieved October 31, 2018, from http://www.share-project.org/ fileadmin/pdf_documentation/FRB1/FRB1_all_ chapters.pdf Dimitriadis, S. (2019). Future of ageing 2019: Maximising the longevity dividend. International Longevity Centre UK. Retrieved from https://ilcuk.org.uk/wp-content/ uploads/2019/12/Maximising-the-longevity-dividend. pdf EUROSTAT/European Commission. (2012). Active ageing and solidarity between generations: A statistical portrait of the European Union 2012. Luxembourg: Publications of the European Union. Retrieved from https://ec.europa.eu/eurostat/documents/3217494/ 5740649/KS-EP-11-001-EN.PDF/1f0b25f8-3c864f40-9376-c737b54c5fcf ILC-BR – International Longevity Centre Brazil. (2015). Active ageing: A policy framework in response to the longevity revolution. ILC-BR. Retrieved from http:// ilcbrazil.org/portugues/wp-content/uploads/sites/4/ 2015/12/Active-Ageing-A-Policy-Framework-ILCBrazil_web.pdf Leeson, G. W. (2017). Realizing the potentials of ageing. Population Ageing, 10, 315–321. https://doi.org/10. 1007/s12062-017-9207-1.pdf. Leeson, G. W. (2018). Living to 100 years and beyond: Drivers and implications. European View, 17(1), 44–51. https://doi.org/10.1177/1781685818758965. Shahid, Z., Kalayanamitra, R., McClafferty, B., Kepko, D., Ramgobin, D., Patel, R., et al. (2020). COVID-19 and older adults: What we know. Journal of the American Geriatrics Society, 68(5), 926–929. https://doi. org/10.1111/jgs.16472. UN – United Nations (2002). Political declaration and Madrid international plan of action on ageing. New York: United Nations. Retrieved from https:// www.un.org/esa/socdev/documents/ageing/MIPAA/ political-declaration-en.pdf

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UN – United Nations. (2019). World population ageing 2019: Highlights. New York: United Nations, Department of Economic and Social Affairs, Population Division. Retrieved from https://www.un.org/en/ development/desa/population/publications/pdf/ageing/ WorldPopulationAgeing2019-Highlights.pdf Van Malderen, L., Mets, T., & Gorus, E. (2013). Interventions to enhance the quality of life of older people in residential long-term care: A systematic review. Ageing Research Reviews, 12(1), 141–150. https://doi.org/10.1016/j.arr.2012.03.007. WHO – World Health Organization (2002). Active ageing: A policy framework. Geneva: WHO. Retrieved from https://www.who.int/ageing/publications/active_age ing/en/ WHO – World Health Organization (2015). World report on ageing and health. Geneva, WHO. Retrieved from https://www.who.int/life-course/publications/2015ageing-report/en/ WHO – World Health Organization (2020a). Decade of healthy ageing 2020–2030. Geneva: WHO. Retrieved from https://www.who.int/docs/default-source/decadeof-healthy-ageing/final-decade-proposal/decade-pro posal-final-apr2020-en.pdf?sfvrsn¼b4b75ebc_3 WHO – World Health Organization. (2020b, May). Seventy-Third World Health Assembly (A73/INF./2). Decade of Healthy Ageing. The Global strategy and action plan on ageing and health 2016–2020: Towards a world in which everyone can live a long and healthy life. Report by the Director-General. Retrieved May 20, 2020, from https://apps.who.int/gb/ebwha/pdf_ files/WHA73/A73_INF2-en.pdf Wiggins, R. D., Netuveli, G., Hyde, M., Higgs, P., & Blane, D. (2008). The evaluation of a self-enumerated scale of quality of life (CASP-19) in the context of research on ageing: A combination of exploratory and confirmatory approaches. Social Indicators Research, 89(1), 61–67. https://doi.org/10.1007/s11205-007-9220-5.

Part I Theoretical and Conceptual Perspectives

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Active Aging and Quality of Life Rocío Fernández-Ballesteros, Macarena Sánchez-Izquierdo, and Marta Santacreu

2.1

Introduction

Active Aging and Quality of Life can be considered key concepts in the field of aging and health, with both emerging from multicontextual biomedical-psycho-social applied perspectives, and therefore with strong support from sociopolitical institutions and policy makers and a minor presence of basic scientific disciplines. Active Aging and Quality of Life share a set of characteristics: they are very broad and complex social constructs which must be examined through multi-trait, multi-dimension, multi-system analyses, taking basic objective and subjective aspects into consideration as well as referring to a diversity of systems, from populations to individuals (e.g. FernándezBallesteros et al. 2007a, Fernández-Ballesteros 2008, 2019; Walker 2005b). These characteristics make them difficult to operationalize and measure, and there is no consensus regarding a definition, and, as pointed out in Sects. 2.2 and 2.3, they share common problematic and conceptual issues. R. Fernández-Ballesteros Autonomous University of Madrid, Madrid, Spain e-mail: [email protected] M. Sánchez-Izquierdo (*) Universidad Pontificia Comillas, Madrid, Spain e-mail: [email protected]

Finally, at a language level they share a diversity of synonymous verbal labels with closely-related meanings; thus Active Aging is in a broad semantic field with other related terms such as healthy, successful, productive, positive, or optimal aging (see FernándezBallesteros et al. 2013a). Although each of these verbal labels has specific nuances (see FernándezBallesteros 2019; Fernández-Mayoralas et al. 2014), it is important to emphasize that they are used almost interchangeably by experts when reviewing the field, and in this text they are all embedded under the term “Active Aging” (Depp and Jeste 2006; Lupien and Wan 2004; Peel et al. 2005). Moreover, although across history, since the time of Plato, a good life and other terms such as living conditions and well-being could be considered synonymous with Quality of Life, without doubt, this verbal label is predominant. Thus, Active Aging and Quality of Life form two overlapping semantic fields and, in a more complicated sense, they are, in geometric terms, two secant constructs. Figure 2.1 shows the complexity of Active Aging and Quality of Life as well as the potential overlapping of their respective systems (population versus individual), epistemological nature (objective or subjective); this classification allows us to divide the components (internal or external), and dimension methods (observable or self-reported).

M. Santacreu European University of Madrid, Madrid, Spain e-mail: [email protected] # Springer Nature Switzerland AG 2021 F. Rojo-Pérez, G. Fernández-Mayoralas (eds.), Handbook of Active Ageing and Quality of Life, International Handbooks of Quality-of-Life, https://doi.org/10.1007/978-3-030-58031-5_2

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2.1.1

R. Fernández-Ballesteros et al.

A Historical Overview

As has already been mentioned, both terms emerged from a positive view of both the science of aging and the conceptualization of health. Thus, throughout the history of gerontology, as the science of aging, age, and the aged (see Birren 1996), research on aging has been mainly devoted to the study of negative (pathological) conditions, emphasizing those human systems, functions, or characteristics that decline, are impaired or lost during the process of aging. It was in the third part of twentieth century when new scientific concepts in the field of aging and health emerged: Quality of Life (QoL), and Successful Aging (healthy, optimal, productive, vital, positive) are currently emblematic concepts in the gerontology of the twenty-first century. As already stated, these two concepts share some characteristics but also some problematic issues which will be discussed later. Starting with Quality of Life, this term has two roots: from a sociopolitical perspective emerged from the opposing positions involved in the concept of welfare and well-being, and also as a consequence of the WHO's change of definition in 1978 from the concept of health as “the absence of illness” to health as “the state of complete physical, mental and social well-being, and not merely the absence of disease or infirmity”. Health is a fundamental human right and the attainment of the highest possible level of health is a most important worldwide social goal whose realization requires the action of many other social and economic sectors as well as that of the health sector (WHO 1978, Declaration I, p. 1 www.euro.who.int/__data/assets/pdf_file/0009/ 113877/E93944.pdf?ua¼1). Several developments continue to be inspired by the WHO's Alma Declaration (WHOQOL 1993, 1995): (1) the definition of the concept of QoL as the individual's perception of quality of life; (2) the construction of the WHOQOL Questionnaire composed of 100 self-reported items (1–5 rating scale) classified into 6 domains: Physical, Psychological, Level of Independence, Social Relationships, Environment, and Spirituality, and finally, (3) the concept of health-related

quality of life (HRQOL) have been developed to encompass those aspects of overall quality of life that can be clearly shown to affect health either in terms of mental or physical illnesses (e.g.: several types of cancer, cardio vascular diseases, arthritis, etc.), which can explain the strong development of QoL in the biomedical fields. Returning to Active Aging, as has already been mentioned this is primarily a concept related to a new positive paradigm in gerontology (simply called “aging well” by Fries 1989) which adopts several verbal labels, all of which are considered by some authors to be oxymorons in conjunction with the term ‘aging', as two terms with opposite meanings, and integrated in the same semantic field: “Healthy” (WHO 1990), “Successful” (Rowe and Kahn 1987), “Optimal” (Palmore 1995), “Vital” (Erikson et al. 1986), “Productive” (Butler and Gleason 1985), “Positive” (Gergen and Gergen 2001), and, the last to arrive, “Active Aging” published by the WHO in 2002. It is important to emphasize that all these terms are used almost interchangeably by experts when they review the field and, in this text all of them are embedded under the term “Active Aging” (e.g.: Depp and Jeste 2006; Lupien and Wan 2004; Peel et al. 2005). From an historical perspective, following the review of both concepts by Fernández-Ballesteros (1997, 2006, 2008), the concept of Quality of Life is older than Active Aging: Quality of Life emerges in the scientific literature at the end of the 1960s, while the formal birth date of Active Aging (although other related terms appeared around the 1970s) is in 2002, on the occasion of the Second International Plan of Action of Aging (United Nations 2002), when it was defined by WHO as: “. . .the process of optimising opportunities for health, participation, and security in order to enhance well-being and quality of life as people age” (p. 12). It is important to note that this definition is highly redundant since health and quality of life (along the same lines as well-being) are contained within the definition, as will be emphasized in Sects. 2.2 and 2.3.

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Fig. 2.1 Overlapping between Active Aging and Quality of Life dimensions, taking into consideration systems and nature dimensions. Source: From Fernández-Ballesteros (2011a, p. 33)

2.1.2

Evolution of Scientific Literature

Let us move on to the evolution of these concepts and their relative growth, both of Active Aging (AA) and Quality of Life (QoL), as assessed by the number of citations in a broad set of scientific literature listed in biology, medical, psychological, and social science databases. Referring Quality of Life (1969–1995), the first appearance was in 1969 in PsycLIT with 3 citations, while only 1 was found in Biosis, 1 in Medline and 2 in Sociofile; at the end of the twentieth century (in 1995) we can find, respectively, 1379, 2242, 187 and 127 citations (see Fernández-Ballesteros 1998). It must be emphasized that QoL refers all ages, but when a new search is conducted including quality of life and age/ageing/aging/older people/elders for the period 1975–2004, an extraordinary growth is noted. Table 2.1 shows the data yielded in this second search. The total number of articles reported in this period is 9398; the total rate in PubMED is close to 83.6% of the total (N ¼ 7944), PsycINFO (N ¼ 994) represents 10.6% of the total, and SocioABS (N ¼ 460) yielded a rate of 4.9% with respect to the growth PubMED is continuous. It can be concluded that there has been a constant increase in scientific

literature in QoL in different scientific fields, but while in the psychological and social fields growth goes from 10% to 40%, in the bio-medical field has been almost exponential (Fernández-Ballesteros 2011a). A parallel analysis performed with respect to Active Aging took into consideration all the synonymously used verbal terms; thus, two searches were conducted, on the Internet and within scientific literature. On the Internet (Google Scholar), the most frequently cited term was “Active Aging” (4,250,000) followed by “Healthy Aging” (2,650,000), “Successful Aging” (2,150,000), “Optimal Aging” (2,010,000) and “Productive Aging” (1,800,000). The search in the scientific literature was conducted in three scientific databases: PubMed, Psychlit and Sociofile. This search was focused on the period 1970–2015 using aging/ageing and healthy, successful, and active (the most frequent terms in the scientific literature in all fields). Table 2.2 shows comparisons between the three publication bases by terms and period. Taking into consideration the three terms, PubMed yielded the highest number of references, its growth multiplying by 10. Along the same lines, PsycLIT, starting from about 40 publications in the first decade, has the highest increase, reaching about 600 publications during the last period (2015–18). Finally,

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Table 2.1 References to QoL in three literature data bases Data bases PubMED PsycINFOR SocioABS Total by period

Periods 1975–1979 114 8 11 133

1980–1984 174 19 25 218

1985–1989 387 70 51 508

1990–1994 916 124 51 1091

1995–1999 2194 194 81 2467

2000–2004 4161 579 241 4981

Total 7944 994 460 9398

Source: Modified from Fernández-Ballesteros (2011a)

Sociofile yielded the lowest increment, rising from 5 to 171 publications in the whole period. On examining these publication databases separately and making comparisons between the terms used, it can be observed that “Healthy” aging is the most used term followed by “Successful”, with “Active” aging being the least used term. It is interesting to note that in the final period there is an inverse tendency between “successful” and “active”; while the use of “successful” aging is decreasing, “active” aging is increasing. There is high growth in references in the field in Psychlit, with “Successful” aging being the most extended term followed by “Healthy” and very few references to “Active” aging. Finally, Sociofile yielded the lowest results, although the most extended term is “Successful” aging followed by “Healthy” and “Active” aging. After this review, it can be concluded that research in the field of positive aging has grown from the 1970s up to today in all scientific literature databases. Also, it can be stated that the terms are linked to a concrete scientific field: “Healthy” aging is a consolidated term within the bio-medical context but has been declining in the last decade; nevertheless, “Successful” aging is the most extended term in psychological and social literature, and “Active” aging was delayed

until the twenty-first century and is starting to grow in most of the databases in the last decade. This result is congruent with the above mentioned fact that “Active Aging” is a very young construct proposed on the occasion of the II International Plan of Action on Aging (UN 2002) and is much more focused on political than scientific actions, as declared in the document entitled “Active Aging. A policy framework” (WHO 2002). In sum, the historical avenues of both concepts, Active Aging and Quality of Life, run close together, almost in parallel, in the sense they are socio-political constructs, as has already been pointed out, with common characteristics, and therefore also sharing similar problematic issues which will be discussed in the forthcoming Sections. Let us discuss a final important epistemological issue they also share.

2.1.3

An Epistemological Framework

Active Aging and Quality of Life are two broad and complex constructs born out of a strong confrontation among two models of the philosophy of science: positivism (and post-positivism) and constructivism, mainly supported by social scientists. In order to better understand the history of our two constructs, let us describe briefly the

Table 2.2 References to Active Aging and related terms (Healthy and Successful) in three literature data bases (PubMed, Psychlit and Sociofile) Terms Successful Active Healthy Total

Periods 1970–1979 334 56 246 636

1980–1989 1087 196 1634 2917

1996–2000 110 12 81 219

2001–2005 260 34 268 586

2006–2010 466 86 708 1326

2011–2015 611 207 1466 2401

Total 2868 591 4403 8085

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confronted assumptions among positivism and constructivism as shown in Table 2.3. In short, positivism is a philosophical approach which assumes that reality exists and knowledge is acquired through experience by means of instruments amplifying (if necessary) the phenomenon under study (objectivism); from a methodological standpoint, experimental approaches, objective measures as well as triangulation and multiplism guarantees data. Conversely, constructivism is a theory of science which holds that reality does not exist given the great diversity of socially constructed realities and that knowledge is acquired or assigned by convention or consensus. Constructivism is based on the belief that each construct is a different perception of reality (or information or morality, etc.) based on our own life experience. According to most social scientists, individual perceptions of reality are primarily influenced by our observations in interaction with other people's observations. Consequently, constructivists believe that “reality is socially constructed.” These two opposite theories are present even in other intermediate grounded theories such as those developed by Glaser and Strauss (1967), who proposed an objectivist-grounded theory of health rooted in post-positivist epistemology, whereas constructivist-grounded theory has its roots in an interpretive tradition and relativism (see: Cruickshank 2012). It must be taken into consideration that both constructs are multi-dimensionally defined because they refer to human processes such as aging (which is a long process throughout human life) and life, which is also a polyhedral concept combining flat polygonal faces with straight edges and sharp corners or vertices, with both referring to two characteristics which are difficult to define: active and quality. Thus, although both could be integrated by perfectly measured physical dimensions -such as step speed (in the case of active aging) or as absence of pollution (on case of quality of life)---both constructs contain important subjective ingredients or facets. Therefore, a consensus regarding their meaning and their measurements is necessary. Finally, we must declare that our analyses of Active Aging and

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Quality of life are supported mainly by a multiplistic approach (Cook 1985).

2.2

Active Aging

Aging is a lifelong process with a long history in the field of science and within human knowledge and its expression (literature, art, etc.). Without doubt, aging is the process of becoming older, and biologists define this process as an age-dependent or age-progressive decline, part of an intrinsically physiological function, leading to an increase in age-specific mortality rate (i.e., a decrease in survival rate, e.g.; Flatt 2012). This negative description of aging has been embedded as a cultural view of aging, age, and the aged, and expressed in human products as well as being shaped throughout the history of science. Nevertheless, from 1850 the growth of life expectancy in selected countries with so called “good practices”, suggested that aging processes are modifiable (e.g. Christensen et al. 2009). Similarly, the compression of morbidity supported the hypothesis that increasing longevity did not inevitably imply morbidity (see Fries and Crapo 1981). Furthermore, behavioral and social sciences pointed out that throughout the process of human aging, positive human characteristics can be optimized and/or certain declines or deficits can be compensated (e.g. Baltes and Baltes 1990b). These and other developments, occurring during the twentieth century, nuanced and complemented the assumption of unavoidable decline of aging, and took into consideration that any intrinsic biological force acts through the interactions with extrinsic circumstances in which the human organism acts or behaves; therefore, the adaptation as a bio-psycho-behavioral-social mechanism and the forces of selection supporting the decline assumption present a plateau (Rose et al. 2012). Thus, as is well-known and recognized and supported by empirical data, the important point can be made that under positive conditions, age-specific morbi-mortality exhibits plateaus late in life, both at individual and cohort level. This means that the age-specific rates of survival and morbidity do not necessarily

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Table 2.3 Ontological, epistemological and methodological assumptions of positivism and constructivism Assumptions Ontological Epistemological Methodological

Approaches Positivism/post-positivism Realism Objectivism Interventionism, multiplism

decrease to zero toward the end of life, as had previously (mostly implicitly yet incorrectly) been assumed (Flatt 2012). Thus, a new paradigm of aging began 50 years ago, as will be specified in Sect. 2.2: successful, healthy, productive, optimal or active aging. Before describing a brief history of this event, let us focus on the interactive process of aging.

2.2.1

The Interacting Process of Aging

As already pointed out, aging is a bio-psychobehavioral-social phenomenon in which the biological organism interacts with a changing environment; therefore, intrinsic and extrinsic factors are continuously interacting to build up the human being across the life span (Bandura 1986; Gould 1977, 1996). Applying the sociocognitive theory by Bandura (1999, 2001) and the systemic theory proposed by Bronfenbrenner (1979) as a contextual frame, FernándezBallesteros (2008) proposed a multidimensional, multi-level life-span model for active aging, which posited that aging is the outcome of all transactions occurring in the person (a biological organism), among his/her psychological and behavioral constituents, and in the context of micro (the individual), meso (the family) and macro (global context) levels. In sum, even the decline in the efficiency and efficacy of biological systems, the interindividual and intraindividual differences in terms of aging are not only due to age or person-specific biological factors, but to the dynamic reciprocal interactions between the biological organism, his/her basic psychobehavioral patterns and the socio-cultural context. Therefore, the process of aging cannot be reduced

Constructivism Relativism Subjectivism Hermeneutic

to biomedical conditions but neither to sociocultural or psycho-behavioral aspects. Throughout history, human life and its contexts have changed extraordinarily, and life has become longer. As mentioned above, Christensen et al. (2009) has shown that in selected countries, from 1850, life expectancy has increased uninterruptedly at a similar rate, until today (even “aging” in its negative sense has been postponed by about 10 years), concluding that “research suggests that aging processes are modifiable and that people are living longer without severe disability” (p. 1196). Also, multicohort studies have shown (Baltes and Mayer 1999; Lang et al. 2002; Palmore et al. 1985; Schaie 2005a, b; Smith et al. 2002) that a currently 70-year old individual not only has a high probability of living longer than his or her their forefathers did, but also of living longer in better bio-psycho-social conditions. These changes from a demographic and individual point of view support the existence of a new perspective in the study of aging, age and the aged. Moreover, increasing life expectancy and concerns about the policy implications of the aging population have led to interest in improving older people's health, independence, mental and physical functioning, activity, social participation, quality of life, and therefore active aging.

2.2.2

The Constitution and Development of the Conceptualization of Active Aging and Related Terms

As mentioned above, aging well has a variety of semantically very close verbal labels (successful, active, productive, healthy, optimal, competent,

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etc.). A review by Depp and Jeste (2006) (PubMed and Google Scholar 1978–2005) found 407 studies referring to “successful aging,” 490 for “healthy aging,” and 12 for “productive aging,” and only 1 for aging well or “robust aging”. Fernández-Ballesteros (2008) in her review (PubMed, PsycINFO, and Sociofile from 1970 to 2007) found that the two most common labels in this field are healthy (in biomedical databases) and successful aging (in psychosocial databases), with “active” aging the most recent label, appearing only after 2001 (see Tables 2.1 and 2.2). In general terms, it is possible to distinguish the following three relevant periods in the constitution and development of the conceptualization of healthy and successful aging: 1. Havighurst (1963) was the first author to propose a conceptualization of successful aging: “adding life to years” and “getting satisfaction from life”. The first period, until the end of the 1970s, focused on biomedical psychological and social changes among age groups, with very few references to the ways of aging. 2. During the 1980s, the so called “new paradigm” or “revolution” started in the field of aging research and in gerontology---a positive view with Rowe and Kahn (1987) postulating several forms of aging: “usual”, “pathological” and “successful”, developing “successful aging” as a way of aging (Rowe and Kahn 1997a). Pioneers in this new paradigm are authors from several disciplines, such as Fries and Crapo (1981), Fries (1989), or Baltes and Baltes (1990a). 3. From the 1990s to date, parallel to the higher demographic changes already described, several well-designed scientific studies have been carried out in an attempt to test predictors and determinants of healthy, successful, vital, active, or productive aging. As described below, in 2002 WHO addressed this new paradigm with the label “active aging”; nevertheless, 13 years later WHO (2015) took a conceptual step backward, substituting “active aging” (with no evaluation of the these 13 years) for “healthy aging”, reducing it to functionality and eliminating any reference to

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any other key psycho-social elements in the process of aging (Fernández-Ballesteros 2017). In sum, it can be stated that development in this field has not yet finished, and that in the coming decades more research and more proposals will follow (for a review see Fernández-Ballesteros et al. 2019).

2.2.3

Multidimensionality Concepts and Theoretical Assumptions

Active aging and related terms are necessarily multidimensional concepts which involve and go beyond the absence of illness, embracing of bio-psycho-behavioral-social perspective. For instance, Rowe and Kahn defined it with the following components: low probability of illness and associated low functioning, high mental and physical functioning, and high social engagement (Rowe and Kahn 1987, 1997b). Other authors emphasized subjective evaluation and life satisfaction components (Havighurst 1963; Lher 1982; Lehr et al. 2000), activity and social productivity (Siegrist et al. 2004), or productivity, participation and engagement with life (Butler and Gleason 1985). Others, such as Ryff (1989), defined successful aging, establishing six, mostly subjective criteria: self-acceptance, positive relationships with others, autonomy, environmental mastery, purpose in life, and personal growth. As this involves multidimensional components, several authors highlighted that it must be addressed by interdisciplinary collaboration (e.g. Baltes and Baltes 1990b). Depending on the definition or conceptualization---some approaches focus more on physical and others more on psychosocial components, while recent definitions attempt to integrate both into a bio-psycho-behavioral-social approach--the definition involves components, outcomes and predictors of these outcomes (for a review, see Fernández-Ballesteros 2019). At the same time, however, a key element of multidimensionality is to take into consideration

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also the nature of Active Aging indicators or the criteria used, that is, whether they are objective and subjective criteria, as indicated above. The importance of multidimensionality and the nature of the criteria used can be tested through the prevalence of this way of aging. For example, those who select survival with high level of functioning make up between 12.7 and 35% (Guralnik 1989; Strawbridge et al. 1996), while and Depp and Jeste (2006), examining 22 studies, reported a prevalence range from 3 to 95% (mean ¼ 20.4; median 19, SD ¼ 14.8) depending on the criteria used. Also, Fernández-Ballesteros et al. (2010) compare simple and combined outcome prevalences: as can be observed in Table 2.4, simple criteria of Successful agers range from 93% with “no support needed” to 27.24% with “no illness reported”. Nevertheless when a combination of outcomes are used, combining subjective indicators, the percentage of successful aging was 41.4%, while with objective indicators the percentage was 27.9%. In sum, both the multidimensionality and the objective/subjective nature of our measure are highly relevant. Since aging is a bio-psycho-social process in which the person interacts with a changing environment across the life span, it is necessary to examine the theoretical assumptions which allow us to study active aging. The four main theoretical assumptions underlying this new paradigm are as follows: 1. The extraordinary variability in the ways of aging, which Rowe and Kahn synthetically reduce to “usual”, “pathological” and “successful” aging. These forms of aging have been tested in most parameters of aging (e.g. Baltes and Smith 2003; Motta et al. 2005; Smith et al. 2002) 2. The plasticity of the human organism (Boldrini et al. 2018) as well as its behavioral correlates (for a review see: Park and ReuterLorenz 2010; Fernández-Ballesteros et al. 2012b), such as cognitive plasticity, with very consistent results in all studies (e.g. Baltes et al. 1988 for a review see Fernández-Ballesteros et al. 2012b).

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3. Empirical proof from the compression of morbidity theory supporting the hypothesis that increasing longevity inevitably leads to morbidity (see Fries and Crapo 1981; Fries 2013) 4. The selection, optimization and compensation mechanisms of aging across the life span, as described by Baltes and Baltes (1990a).

2.2.4

Active Aging Definitions

The Encyclopedia Britannica offers the following definition of ‘definition': “In philosophy, the specification of the meaning of an expression relative to a language. “Definitions can be classified into two large categories: intensional definitions, which try to give the sense of a term, and extensional definitions, those proceeding to list the “objects”, “ingredients”, or “aspects” that the term covers. This last category means that the definition introduces the elements grouped by the construct, or in methodological terms, how a scientific concept is operationalized or what constitutes its outcomes. On searching for operational definitions of active aging, some, although not all, confuse determinants and outcomes. It must be stated that definitions need to be specifications or components which imply outcomes, and this should not be confounded with what determines these outcomes. This is particularly fundamental in active aging because it is a common mistake that definitions confound the ingredients of active aging with its determinants. Attempting to define successful aging, Ryff (1989) establishes six criteria: self-acceptance, positive relationships with others, autonomy, environmental mastery, purpose in life, and personal growth. The author clearly considers that active or successful aging is a multidomain concept that cannot be reduced to any of its components (such as well-being or health). On the model of successful aging, “Selective, Optimization With Compensation,” Baltes and Baltes (1990a) distinguish between antecedent conditions (e.g., reduction in general reserve),

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Table 2.4 Simple and combined definition/outcomes prevalence from ELEA study Type Simple

Combined

(N ¼ 458 M 55–75 years old Spaniards) Outcomes 1. No support needed 2. High or very high life satisfaction 3. Good or very good reported health 4. MMSE score more than 28 5. No illness reported 1 SUBHEALTH ≥ 3 & Func ¼ 1 & MMSE ≤ 29 & Statis > 03 2. ILLNESS ≤ 1 & func1 ¼ 3 (yes); & MMSE ≥ 29 & Statis ≥ 3; 3. LEISURE ACTIVITIES ≥ mean & Func1 ¼ 3 & MMSE ≥ 29 & Statis1 ≥ 3 4. PRODUCTIVITY ≥ mean & SubjHealth > 3 & Func1 ¼ 3 & MMSE ≥ 29 & Statis > 3

process (selection, optimization, and compensation), and outcomes (effective life) seeing successful aging as: “length of life, biological health, mental health, cognitive efficacy, social competence and productivity, personal control, and life satisfaction.” Perhaps the most important development was Baltes and Baltes' process theory of promoting gains and preventing losses through selective optimization with compensation (SOC)”. Again citing Rowe and Kahn (1997b), the authors define successful aging as multidimensional, encompassing three distinct domains: (1) low probability of disease and disease-related disability, (2) high cognitive and physical functional capacity, and (3) active engagement in social and productive activities. The relationship between the three components is to some extent hierarchical: “successful aging is more than absence of disease, important though that is, and more than the maintenance of functional capacities, important as it is. Both are important components of successful aging, but it is their combination with active engagement with life that represents the concept of successful aging most fully” (p. 433). In the book “Active Aging. A policy framework”, the World Health Organization (WHO 2002) defines active aging as “. . . the process of optimizing opportunities for health, participation, and security in order to enhance quality of life as people age” (p. 12). It is important to emphasize that WHO is also considering that this construct is based on the three pillars mentioned in the definition: health, participation, and security as

Prevalence 93.00% 80.00% 57.20% 47.00% 27.24% 41.40% 27.90% 19.50% 15.50%

outcomes of the process. Let us underline that these three conditions are of a totally different nature: while participation and health concern individual output, security implies the context, and therefore seems to be not an outcome element but a socio-political determinant of the entire process of active aging and the output of health and participation. According to this definition, the key aspects of Active Aging are as follows: 1. It is a lifelong process, in other words, it starts from birth and continues until death. 2. This process requires external efforts as well as individual commitments; thus it is considered a collective approach. 3. Therefore, it demands commitments and political investments from society as well as individual ability to control life, to cope with and make personal decisions about how one lives on a day-to-day basis. 4. The whole process requires independence, that is, the ability to perform functions related to daily living, in other words, the capacity to live independently in the community with no and/or little help from others. 5. WHO considers that a consequence of Active Aging is Quality of life, which is defined totally subjectively by WHO as “an individual's perception of his or her position in life in the context of the culture and value system”. This, then, would imply that Active Aging is a determinant of Quality of Life but, at the same time, Quality of Life is necessarily a life-long determinant of Active Aging. Along similar lines, as already mentioned,

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Fig. 2.2 The determinants of Active Aging. Source: WHO (2002)

there are some conceptual inconsistencies in the definition (see: Fernández-Ballesteros 2008). The question remains whether QoL is a consequence of Active Aging or whether Quality of Life is a lifelong pre-requisite for Active Aging. 6. Finally, is Healthy Life Expectancy, a demographic and epidemiological population measure, conceptually close to “Disability-free Life Expectancy”, considered a condition for Active Aging, or is it its consequence? In our opinion, both are partial measures of Active Aging. Furthermore, WHO (2002) establishes that Active Aging depends on a diversity of influences and “determinants” (Fig. 2.2). – Cross-Cutting Determinants: Culture, which influences all of the other determinants of active aging and Gender, taking into account how the policy options may affect the wellbeing of both men and women. – Determinants Related to Health and Social Service Systems: focusing on health promotion, disease prevention and equitable access

–

–

–

–

to quality primary health care and longterm care Behavioral Determinants: adopting healthy lifestyles (such as regular physical exercise, Mediterranean diet, non-smoking and drinking in moderation) and actively participating in one's own care for preventing disease and functional decline, extend longevity and enhance one's quality of life. Determinants Related to Personal Factors: which include biological and genetic factors, cognitive capacity (intelligence and mental aptitudes), psychological factors (i.e., personality, affect and motivation and control, conscientiousness, purpose in life, positive affect, self-efficacy, self-perception of aging and prosocial behavior). Determinants Related to the Physical Environment: age-friendly environments which promote independence for older adults, with specific attention to rural areas, where disease patterns may be different due to environmental conditions and a lack of available support services. Determinants Related to the Social Environment: highlighting the importance of social

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support, opportunities for education and lifelong learning, peace, and protection from violence and abuse – Economic Determinants: three aspects are key for an active aging: income, work and social protection The concept “Active Aging” was adopted by the United Nations II International Plan of Action on Aging, Madrid, and policies for promoting active aging were therefore developed and implemented around the world through all UN Regions (see: Caprara and Mendoza 2019; Mendoza-Nunez and Martínez-Maldonado 2019). Focusing on Europe, the FUTURAGE (2011) Road Map contains a research agenda developed from the Seventh Framework Programme of the European Commission, with the aim of enabling Europe to respond successfully to the unprecedented demographic challenge of population aging, with “Active Aging” emerging as a political keyword for inspiring policies, programs, and actions. Another Active Aging definition is proposed by Fernández-Ballesteros (2002, 2008, 2011b), who posited a Four Domains Model (see Fig. 2.3) which establishes “Aging well” as a common and popular term, involving other technical terms (healthy, successful, productive and active aging) as well as the concepts implied: (a) health and preserved functionality (ADL), (b) high levels of physical fitness and cognitive

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functioning, (c) positive affect, coping, and control, and (d) social participation and engagement. The first and second domain of this model correspond to Rowe and Kahn's model, and the fourth model refers to their third dimension (social participation and engagement). The third domain, positive affect, coping and control, is neither in the WHO model nor in Rowe and Kahn's. Active (within a sociopolitical and mass media perspective) and successful aging (within a bio-psycho-social scientific context) are defined through the four domains. This four-domain model has been tested on empirical data, both from the study of lay conceptualizations of aging well (FernándezBallesteros et al. 2008, 2011) and with data from the Longitudinal Study of Active Aging (ELEA-Estudio Longitudinal sobre Envejecimiento Activo, Fernández-Ballesteros 2011b). Indeed, it supported the multidimensionality of four factors of successful aging (excluding age and gender), which accounted for 48% of the variance: health; cognitive and physical functioning; positive affect and control, and social participation (Fernández-Ballesteros et al. 2013b). In brief, successful and active aging involve the four domains, while healthy aging only refers to health and functionality, and productive aging is reduced to social participation and engagement. Therefore, multidimensionality only refers to successful and active aging. From a scientific perspective, both Successful and Active Aging can

Fig. 2.3 Four domains model and four labels of aging well. Source: Modified from Fernández-Ballesteros et al. (2013a)

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be considered as umbrella concepts embracing a semantic space in which healthy and productive aging are strongly related (Fernández-Ballesteros et al. 2019). Apart from these definitions, in its booklet “Active Aging: A Policy Framework”, the International Longevity Centre, Brazil (ILC 2015) adds lifelong learning as a fourth pillar of the Active Aging concept proposed by WHO (2002). In this definition, lifelong learning is the fourth pillar which supports all the other pillars, thus equipping people to stay healthy, remain relevant and engaged in society, and ensure personal safety. Analyzing this definition we can point out that it establishes these four pillars simultaneously as determinants and outcomes, thereby confusing outcomes with determinants. The principles underlying this definition are: 1. Being “active” covers meaningful engagement in social, cultural, spiritual and family life, as well as in volunteering and civic pursuits. 2. Active Aging considers the great heterogeneity of older adults, including older adults who are frail, disabled and in need of care, as well as older persons who are healthy and high functioning. 3. The goals of Active Aging are preventive, restorative and palliative. 4. It promotes personal autonomy and independence as well as interdependence. 5. Active Aging promotes intergenerational solidarity and opportunities for contact and support between generations. 6. Active Aging combines top-down policy action with the promotion of opportunities for bottom-up participation. 7. This approach recognizes the rights of people to equality of opportunity and treatment in all aspects of life. It emphasizes the rights of persons who experience inequality and exclusion throughout life. 8. Active Aging promotes individual responsibility while not assigning blame to individuals who have been excluded from society. All these definitions are “technical” or expert definitions, but, what do individuals consider

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Active Aging to be? Let us introduce several empirical studies to answer this question: 1. Bowling (2008) reports an interview survey with 337 people aged 65+ living in Britain, showing that a third of respondents rated themselves as aging “Very actively”, and almost half as “Fairly actively”. Independent predictors of positive self-rated active aging were optimum health and quality of life. The concept of active aging was associated with having/maintaining physical health and functioning (43%), leisure and social activities (34%), mental functioning and activity (18%) and social relationships and contacts (15%). 2. Based on the study developed by Phelan et al. (2004) in USA (two samples of Japanese and European origin) and Matsubayashi et al. (2006) and using the same questionnaire, Fernández-Ballesteros et al. (2008) explored older adults' views in seven Latin American (Brazil, Chile, Colombia, Cuba, Ecuador, Mexico and Uruguay) and three European countries (Greece, Portugal and Spain). In sum, lay people from 12 countries in four continents agree (more than 70%) about the most important events for successful aging or aging well (items 2–18 Health, 3–16 Satisfaction, 5 Friends & Family, 7 Control, 10 Coping, 11 Independence). It must be emphasized that the elements appraised by lay people are coincident with most of the definition of Active Aging. 3. Recently, Stenner et al. (2011) showed that most people refer to physical activity, autonomy, interest in life, coping with challenges, and keeping up with the world. As we can see, people mix physical, mental, and social engagement, as well as a proactive attitude, and as Fernández-Ballesteros et al. (2008) point out, this occurs in various countries around the world. Finally, Pruchno et al. (2010) emphasized that there is no consensus on the conceptualization and measurement of active aging; it lacks clarity as studies often confound correlates with the construct itself and, therefore, the measures used in the different studies. Furthermore, this author

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emphasizes that successful aging, as a multidimensional concept, incorporates both objective and subjective indicators. Nevertheless, there is a certain consensus that it embraces a set of domains: low probability of illness and disability, high physical fitness and cognitive functioning, positive mood and coping, and being engaged with life (see Rowe and Kahn 1997b; Fernández-Ballesteros 2008).

2.2.5

Measuring Active Aging

Successful aging as an umbrella term with a substantial body of literature has emerged with a variety of dimensions in different studies. This section aims to determine which dimensions have been implemented in aging studies, contributing to the construction of the concept of successful aging. Therefore, we are going to briefly introduce a set of studies of aging and aging well alongside an introduction to the Active Aging Index (AAI) as a population measure. Cross-sectional and longitudinal studies about aging have been carried out to estimate successful or active aging and measure different domains at individual level in several countries and several regions around the world. Let us introduce a brief summary of those studies. – In a South Australian context, the Australian Longitudinal Study of Ageing (ALSA) interviewed participants aged 65 years or more at 13 time points from 1992 to 2014. The domains included in the interviews were: demographics, health, depression, morbid conditions, hospitalization, cognition, gross mobility and physical performance, activities of daily living and instrumental activities of daily living, lifestyle activities, exercise education and income (Luszcz et al. 2007). – The Survey of Health, Ageing, and Retirement in Europe (SHARE), assessing N ¼ 140,000 individuals aged 50 or older (around 380,000 interviews) in 14 European countries and Israel (Hank 2011; Santos-Eggimann et al.

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2009). This study collected information on sociodemographic variables, physical and mental health, biomarkers, psychological and economic status, and social and family networks. The sociodemographic variables associated with the absence of Active and Healthy Aging were advanced age, female, death of spouse, low educational level, lack of employment, and low financial status (Bosch-Farré et al. 2018). – The European Longitudinal Study of Aging (EXCELSA, Fernández-Ballesteros et al. 1998; Schroots et al. 1999) developed the European Survey on Ageing Protocol (ESAP, Fernández-Ballesteros et al. 2004), a crosssectional study conducted in 7 European countries (Austria, Finland, Germany, Italy, Poland, Portugal and Spain); through quota sampling by age/gender/SES/Education; aged 30–85 (mean age ¼ 60.58; SD ¼ 15.48 years), N ¼ 96 from each of the seven participant countries. Since the objective of EXCELSAPilot was the validation of the ESAP, with the main goal being to arrive at a definition of the concept of Competence. ESAP contains the following measures: Anthropometric, Bio-behavioral, Mental abilities, Personality and control, Life satisfaction, Health and Lifestyles, Social Relationship. Data from the seven countries yielded interesting results. Since the ESAP was designed to assess competence, and even though the EXCELSA-Pilot is only a pilot study, it is important to test whether our protocol actually assesses competence. In fact, two factors are related to competence: (1) subjective capacity, measured by the subject's appraisal of his/her fitness, strength, endurance, flexibility, speed and subjective health, and (2) objective cognitive and physical competence, assessed by measures of cognitive abilities (working memory and learning and performance), vital capacity (assessed by peak flow) and speed (assessed by a tapping test). Two long-term predictors of competence are education, income and age. Finally, as expected: social relationships,

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lifestyles and illness are also predictors of both subjective and objective competence. – Using data from the Health and Retirement Study (HRS), the Longitudinal Study of Successful Aging (McArthur Foundation, USA) calculated the prevalence of successful aging for adults aged 65 years and older at four time points: 1998, 2000, 2002, and 2004. Guided by Rowe and Kahn's conceptualization of successful aging, successful aging was defined as having (a) no major disease, (b) no activity of daily living (ADL) disability, (c) no more than one difficulty with seven measures of physical functioning, (d) obtaining a median or higher score on tests of cognitive functioning, and (e) being “actively engaged” (McLaughlin et al. 2010). – The Survey on Health, Well-Being, and Aging in Latin America and the Caribbean (Project SABE) was conducted during 1999 and 2000 to examine health conditions and functional limitations of persons aged 60 and older in Latin-American countries: Argentina, Barbados, Brazil, Chile, Cuba, Mexico and Uruguay. Demographic variables included were age, sex, race, level of education, birthplace, religion, ethnic group, marital status and income. Also, the study examined cognitive status, health status, functional status, nutritional status, and use and accessibility of services (Pelaez et al. 2006). Arias-Merino et al. (2012) estimated the prevalence of successful aging in 3116 elderly people in Western Mexico based on Rowe and Kahn's and Kahn's model assessed through the SABE Protocol. The results showed that an average of 12.6% older adults were considered to be “aging well” and significant differences were found by age (lower percentage in those older), gender (women), education (lower education), and marital status (single). After reviewing how the different studies measure active aging, despite an identifiable set of

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variables such as sociodemographic, health, functional and cognitive status being present in most studies, a lack of consensus regarding the instruments and measures used in the research protocols can be highlighted. The Active Ageing Index (AAI) was developed with the aim of measuring the multidimensional concept of active aging in EU (Zaidi et al. 2012), thereby providing quantitative evidence for policy reforms, trying to engage key stakeholders to formulate and implement policies and programmes to improve older adults' quality of life and also improving the intertwined financial and social sustainability of public welfare systems in Europe. From this point of view, active aging is defined as: “the situation where people continue to participate in the formal labour market as well as engage in other unpaid productive activities (such as care provision to family members and volunteering) and live healthy, independent and secure lives as they age” (p. 6). And it embraces 4 domains: (1) Contributions through paid activities: Employment, (2) Contributions through unpaid productive activities: Participation in society; (3) Independent, healthy and secure living; and (4) Capacity and enabling environment for active aging. In Fig. 2.4 we can observe the ranking in the four AAI domains (updated in February 2019). It is noticeable that two Nordic countries (Sweden, and Denmark), and the Netherlands are confirmed as the top performers of active aging, while Greece and Central and Eastern European countries (excepting Estonia, Austria and the Czech Republic) remain at the low end of the 2019 AAI results. The four southern European countries (Italy, Portugal, Spain and Malta) are middle-ranked countries. Compared with 2014 AAI results, a certain degree of stability continues in the relative position of EU28 countries: Sweden, Denmark and the Netherlands as well as Finland, the United Kingdom and Ireland remaining at the top, while Poland, Hungary, Slovakia, Romania, Bulgaria,

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Fig. 2.4 AAI: Ranking of 28 EU countries. Source: Retrieved from UNECE (2019)

Lithuania, Latvia and Greece continue at the bottom of the ranking.

2.2.6

Problematic Issues

2.2.6.1 The Nature of Domains If successful aging is to be considered a multidimensional construct, it must include both objective and subjective dimensions. But depending on the nature of the domains or conditions included in the conceptualization, some authors include only objective conditions (Rowe and Kahn 1997a, 1998), while others only include subjective conditions (Ryff 1982). Using data from 458 participants (age: 55–75) from ELEA (Longitudinal Study of Active Aging), Fernández-Ballesteros et al. (2010) showed that objective conditions do not correlate with subjective conditions; furthermore,

subjective conditions (satisfaction and health perception) seem to be better predictors of successful aging than objective indicators (illness and productivity), with the sociodemographic variables (men, greater income, higher education, younger) being the most consistent predictor of successful aging. Of older adults reporting successful aging, 80% presented a high or very high satisfaction with life, 57.2% reported good or very good subjective health, 46% obtained an MMSE score greater than or equal to 29 and, finally, 27.4% reported not having any disease. In this sense, Pruchno et al. (2010) points out there is no consensus in the empirical definition of active aging, emphasizing that successful aging incorporates both objective and subjective indicators to integrate this multidimensional concept, suggesting that it is possible to identify “people who are successful according to both definitions, others are successful according to

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neither, and still others are successful according to one, but not the other definition” (p. 829).

2.2.6.2

The Confusion About Dependent and Independent Components As has been underlined above, the WHO definition of active aging includes three components, but while participation and health are individual outputs, security implies the context, which is not an outcome but a socio-political determinant of the entire process of active aging and the output is health and participation. As has been stated elsewhere, a problematic issue emerges “from the confusion about dependent (outcomes) and independent (predictors or determinants) components” (Fernández-Ballesteros 2019, p. 14). This is a confusion between outcomes (dependent variables) and independent variables. The type of aging depends on the interaction between psycho-behavioral factors, genetic, and environmental conditions, along the lines of Bandura's socio-cognitive theory. As FernándezBallesteros (2019) highlights, to describe the type of aging, “the observable conditions in the individual are the way to operationalize it” (p. 15). 2.2.6.3

Is Active Aging the Same Concept as Healthy, Successful or Productive Aging? Although Active Aging is embedded with other positive verbal labels such as healthy, successful and productive aging in a common semantic field, it is possible to establish some differences among the terms. Healthy Aging (WHO 2015) is defined as mainly health and functional abilities (ADL); Productive Aging is considering as only the fourth domain, that is, social participation; while Successful aging (Rowe and Kahn 1997b) considers three domains with the exclusion of affect, coping or control, and finally, Active Aging (of course following this model) embraces the four domains. Active aging is a multidimensionalmultidomain concept expressed both at individual and population level, and measuring objective and subjective bio-psycho-social outcomes. Unfortunately, some definitions confound

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determinants and outcomes (i.e. ILC 2015; WHO 2002), which is particularly fundamental in active aging given the common mistake of definitions being confused with determinants. Furthermore, after 13 years WHO (2015) has gone a step backwards by reducing active aging to biomedical components and functionality, forgetting the essential psychosocial components. Thus, there is no consensus on its conceptualization and measure, it lacks clarity as studies often confound correlates with the construct itself and therefore, the measures used in the different studies. In sum, studies related to aging well should: (1) be multidimensional; (2) be assessed as multidomain and multi-method; (3) take into account both objective and subjective conditions.

2.3

Quality of Life

From an historical perspective, following the review in the Introduction (Fernández-Ballesteros 1997, 2006, 2008), Quality of Life emerges at the end of the 1960s. In an attempt to overcome the economic utilitarian perspective of welfare, to supplant it as a central political goal of wellbeing, the new concept of Quality of Life was introduced. Although it has been broadly used during the last 60 years, it continues to be an unclearly defined concept, without consensus, as “an extremely complex, abstract and scattered concept with high impact on research and practice . . . highly used in environmental, social, medical and psychological sciences and within political contexts” (Fernández-Ballesteros 1997, p. 387). In sum, Quality of Life is an overused term which lacks a commonly agreed definition and its conceptualizations are almost as varied as the contexts and authors that use it. Fortunately, Walker (2005a) provided a frame definition, without components, which is reasonably well accepted by several experts in the field: “an amorphous, multilayered and complex concept with a range of components---objective, subjective, macro-societal, micro-individual, positive and negative---which interact together” (p. 3) (Fernández-Ballesteros 2011b; Halvorsrud and

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Kalfoss 2007; Vaarama 2009). However, as we have already seen above and will detail below, the complexity of the term is usually underestimated and misused. Thus, let us firstly see a detailed description of how Walker's definition is operationalized through elements or components and, secondly, let us discuss the misuse of the concept.

2.3.1

QoL Components

QoL, is composed of two distinct words: (1)“Quality” (as opposed to quantity) is considered to be the standard of something in comparison to other things of a similar nature, as well as the degree of excellence of something; (2) The subject of this quality is “Life”, so that it could theoretically include as many ingredients as human life itself. Commonly, however, authors highlight its multidimensional character; it is very challenging to find agreement among them about its components (see Fernández-Ballesteros 1998; Brown et al. 2004). Below is a description of all QoL domains cited by both experts and by lay people and reported by several research reviews: • Ecological and environmental qualities: there are different indicators to assess this, such as air and water conditions, energy resources, forestation, green zones and waste containers available in a city, and/or percentage of people who recycle. • Economic resources are assessed by gross domestic product, the budget available for a particular region, district, or neighborhood, and/or individual income. • Biomedical and health aspects include epidemiological indices, such as mortality, morbidity, life expectancy, or disability-free life expectancy. It is also important to measure available health services, health status, functional abilities, physical activity, health selfperception and satisfaction. • Sociopolitical and cultural variables at macro and aggregate levels, for example, security indices (prevalence of crime, suicide, public

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violence and family breakdown, etc.), policy and management aspects (such as educational resources), social climate perception, social values, and cultural images. • Psychosocial aspects at the individual level, which include social network and social support, frequency of relationships, satisfaction with those relationships, and social leisure activities. • Psycho-behavioral aspects refers to the broadest components, from lifestyles to perceived health, including independence, leisure activities, working conditions, life satisfaction, well-being, mental health (depression/happiness, anxiety/relaxation, dementia/preservation of memory, etc.) and subjective assessments of any psychological condition relevant to life. All these elements making up the QoL concept can be set in the square of Fig. 2.1. There are elements referring to aspects of the population, such as the health system, GDP or cultural values, or to the individual circumstances, such as the individual's health, income or satisfaction. Moreover, all these ingredients can be divided into two groups depending on the nature of the population and individuals components: among the former, for example, The Economist developed a list of Quality of Life Indexes through the following indicators: (1) Material well-being GDP per person; (2) Health Life expectancy at birth; (3) Political stability and security ratings; (4) Family life Divorce rate (per 1000 population); (5) Community life Dummy variable taking value 1 if country has either a high rate of church attendance or trade-union membership; (6) Climate and geography Latitude, to distinguish between warmer and colder climes; (7) Job security Unemployment rate; (8) Political freedom Average of indices of political and civil liberties; (9) Gender equality Ratio of average male and female earnings, latest available data. This was used to calculate the quality of life index for 111 countries. Regarding the ingredients addressed from an individual perspective, as already mentioned,

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these can be analyzed from an objective perspective or from directly observable data (for example, GDP/income, social network size or number of illnesses) and from a subjective perspective--that is, individuals' appraisals of given components (for example, cultural values, income satisfaction, health perception or satisfaction with social relationships). As Tesch-Roemer (2012) pointed out, “the distinction between objective and subjective quality of life implies that the two concepts are not congruent and, hence, nor redundant” (p. 3); a combination of high and low levels of both types of indicators may result in a general QoL index. In other words, objective and subjective results are not interchangeable, but they complement each other (e.g., FernándezBallesteros 2011a; Michalos et al. 2012; Santacreu et al. 2016; Wahl and Iwarsson 2007; Wettergren et al. 2009). In order to show and understand the complexity and the importance of the multidimensional, multisystems and multinature concept of Quality of Life, we developed a cross-cultural study in Mexico and Spain (Fernández-Ballesteros et al. 2012a; Santacreu et al. 2016). In this study we found that despite both objective macro (population/contextual) and micro (personal) level factors, indicators of QoL were higher in Spain than in Mexico, while subjective appraisal of the quality of life and life satisfaction were higher in Mexico than in Spain. These results underline the importance of taking into consideration a multidimensional concept of QoL, including objective and subjective personal and contextual measures and indicators in order to achieve a good representation of QoL. Similar to other studies, this study highlights the importance of both the multidimensionality of the constructs and the other components proposed by Walker (2005b) which express its complexity: objective, subjective, macro-societal, micro-individual, positive and negative.

2.3.2

Multidimensionality of Quality of Life

With the aim of providing empirical support to overcome this conceptually related problem, we have developed a cross-cultural study that ratifies

the scientific approach of the QoL concept. In this study, we test a nomothetic and multidimensional concept, comprising a set of personal (common to those present in Active Aging) and environmental circumstances, including subjective and objective indicators (see Fig. 2.5) (Santacreu et al. 2016). In this study, the inclusion of life components in the model is not exhaustive, since the focus of the research is the objective and subjective nature of each of the elements included. Given the aim described, multi-group Structural Equation Modelling (SEM) analysis was applied to two representative samples made up of 1217 participants aged over 60 from Spain and Mexico, who completed the CUBRECAVI. The results indicated that although the QoL construct has the same meaning in the two countries, the importance of the indicators and the relationships between the variables are not equivalent, with the same happening in Active Aging. These results are in accordance with those reported by Walker and Lowenstein (2009), who found that the relations between variables varied across persons and cultures. Nevertheless, this does not mean that the indicators we use to measure QoL should be different in each country, or that the concept is idiographic. Bowling et al. (2003) attribute these differences, for example, low levels of a particular component (poor health, low income, short social support), to people's values and aspirations, or to living circumstances. Thus, these results support the hypothesis that the dynamic property attributed to the QoL concept refers not to the fact that the construct's composition changes across individuals, cultures or/and age (Bowling and Gabriel 2004), but rather that the importance of domains and the relations between them are what actually changes across living conditions. As mentioned elsewhere, this is in contrast with the constructivist perspective, which defends the belief that each construct is a different perception of reality. Finally, although it seems that, in line with Bowling's (2004) results, the QoL construct is better explained by general subjective questions about health, functional abilities, social relationships and environment satisfaction than by their respective objective indicators

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Objective Health

33

.47 Health

Subjective Health Objective Functional Abilities

Subjective Functional Abilities

Objective Social Relationships

Subjective Social Relationships

Environmental elements General Environment

.90

.68 Personal QoL .68 Functional Abilities

.88

.99

.75

QoL .35 Social Relationship .38

.69

Environment Satisfaction

.80

.76

.48

.84

External QoL

.34 SES

Fig. 2.5 Standardised estimations of the multidimensional model of QoL. Source: Santacreu et al. (2016)

(Fig. 2.5), the empirical model does not dismiss the importance of objective indicators as components of QoL. In conclusion, these results report relevant support for the scientific nature of QoL and highlight the importance of including both types of indicators as significant for the different elements potentially making up QoL.

2.3.3

QoL Problematic Issues

A new concept is born in the scientific literature because of the need to describe a situation that had not been described before, in order to provide

some advantages over existing terms. QoL was born as a concept to improve mainly on two previous simplistic approaches: on the one hand, the term welfare (“welfare state”), which exclusively measured objective indicators in the economic context, and on the other hand, overcoming the conceptualization of health as a simple absence of disease in the medical model; hence the commitment of many authors to focus their efforts on providing a scientific model of the concept of QoL to meet the demands and characteristics for which it was created: multidimensionality, with objective and subjective nature and applicable at different contextual levels (individual vs. population) (e.g. Cummins 2000; Fernández-Ballesteros and

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Santacreu 2014; Hagerty et al. 2001; Lawton 1991; Walker 2005a,b). However, as emphasized by FernándezBallesteros, the concept of Quality of Life has been diffuse and controversial since its inception and shows broad problematic conceptual and methodological issues: the reduction to health in the extensive approach of Health Related Quality of Life (HRQOL) or to the subjective appraisal of a set of domains---as it is defined by the WHO-, the confusion of QoL with other subjective or positive concepts (such as well-being) and, finally, its methodological reductionism to selfreports as an exclusive procedure for QoL data collection, all of which should be addressed. Essentially, the concept of QoL has suffered two types of threats that we have summarized as reductionism and subjectivism (FernándezBallesteros 2011; Fernández-Ballesteros and Santacreu 2014). The first term refers to the fact that QoL has frequently been reduced to some of its components, ignoring its multidimensional character. The second refers to the fact that QoL has been reduced to or confused with subjective indicators; that is, the effort to escape from dominant objectivist approaches has led to the opposite extreme, in which life is reduced to subjective perceptions. These types of error are not exclusive to one area of study but are present in several empirical studies, as the examples below show.

2.3.3.1 Reductionism QoL has been reduced to a minimum number of indicators which often only refer to health or subjective aspects. In the bio-medical field, the use of the concept of QoL is massive (Table 2.1), and so is the frequency with which the term is wrongly used (Michalos et al. 2012). In this area, QoL is repeatedly reduced to health and/or to the impact of a given disease or treatment in terms of symptoms, physical functioning or subjective perceptions of health. The extension of the term health proposed by Declaration I of Alma Ata recommended that the biomedical sciences adapt the term of QoL to its scope of application, leading to the appearance of a new term: Health Related Quality of Life

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(HRQoL). However, despite the fact that the intention was to expand the definition of health, it had the opposite effect of reducing the concept of Quality of Life to health. Since then, instruments which had been traditionally used to assess health status are used to measure Quality of Life (e.g., Nottingham Health Profile (NHP)---or the Sickness Impact Profile). Moreover, some other self-report questionnaires have been developed which, although measuring only the symptoms frequency of a given pathology, are given names which include the term QoL (e.g., Adolescent Asthma Quality of Life Questionnaire, Alzheimer's Carer's Quality of Life Instrument, etc.). In psychology as well as socioeconomic and political areas, the simplification or reduction of the term has had a very clear direction towards subjective aspects of QoL, such as happiness, subjective well-being, positivity, etc. This leads us to introduce the following section, which explains the second misuse regarding QoL, subjectivism.

2.3.3.2 Subjectivism In addition to being reduced to one of its components, QoL is also confused with its subjective components, although in these cases it sometimes maintains its multidimensional nature, referring to different aspects of life. As a result, many QoL assessment tools include different areas, but only measure the individual's subjective appraisals, such as satisfaction with health, environment, social relationships, etc. (e.g., WHOQOL 1995) (Fernández-Ballesteros and Santacreu 2014). In the field of psychology, QoL is equated to or confused with not only positive emotions, such as well-being and life satisfaction, but also with personality characteristics, such as optimism. An example of this is the QoLI inventory (Frisch 1994, 2013), which includes self-esteem and creativity as relevant psychological variables to measure the Quality of Life. Finally, from a socio-economic, political and human development perspective, some authors have equated QoL to happiness. For example, Blanchflower and Oswald (2011) encourage the

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use of happiness measures as an index of life quality, replacing objective economic measures. This has probably been a consequence, on the one hand, of an sudden attempt to move away from the exclusive use of traditional objective indicators to assess QoL in populations, and, on the other, of a purely methodological issue. The lack of correlation between objective and subjective aspects makes it extremely difficult to match these two types of indicators in the same methodologically acceptable model (Cummins 2000; Fernández-Ballesteros and Maciá 1996; Smith 2000; Graham and Lora 2010). The equivalence to happiness, together with the exclusive use of self-reports to collect data, makes it especially frequent in subjective indicators (FernándezBallesteros 2011). However, as many authors have pointed out (e.g. Michalos), subjectivism is problematic in many ways. As emphasized by Fernández-Ballesteros, when QoL is reduced to subjective indicators we run several risks. First, people provide very little variability in satisfaction responses, most reporting being satisfied with life in general, or with different aspects of life such as health or social relationships (FernándezBallesteros et al. 2012b). Thus, the measures usually have low discriminative power to identify potentially improvable elements (Michalos 2002). Secondly, when the aim is to measure intervention program effects, the exclusive use of subjective perceptions can show improvements that do not necessarily account for real changes (Fernández-Ballesteros and Santacreu 2014). For example, a political campaign to promote environmental quality can lead people to report that they are more satisfied after the campaign, although no environmental changes have been produced, only because of the positive message transmitted. This was already pointed out by Sampson in 1981, who argued that a scientific concept used as a social result (such as QoL) cannot be reduced or transformed to subjective perceptions if the aim is to make real changes in people's lives. Finally yet importantly, the need to use objective indicators becomes more relevant when

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people have some physical or cognitive impairment, with limitations in communication, as can happen in people with dementia (Fernández-Ballesteros and Santacreu 2010). Everyone would agree that the best possible QoL needs to be guaranteed for people with dementia, identifying the objective conditions that best guarantee it (e.g., care, facilities, cleanliness, physical functioning, etc.), without being able to report their individual or subjective perception of it, or what they consider important in their lives (Fernández-Ballesteros and Santacreu 2014).

2.3.4

QoL Assessment

As expected, the lack of agreement on the elements that define QoL is also evident in the assessment tools developed and used to measure it. In fact, as Netuveli and Blane (2008) point out, each definition of QoL is associated with an assessment tool or given individual indicators. Given the immense variety of QoL assessment tools proposed, making a decision on what to choose becomes a difficult task. Thus, two main questions have to be answered: What is the aim of the assessment? And what are the characteristics of people who are going to be assessed? (Arnold 1991). Finally, it will be necessary to select, among those that best respond to our aims and target population, those that guarantee the best methodological characteristics and psychometric properties. The five most common objectives to assess QoL are: • Understanding the causes and consequences of individual differences in QoL. • Assessing the impact of social and environmental interventions on QoL. • Assessing the needs of a given population. • Assessing the efficiency or effectiveness of health interventions and / or the quality of the health system. • Improving clinical decisions.

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Regarding the methodology, we need to ask what the best way to obtain the information is. Most instruments to measure individual QoL are based on self-report questionnaires. Indeed, this is the most appropriate methodology for obtaining individuals' perceptions of different life components, subjective appraisals, life satisfaction and levels of happiness; thus, all those instruments that reduce QoL to subjective aspects use self-report to measure it. However, although the self-report also allows the collection of objective data, this type of indicator can also be collected through other assessment procedures, such as direct observation and third-party reports (e.g. family members, doctors, etc.). In addition, this type of data also allows methods to be combined (self-report, third-party reports and/or observation), which offers a more complete picture of an individual's or population's QoL (e.g., a person can report having several friends, which can be confirmed by a family member and observed by a social worker). However, we often find that data from different sources of information do not correlate. Fernández-Ballesteros et al. (1997) found that when measuring environmental QoL through self-report and observation, the correlation between both was very low. Moreover, Birren and Dieckmann (1991) stressed the importance of using the information provided by a doctor to provide objective data on health, because they are more reliable than those reported by patients' selfreport. Conversely, in the Bond Longitudinal Study (BOLSA) Lehr (1993) found that subjective health predicted better longevity than objective health. Again, the presentation of these contradictory results suggests the need to use both types of indicators, objective and subjective, to provide a complete picture of different aspects of life and the relationship between its components, which are not the same in all samples. Finally, it must be emphasized that, as in the assessment of any other construct, in order to select a quality assessment instrument, it is necessary to pay attention to its psychometric properties, such as validity, reliability and

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sensitivity to change (see: Fernández-Ballesteros and Santacreu 2010). Given the close relationship between the models and definitions of QoL and the assessment tools used to measure it, we find in the latter the same problems of conceptualization. As mentioned elsewhere, multiple examples can be observed in the field of medicine. The PROQOLID database (https://eprovide.mapitrust.org/about/about-proqolid) created in 2002 by Mapi Research Trust, is a tool to help users find the Clinical Outcome Assessments (COAs) which are right for their needs and to provide better knowledge and understanding of the relevant use of COAs, as well as to extend access to Patient-Centered Outcome (PCO) resources for the scientific community. To date, PROQOLID has collected and described more than 2000 assessment tools to help identify the most appropriate one. In this collection, we found that many instruments which are traditionally used to measure health are currently described as questionnaires to measure QoL or HRQoL--although often this specification is not made and the terms are used interchangeably (Halvorsrud and Kalfoss 2007). Some examples are: Nottingham Health Profile, NHP; Sickness Impact Profile, SIP; Medical Outcome Study 36-Item Short Form Survey, SF-36. Furthermore, there has been a proliferation of tools designed to measure the quality of life associated with health in general (e.g., multitrait-multimethod analysis of health-related quality of life measurement (HRQoL); Hadorn and Hays 1991). In addition, the assessment tools used to measure the impact that a specific disease has on people's QoL are becoming more frequent (e.g., Quality of life in Alzheimer's Disease (QOLAS); Abert and Logsdon 2000). Now, let us give some examples of measures of QoL from an individual and population perspective which seek to overcome the reductionism and the subjectivism of the assessment tools. Efforts have been made to remedy the shortcomings of Life Satisfaction Survey measures, which, it was argued, reduced QoL to happiness, life satisfaction or other subjective

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conditions. From the population perspective, QoL refers globally to a given universe, covering a territory and/or society or a given context. A good example of multidimensional population measurement is The Economist QoL Index (The Economist 2005). From an individual point of view, CUBRECAVI (Brief Questionnaire of Quality of Life) measures different life aspects, including personal and environmental aspects, assessed from an objective and subjective perspective.

2.4

Conclusions

Over the last 60 years, Quality of Life (QoL) has been commonly accepted as a multidimensional (several components), multi-nature (objective and subjective), multilevel (involving several systems) concept. These three aspects also refer to Active Aging (AA) over the last 50 years. Moreover, throughout this time, very closely related problematic issues have emerged, most of them quite common, such as reductionism, subjectivism, and methodological and conceptual confusion. As outlined in the Sect. 2.1, the semantic fields of Active Aging and Quality of Life potentially overlap in their respective systems. Both Active Aging and QoL embrace health, functional state and activity levels, family and social relationships, emotional well-being, socio-economic and environmental components assessed objectively and subjectively at population, context and individual levels, which can be classified in terms of the four different boxes in the proposed classification system (FernándezBallesteros 2011a, see Fig. 2.1 in the Sect. 2.1). – Population or macro level (measuring aggregated data), context or meso level (the unit of assessment is the community versus individual) or micro level (at the individual level, a person is always interacting with a given context and this reciprocal interaction is relevant to QoL). While Active Aging involves mostly individual conditions (behavioral health and physical fitness, good

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cognitive functioning, life satisfaction and social participation), QoL necessarily embraces contextual/environmental components as well as objective conditions (individual circumstances such as health or ADL) and cultural (subjective) conditions (such as cultural values, aggregate well-being or satisfaction) of individuals' lives (Fernández-Ballesteros 2009). – Epistemological nature: objective (income, education, etc.) or subjective (health appraisal, satisfaction, etc.). Both Active Aging and QoL are multidimensional concepts integrating objective and subjective conditions which cannot be reduced to objective or to subjective components of life. Both types of component are important for the assessment of Active Aging and QoL. This classification allows us to divide the components (internal or external), and dimension methods (observable or self-reported). In sum, active aging and quality of life are both multidimensional concepts which component are overlapped. Moreover, WHO posited QoL as a consequence of active aging nevertheless this assumption has not been tested. A strong effort must be undertaken through longitudinal/experimental studies across where both concept are systematically assessed searching in what extent, across life span, Active Aging and Quality of Life are interacting and trying to disentangle which is first, the egg or the chicken but also arriving to conceptualized their respective uniqueness.

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39 longitudinal study of aging, pilot study). European Psychologist, 3(4), 298–301. https://doi.org/10.1027/ 1016-9040.3.4.298. Fernández-Ballesteros, R., Zamarrón, M. D., Rudinger, G., et al. (2004). Assessing competence: The European Survey on Aging Protocol (ESAP). Gerontology, 50, 30–347. https://doi.org/10.1159/ 000079132. Fernández-Ballesteros, R., Kruse, A., Zamarrón, M. D., & Caprara, M. G. (2007a). Quality of life, life satisfaction and positive ageing. In R. Fernández-Ballesteros (Ed.), GeroPsychology: European perspectives for an ageing world. Göttingen: Hogrefe & Huber. Fernández-Ballesteros, R., Zamarrón, M. D., Calero, M. D., & Tárraga, L. (2007b). Cognitive plasticity and cognitive impairment. In R. Fernández-Ballesteros (Ed.), GeroPsychology: European perspectives for an ageing world. Göttingen: Hogrefe & Huber. Fernández-Ballesteros, R., García, L. F., Abarca, A., Blanc, L., Efklide, A., Kornfeld, R., & Patricia, S. (2008). Lay concept of ageing well: Cross-cultural comparisons. Journal of the American Geriatrics Society, 56, 950–952. https://doi.org/10.1111/j.1532-5415. 2008.01654.x. Fernández-Ballesteros, R., Zamarrón, M. D., López, M. D., Molina, M. A., Díez Nicolás, J., Montero, P., & Schettini, R. (2010). Envejecimiento con éxito: criterios y predictores. Psicothema, 22(4), 641–647. Fernández-Ballesteros, R., Zamarrón, M. D., López, M. D., Molina, M. A., Díez, J., Montero, P., & Schettini, R. (2011). Successful aging: Criteria and predictors. Psychology in Spain, 15, 94–101. Fernández-Ballesteros, R., Arias-Merino, E. D., Santacreu, M., & Mendoza, N. M. (2012a). Quality of life in Mexico and in Spain. In S. Chen & J. L. Powell (Eds.), International perspectives on aging and social welfare: A global analysis (pp. 3–24). New York: Springer. Fernández-Ballesteros, R., Schettini, R., Santacreu, M., & Molina, M. A. (2012b). Lay concept of aging well according to age. Journal of the American Geriatric Society, 60(11), 2172–2173. https://doi.org/10.1111/j. 1532-5415.2012.04232.x. Fernández-Ballesteros, R., Robine, J. M., Walker, A., & Kalache, A. (2013a). Active aging: A global goal. Current Gerontology and Geriatrics Research, 2013, 1–4. https://doi.org/10.1155/2013/298012. Fernández-Ballesteros, R., Molina, M. A., Schettini, R., & Santacreu, M. (2013b). The semantic network of aging well. Annual Review of Gerontology and Geriatrics, 33 (1), 79–107. https://doi.org/10.1891/0198-8794.33.79. Fernández-Ballesteros, R., Benetos, A., & Robine, J. M. (Eds.). (2019). Cambridge handbook of successful aging. New York: Cambridge Press. https://doi.org/ 10.1017/9781316677018. Fernández-Mayoralas, G., Rojo-Perez, F., et al. (2014). Revisión conceptual del envejecimiento activo en el contexto de otras formas de vejez. Sevilla: AGE.

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Active Aging and the Longevity Revolution Alexandre Kalache, Ina Voelcher, and Marilia Louvison

3.1

Background

Active Ageing is predicated on two very simple truths—that ageing is a universal experience (i.e. it is about all of us); and that ageing with longevity and quality of life is largely about context (i.e. the life course). The universality of ageing in individual human terms has always been obvious, albeit often unembraced. Its universality in global population terms was much less obvious for a long time. Until the 1990s, population ageing was largely framed as a phenomenon limited to advanced economies. Researchers and policy-makers gave scant attention to the emerging ageing trajectories in developing regions of the world. The United Nations First World Assembly on Ageing (Vienna 1982) strongly reflected this perception that population ageing was a developed world issue. In addition, ageing as an issue in the 1980s remained crudely compartmentalized. The World Health Organization (WHO) focus on ageing up until the mid 1990s was almost entirely diseaseorientated and its global program was strongly partnered with its program on disabilities—signaling that older age was synonymous with disability. The emphasis was on old age, not on ageing as a dynamic relational process. This was even illustrated in the program name at the time— A. Kalache (*) · I. Voelcher · M. Louvison International Longevity Centre Brazil, Rio de Janeiro, Brazil e-mail: [email protected]; [email protected]

the WHO Global Program on Health of the Elderly (PHE). It may seem self-evident now but it took time for a life-course approach to be fully incorporated into the policy map of older age. New narratives, however, were emerging. The WHO Ottawa Charter on Health Promotion (WHO 1986) firmly established that the “prerequisites and prospects for health cannot be assured by the health sector alone” and that “health is created and lived by people within the settings of their everyday life: where they learn, work, play and love”. The Charter marked a departure from a strict focus on illness prevention and presented a more holistic model that went far beyond the health sector itself. That health outcomes are largely determined by factors other than healthcare was firmly restated by WHO in their social determinants of health study more than two decades later (WHO 2008a) (Fig. 3.1). As a concept, Active Ageing coalesced in the 1990s alongside an increasing recognition of the need for a radical shift in paradigm. It subsequently emerged as a policy tool that was articulated by WHO in 2002 and soon became established as “the leading global policy strategy in response to population ageing” (Walker 2016). WHO was not the first to use the term but it has created the most resonance with its particular vision. That vision continues to evolve in the context of new geographical settings, research data and shifting political and cultural landscapes.

# Springer Nature Switzerland AG 2021 F. Rojo-Pérez, G. Fernández-Mayoralas (eds.), Handbook of Active Ageing and Quality of Life, International Handbooks of Quality-of-Life, https://doi.org/10.1007/978-3-030-58031-5_3

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Within the imperfect constraints of language, active was felt to convey greater inclusiveness than alternative descriptors such as healthy, successful, productive, positive or ageing well. The intention was to reference a continued participation in meaningful engagements—social; economic; cultural; spiritual; civic;—not simply physical activity or longer working lives. The goals were intended to be preventative, restorative and palliative—to address needs and desires across the full range of capacity and resources. Assuring quality of life for persons who could not regain health and function was given as much value as extending health and function. The policy framework established a rights-based, lifecourse approach that was firmly grounded within a health promotion model and was targeted to individuals and population groups alike. The overall aim was to identify the features and to define the language and actions of a fresh ideological approach to ageing.

3.2

The Longevity Revolution

The gift of longer life has arguably been the most consequential legacy of the past century. Reaching older age has ceased to be the privilege of the few and has become the realistic expectation of the many. Currently, two people in the world reach their 60th birthday every second (UNFPA/HelpAge International 2012). By 2050, the 60-plus age group will constitute 30% of the populations in 64 countries—both developed and developing (UNFPA/HelpAge International 2012). At this time, the worldwide population over 60 years will outnumber those under 15 years of age (UNDESA 2013a). There are already more Germans over the age of 60 than their compatriots under the age of 25 (UNDESA 2015a). Brazil currently has twice as many children under 15 as older persons, but this situation will reverse by 2042 (UNDESA 2015a). Importantly, it will have the same age composition as present-day Germany by 2050 (UNDESA 2013a). These extra years afforded to hundreds of millions of people all over the world amount to a longevity revolution and are a great human

triumph. This gift of the twentieth century must be translated into opportunity for all in the twenty-first century. The two main contributors to this population ageing revolution are increasing life expectancies and declining fertility rates. Globally, life expectancy has increased 8.5 years in just the last 30 years (UNDESA 2013b). Today, there are 36 countries with a life expectancy at birth (LEB) of 80 years or above (UNDESA 2013b). By 2050, almost half the countries in the world will be on that list (UNDESA 2013b). Much of the increase in life expectancy is due to greater survival in the early years and is largely as a result of improvements in basic hygiene, nutrition and medical interventions; most notably anti-biotics and vaccinations. The number of years added to life has been particularly dramatic in certain countries. Newborn Brazilian babies have gained 4 months and 17 days of life expectancy every year over the past three decades, which amounts to a bonus of 12 years of life within one generation (IBGE 2014). More apparent in developed countries, however, is that life expectancy is also increasingly influenced by the improved survival of older persons. Individuals in their 60s, 70s and even 80s are also gaining more longevity. A 60-yearold German today has about four more years of life expectancy than did a 60-year-old German in 1980. An 80-year-old Brazilian has more than 2.5 extra years than a fellow 80-year-old compatriot in 1980 (Camarano et al. 2019). In most countries, the older population, and those aged 80 and above in particular, are growing proportionally faster than any other single age group. People aged 80 and above represented 14% of the global older population in 2013 but they will constitute 19% by 2050 (UNDESA 2013a). Even the number of centenarians is expected to grow tenfold by 2050 to 3.2 million (UNFPA/ HelpAge International 2012). The longevity revolution thus far, however, has not impacted evenly. Sharp regional differences in life expectancy are clearly evident. The prize of a long life is still denied to many. LEB can vary from about 56 years in some low-income countries to about 83 years in a

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Fig. 3.1 Social determinants of health. Source: Emerging Markets Symposium (2015)

country like Japan. Regional differences also reveal themselves at older ages. A 60-year-old Japanese person can anticipate a further 26 more years of life whereas a 60-year-old person from Sierra Leone can expect to live only an additional 11 years (UNDESA 2013). There are stark contrasts within countries too—even within community boundaries in small geographic spaces. There are life expectancy disparities within London of nearly 25 years reported by the London Health Observatory (LHO) (n.d.). “If you rank neighbourhoods from the richest to the poorest, you have, almost perfectly, ranked health from the best to the worst” (Pickett and Wilkinson 2014). Furthermore, the life expectancy gap between social classes in some countries is widening. The life expectancy of women in the poorest areas of England has fallen by 3 months at the same time that it has risen by a comparable amount in the nation’s most affluent areas (2012–2017) (ONS 2019). In addition, many of the correlations are clear. For instance, women’s life expectancy cannot be separated from women’s economic conditions; women’s economic conditions cannot be separated from women’s economic empowerment; and women’s economic empowerment cannot be separated from women’s reproductive rights. Extreme variations of both life expectancy and quality of life are also evident when there is an even more forensic examination of population sub-groups based on such variables as social

class, gender, ethnicity, and sexuality/gender identity. In 2019, more than 141 million children will be born—73 million boys and 68 million girls. Based on current data of mortality risks, the girls will live on average 4.4 years more than the boys. Of the 40 leading causes of death, 33 contribute more to a reduced life expectancy in males than in females (WHO 2019)—not least among them are those relating to violence and accidents.. At age 80, women already outnumber men by 100 to 61 (UNDESA 2013). Male life expectancy is making some gains on female life expectancy in more developed regions but the United Nations predicts that the current sex ratios in less developed countries will remain largely unchanged (UNDESA 2001). As documented by the World Economic Forum (WEF) (2014), women continue to be disadvantaged to varying degrees in all countries and in all areas of life—from economic participation/ opportunity to educational attainment, health and political empowerment. Vast numbers of women have never had the experience of paid employment at any point and are relegated to lives in the shadows in older age. The number of years of full health lost through living in poor health from birth is greater in women (9.5 years) than in men (7.8 years) (WHO 2019). Women at advanced ages are the population group most in need of community care (Johnson and Wiener 2006). They are also overwhelmingly the main providers of care.

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In many countries, ethnicity and skin colour reveal one of the greatest disparities. In Brazil, even when such factors as gender, income, schooling, marital status and occupation are taken into account, research reveals that race/ skin colour remains a significant indicator of inequality. As a consequence, functional impairments and other outcomes related to life conditions are measurably worse for older black Brazilians. The darker is the skin colour, the more pronounced are these outcomes (Silva 2017). In the United States, “race and ethnicity continue to influence a patient’s chances of receiving many specific health care interventions and treatments” even when income and education are taken into account (RWJF 2014). The Robert Wood Johnson Foundation (RWJF 2014) has determined that African-Americans and Latino Americans face 30–40% poorer health outcomes than white Americans. Sexual orientation and gender expression/ identity also often reveal particular health realities. Placing all LGBTI persons into a single category is “as uninformed and dangerous as treating them as invisible” (Sitra n.d.) but it can be said that older LGBTI adults have a higher prevalence of many common health issues, even when accounting for differences in age distribution, income and education. They can be characterized as a “resilient yet at risk population experiencing significant health disparities” (Fredriksen-Goldsen 2011). The global reality is that very large numbers of LGBTI persons are routinely subjected to violence, abuse, bullying and stigmatization with inevitable health consequences (Targema and Nomabandla 2018). A damaged older life marked by a trajectory of accumulated social disadvantages is more than a personal tragedy. It is a social disaster with very real consequences for all of society. A long life in poor health is an empty prize. Globally, healthy life expectancy (HALE) at birth has increased but at a slower rate than life expectancy at birth (LEB). In 2015, HALE at birth for men and women combined was 63.1–8.3 years lower than the total LEB. In other words, poor health resulted in an average global loss of nearly 8 years of healthy life (WHO 2018). The mantra

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must continue to be “years have been added to life, now we must add life to years”, a goal emphasized by WHO in 2012 when the slogan of the World Health Day was “Good health adds life to years” (WHO 2012). In some countries, the gain in LEB has been gradual. In much of Europe, but also in such nations as Argentina, Canada and New Zealand, the demographic changes occurred over the course of more than a century. It took France 145 years (from 1845) to double its older population from 10 to 20% (WHO 2018). Countries like China, Thailand, Chile and Brazil are on course to experience the same doubling within just 25 years (before 2030) (WHO 2018). A Brazilian newborn today can expect to live an additional 20 years compared to a baby born in the 1960s (IBGE 2018). Mortality patterns are also changing. In less developed countries, death still predominates in early childhood and is spread relatively equally across all other age groups. In more developed countries, however, most deaths occur in older ages. There is a change in the causes of death as countries develop. Following the pattern of the global north, non-communicable diseases are becoming much more prominent in developing countries where significant challenges from communicable diseases still persist—creating a double burden of diseases. Chronic, non-communicable diseases are now the biggest cause of death and disability worldwide (WHO 2011). It is expected that the occurrence of these chronic disease deaths will increase globally by 15% between 2010 and 2020 (WHO 2011). The vast majority of older persons have chronic conditions of one form or another. In the United States, 92% of persons aged 65 and older report at least one chronic condition and 24% of them report living with three conditions (Hung et al. 2011). In less developed countries, 29% of chronic disease deaths occur among persons under the age of 60 (WHO 2011). It is these less developed countries that will experience the greatest proportional increase in the numbers of older persons over the coming decades. By 2050, almost 80% of the world’s older persons will be living in these nations (UNDESA 2013). Even

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countries with a still relatively small current population of older people will experience very significant demographic changes. By and large, developed countries first became rich, then became aged. Developing countries are becoming older before becoming rich. The latter face their more rapid population ageing within a context of persistent poverty, fierce competition for limited resources and challenging cultural transformations such as changing family structures and urbanization. Developed countries have had more time and more resources to provide care, income and housing for their older population (Kalache 2011). Concurrent to the impressive gains of LEB are equally impressive declines in fertility. Global fertility halved between 1950 and 2015 (UNDESA 2013). Already, half the countries in the world (incorporating 46% of humanity) have fertility rates below the replacement level of 2.1 children per couple—over 30 of them in developing countries (UNDESA 2015b). In addition to all of Europe and North America, low fertility countries now include many countries in Asia, Latin America and the Caribbean (UNDESA 2015b). In fact, five of the ten lowest fertility nations are now in Asia (UNDESA 2015b). It is anticipated that by 2030 about two thirds of the world’s population will live in countries with fertility below the replacement level (UNDESA 2017a). Global total fertility is projected to decline to 2.4 children per woman by 2030 and 2.2 children per woman by 2050 (UNDESA 2015b). As previously observed, these fewer numbers of born children will live longer than their parents and their grandparents. A strong correlation can be witnessed between fertility rates and educational attainment. The fertility rate among Brazilian women with 7 years or less of schooling is as high as 3.19 children, while those with more than 8 years was almost half that number (1.68) (IBGE 2010). Better child survival, urbanization, improved access to contraception and greater aspiration and labour force participation by women are all contributing to the declines. While mortality and fertility are the main contributing factors to population ageing,

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migration also significantly determines changes to both age structure and population totals. The United Nations has determined that the European population would have fallen by a full percentage point between 2000 and 2015 in the absence of its net inward flow of migrants (instead of its actual two percent growth) (UNDESA 2017b). Even the large 2015 influx of a million refugees into Germany, a country whose death rates have exceeded its birth rates since the 1970s, was not enough for that country to avoid future population decline. It is estimated that its population will shrink to 76.5 million (from 82.2 million in 2015) by 2060 (DESTATIS n.d.). Perhaps even more surprising to many people, it is further predicted that the Brazilian population will be in decline from 2048 onwards so that the 2060 population of Brazil will be roughly the same as it is today (Agência IBGE Notícias 2018). Of the 12 European Union (EU) nations that reported actual population declines in 2014, negative net migration was determined to be the main reason for that decline in 5 (Eurostat 2018). According to the United Nations, the current global numbers of refugees, asylum seekers and internally displaced people are comparable to the aftermath of the Second World War (United Nations 2015). Indeed, large-scale involuntary migration was recognized as one of the five most impactful risks in the World Economic Forum Global Risk Assessment (WEF 2016). Despite the narrative in many developed countries, developing countries host the largest numbers of refugees and asylumseekers (UNDESA 2017b).1 The impact of migration on population ageing is even more apparent at the regional level. Rural to urban migration, in particular, which is more often youthful in nature, tends to accentuate population ageing in the rural communities that are left behind. The social repercussions triggered by migration are complex. In addition to the distortions to community age structures and the distancing of intergenerational contact, there is an unbalancing of care provision (whereby the pool of potential carers is lost to richer regions). Despite the fact that 1

Turkey, Jordan, Palestine, Lebanon and Pakistan host the largest refugee populations.

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migration, like ageing itself, impacts almost every nation and community, the nexus between ageing and migration remains a very under-examined area of research. The Longevity Revolution has produced a new curiosity into the process of ageing, older age itself, the implications for public policy and the sustainability of existing systems. It has engendered many predictions of dire economic and social consequences, based on a simplistic assumption that older persons constitute a growing burden on the rest of society. The substantial and fast-moving demographic transitions that make up this revolution do not signal macroeconomic catastrophe but they do point to the need for an urgent re-evaluation of the life-course trajectory and older adulthood itself (Bloom et al. 2014). Given the magnitude, speed and dynamism of the longevity revolution, however, the international responses are still restrained.

3.3

The Life Course

Physiological science shows us that the ageing journey up until our mid twenties (when we reach the peak of our functional capacity) has different features from the ageing journey that is taken beyond those years. Nevertheless, it is the same journey. We do not become a different person as we age. We become more of the same person. Clearly, our older selves do not exist in a vacuum but within a continuum. Health and wellbeing are built upon all our previous life events, circumstances, decisions and behaviours. The way that we age will reflect the manner in which we have lived—from nutrition, education and personal resilience to our home/work environments and our social inclusions or exclusions. Too often, old age itself has been viewed as an “end product” rather than a “work in progress”. Old age is not a condition. It is a process. A comprehensive life-course policy perspective is fundamental to identify the most appropriate and effective actions that maintain individuals and communities in optimal health from birth into very old age. It requires multiple, simultaneous

focuses that reach far beyond the biological and medical components to the social, environmental and behavioural determinants of health. The policy position must be to seek to interrupt the accumulation of risks and to promote the best protections. In line with the health promotion mantra, it must make the best choices, the easy choices. Importantly, it must identify the critical points in life in which health promotion and disease prevention interventions are most likely to succeed and to produce the biggest impact. The earlier that positive change occurs, the better, but it is never too late to experience worthwhile gains. The human life course is in a process of evolution. Alongside the much greater longevity for many, there are also new emerging definitions of health/ well-being and more ambitious expectations and demands from people at all ages. The demarcations of the traditional three-stage life course (learning, working, retiring) are inevitably going to become even more ill-defined (Figs. 3.2, 3.3, and 3.4). Learning will probably continue to predominate in the first two decades of life, but it will not stop there. At each stage of life, all individuals will increasingly need to gain a familiarity with the necessary intellectual and emotional tools for a rapidly evolving present and an unclear future. A fit-for-purpose twenty-first century architecture of inclusive learning at all ages must transcend the narrowly vocational. It must embrace the broadest possible vision of a la carte, modular learning at every stage of life. The new model must strengthen health, technology and financial literacy but it must also value experience, metacognition and intuition. In addition, it must seek to enhance resilience, self-reflection and empathy. Continuous in-job training, short courses, on-line tutorials and stackable diplomas to keep pace with the ever-more rapid changes in knowledge and technology will need to accompany people throughout the entirety of their lives. In the face of an additional 30 years of life, it has become unrealistic to rely on the sustainability of a career decision taken in youth. The trend toward extended working lives is likely to continue but more people will retire in a more gradual and

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Fig. 3.2 Life course in the era of Bismarck. Source: ILC-BR (2015)

individualized manner (Ramey and Francis 2009) and that retirement is less likely to be a withdrawal into privacy and seclusion. The sharing of family and home management duties within relationships will continue to be negotiated

(Kohli 2007). Some research in developed countries predicts that a more equal division between men and women in the home will emerge (Kluge et al. 2014). Increasingly, individuals are learning, caring, working and

Fig. 3.3 Women’s life course today. Source: ILC-BR (2015)

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Fig. 3.4 Women’s life course in the future. Source: ILC-BR (2015)

taking leisure throughout their lives with much less attention to both social expectation and chronological age. As the boundaries to the different stages of life become even more porous and variable, there will be less segregation of age groups. More generations, but fewer representatives of each, will be simultaneously present and engaging in society. Even greater numbers of older and younger adults will contemporaneously share the same spaces and experiences. The gift of longer life is among the finest achievements of civilization and it is generating almost limitless potential for overall human development. As the leading gerontologist Linda Fried (2015) has observed, older people constitute the “largest renewable, natural resource in the world”. It is a reality that large numbers of current and future generations of older people are experiencing a very different older age to that of their antecedents. In much the same way that the social construct of adolescence evolved in the early to mid-twentieth century, gerontolescence—a contemporary transitional phase at the beginning of older adulthood that is

delineated more by functional and attitudinal markers than chronological age—is now emerging in the twenty-first century. It was the baby-boomers who defined the former in their past and now they are defining the latter in the present. As gerontolescents, they are reinventing the way that older age is lived and viewed and humanity is forever different as a result. Their health status and aspirations are unlike any previous generation (Kalache 2011). In the words of Maggie Kuhn, the founder of the Grey Panther movement, “we are trying the future on for size. That is our role” (GAROP n.d.). This new age of old age, however, does not embrace everyone. Older person’s realities vary radically across locations, social classes, ethnicities and genders. More people in highincome countries are living longer in better health, with a shorter period of disability and decline towards the end of life (Chatterji et al. 2015) but this gain is not shared equally by persons living in poverty and social exclusion in those same countries; let alone beyond the national borders. Those who have lived a life

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marked by unmet needs, threatening environments, disempowerment or outright exclusion cannot be blamed for poor health outcomes in older age. As observed by the World Economic Forum (2019) Global Risk Report, environmental hazards are now more prominent than ever. According to the WHO (2016), unhealthy environments are either directly or indirectly responsible for almost one quarter of all global deaths—57% of diarrheal diseases, 42% of strokes, 35% of ischemic heart diseases, 35% of lower respiratory diseases and 20% of cancers can be attributable to them. The situation goes far beyond the disproportionately high number of deaths among vulnerable groups due to extremes of hot or cold, catastrophic emergencies or the health consequences of pollution. Infectious disease patterns are changing, many human habitats are under severe stress and fresh water supplies and food production feasibility are being compromised in many regions. Circumstances matter enormously but adversity itself is not accurately predictive of later-life functioning. More accurately predictive are the responses to that adversity and it is clear that these responses are not fixed. There is more to us than our default settings. The new research on neuroplasticity has revealed that the human brain is far from hard-wired and is able to significantly change its own function, and even its own physical structure, far into very old age (Voss et al. 2017). Magnetic resonance imaging is now allowing us to witness this dynamism of our own brain maps. We are learning more and more about our enormous capacity to generate responses that are more beneficial to us. Skills that lead to an increased resilience can be learnt at any age and an enhanced well-being can be achieved as a result (SAHMRI n.d.). Success or failure, however, cannot be purely attributed to a person’s character. Resilience is a common good and a collective responsibility. It is clear that it is more likely to occur in the presence of cumulative protective factors such as strong family/friendship networks, supportive built environments, the reassurance of security, a rich culture of care and well-conceived policies and

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actions—and less likely to occur in the absence of them. Individuals who have been systematically excluded cannot be blamed for missing the opportunities for healthier choices throughout their lives. The dynamics of power and powerlessness cannot be ignored. It is concerted efforts that are required for progress on the promotion of health and citizenship in the face of inequality and discrimination. The promotion of resilience should license neither a tolerance of adversity nor delusionary and damagingly individualistic instincts. We are learning how to build and to strengthen individual resilience through interventions at the community level at the same time that community resilience itself is built and strengthened—thus creating a virtuous circle (SAHMRI n.d.). The improved health of older people as a group is largely driven by middle- and higherincome earners. Poor adults in their 50s and 60s consistently exhibit lower functional capacity than more privileged adults who are 20–30 years older. A goal of optimum functional capacity (both physical and social) for everyone at all ages must drive policy—not only to achieve desirable moral outcomes but also for social cohesion, the sustainability of communities and a national economic dynamism. With their collective experience and skills, the rising population of older women and men offer almost limitless potential for overall human development. Studies clearly indicate that even relatively small increases in workforce participation by older workers translate into enormous macro-economic gains (Deloitte Access Economics 2012) that are central to future growth. It will be increasingly vital for policymakers to address early work-force exits and to create imaginative workforce re-entry opportunities; particularly for adults in their 50s and 60s in less advantaged communities. Many of us are living longer but the relevance of much of our acquired knowledge is expiring earlier. A much-referenced Oxford University study predicted that almost half of present-day jobs are at high risk over the next two decades (Frey and Osbourne 2013). Other studies suggest a much lower risk of the wholesale displacement of jobs yet nevertheless warn that a likely

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majority of occupations will be radically redefined through new technologies (OECD 2017). The OECD (2017) estimates that an average of only 9% of jobs are at risk of total disappearance but predict that between 50 and 70% of all jobs will be radically transformed. It has been suggested that as many as 60% of the jobs that will be performed by the next generation do not yet even exist (Bris 2016). Accompanying the longevity revolution must be an education revolution that structurally embeds inclusive life-long learning at all ages. Access to information is no longer the main driver of change. It is discernment and application of information that is now the principle driver of change. The Fourth Industrial Revolution is producing profound and ultra-fast systemic shocks that require highly imaginative and continually adaptive human responses. The speed and depth of the changes, the increased job insecurity, the imposed mobility, the growing need for multiple identities and the uneven ownership of the new technologies necessitates that much more attention is given to the human and cultural disruptions. There must be a focus on enhancing markers of well-being (such as resilience, emotional intelligence and sense of control) across the entirety of the life course (Schwab 2016). Individuals must adapt to these cultural shifts inherent within the longevity and technological revolutions but so too must institutions. Furthermore, these institutions must be strategic. Much of the life-long learning that is currently offered is inclined toward the already advantaged. Those who could benefit the most, tend to participate the least (Public Health England 2014) and participation tends to decrease with age (Field 2012). It is clear too that the nature and applications of the new technologies are also reinforcing inequalities because they impact disproportionately. 40% of workers with a lower secondary degree are in jobs with a high risk of displacement whereas less than 5% of workers with a tertiary degree are at risk (OECD 2016). 31% of 15–19 year olds and 71% of 20–24 year olds in Brazil are not enrolled in education (OECD 2018). How will these individuals be integrated into the rapidly changing labour market and what

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health habits will they employ throughout their life courses? What kind of support will they be able to provide to their aged parents in 20–30 years time? And what kind of older citizens will they themselves become in 2060? Political disaffection from groups of people who feel marginalized is increasingly evident throughout the world. There must be a targeting of key demographics, such as men in low-skilled and blue-collar occupations, who are at the very highest risk from technological disruption. Alongside other health interventions, imaginative retraining pathways must be established that counter this group’s rejection of roles that are seen as less masculine, like those in fastexpanding areas such as healthcare. Smaller, more complex and more dispersed family networks are becoming less able to provide care—creating a global crisis of family insufficiency (ILC-BR 2013). The policy response must be to support a holistic culture of care that includes, but goes far beyond, family and public care and significantly addresses the current gender imbalance in care provision. This culture of care must embrace employers, businesses, public community structures/services (such as housing, transportation, recreation), voluntary groups, in addition to family and friendship networks, in a broad intergenerational enterprise. There must be a shared solidarity with both the persons in need of care and the individuals involved in the provision of that care in an acknowledgment that it is a symbiotic ecosystem. Those aged 80 and over years are the most diverse age group—both physically and mentally (Poon and Cohen-Mansfield 2011). In very general terms, about one third of this age group continue to enjoy high levels of physical and cognitive function; one third have a significant degree of impairment but can function with support; while the remaining third experiences severe disability and dependency (Poon and CohenMansfield 2011). Individuals who are able to maintain good functioning in advanced years are exemplars to provide insight into the potential for continued health and wellbeing. They have much to teach us about the conditions, behaviours and

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attitudes that sustain vitality in later life (Terry et al. 2007). Those, who despite infirmities, continue to find meaning and pleasure in their lives, illustrate the capacity for human transcendence and are a major source of inspiration. Others, who may be entirely dependent and wordless, remain distinct personalities who have lived unique and meaningful histories. They call upon all of us to recognize and promote the continued expression of their identity and individuality and to safeguard their dignity and rights. This stage of life too, was intended to be unequivocally embraced within the vision of Active Ageing. Clearly, the expectation of death is greater in older age. Dying free from pain and emotional suffering within the frame of a culture of care, that places person before pathology, is also an important component of this vision. Quality of death must be considered alongside quality of life. The reality, however, is that it remains a reluctant subject for public contemplation and one of the most under-examined areas of health care. Despite the emergence of a culture of palliative care in some, predominately developed, countries, most health-care professionals throughout the world still have little training in the multiple considerations that make up the requirements and rights of the dying.

3.4

WHO Active Ageing Policy Framework

From the mid-1990s onwards, WHO embarked on a journey to identify and to define the features of a new ideological approach to ageing that would have a global resonance. The remit was to build solid policy in an easily communicable/ reductivist format that was as readily accessible to individuals and population groups as policymakers. Foundational to the thinking was an emphasis on the social, personal and environmental influences, or determinants, of health (in its broadest possible sense) and the dynamic, interactive nature of them, across the full human life-course continuum. Intrinsic to it, was a divergence away from a calculus based primarily on need (older people as passive recipients) to one

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fully grounded in rights (equality of opportunity and treatment) as people age. Workshops were conducted in multiple countries2; key experts from all WHO regions provided evidence and models of good practice; and drafts were circulated amongst academics, governments and non-governmental organizations from both developed and developing countries for feedback over a two-year period. Particularly contributive were a series of joint workshops with the UK Faculty of Community Health and both human and financial resources from the Canadian Government. Eventually, at a conclusive meeting of experts at the WHO Kobe Centre, Japan, the Active Ageing Policy Framework was finalized and subsequently launched at the 2nd UN World Assembly on Ageing (WAA) in Madrid in 2002 (WHO 2002). The policy document was an acknowledgement that life for many people worldwide is indeed becoming more like a marathon; albeit run in a continually changing landscape, where there is a constant interplay between opportunity and risk. The framework aimed to extend a healthy and/or quality of life agenda to all people as they age, including the frail and/or those who were requiring palliative care. WHO championed Active Ageing as “the process of optimizing opportunities for health, participation and security in order to enhance the quality of life as people age” (WHO 2002). The intention was to go far beyond just physical and economic activity and to clearly flag participation in social, economic, cultural, spiritual and civic affairs. The policy document framed ageing within the life course to promote a policy continuum from birth until death and to facilitate the engagement of all age groups. It was designed to apply to both individuals and population groups alike. The ideological view point derived from the model of health promotion, defined as “the process of enabling people to take control over and improve their health” (WHO 1986). The 2

Argentina, Australia, Brazil, Botswana, Canada, Chile, Hong Kong, Jamaica, Jordan, Lebanon, Malaysia, Netherlands, Portugal, South Africa, Spain, Thailand, USA.

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framework approached health “from a broad perspective and acknowledges the fact that health can only be created and sustained through the participation of multiple sectors” (WHO 2002). While recognising the great importance of health as a component of Active Ageing, WHO was not mono-dimensional in its approach. The view was that healthy ageing was a core subset of Active Ageing. The applied definition of health incorporated mental and social as well as physical well-being. “Thus, in an Active Ageing framework, policies and programmes that promote mental health and social connections are as important as those that improve physical health status” (WHO 2002). Full participation in socioeconomic, cultural and spiritual activities “according to their basic human rights, capacities, needs and preferences” (WHO 2002) was given an equal prominence to that of health. In the Active Ageing perspective, participation is extended to decision making. It involves the identification and correction of power imbalances so that there is genuine inclusiveness in the shaping of decisions and policy design that goes beyond mere consultation. Intrinsic to it, was a call for “greater flexibility in periods devoted to education, work and care-giving responsibilities” (WHO 2002) and support for embedding a culture of life-long learning. The third fundamental, or pillar, proposed in the Active Ageing model was security, as measured by the assurances of protection, safety and dignity within the context of the life-long primacy of rights. Insecurity was recognised as corrosive to physical health, emotional well-being and social fabric. The WHO Active Ageing Policy Framework was informed by a very simple but compelling graphic depicting the trajectory of functional capacity across the life course. It is clear that the physical functional capacity of humans typically increases to its peak in early adulthood. It is at this point that muscular, respiratory and cardiovascular strength are likely to be at their optimum overall lifetime levels. An inevitable decline in that capacity follows and it is self-evident that it is greatly influenced by chronological ageing. To a much more significant extent, however, this decline is impacted by behaviours and external

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variables, including access to health services—all of which are modifiable. If the predominance of these personal and external conditions is favourable, the rate of decline will be gradual and the individual will continue to be able to perform the requisite activities of life well into older age. This strong sustained functional capacity ideal can lead to a compression of morbidity (Fries 1980) in which any eventual debilitation or disability is squeezed into a very short period of time immediately prior to death. Recent analysis of population morbidity trends in the United States and other high-income countries (Fries et al. 2011) suggests that this compression is indeed already a reality for some. Other studies, however, also indicate that the gains in HALE are threatened by features such as rising inequality, increasingly sedentary lives and sub-optimal/over nutrition leading to obesity and diabetes. It should be further noted that the compression of morbidity is not at all the experience of the vast majority of older people living in developing countries (Mathers et al. 2015) who will increasingly constitute the overwhelming mass of older persons worldwide. The dependency threshold (represented in the Fig. 3.5 by the central bar) is the level of barrier in the environment (physical and social) that transforms a functional impairment (such as diminished vision, an arthritic knee or persistent back pain) into a chronic debility. A high threshold increases the likelihood of a degree of dependency. Poor urban design, inadequate public transportation, hard-to-access information, architectonic barriers, an absence of social support, and economic obstacles inter alia are all features that contribute to this elevated threshold. Lowering the threshold by reducing barriers (e.g. adopting inclusive, user-led design; ameliorating such essential infrastructures as pavements, street lighting and signage; fostering social inclusion; assuring an adequate degree of economic security inter alia) frees people with impairments to continue to function at a satisfactory level. Interventions that prevent or manage diseases, protect safety, support mobility and community interactions are all important to

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Fig. 3.5 The life-course approach to Active Ageing. Source: WHO (2002) and ILC-BR (2015)

mitigate or to delay decline; and therefore, to lower the threshold. The disability threshold is depicted as a bar, not as a fixed line, precisely to illustrate its modifiability.3 Even small variations in the upward or downward direction of the disability threshold can translate into gains or losses, autonomy or dependency for substantial numbers of people. Concerted policy actions that elevate the threshold can result in greater citizen engagement by millions of people while simultaneously producing enormous macro-economic dividends. The WHO Active Ageing Policy Framework identified a number of key, highly interactive determinants, or influences, that together form a dynamic web around the process of ageing (Fig. 3.6). While careful not to attribute direct causation to any single determinant, WHO contended that “these factors (and the interplay between them) are good predictors of how well both individuals and populations age” (WHO 2002). A particular focus was given to the transitions and windows of opportunity for enhancing health, participation and security at different stages of the life course. The Active Ageing determinants incorporate both the personal—the idiosyncrasies and behaviours that It should be noted that, over time, the term ‘disability threshold’ has largely been replaced with the term ‘dependency threshold’. 3

are specific to the individual; and the contextual—the physical, social and economic environments, in addition to health/social services. In this model, gender and culture are represented as overarching/cross-cutting determinants that shape both person and context. WHO called upon the international research community to increase their investigations into the role and collective interactions of each determinant. Since its 2002 launch, the WHO Active Ageing Framework has informed ageing policy development in a number of countries—Australia, New Zealand, Sweden, UK, USA (Healthpact Research Centre for Health Promotion and Wellbeing 2006), Canada (Office of the Chief Public Health Officer of Canada 2010), Singapore (Goh 2006), Spain (Gobierno de España 2011), Portugal, (Ministério da Saúde 2004), Costa Rica (Consejo Nacional de la Persona Adulta Mayor 2013), Chile (Servicio Nacional del Adulto Mayor 2013), Brazil (Ministério da Saúde 2011), Hong Kong (Government of Hong Kong 2016) and Slovenia (Institute of Macroeconomic Analysis and Development of the Republic of Slovenia 2018); and provinces and States— Quebec (Gouvernement du Quebec 2012), South Australia (Kalache 2011), Sao Paulo (Governo de São Paulo n.d.), Andalusia (Junta de Andalucía

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Fig. 3.6 Determinants of active ageing. Source: WHO (2002)

2011) and the Basque Territory (Gobierno Vasco 2015), among others. The extent to which the Active Ageing thinking has permeated Spanish social policy was evident at the December 2017 Madrid meeting of the Spanish Federation of Municipalities and Provinces (FEMP) where it was restated that the pillars of Active Ageing form the basis of all their work on ageing being undertaken across the country (Red Española de Ciudades Saludables 2018). At the intergovernmental level, the European Commission (2012) declared 2012 to be the European Year of Active Ageing and Solidarity between Generations. The United Nations Economic Commission for Europe (2015) has developed an Active Ageing Index consisting of 22 indicators to monitor the level of achievement in Europe. Active Ageing is the concept underlying the WHO (2008b) Age-friendly Primary Healthcare Toolkit and the WHO (2007) Age-friendly Cities Guide (AFC) and in turn it underpins the WHO Global Network of Age-friendly Cities and Communities (GNAFCC). As observed by the past President of the World Medical Association, Sir Michael Marmot (2015), “one of the two major reasons why the Age-friendly Cities Guide is so sensible

is that it is based on the principle of active ageing”.4 As described by the first WHO Coordinator of the WHO Network of Age-friendly Cities and Communities, Lisa Warth (2015), “the WHO Age-friendly Cities Guide operationalized the Active Ageing Policy Framework” and “its comprehensive framework for physically accessible and socially inclusive environments have remained the centerpiece of WHO’s age-friendly cities approach”. The Age-friendly Cities project was adopted by WHO “as a way to bring its Active Ageing Framework to life” (University of South Australia (2014). The built environment can promote health and well-being as effectively as it can marginalize and disable. As of mid 2019, the WHO Global Network of Age-friendly Cities and Communities had a formal membership of over a thousand cities and communities across 41 countries (WHO n.d.).

The cited second major reason was “the practical recommendations [of the AFC Guide] were developed bottom up: by listening to the voices of older people round the world who said what they needed, and to service providers who have experience from the coal face.” 4

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Active Aging and the Longevity Revolution

3.5

Active Ageing: A Policy Framework in Response to the Longevity Revolution

As both, a concept and a policy template, the WHO Active Ageing Policy Framework retains enormous relevance today. Reflecting the dynamism of worldwide population ageing however, a lot has been learned since its first publication in 2002. We now know more about the complexity of the heterogeneity within older age and the lived experiences that sit below the data. Greater prominence is now given to the empowerment and human rights of older persons; the indispensability of life-long learning; the prolongation of working lives; generativity and intergenerationalism, age-friendly and universal design; the appropriateness and ownership of technologies; frailty and mental health (including loneliness and depression); and the new paradigms that frame care culture and quality of death. More is known about resilience (both individual and collective) and the measures of well-being, along with the tools for strengthening each. Ageing is now much more examined in the context of other defining global trends—notably urbanization, growing inequity, globalization, migration, technological innovation, environmental change and emergencies. The public landscape has also shifted. The longevity revolution is now much more understood. New visions of older age (such as gerontolescence) are being presented and ageism is more recognized. An international body of experts convened by the Brazilian International Longevity Centre (ILC-BR 2015)5 initiated the process to update the WHO framework. The resultant Active Ageing: A Policy Framework in Response to the Longevity Revolution was launched at a side event at the United Nations in New York in 2015. This 100-page publication substantially expanded on the original WHO framework by adding new evidence and

5

ILC-BR is a think-tank on population ageing based in Rio de Janeiro that is part of a 16-country global alliance that has consultative status with the United Nations Economic and Social Council.

57

emphasis and promulgated around 125 policy recommendations. Although referenced as a key component of participation in the original WHO framework, Life-long Learning (LLL) has since been given greater focus as a consequence of the exponential proliferation of the knowledge economy and the complex fusions of new technologies across the digital, physical and biological domains (Fig. 3.7). The OECD now considers continuous learning to be one of the most important components of human capital in an ageing world (Keeley 2007). According to UNESCO, it is the key philosophy, conceptual framework and organizing principle for education in the twentyfirst century and regards it as a major priority issue in the global developmental agenda (UNESCO-UNICEF 2013). The case for LLL to be represented as a fourth pillar of active ageing has been strongly articulated. Support for this change initially came from an international conference on active ageing in Seville hosted by the Andalusian government in 2010. The idea became further embedded in the active ageing thinking following the publication of that government’s 500-page White Pages Report on Active Ageing in the same year (Junta de Andalucía 2011). Well-being, and not just vocational opportunity, is reinforced by Life-long Learning. It supports every other pillar of active ageing. It equips us to stay healthy, relevant and engaged in society and it empowers and provides greater assurance of personal security even in very old age. Learning needs are multiple and constant over the life course. Beyond digital/technological literacy, health literacy is necessary for self-care, financial literacy is necessary to manage income, and citizenship literacy is necessary to sustain an informed and beneficial community relationship. At the time of the publication of the WHO Active Ageing Policy Framework in 2002, the first wave of Baby-Boomers had not yet reached older age. The “coming of age” of this population group has transformed the cultural and political landscape of ageing. There is a much larger and more vocal global constituency on ageing issues. Greater numbers of older people are now

58

A. Kalache et al.

Fig. 3.7 The pillars of Active Ageing. Source: ILC-BR (2015)

rejecting passivity in relation to their lives and communities. This new-found assertiveness has been reflected in legislative advances in many countries and greater international consideration of the human rights of older persons; notably at the level of the United Nations6 and regional levels, most importantly the Organization of American States (OAS).7 The WHO policy framework was firmly grounded in the “rights of people to equality of opportunity and treatment in all aspects of life as they grow older” (WHO 2002) and rights were intrinsic to every pillar of 6

The General Assembly established by resolution 65/182 on 21 December 2010 the Open-Ended Working Group on Ageing, which meets annually, specifically on the international framework of the human rights of older persons. Further strengthening this debate, the Human Rights Council established in 2013 the mandate of the Independent Expert on the enjoyment of all human rights by older persons, which was appointed in 2014. Already in 2011, civil society organizations joined forces by establishing the Global Alliance on the Rights of Older People (GAROP) to enhance civil society engagement. 7 The OAS has, since 2015, a specific human rights instrument to protect the rights of older persons, the so-called Inter-American Convention on Protecting the Human Rights of Older Persons.

the Active Ageing model. This was further supported by the Madrid International Plan of Action on Ageing and its guidelines for implementation which highlighted the role of older persons in all decision-making processes. The subsequent expansion of activism, advocacy and research since 2002, however, has further reinforced older person empowerment as both a theoretical and an applied driver of change. The ubiquity of technology is presenting more opportunities for protagonism at every stage of the design continuum—whether it is design of policies, services, environments or products. Much greater potential now exists for real older people (as opposed to averages or personas) in the context of their lived experience, to be the starting point and driving force of all age-friendly design. That age-friendly design must include the architecture for a truly inclusive global culture of care, reconfigured as a shared responsibility.

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3.6

Concluding Remarks

The Active Ageing model has generated considerable global resonance. It continues to stimulate and to orientate actions across a very wide range of dynamic political, economic and cultural landscapes. The purposefully reductive messaging of the Active Ageing approach allows for an easy communication of a complex set of understandings that is accessible to both individuals and population groups, in addition to policy-makers. Active Ageing remains the most internationally recognised, the most applied and the most all-encompassing framework for population ageing to date—comprehensively embracing, as it does, the foundational pillars of life-long learning, participation and security/protection alongside that of health. The body of knowledge about the characteristics and determinants of Active Ageing and the constant interplay between them (opportunities and risks) across the life continuum is expanding exponentially. More and better data are emerging from internationally comparable, population based surveys and longitudinal studies. The enormous heterogeneity of older age is now being more forensically examined. New insights are being derived from the instant collection/collation, analysis and compression of data/mega data permitted by technological advances. This, in turn, is creating a promise of enhanced opportunities for more permeable process, greater design inclusiveness and a meaningful, user-led customization of services, environments and products by all population sub-groups. More pathways are being revealed for individuals at every stage of life to assemble the necessary emotional, mental, social, physical, financial and citizenship tools for a rapidly evolving present and future. This is giving rise to a growing potential for many more levels of decision-making about what enhances or diminishes our collective humanity.

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4

Active Ageing and Quality of Life: A Systematized Literature Review Fermina Rojo-Pérez, Gloria Fernández-Mayoralas, and Vicente Rodríguez-Rodríguez

4.1

Introduction: Backgrounds and Objectives

Population ageing is a global process that is affecting every society and territory. Trigger factors include low fertility rates and increased life expectancy, reflecting the development of all facets of society (health, employment, economy, technology, etc.). This phenomenon is seen as a success for humanity. Never before have whole generations had such high levels of life expectancy and expectations of living into old age. Demographic projections indicate that the proportion of people aged 65 years and above will increase from 9.3% of the global population in 2020 to 15.9% in 2050, and the region with the highest percentage of population aged 65 and above in 2050 will be Europe (28.1%), followed by North America (22.6%), Latin America and the Caribbean (19.0%), Asia (18.0%) and Oceania (17.9%), although Africa will only reach 5.7% (UN 2019). In view of the current and future situation, population ageing is an immediate challenge for

F. Rojo-Pérez (*) · G. Fernández-Mayoralas · V. Rodríguez-Rodríguez Institute of Economics, Geography and Demography (IEGD), Spanish National Research Council (CSIC), Research Group on Ageing (GIE-CSIC), Madrid, Spain e-mail: [email protected]; gloria. [email protected]; [email protected]

both society as a whole and its individuals. Society must provide and individuals must secure the best possible conditions for ageing with quality of life (hereinafter, QoL). Recent studies highlight the challenges arising from the ageing process, including in particular maintaining the pensions system, providing essential care and long-term care, and maintaining good conditions of health and access to healthcare services, in addition to other issues relating to how society works as a whole as well as the influence on family and community and their interaction with older members (UNECE/EC 2019). During the Second World Assembly on Ageing (held in 2002 in Madrid, Spain), the World Health Organization (hereinafter, the WHO) recognised the success of social and economic development and public health policies in achieving longer life expectancy and the need for ageing to be a positive and holistic experience pursuant to the active ageing paradigm (WHO 2002). The WHO describes active ageing (hereinafter, AA) as “the process of optimizing opportunities for health, participation and security in order to enhance quality of life as people age” (WHO 2002, p 12). Subsequent revisions confirmed the paradigm and its definition, with the addition of a fourth pillar, lifelong learning, at the Conference on Active Ageing held in Seville (Spain) in 2010 (ILC-BR 2015; Kalache 2013). This model has also been adopted by other international organizations (Ramiro Fariñas et al. 2012), such as the United Nations Economic Commission for

# Springer Nature Switzerland AG 2021 F. Rojo-Pérez, G. Fernández-Mayoralas (eds.), Handbook of Active Ageing and Quality of Life, International Handbooks of Quality-of-Life, https://doi.org/10.1007/978-3-030-58031-5_4

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Europe/European Commission (UNECE/EC), which marked the celebration in 2012 of the European Year for Active Ageing and Solidarity between Generations (EY2012). It was used to launch a major research project to design a methodology for the study of active ageing (Zaidi et al. 2018). EY2012 was justified by the need to promote a culture of AA based on the promotion of a society for all ages and on intergenerational integration. In line with these aims, the definition adopted by UNECE/EC reconsiders the key elements of the seminal definition of AA, defining it as “the situation where people continue to participate in the formal labour market as well as engage in other unpaid productive activities (such as care provision to family members and volunteering) and live healthy, independent and secure lives as they age” (Zaidi et al. 2013, p. 6). The UNECE/EC group of experts designed a composite indicator to identify levels of AA. The Active Ageing Index (AAI) is made up of four dimensions of ageing (employment; participation in society; independent, healthy and secure living; capacity and enabling environment for AA), with a range of indicators for each dimension (Zaidi et al. 2013). The positive view of AA is rooted in previous research within the framework of the WHO, which was carried out in the context of various gerontological disciplines from social sciences to biomedicine (Fernández-Ballesteros et al. 2013). Along these lines, Walker describes “a modern concept of active ageing” that developed in the 1990s (Walker 2002), noting that at that time there were already other approaches to the concept that departed from the traditionally negative and decay-focused perspective of ageing. A summary of the leading previous theories can be found in Avramov and Maskova (2003), who identify theories including disengagement, activity, continuity, subculture, personality, exchange, age stratification, phenomenological, restructuration, and modernisation strategies. More recent ageing studies treat “active” ageing as a term within a group of positive conceptual labels that form part of the ageing model, including active, successful, positive, healthy

F. Rojo-Pérez et al.

and productive (Fernández-Ballesteros 2019; Ramiro Fariñas et al. 2012). Although each one of these terms appears most closely related to the aspects that give it its name, together they comprise the bio-psycho-social domains and can be grouped under the generic term of “ageing well” (Fernández-Ballesteros 2019). The global aim of enhancing QoL based on needs, desires and expectations throughout a lifetime forms part of the WHO concept of AA. QoL is a term with widespread currency across all areas, whether scientific, popular or in the media (Andráško 2013). However and as in the case of AA, QoL is another multidimensional concept that does not have a settled and globally agreed scientific definition, although the general public appears to have an intuitive idea as to its meaning (Fayers and Machin 2000). Among many other references, the conceptual evolution and use of the term are particularly clear from regular publications produced by the two leading international organisations for QoL studies—the International Society for Qualify-of-Life Studies (ISQOLS) and the International Society for Quality of Life Research (ISOQOL)—as well as in the book providing an introduction to the concept of QoL that begins by defining the partial terms “life” and “quality”, and proceeds to use the connection between the terms to argue that QoL is “the degree to which a set of characteristics of human life meets the demands placed upon it” (Andráško 2013, p. 24). The same author also notes that this simple definition does not address all the issues regarding this complex concept, which concerns the features and demands of and satisfaction with both individual life and society. Another important and all-embracing definition of QoL is provided by the WHO and its Quality of Life Group, and was developed in the context of a transcultural and international collaborative project. The WHOQOL Group defines QoL “as an individual’s perception of their position in life in the context of the culture and value systems in which they live and in relation to their goals, expectations, standards and concerns. It is a broad ranging concept affected in a complex way by the person’s physical health, psychological

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Active Ageing and Quality of Life: A Systematized Literature Review

state, level of independence, social relationships, and their relationship to salient features of their environment” (the WHOQOL Group 1993, p. 153). This definition provides a basis for the design of the WHOQOL questionnaire, acting as a generic measure of QoL in the two versions of the instrument (WHOQOL-100 and WHOQOLBREF), as well as for all QoL measurement instruments adapted to specific population groups: old people (WHOQOL-OLD), adults with physical or intellectual disabilities (WHOQOL-DIS), population with HIV (WHOQOL-HIV and WHOQOL-HIV BREF), and QoL aspects related to spirituality, religiousness and personal beliefs (SPRB) (WHOQOLSRPB). There is also no straightforward definition for QoL in the area of studies with older adults. For Walker and Mollenkopf, “QoL is a rather amorphous, multilayered, and complex concept with a wide range of components—objective, subjective, macro societal, micro individual, positive, and negative—which interact” (Walker and Mollenkopf 2007, p. 3). A summary of QoL definitions can be found in another publication (Rojo-Perez et al. 2015), though other authors have used scientific literature reviews to conclude that few QoL studies among the older population offer a definition of the concept (Halvorsrud and Kalfoss 2007). With this background, it is noteworthy that the concept of QoL has been used in different areas and fields of knowledge. At its beginnings in the academic world, QoL was used by the social indicators movement of the mid-twentieth century, by economists to refer to material wellbeing (Fernández-Mayoralas and Rojo Pérez 2005) and by health professionals to measure health-related quality of life (hereinafter, HRQoL) (Martínez Martín and Frades Payo 2006). It has also been used and standardized in other fields beyond social and health-related disciplines, including technology, assistive technologies and information and communication technologies (hereinafter, ICT) (Blaschke et al. 2009; Gallistl and Nimrod 2020; Schlomann et al. 2020, first online; Slegers et al. 2008). In this regard, current literature reviews report on the disciplinary fields in

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which the concept of QoL is used. It can be observed in medicine and HRQoL (Haraldstad et al. 2019; Makovski et al. 2019), disability and dependence (Sanchis Sánchez et al. 2014), dementia and family members caring for people with dementia (Bowling et al. 2015; O’Rourke et al. 2015), ageing in place, age-friendly communities and build-environment (Gomez et al. 2019, first online; Huang et al. 2014; Vanleerberghe et al. 2017), spirituality (Counted et al. 2018), tourism (Uysal et al. 2015, first online), leisure and culture (Galloway 2006), older adults (Kelley-Gillespie 2009) and institutionalized older adults and long-term care facilities (de Medeiros et al. 2020; Huang et al. 2014; Van Malderen et al. 2013a), indigenous population (Angell et al. 2016), paediatric population (Germain et al. 2019) and measurement instruments (Leegaard et al. 2018). The foregoing paragraphs have indicated the diversity of outlooks and approaches relating to both AA and QoL, as well as the difficulty of defining and measuring them due to their multidimensional and dynamic nature. Following the WHO (2002) definition of AA that classifies QoL as an outcome variable of AA, the aim of this chapter is to carry out a systematic review of the papers that cover both constructs whether using a global or a domain-specific approach. A further aim is to identify the conceptual bases underpinning these studies, the sources and measurement indicators or instruments used, the analytical methodology applied and the main results obtained. The interest of this type of contribution lies not in compiling a list of relevant studies, but in understanding the extent of use and applicability of the AA model and its outcome variable, QoL, across all literature produced since the appearance of the WHO AA model in 2002.

4.2 4.2.1

Material and Methods The Framework of the Literature Review

A scientific literature review was performed to achieve the study aims. Broadly speaking, a

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scientific literature review is a selection and critical assessment of what has been researched and published with regard to a certain topic in various formats (article, monographic work, others). Several review procedures have been developed in recent decades for purposes of summarizing accumulated scientific knowledge. A literature review is research in itself, albeit of a secondary nature in support of primary research. A review must thus be planned and implemented with the same methodological rigour as any other study, reporting the phases of execution and the results obtained, all in order to comply with the principles of being clear, transparent, methodical, objective, structured and reproducible (Booth et al. 2016; Templier and Paré 2015). The success of literature reviews is reflected in their position among the most-searched references since the middle of the first decade of the twenty-first century (Grant and Booth 2009). They are fundamental to understanding the research background of any topic of interest, develop an understanding of that topic, summarizing the empirical evidence and identifying gaps or areas in need of further research (Paré et al. 2015). When a critical assessment is required with regard to a research question, it will be necessary to choose from among several types of review to obtain the results that best fit the proposed aims, find and extract relevant information, and assess and synthesize it. More information can be found in other references relating to the classification, denomination, scope and importance of reviews (Booth et al. 2016; Paré et al. 2015; Petticrew and Roberts 2006; Sutton et al. 2019). This chapter does not comprise a literature review to understand the background to a topic. Rather, the data included in the review are the systematically compiled and rigorously evaluated and analysed publications that link AA and QoL. Templier and Paré describe this as a standalone literature review (Templier and Paré 2015). A systematized review (Grant and Booth 2009) or narrative review (Petticrew and Roberts 2006) was selected for the purposes of this study. This type of review is “a systematic review that synthesizes the individual studies narratively (rather than by means of a meta-analysis). This

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involves systematically extracting, checking, and narratively summarizing information on their methods” (Petticrew and Roberts 2006, p. 39). As this definition states, the review carried out in this chapter involves a systematic and comprehensive search, though in this case it was performed by a group of researchers rather than by a single researcher, in order to avoid potential biases in terms of selection, quality assessment or analysis of the studies (Barr-Walker 2017). The review was implemented following a series of steps (Templier and Paré 2015): (1) formulation of the research question, which is broadly framed in this case (what studies have been carried out and how have they approached the issue of the relationship between AA and QoL, and what are the results arising from the relationship between the constructs?); (2) search for scientific literature in high-quality databases; (3) refinement of results according to inclusion and exclusion criteria; (4) quality assessment of studies in accordance with the research question; (v) extraction and narrative analysis of content of the retained studies based on concepts examined, documentary sources for the study and measurement instrument, analytical methods and results obtained.

4.2.2

Search Strategy for Identification of Studies

The first stage involved the performance of a systematic review of scientific references published between 1997 and 2015, intended to identify the research carried out in relation to AA and other associated concepts (healthy, productive, successful or positive ageing). The search was conducted across several electronic databases of recognized quality: Web of Science Core Collection (WoS) (sub-bases: Science Citation Index (SCI), Social Sciences Citation Index (SCCI) and Arts & Humanities Citation Index (AHCI)), Scopus, Pubmed, Sociological Abstracts and PsycINFO. Searches were also performed using other Ibero-American bibliographic databases: ScIELO Citation Index, CLACSO, CEPAL, Dialnet, ISOC and REDALYC.

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Active Ageing and Quality of Life: A Systematized Literature Review

With a comprehensive overview of AA and related concepts, several descriptors were used in English [active ag(e)ing, healthy ag(e)ing, productive ag(e)ing, successful ag(e)ing)] and in Spanish (envejecimiento/vejez activo/a, envejecimiento/vejez/anciano/s saludable, envejecimiento/vejez/anciano/s productivo/a, envejecimiento/vejez exitoso/a/con éxito, anciano/s exitoso, anciano/s activo/s). The search fields were title, abstract and keywords. At this stage of the procedure, the researchers were assisted by experts specializing in scientific information and documentation and in searching for bibliographic references. A non-systematic and hence non-representative search of the scientific corpus was carried out for the second stage and in order to update the results obtained in stage one.

4.2.3

Eligibility Criteria and Strategy for Quality Assessment

A total of 15,748 references were obtained through a systematic search across all the aforementioned databases. The results were subjected to a peer review process involving several researchers to adjust the selection of references to the inclusion and exclusion criteria. This review was implemented by screening the title and the abstract content. When necessary, the full document was also examined and the researchers discussed the process with each other in the case of any doubt. The team first checked and eliminated any duplicated references, and also any records that did not meet the criteria for inclusion based on type (book reviews, conference papers, doctoral theses, journal editorials, opinion articles, articles in non-scientific journals or magazines, grey literature, non-scientific reports), topic and field (biomedicine, neuroimaging, nutrition/diet, intervention studies, gerontoengineering, gerontotechnology, natural disasters) and language (other than Spanish, English, French or Portuguese). As a result 2062 references were retained, in addition to a further 320 found using a non-systematic search, and managed using

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EndNote software. The full documents were obtained using resources to which the institution subscribed or by paying fees. With this selected range of 2382 references and in order to address the object of study of this chapter, the following inclusion criteria were applied: (1) the search terms were limited to “quality of life” and “active ag(e)ing”, in English, and “calidad de vida” and “envejecimiento/vejez activo/a”, in Spanish, in the title, abstract and keywords fields; and (2) applied research articles published in scientific journals that study both constructs (AA and QoL) from a global or domain-specific perspective. This approach result in 162 articles from systematic search and 6 from non-systematic search. Subsequently, an exhaustive screening of the full contents of the selected articles provided a comprehensive review and excluded 152 references that studied only one of the constructs (AA or QoL) or were systematic review articles, theoretical articles, books, chapter books, policy or intervention programs, monitoring programs, health promotion or regulatory/legislative studies. This resulted in 16 articles meeting the inclusion criteria and therefore being selected for this chapter. In accordance with the research aim, the retained references were both quantitative and qualitative. This means that the data, instruments used and results are not strictly comparable. Although the reference search and selection was systematic, the study analysis was therefore carried out in a narrative or thematic form.

4.3

Results

The content of the selected references was reviewed and discussed by the researchers, focusing on the context subject to analysis (geographical area and country), type of residence (family home; nursing home), participant age and sex, study type (cross-sectional, longitudinal), conceptualization of studied constructs (AA and QoL) and main study aims, methodology (data sources and indicators, analytical procedure) and

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main results. This information is charted in Annex. As general features, 2015 stands out as the year with the highest number of retained publications (nine), with the remainder published between 2007 and 2017. In relation to the language filter, eight studies were written in English, seven in Spanish and one in Portuguese, although all references had a title, abstract and keywords in English as a requirement for quality and dissemination of the bibliographic platforms used.

4.3.1

Personal and Contextual Characteristics of the Selected Studies

Participants age was not uniform. As such, studies were found involving participants aged 35 years and above and 50–60 (ten studies), 55+ years old (Fernández-Campomanes and FueyoGutiérrez 2014; Montoro Rodríguez et al. 2007), 60+ years old (Ahmed-Mohamed et al. 2015; Fernández-Mayoralas et al. 2015; Kwok and Tsang 2012; Viana Campos et al. 2015), and 65 + years old (Bowling 2008, 2009; Escarbajal de Haro et al. 2015; Gañán Adánez and Villafruela Goñi 2015). Other publications included specific groups: 56–81 years old (Llorente-Barroso et al. 2015), 51–100 years old (Ovsenik 2015), 62–102 years old (Van Malderen et al. 2016), 65–74 years old (Colombo et al. 2015), and older adults in several age groups to meet the requirements of the applied method (RodríguezRodríguez et al. 2017). There were no articles specifically focusing on nonagenarians or centenarians other than those examining people aged up to 100 (Ovsenik 2015) and up to 102 years of age (Van Malderen et al. 2016). As regards sex, almost all studies included men and women, with only two publications studying women exclusively (Escarbajal de Haro et al. 2015; Fernández-Campomanes and Fueyo-Gutiérrez 2014). A study by LatorreRoman only includes men (Latorre-Roman et al. 2015). Fewer than half of the articles referred to Spain as a whole (Ahmed-Mohamed et al. 2015), the Spanish regional communities

(Rodríguez-Rodríguez et al. 2017) or some of the regional communities (Escarbajal de Haro et al. 2015; Fernández-Mayoralas et al. 2015; Gañán Adánez and Villafruela Goñi 2015; Latorre-Roman et al. 2015; Llorente-Barroso et al. 2015; Montoro Rodríguez et al. 2007) or regions (Escarbajal de Haro et al. 2015) as a geographical area of research, while two references corresponded to the United Kingdom (Bowling 2008, 2009). Other European countries and/or regions were also included: Flanders (Belgium) (Van Malderen et al. 2016), Italy (Colombo et al. 2015), Slovenia (Ovsenik 2015), as well as Hong-Kong (Kwok and Tsang 2012) and Minas Gerais (Brazil) (Viana Campos et al. 2015). Out of the group of retained studies, two featured elderly residents in long-term care facilities as their object of study (Fernández-Mayoralas et al. 2015; Van Malderen et al. 2016). The other articles concerned older adults resident in family dwellings, and two of them involved research directed at individuals engaged in university studies for older adults or mature learners (Gañán Adánez and Villafruela Goñi 2015; Montoro Rodríguez et al. 2007) or participating at socio-educational centres (Escarbajal de Haro et al. 2015).

4.3.2

Conceptual Bases for Active Ageing and Quality of Life and Research Aims

All of the retained references were examined to identify their underlying conceptualizations of AA and QoL. The studies were grouped into two large categories for this purpose: (1) those adopting the conceptual bases for AA provided by the WHO (2002), whether from a global or multidimensional perspective or from a domainspecific standpoint, as well as other studies based on the UNECE/EC conceptual model of AA (which, in turn, follows the WHO model); and (2) research not based on the seminal WHO conceptualization of AA and focusing on a domainspecific approach to AA.

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Active Ageing and Quality of Life: A Systematized Literature Review

4.3.2.1

Studies Adopting the Conceptual Bases of the WHO AA Model These papers followed the AA model established by the WHO (2002), whether from a global or multidimensional standpoint or on a domainspecific basis: – based on the multidimensionality of the concept of AA, Bowling refers to the WHO conceptualization (2002) as well as to all previous theories (activity theory; disengagement theory; continuity theory; adjustment and adaptation theory) that she considers part of the background to AA (Bowling 2008), noting that current definitions include social, psychological and physical health, autonomy and independence, empowerment, and meaning and purpose in life (Bowling 2009). In the first article, the author specifies that the concept of AA overlaps with that of successful ageing. There is an attempt to identify the perceptions and self-assessments of older people in relation to AA, based on the assumption that higher AA scores will show a direct association with levels of QoL (Bowling 2008), examining QoL from a subjective and global approach rated by the participants. In the second retained study and using a lay perspective approach with older people, the author assumes a different perception of AA among ethnically homogeneous and diverse groups of older people (Bowling 2009), and QoL is interpreted in a global and domain-specific sense. – the seminal conceptual basis for AA specifies that this paradigm must be spread throughout the population, regardless of residential context and abilities or level of functionality and type of residential setting (WHO 2002). The study regarding AA levels among the older population in nursing homes in Flanders (Belgium) aims to identify explanatory factors and the importance that residents assign to these determinants (Van Malderen et al. 2016). QoL has a multidimensional

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conceptualization (Gilhooly et al. 2005; The WHOQOL Group 1995). – also from a multidimensional perspective, one paper studied Internet usage as a source of opportunities for AA, focusing on Internet access as a facilitator of social and communicative opportunities and as a factor in AA and QoL (Llorente-Barroso et al. 2015). In relation to QoL, this work follows the tenets of Gilhooly et al. (2009), for whom the main determinants of QoL are wealth, health and social relations. – included as well within this WHO framework is the aim of constructing an AA indicator in two groups (active and normal) to identify their relationship with QoL and other personal determinants relating to health and functioning, behaviour and the physical residential setting among the older population of the state of Minas Gerais (Brazil) (Viana Campos et al. 2015). This work uses a multidimensional understanding of QoL (the WHOQOL Group 1995). – a study following the conceptual model of AA adapted to the European context in accordance with the UNECE/EC bases was also classified as part of this group (Rodríguez-Rodríguez et al. 2017). The Active Ageing Index (AAI) methodology (Zaidi et al. 2013) was applied to identify its applicability in sub-national contexts. The conceptualization of QoL follows the tents of multidimensionality of this construct to test the distribution and applicability of the AAI and its association with QoL; in this case, for the regions of Spain. From a domain-specific perspective, a range of studies investigated participation in a broad sense in any social, economic, cultural, spiritual, civic or community area, in line with the relevant pillar of the WHO AA framework (2002). – in the case of Spain, community participation in volunteer organizations and the performance of leisure activities in one’s residential area were used to identify their effects on global and domain-specific QoL (leisure,

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–

–

–

–

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social and community integration and emotional resources) (Ahmed-Mohamed et al. 2015). an investigation of AA and QoL among the institutionalized older population with and without dementia (Fernández-Mayoralas et al. 2015) also followed the WHO conceptualization of AA (2002) based on the pillar of participation in activities, with QoL based on the HRQoL index (the EuroQol Group 1990). supported by the AA pillars relating to participation and learning, one study examined AA and QoL among the older adult population participating in university courses for older adults. Its aim was to analyse the relationships between participation in leisure activities and their influence on AA and QoL for students attending a university programme for older adults (Gañán Adánez and Villafruela Goñi 2015). This work does not state the conceptualization of QoL, but instead uses a multidimensional interpretation that is self-reported by the participants. Based on a conception of AA using the AA White Book (IMSERSO 2011), which in turn derives from the conception expressed by the WHO (2002), AA and QoL are analysed for older women in rural areas and in small cities, with a focus on participation in socio-educational activities at social centres (Escarbajal de Haro et al. 2015). This study does not state the concept of QoL but takes its multidimensionality as a starting point. as a transversal determinant of AA, women’s perceptions were examined regarding the use of ICTs and the digital gap between men and women (Fernández-Campomanes and FueyoGutiérrez 2014). The concept of QoL is based on a multidimensional interpretation, following Schalock et al. (2010). daily living patterns in Hong Kong were studied to identify how active older people organize their daily lives to enjoy an active and high-quality lifestyle (Kwok and Tsang 2012). In relation to the conceptualization of QoL, this article follows the tenets of the multidimensional interpretation, in accordance with

Gabriel and Bowling (2004) and Raphael et al. (1997).

4.3.2.2

Studies Not Following the Seminal WHO Conceptualization of AA Another group of references did not state that they were following the WHO’s conceptualization of AA. However, these studies also focus on approaching AA from a multidimensional or domain-specific perspective: – participation and behavioural and lifestyle determinants were analysed in a study on veteran sportsmen (Latorre-Roman et al. 2015). The paper aim was to identify the benefits of physical activity for health, functional capacity and QoL among the adult and older adult population that exercise, on one hand, and are sedentary, on the other, in order to compare the results with what are described as two models of active ageing or sports practice (long-distance runners and bodybuilding practitioners). QoL is based on the concept of HRQoL. – the influence of QoL, of engaging in learning activities and of social participation on the motivation to be mobile, to travel and to engage in tourism was analysed for the older adult population of Slovenia (Ovsenik 2015). The author maintains that AA is the framework that supports a desire to extend one’s social network, to have new experiences through tourism and to lead a health and active life. QoL is considered as an overall assessment of one’s life. – the adoption and use of ICTs and their effect on AA and QoL were the subject of an Italianbased study (Colombo et al. 2015). The authors consider the overlap between the concepts, and state that AA should be understood not merely as being in good or poor health, or in economic terms or with relation to activity, but also in terms of QoL and of subjective and socially gratifying ageing. They use a multidimensional interpretation of QoL,

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Active Ageing and Quality of Life: A Systematized Literature Review

without specifying the conceptualization or model that is being followed. Also included as part of this group was a paper that did not refer to a conceptualization of AA but did follow a domain-specific interpretation of it, as with the other references in this group. This study concerned the reasons for participating in a university programme for older people (UPOP) (Montoro Rodríguez et al. 2007), in line with the participation and learning pillars from the seminal WHO conceptualization of AA (2002). The paper refers to a global conception of AA, in the generic sense in which it is used by the participants of the study.

4.3.3

Methodology: Data Sources and Analytical Procedures

Almost all of the studies retained are crosssectional, including the study by Montoro Rodríguez et al. (2007), although it analyses the reasons for enrolling in a university programme for older adults over a period of two academic years. In her publication from 2009, Bowling designed a cross-sectional and longitudinal study to make comparisons in the AA and QoL model and to identify explanatory factors (Bowling 2009). The main idea is that all the studies use domains and variables relating to personal and contextual features, as well as ad hoc information, to analyse AA and QoL. The sources and analytical procedures used in the retained studies are explained below. Databases were generally designed as sources of study specific to the particular research aims. In a small proportion of cases and also depending on the goals, relevant indicators were selected from secondary sources of information. The studies were categorized in three classes according to type of data source and analytical procedure: (1) quantitative; (2) qualitative; and (3) mixed studies.

4.3.3.1 Quantitative Studies This group encompasses references that approach research into AA and QoL from a global or a

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domain-specific perspective. In general, multidimensional databases were used in line with this characteristic of old age and ageing, although each study used one or more dimensions depending on its scientific aims. Bowling’s studies used quantitative questionnaires but included open-ended questions to identify the understanding and assessment of AA and QoL expressed by the older population. The first article (Bowling 2008) was a crosssectional study using data from the Omnibus Survey (2006) and introduced an additional module to identify understanding (open-ended) and selfassessment of AA (very actively; fairly actively; neither actively nor inactively; fairly inactively; very inactively) and of QoL (so good, it could not be better; very good; good; alright; bad; very bad). A descriptive statistical analysis (frequency distribution) was applied to characterize the older population according to its sociodemographic, health-related and functional features and residential setting. The explanatory factors of AA were analysed through multiple regression analysis. The second study (Bowling 2009) was both cross-sectional and longitudinal, using two cross-sectional surveys: the Ethnibus Omnibus Survey (2007–2008) (with the most common ethnic groups: Indian, Pakistani, Caribbean, Chinese) and the Omnibus Survey (2007–2008), both with the same questionnaire. A QoL follow-up survey sample (2007–2008) “was used to examine a longitudinal model of active ageing” (Bowling 2009, p. 708). Univariate (frequency distribution), bivariate (chi-square tests, Spearman’s rho correlations) and multivariate (multiple regression analysis and hierarchical regression analysis) statistical techniques were applied to examine associations with self-rated active ageing. The study used various QoL scales: the older people’s quality of life questionnaire (OPQL) (Bowling and Stenner 2011), CASP-19 (Hyde et al. 2003) and WHOQOL-OLD (Power et al. 2005). The study concerning the municipality of Sete Lagoas (Minas Gerais, Brazil) was based on the AGEQOL (ageing, gender and quality of life) study performed in 2012 and representative of a population cohort (Viana Campos et al. 2015).

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Information was selected relating to sociodemographic factors, financial resources, healthcare infrastructure and residential setting, urban setting, family and social networks, social support, religiousness, health and healthy habits, access to and use of health services and perception of safety. Cluster analysis and validation through discriminant analysis were used to construct an ageing indicator (normal ageing, active ageing) using variables relating to activities of daily living (ADL), instrumental activities of daily living (IADL), cognitive functioning, depression, self-perceived health status and family functioning. QoL was measured using WHOQOL Group instruments, specifically WHOQOL-Brief (the WHOQOL Group 1998) and WHOQOL-Old (Power et al. 2005). The independent variables were grouped according to the WHO’s determinants of AA into behavioural, personal, environmental, social setting, financial resources, health and social services, gender and cultural factors. Logistic regression analysis was applied to identify factors in the profile of active people on a separate basis for men and women. Designed and implemented on a representative basis for the population aged 60 years or above and resident in a family dwelling in Spain, the “quality of life in older adults— Spain” survey (CadeViMa-Spain-2008) (Fernandez-Mayoralas et al. 2012) was used by Ahmed-Mohamed et al. (2015). Objective and subjective information on global and domainspecific QoL was selected (sociodemographic characteristics, health, family and social networks, financial resources and retirement, leisure activities and social participation, residential setting). The QoL indicators followed the design of the Personal Wellbeing Index (made up of several domains: standard of living; personal health; achieving in life; personal relationships; personal safety; community-connectedness; and future security) (IWG 2013; Rojo-Perez et al. 2012). This work applied structural equation modelling to identify whether there is a bidirectional relationship between associative participation and satisfaction with leisure, with social integration, with emotional resources and with life as a whole.

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The study of the institutionalized population with or without dementia (Fernández-Mayoralas et al. 2015) was based on the use of two comparable surveys specifically designed to identify the profile of activity and AA, QoL and the explanatory factors for two populations of people aged 60 years or above. QoL was based on the EQ-5D index that measures HRQoL (The EuroQol Group 1990). In addition to sociodemographic and contextual information, this study used data relating to leisure and free-time activities. It also applied a cluster analysis to obtain an activity profile (frequency of participation in a range of leisure and free-time activities) for institutionalized older people divided into three groups (active, moderately active, inactive) and an ordinal regression model, taking the profile of active people as a dependent variable, and identifying as independent variables those which were significant in a bivariate analysis and in two partial ordinal regression models (sociodemographic characteristics and living conditions in the family, social and economic dimensions, and health and functioning conditions). The study of factors influencing older people’s use of ICTs (Colombo et al. 2015) was supported by the design and collection of data using a representative face-to-face questionnaire administered in 2013–2014. In addition to several dimensions regarding conditions and QoL (family relationships, state of health, leisure time and cultural consumption, relationship with activity, participation in social and political or volunteering activities, social capital and social solidarity, family and friend networks, values, and socio-economic status of older people, financial circumstances of participants and general satisfaction with life), information was obtained relating to the technological devices used, preferred times and forms of use (including websites and platforms visited), activities, learning process, perception of use of ICTs for QoL and changes experienced through that use. The work applies descriptive statistics, Spearman’s correlation analysis and cluster analysis to obtain five groups of subjects according to their sociodemographic, personal and activity-related characteristics (prematurely ageing women;

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Active Ageing and Quality of Life: A Systematized Literature Review

couples enjoying their retirement; large families with high levels of solidarity; sociable older adults; busy older adults). A questionnaire on participation in a university programme for mature adults was designed to identify participant assessments, and sociodemographic, leisure and free-time and QoL data were also obtained (Gañán Adánez and Villafruela Goñi 2015). The understanding expressed by participants across a series of dimensions (health, financial income, avoiding loneliness, family support, free time, social activities) was used as an indicator of QoL. This contribution applied descriptive statistical analysis to compare men and women. An intentional sample of veteran male athletes in two physical activity groups (bodybuilding practitioners, long-distance runners) and a group of sedentary males (engaging in moderate or no activity) was set out in the study by LatorreRoman et al. (2015). Variables relating to body composition were used in addition to age. The SF-36 instrument was used to evaluate HRQoL based on eight dimensions (physical function, physical role, body pain, general health, vitality, social function, emotional role and mental health) (Vilagut et al. 2005). Descriptive statistical techniques, variance analysis (ANOVA) and logistic binary regression were applied. Also an intentional sample of older adults living in different parts of Slovenia was obtained to identify whether QoL influences the desire to engage in tourism (Ovsenik 2015). The information-gathering questionnaire was structured in two sections: QoL (emotional wellbeing, active learning, social networking, global QoL) and personal factors concerning demography, financial resources, health, retirement and the frequency of trips and tourism undertaken during the previous year. The factor scores for the QoL factor were used as an indicator of QoL (with the healthy diet, autonomous decision-making, family contact, deserving the best from the world, being in a good mood, satisfaction with achievements during one’s lifetime and since retirement, planning of activities and satisfying expectations variables correlating). Descriptive statistical techniques and multivariate

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analysis were applied to reduce dimensionality (principal component analysis resulted in four factors: QoL, emotional wellbeing, active learning, social networking) as well as multiple regression analysis, taking frequency of tourist travel as a dependent variable and the factors as independent variables. The final paper in this group (RodríguezRodríguez et al. 2017) used secondary data sources from national public institutions in order to calculate the Active Ageing Index (AAI) on a sub-national scale (Spanish regions), following UNECE/EC methodology (Zaidi et al. 2013). The AAI is a multidimensional composite index based on four dimensions (employment; participation in society; independent, healthy and secure living; and capacity and enabling environment for active and healthy ageing) and 22 indicators to measure the potential of older people to enjoy AA. A synthetic QoL index (Argüeso et al. 2014) (based on nine dimensions: material living conditions and economic resources; job; health; education; social relationships; unsafety; governance and basic rights; residential environment; subjective wellbeing) was used.

4.3.3.2 Qualitative Studies Two references examining the use of new technologies compound this category. The study concerning use of ICTs other than in workplace contexts by female caregivers and social media users was designed for an intentional sampling of five in-depth interviews and one discussion group (Fernández-Campomanes and Fueyo-Gutiérrez 2014). Information was collected on the use of ICTs and social media, its benefits, the influence on QoL and differences in use between men and women. For their concept of QoL, these authors took analytical categories for the most important areas of life (emotional wellbeing, interpersonal relations, material wellbeing, personal development, physical wellbeing, self-determination, social inclusion, human rights) as established by Schalock et al. (2010). An inductive qualitative analysis was applied. A study on Internet use and its influence on AA via communicational and social aspects also relied on qualitative methodology based on

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discussion groups and content analysis (LlorenteBarroso et al. 2015). In this case, the conceptualization of QoL followed the tenets of Gilhooly et al. (2009), who considered QoL to be a broad concept capable of describing anything and noted an absence of agreement as to definition, methods or measurement instruments.

4.3.3.3

Studies Using a Mixed Methodology This category includes research conducted using quantitative and qualitative methods. A mixed exploratory-descriptive study was designed in order to investigate the participation of women at social centres (Escarbajal de Haro et al. 2015). A semi-structured questionnaire was constructed using scales to analyse psychoaffective assessments, based on the YESAVAGE-15 instrument (Martínez de la Iglesia et al. 2002; Yesavage et al. 1982), and stereotypes toward old age were measured using the CENVE scale (questionnaire of negative stereotypes of ageing) (Sánchez-Palacios et al. 2009). The descriptive results obtained were examined in several discussion groups and analysed by applying a content analysis. The study on motivations and expectations of older people on participating in university programmes (Montoro Rodríguez et al. 2007) used qualitative techniques involving in-depth interviews and discussion groups to understand the process of deciding to participate, while quantitative techniques were applied to analyse the results of a survey including information on sociodemographic features, relationship with activity, family networks, health, functional capacity and academic schedules. This questionnaire also obtained quantitative data on motives for participation using a scale constructed using qualitative results. The intuitive understanding expressed by participants as one of their reasons for participation (“improving my quality of life”) was applied as an indicator of QoL. The publication relating to a study of nursing home active ageing (NHAA) in Flanders, Belgium (Van Malderen et al. 2016) was quantitative, but has been included within this category as its design was based on the results of a

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previous qualitative study by the authors (Van Malderen et al. 2013b). As such, the quantitative questionnaire includes information on the 61 determinants of AA obtained in the previous work, which were grouped into nine categories (culture; behaviour; psychological factors; physical environment; social environment; economic factors; care; meaningful leisure; participation). All of the determinants were evaluated by the residents in relation to their experience and the importance of each determinant. This information was used to construct an indicator labelled NHAA (nursing home active ageing). The anamnestic comparative self-assessment (ACSA) scale was used to measure global QoL (Bernheim et al. 2006). A descriptive statistical analysis was applied to identify frequencies of personal and contextual variables, in addition to multivariate hierarchical regression analysis to examine the associations between the AA determinants and QoL. In the context of the Hong Kong paper, a semistructured study was designed with closed questions to obtain a profile of older adults (sociodemographic variables, financial resources, perceived health conditions) and open-ended questions to identify how active older people were organizing their daily lives and what responses and discourse they would provide using their own words (Kwok and Tsang 2012). In relation to active participation, information was gathered regarding participation in activities (at home, outside the home, connection with outside world via activities involving communication, social relations or learning), location of activity, timetables and schedules. As regards the QoL indicator, on one hand, the tenets of the multidimensional conceptualization by Gabriel and Bowling (2004) were followed (social relationships with family, friends and neighbours; home and neighbourhood; psychological wellbeing and outlook; social activities and hobbies (communal and solo); financial circumstances; and independence). On the other, the classification of QoL provided by Raphael et al. (1997) was adopted in three areas: being (physical, psychological, and spiritual components); belonging (the fit between a person

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Active Ageing and Quality of Life: A Systematized Literature Review

and his or her physical, social, and community environments); and becoming (referring to the activities that a person carries out to achieve personal goals, hopes, or aspirations). A descriptive and thematic analysis was applied.

4.3.4

Major Findings: Understanding the Relationships of AA and QoL

When older people are given a voice in order to obtain the richness of results that the lay perspective makes possible, AA is interpreted as a range of dimensions relating to their lives. Among British people, the most commonly mentioned domains were maintaining physical health and functionality, participating in leisure/social/mental activities, social relationships, residential setting and its services and facilities, and in a smaller proportion of cases, psychological functioning, financial resources and maintaining independence (Bowling 2008). This study reported a predictive power of 41.3% of variance by means of the health status, longstanding illness and QoL indicators. In research on the comparison of AA and QoL among two groups of older British adults (ethnically homogeneous and diverse), the most common definitions of AA again involved having good physical and functional health, exercising body and mind, and psychological resources (control, attitude, positive thinking). But the likelihood of defining AA as maintaining good physical health and being physically fit was lower among ethnically diverse older people (Bowling 2009), and the predictive power under these models was 41.4% (ethnically homogeneous group) and 16.9% (ethnically diverse group). At follow-up, higher AA was associated with optimal levels of follow-up QoL, measured through OPQL, health, functioning and social participation with an explained variance of 63.9%. Along the same methodological lines, the assessment by older women of their participation at social and educational centres (Escarbajal de Haro et al. 2015) was based on alleviating the educational deficit of their childhood or

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adolescence, developing experience of participation, and their functional and socio-affective capacities. At higher educational levels, involving participation in and continuation of university courses for older adults, assessment was based on behavioural factors and attitude to participation in training and learning activities, improving cultural levels, getting to know and have relationships with new people and feeling active, which produced an improvement in QoL (Gañán Adánez and Villafruela Goñi 2015; Montoro Rodríguez et al. 2007). As in the case of the United Kingdom, health and functional aspects as well as community participation were explanatory factors for AA in the study of Minas Gerais, Brazil (Viana Campos et al. 2015). Moreover, this study showed that behavioural variables (not smoking, engaging in physical activity, not having a loss of appetite) and being economically active, for men, and having a higher level of income and not suffering from falls, for women, were positive factors for AA. Included within the AA group were 52% of older people, but of those within the normal ageing group, almost 65% were women, and the odds ratio of the significant variables was between 0.48 and 1.88. For the model that incorporated determinants relating to healthy behaviours based on physical exercise in two groups of the adult and older adult population who exercised (long-distance runners, bodybuilding practitioners) and did not exercise (sedentary group) (Latorre-Roman et al. 2015), a better HRQoL was observed among longdistance runners compared with the other groups in different dimensions (physical function, general health, vitality, social function, emotional role, mental health), to conclude that physical exercise influences physical deterioration as one ages. In line with the pillar relating to participation, the study on associative participation among older adults and global and domain-specific QoL (Ahmed-Mohamed et al. 2015) did not find statistically significant relationships. In other words, bi-directional associations were not found between the constructs, although statistically significant associations were encountered in the

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other relationships analysed between sociodemographic, personal and contextual variables. In relation to active participation and QoL, the results of research into daily living patterns of active people (Kwok and Tsang 2012) showed that participants usually carried out activities outside the home during the daytime and they were highly mobile. Other activities were performed at home, in addition to family and social relationships, learning, and connecting to the world. And most of the participants reported a high satisfaction with their lives due to they were healthy, financially independent and able to control their lives. Mobility through participation in tourist activities in the case of older adults in Slovenia (Ovsenik 2015), studied through various QoL domains and indicators, explained 21% of variance via three predictors: QoL, learning activities and social networking. However, the emotional wellbeing factor was not found to be statistically significant. Among the institutionalized older Spanish population and also within the context of participation in leisure activities, 26.8% of the population fell within the profile of more active subjects with an EQ-5D index of 0.573, while 38.2% of subjects were classified as inactive with a EQ-5D index of –0.027. Thus, a higher level of activity was associated with higher levels of cognitive functioning, functional capacity in the performance of daily activities, perceived health, family and social contact, and educational level, with a Nagelkerke pseudo R2 of 0.50 in the final model (Fernández-Mayoralas et al. 2015). In terms of older people in nursing homes, in the case of AA and QoL in Flanders (Belgium), the AA score was observed to be 71.1% and all the determinants of AA had values ranging between 71.2 and 80.4%, with the highest values corresponding to culture, care, behavioural factors and healthy lifestyles, followed by setting and psychological factors. The global model of QoL explained 22.9% of variance through psychosocial and participation determinants (Van Malderen et al. 2016). In relation to the use of ICTs (computers, Internet access, social media), 21.3% of older adults owned and used a computer, with higher

F. Rojo-Pérez et al.

proportions among men. However, this gender gap is mitigated when taking into account mobile devices, and those who had started to use these technologies reported having done so specifically with this type of device, particularly in the case of women (Colombo et al. 2015). The benefits and opportunities offered by Internet usage include information, family and social communication and interaction, the performance of administrative tasks and chores, and leisure and entertainment (Llorente-Barroso et al. 2015), again emphasizing that access to and use of ICTs differs based on gender (Fernández-Campomanes and FueyoGutiérrez 2014). From a geographical perspective, the study on AA in Spain showed an association between the distribution of the active ageing index and the level of urbanization and social and economic development of Spanish regions. A significant but relative correlation was observed between this indicator and QoL, and there was a greater correlation with income per capita and with the human development index (Rodríguez-Rodríguez et al. 2017), with the conclusion being that in a European context, Spain still has some way to go before reaching the level of AA enjoyed in other countries.

4.4

Final Remarks

AA and QoL are concepts of great interest in developed societies and are beginning to be seen as such in other less developed countries and settings. Regardless of other indicators, the unstoppable advance of ageing announces the arrival of this state of “development”, at least in demographic terms. In this context, it has already become essential to propose AA and QoL as social paradigms and instruments for the assessment of social and human development in relation to older people. One way to approach these concepts is to analyse the great diversity of scientific studies offered by the international literature, in addition to reports, proposals and programmes from various international bodies, in which both AA and QoL feature as emerging topics of great

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Active Ageing and Quality of Life: A Systematized Literature Review

importance for the political agenda. National and international civil society organizations are not being left behind in this regard; whether individually or collectively, they are also offering their own AA and QoL proposals in order to achieve the implementation of these concepts in ageing societies. This chapter has only focused on reviewing the scientific studies that have examined the relationship between AA and QoL. Its conclusions are comparable to those drawn in other scientific reviews, showing their importance and vitality in the light of social and political demand for scientific knowledge. It is clear that nobody is dispensable in the field of social research, as is shown by the number of studies that are found for the purposes of literature reviews such as this one. The results are indicative of a heterogeneous reality, which far exceeds the expected and supposed homogeneity of the conceptual constructs AA and QoL. The systematized search performed shows that both concepts, while widely and generally used, do not tend to be linked in research as would have been expected in view of the WHO’s conceptualization of AA (WHO 2002). In the lay community, it is common to find references to the fact that individual practices (relating to factors such as health or participation) that promote an active form of ageing have an immediate, visible and measurable impact on people’s QoL. It is also easily shown that perceiving that one has a good QoL predisposes oneself? to engage in activities classified as forming part of AA in older people. This reversibility is not so common in many studies, however, perhaps because other scientific interests prevail or because there are limitations not so easily overcome and which make it difficult to focus on the relationship between AA and QoL. Perhaps the fact that AA and QoL are concepts that do not have a common definition accepted in the scientific literature, by political decisionmakers or by society as a whole contributes to this. And this is the case despite the efforts of the WHO to define the frame of reference for AA, or those of different scientific societies (ISQOLS, ISOQOL) to do the same with QoL. In short, the

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patent lack of definition means an element of confusion, a clear freedom when studying both concepts, and, hence, an inherent difficulty in terms of operationalization, whatever the geographical, social or political scale used. This fact is proven in this review when the priorities of retained articles do not include defining the objects of study that are being investigated. This means that interpretative schemes do not always move in the same direction, since they can be managed according to the interests of the research being conducted, nor are previously established theoretical bases, and the available data do not always make it possible to reach standard conclusions. Official sources that are used contain generic data, prepared for purposes essentially linked to national policies for the production of data and not adapted to the aims of research focused on diagnosing social problems, which are far more demanding in terms of the format required for analysis and diagnosis. In short, AA and QoL are not generally developed from a theoretical and reflective perspective, but rather based on a utilitarian approach, pursuant to which the bottom line appears to be whether they fit particular scientific aims. A range of conditioning factors impact on this approach, in addition to some that have already been mentioned. For example, proper assessments and interpretations are not easily found, with conditioning factors of AA and of QoL treated as influential factors in some studies and as effects in others. The absence of a critical approach to the striking difference that may be established in terms of the value offered by data referring to objective facts or to subjective opinions when analysed in quantitative form is also of interest. Our review clearly shows the influence of these decisions on the achievement of stated aims and on the results obtained. The review of scientific literature in this chapter comes from a task performed to identify the state of the art as regards the link between AA and QoL, insofar as the latter is considered an outcome variable even within the seminal WHO framework. As described, the results analysed are uneven, as an immediate consequence of the range of

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approaches adopted and also particularly with regard to the explanatory power of the models obtained. The most common analysis uses the multidimensional WHO model, with its pillars for action, its determinants of AA and its reference to QoL as a consequence of AA. The UNECE/EC model arises less frequently but also rouses interest and is related to the foregoing. Whether or not these general paradigms are followed, the studies analysed use organizational patterns that place the focus on different geographical and political settings (countries, regions, areas, municipalities, neighbourhoods, urban or rural areas), on different human groups (older people in varied age groups, very difficult to compare with one another, men and/or women), on various residential and habitational environments (nursing or care homes, community spaces, family dwellings, social and/or education centres), and on specific tasks such as physical activities, learning and the use of ICTs. The results also present a striking variation in terms of analytical instruments designed for research purposes, with a far lower use of general or secondary sources. As is customary in social sciences research, a dual and to date uneven route is detectable. Quantitative studies predominate of various kinds (descriptive analysis, multivariate, cross-sectional, use of indicators); they synthesize the data obtained from surveys specifically prepared for each study, of varying breadth and focused on their own aims and conditions for representativeness. However, qualitative studies are beginning to gain analytical importance; they involve a strategy based on obtaining information directly from people via in-depth interviews and focus groups, adapted to the exploration of opinions or motivations regarding multifaceted issues such as QoL, aspects highly refined by the lived experiences of participants, experiences that cannot always be generalized. A third route has recently been emerging as a result of researchers recognizing that quantitative and qualitative methods are not mutually exclusive, but they can be combined and thereby generate richer results. The literature review also reveals its limitations, as is common in social sciences.

F. Rojo-Pérez et al.

Some are operational in nature. For example, it is customary and necessary to draw on a broad selection of bibliographic platforms to search for and obtain a high number of existing references. This leads to a need to evaluate the criteria for retaining studies that do not always offer the desired quality for the purposes of the review. Another limitation linked to the foregoing point is that very heterogeneous references are sometimes obtained from these platforms, which do not always meet impact factor-based quality standards. Some of these cases have been detected in Ibero-American bibliographic databases. Other limitations are far more fundamental for the research process. As happens in multiple reviews of scientific literature, retained articles can be expected to comply with scientific standards that are based on seeking theoretical foundations, on positioning research within reference frameworks already developed by other authors, or on offering a detailed description of data production and its link with methodological tools. It is hence understandable that, using these strategies, sufficient content becomes available for an analysis of results obtained that permits a matching process with other studies already carried out on the same topic. We have been able to confirm that in some works analysed as part of this review, these criteria have not been heeded; rather, a quasi-discursive approach has been used, in which personal assessment criteria have prevailed over purely scientific ones. A limitation such as this one is known to render comparison of topics, geography and results difficult. The solution is to use stricter exclusion criteria with this type of discursive study in bibliographic reviews. Reference has already been made to other limitations, in observing the non-use of homogeneous theoretical frameworks, of generalizable data or of standardized methodologies. In conclusion, studying AA and QoL represents a highly significant challenge in a world with an ageing population and at a time when societies are seeking the best conditions for citizens to live their increasingly lengthy lives. Laudable efforts are being made in this regard across all of the social fields that take the older

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Active Ageing and Quality of Life: A Systematized Literature Review

population as their object of study. And this is the case in spite of the inherent difficulties affecting the review of the research that has been carried out. Acknowledgments The results of this work are supported by: (1) The ENVACES R&D+i project (MINECO-FEDER, ref. CSO2015-64115-R. LR: F. Rojo-Perez); (2) the ENCAGE-CM R&D activities programme (Community of Madrid-FSE, ref. S2015/ HUM-3367. LR: G. Fernandez-Mayoralas); and (3) the ENACTIBE excellence network (MINECO, ref. CSO2015-71193-REDT. LR: V Rodriguez-Rodriguez). A previous version of this document was presented at the 15th International Society for Quality of Life Studies Annual Conference (September 28–30, 2017, Innsbruck, Austria).

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The authors are grateful to Borja González-Albo Manglano, Javier Aparicio García and Aurora Garrido Domínguez (specialists in scientific documentation and information and members of the Centre for Human and Social Sciences, at the Spanish National Research Council (CCHS, CSIC) and to Ana Noelia González Cabezas (specialist in scientific documentation and information and research assistant on Proyecto ELES www. proyectoeles.es) for their help during the process of searching for the bibliographic references and obtaining complete documents. We also thank L. P. Gallardo-Peralta (University of Tarapacá, Chile) for her help in examining bibliographic references found in the databases in order to ensure their quality and suitability for inclusion in this study.

Annex

Charting the data of the retained studies in a tabular and narrative format

Authors and year Language Ahmed-Mohamed et al. English (2015)

Methodological sinthesis (type of study, sources, indicators, Settings and Summary of the analytical participants objectives techniques) Cross-sectional. Spain; residents in To explore the Quantitative. family housing. possible self60 years old and selection effects of CadeViMa-Spain survey 2008. more; men & associative Sample size: 1106 women participation in individuals. both the overall DV: personal measure of wellbeing individual (satisfacion with wellbeing (satisfaction with life) and domains life) and in other specific satisfaction specific domains (spare time, social (satisfaction with integration, emotional leisure, community social resources). IV: associative integration and partitipation. emotional CV: Sex, age, level resources). of education, employment status, social network, satisfaction with standard of living, health, size of residential habitat, religious attitude in life.

Major findings Associative participation shows no effects, either direct or indirect, with the subjective quality of life indicators (global life, spare time, social integration, emotional resources), but statistical significance resulted in coefficients of the rest of the relationships analysed.

(continued)

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Authors and year

Bowling (2008)

F. Rojo-Pérez et al.

Language

English

Settings and participants

Summary of the objectives

Methodological sinthesis (type of study, sources, indicators, analytical techniques)

Descriptive statistical analysis and structural equation modeling. United Kingdom; To identify older Cross-sectional. Quantitative residents in family people’s through openperceptions and housing. ended questions. 65 years old and self-ratings of Omnibus Survey active ageing, to more; men & compare them with 2006. Comparisons women the literature, and with previous studies. to compare their Sample size: perceptions with 337 individuals. comparable DV: active ageing literature. based on the selfrated assessment (very actively; fairly actively; neither actively nor inactively; fairly inactively; very inactively). IV: sociodemographic characteristics, residential facilities and services, health and functioning, realtionships, finantial resources, relationship with activity status, selfrated quality of life as a whole (so good, it could not be better; very good; good; alright; bad; very bad). Lay model based on opinions/ definitions about active ageing and self-rated quality of life. Descriptive statistical analysis and multiple regression analysis.

Major findings

Active ageing is commonly perceived as having/ maintaining physical health and functioning, leisure and social activities, mental functioning and activity, and social relationships and contacts. Most of the aged people rated themselves as ageing Very or farily actively. A significant association between active ageing and quality of life was found. 47% of the participants rated themselves as ageing very actively.

(continued)

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Active Ageing and Quality of Life: A Systematized Literature Review

Authors and year Bowling (2009)

Language English

Methodological sinthesis (type of study, sources, indicators, Settings and Summary of the analytical techniques) participants objectives United Kingdom; This study aimed Cross-sectional and longitudinal residents in family to examine selfrated active ageing surveys housing. 65 years old and among ethnically (2007–2008). diverse and more Quantitative with more; men & open-ended women ethnically ethnically questions. homogeneous diverse and The Ethnibus samples of older homogeneous people in Britain. Surveys samples (2007–2008): faceto-face survey, sample size 400 individuals. The Omnibus Survey (2007–2008): faceto-face survey, sample size 1200 individuals (589 respondents aged 65+). The QoL follow-up study (2007–2008). DV: active ageing. IV: sociodemographic, residential/housing facilities and services, health and functioning, use of health services, realtionships, finantial resources, relationship with activity/ employment status, participation in leisure and social activities, household characteristics. Lay model based on opinions/ definitions about active ageing. Quality of life measures: OPQO, CASP-19; WHOQOLOLD. Descriptive statistical analysis, Spearman’s rho,

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Major findings The active ageing most common definitions are related to physical health and functioning (rated higher among old people ethnically homogeneous), and psychological factors (rated higher among old eople ethnically diverse). The later were less likely to rate themselves as ageing actively (40% very or fairly actively) in contrast with homogeneous participants (85%).

(continued)

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Authors and year

Colombo et al. (2015)

F. Rojo-Pérez et al.

Language

Spanish

Escarbajal de Haro et al. Spanish (2015)

Settings and participants

Summary of the objectives

Methodological sinthesis (type of study, sources, indicators, analytical techniques)

multiple regression analysis. Cross-sectional. Italy; residents in To examine the Quantitative. family housing. factors that Face-to-face 65–74 years old; influence the interview men & women adoption of (December 2013– information and January 2014), communication sample size: technologies by 900 individuals. the elderly, and their contribution DV: Information to improving the and quality of life and Communication Tecnologies (ICT) active aging. use: devices, preference hours and time of use, web sites and platforms, activities done through ICT, learning activities, reasons of use. IV: sociodemographic characteristics, quality of life conditions (family and social relationships, health status, leisure/cultural/ voluntary activities, relationship with activity/ employment status, values and beliefs, economic resources). Descriptive statistical analysis, Spearman’s rho, cluster analysis. Cross-sectional. To study the Valle Ricote, Mixed perception of Murcia methodology quality of life (SouthEastern (quantitative & Spanish region); among female qualitative). residents in family users of social Face-to-face survey housing, and users centres, and the with 64 women relevance for of municipal participants (not taking part in social centres. reported year): sociocultural

Major findings

A pronounced digital gender gap was observed in the ownership and use of computers. But the use of mobile devices (tablets, e-readers) mitigates this gap, given that women tend to comprise a large proportion of the new users of these recent technologies. In terms of active ageing, older people with high levels of digital competence were observed to report a healthy lifestyle as they aged, although it cannot be concluded that the use of ICTs guarantees inclusion and participation.

High assessment and selfperception of the ageing process; development of functional and socio-affective capacities. (continued)

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Active Ageing and Quality of Life: A Systematized Literature Review

Authors and year

Language

FernándezSpanish Campomanes and Fueyo-Gutiérrez (2014)

Settings and participants

Summary of the objectives

65 years old and more; women

activities for an active ageing.

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Methodological sinthesis (type of study, sources, indicators, analytical techniques)

sociodemographic characteristics, health & functioning, social and community participation, depression scale (Geriatric Depression Screening Scale by Yesavage), negative stereotypes (Questionnaire of Negative Stereotypes against Older Persons: CENVE). Focus Group: 8 groups: examining quality of life and socio educational activities y social centers. Descriptive analytical analysis. Content analysis. Asturias In the framework Cross-sectional. (a northern of active aging and Qualitative. In-dept interviews Spanish region); based on the (5) and Focus residents in family transversal Groups (1), based housing. determinant of 55 years old and gender, the aim is in an intentional sample methods more; women to know the (year 2012). women’s Topics examined: perception the use of internet and influence of ICT use in improving social networks by women and their well-being and effects in quality of quality. life, perception of internet use by gender. Analysis of the thematic categories.

Major findings

Access to the Internet and social media has a positive influence on QoL for older women, whose reasons for using such technology particularly included having more links with family and social networks, communicating with other people via email and social media, obtaining news and information regarding current affairs, carrying out chores and enter-tainment. (continued)

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Authors and year

Fernández-Mayoralas et al. (2015)

F. Rojo-Pérez et al.

Language

Spanish

Settings and participants

Summary of the objectives

Methodological sinthesis (type of study, sources, indicators, analytical techniques)

Major findings

Women perceived there to be a digital gender gap. The sample was Cross-sectional. 14 municipalities According with clustered into Quantitative. the participation in 7 Spanish three groups of pillar of the active 2 comparable regions; old people residents in ageing, this work surveys carried out people (active, moderately active aiming at defining in 14 nursing long-term care and inactive). A homes: and explaing settings or higher level of – QoL survey to institucionalized, leisure activity activity was people aged 60+ profiles among with/without without cognitive associated with dementia. Half of institutionalized older adults (with impairment (2008 better cognitive the centres were function, selfsurvey): and without public-owned perceived health 234 individuals. dementia), managed by status and considering their Cognitive private entities, functional ability, and the rest were sociodemographic impairment scale characteristics and based on the Short higher frequency private or mix. of contacts with Portable Mental objective and 60 year old and State Questionnaire family and subjective more; men & friends, and (SPMSQ) de conditions in women having higher Pfeiffer. relation to their educational level. – QoL survey to quality of life. Three groups of people aged 60+ people: active with cognitive impairment (2010 (27%), moderately active survey): people (35%), 525 individuals. and inactive The dementia people (38%). criteria measured by the Diagnostic and Statistical Manual of Mental Disorders: DSM-IV-TR. DV: activity profile based on leisure activities in 4 groups of people (physical, passive, cultural, and social). IV: sociodemographic characteristics, family-social networks, economic resources, health status, Health Related Quality of (continued)

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Active Ageing and Quality of Life: A Systematized Literature Review

Authors and year

Language

Settings and participants

Summary of the objectives

Gañán Adánez and Spanish Villafruela Goñi (2015)

Participants in the Older People University of Experience (University of Burgos, Spain). 65 year old and more; men & women

To examine the relationship between the entertainment, leisure and perceived quality of life by old people attending the education program and its contribution to the active ageing.

Kwok and Tsang (2012) English

Hong-Kong. 60 year old and more, who met following qualifications: (1) age 60 or older; (2) in good physical and psychological health; and (3) having attained at least a junior

In order to examine the active ageing in the Hong Kong’s local context, this paper aimed at analyse how active older people organized their everyday lives through their daily schedules and itineraries, activities engaged

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Methodological sinthesis (type of study, sources, indicators, analytical techniques) Life (HRQoL) based on the EQ-5D, Barthel functional capacity. Bivariate statistical analysis (Chi-square, Kendall’s tau-b test, ANOVA), and multivariate analyses (cluster; ordinal regression). Cross-sectional. Quantitative. Encuesta presencial a estudiantes del Programa Interuniversitario de la Experiencia (varias sedes provincia de Burgos, España) (curso académico 2012–2013). Topics examined: personal characteristics, leisure and free time, quality of life. The self-perception by the participants is used as QoL meaning (health, income, avoiding loneliness, family support, free time, social activities). Descriptive statistical analysis. Cross-sectional. Qualitative (and personal characteristics recorded). Semi-structured qualitative interview to 50 informants from community centres, church organizations and elderly university,

Major findings

A relationship has been observed between participation and ongoing involvement in uni-versity programmes for older people and improved QoL. The population enrolled on these courses also showed higher preparedness to engage in leisure and free-time activities, which also influences QoL.

All the participants staying active with an average time spent outside of 9.5 h during weekday and 11.5 h in the weekend. Participants usually carried out activities outside the home (continued)

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Authors and year

Latorre-Roman et al. (2015)

F. Rojo-Pérez et al.

Language

English

Methodological sinthesis (type of study, sources, indicators, analytical techniques)

Settings and participants

Summary of the objectives

high school education

during the daytime (such as self-employment/ paid jobs/ volunteer activities, physical exercise, cultural activities, leisure and shopping), and they were highly mo-bile. Other activities at home (homemaking, entertainment, arts and crafts, cultural activities), family and social relations, learning, and connecting to the world were performed. And most of the participants reported a high satisfactions with their lives due to they were healthy, financially independent and able to control their lives. A better HRQoL Cross-sectional. In the context of was observed Quantitative. the behavoural determinants of the Face-to-face survey amount the longdistance runners carried out (year active ageing compared with model, the aims of not reported) the other groups this study were: to recluted from (bodybuilding analyze the body different sports clubs in Andalusia practitioners and composition, sedentaries) in strength level and (Spain). different the quality of life 148 males dimensions distributed in related to the (physical health in veteran 3 groups: longfunction, general sportsmen (long- distance runners (53), bodybuilding health, vitality, distance runners social function, and bodybuilding practitioners emotional role, (50) and practitioners) in mental health), sedentaries (45). relation to (continued)

Andalusia (a Southern region of Spain). Veteran sportment (35 years old and more; no inclusion criteria for age, but older adults –50 to 60 years old are included); men

in, and locations they regularly visited.

and friends and colleagues. Information on daily schedules and itineraries activities engaged in (at home, outside home, connecting to the world), and locations they regularly visited, family and social realtionships, learning, personal characteristics (age, gender, self-rating of health condition, education, former occupation, current occupation, and financial situation). Fieldwork carried out: 2007 to 2009. Analysis and categorization of the findings were applied.

Major findings

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Active Ageing and Quality of Life: A Systematized Literature Review

Authors and year

Language

Settings and participants

Summary of the objectives

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Methodological sinthesis (type of study, sources, indicators, analytical techniques)

sedentary ones, and to compare the results between two models.

Llorente-Barroso et al. (2015)

Spanish

Montoro Rodríguez et al. (2007)

Spanish

Varaibles used: age, the body composition (weight, fat mass, skeletal muscle mass), body max index, height, overweight, obesity, handgrip strength, the countermovement jump. The Health Related Quality of Life (HRQoL) was measured through the Short Form of the Quality of Life Survey (SF-36) (8 dimensions). Statistical techniques: mean, standard deviation and percentages, KolmogorovSmirnot test, ANOVA, and logistic binary regression. Within the social Cross-sectional. Spain (central Qualitative. regions); residents communications Focus groups aspects of the in urban areas; active ageing, this (3) with men and family housing (implicit); adults research focussed women, carried out on the usefulness in 2014. school. Topics of the script: 56–81 years old; of using the use of the Internet, internet by the men & women reasons, older adults in opportunities for an order to explain the potential this active ageing. Content analysis. medium has for ageing actively.

Valencia (a Eastern region of Spain) participants in the University Programme for Older People (UPOP).

To know the reasons that move older people to follow university educational programs.

Cross-sectional. 2 groups of old people engaged in university seniors programs (academic courses 2002–2003; 2003–2004).

Major findings concluding that the practice of physical exercise influences over the physical deterioration with ageing.

Internet usage offers various benefits and opportunities, including information, family and social communication and interaction, the performance of chores and resolution of admin-istrative issues, and leisure and entertainment. The main reasons given for participating for the first time as students on university courses for older or mature adults (continued)

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Authors and year

F. Rojo-Pérez et al.

Language

Settings and participants 55 years old and more; men & women

Ovsenik (2015)

English

Summary of the objectives

Methodological sinthesis (type of study, sources, indicators, analytical techniques)

Mixed methodology: qualitative (7 focus groups with 50 participants; 10 in-dept interviews; quantitative (a survey with 400 individuals). Quantitative questionaire: sociodemographic features, health, academic activities, social integration, qualiaty of life, expectations and motivations of the students when deciding their participation in the older university. Descriptive statistical techniques; content analysis. Cross-sectional. Slovenia; family To explore how housing (implied the perceptions of Quantitative. residential the quality of life, 221 retired older people from setting). active learning, various parts of 51–100 years old; and social Slovenia. men & women networking Survey stimulates the mobility of older questionnaire with people through the 26 items in several quality of life engagement in dimensions (quality tourism travel. of life, emotional well-being, active learning, social networking) and sociodemographic features, as well as the frequency of travel in the previous year. Not reported year of the fieldwork. Descriptive statistics, factor analysis and

Major findings were improving culture, feeling active, doing something new, improving quality of life and getting to know new people.

Participation in tourism travel activities showed direct relationships with predictors related to quality of life, active learning and social networking, with an adjusted R2 ¼ 21.181.

(continued)

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Active Ageing and Quality of Life: A Systematized Literature Review

Authors and year

Language

Settings and participants

Summary of the objectives

Rodríguez-Rodríguez et al. (2017)

English

Spanish regions. Following the 51–100 years old; Active Ageing Index men & women methodology (UNECE/EC), this paper aimed at evaluate its adaptation to subnational spaces (Spanish regions) as well as its relationships with other general indicators (gross domestic product, synthetic quality of life index, and the new index of human development) to examine the level of economic and social development of the Spanish regions.

Van Malderen et al. (2016)

English

Flanders, Belgium; nursing home residents without dementia. 62–102 years old; men & women

To analyse the AA status in nursing homes in Flanders (Belgium), to examine to what extent AA and its various determinants are already embedded in the nursing homes from the residents perspective, and

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Methodological sinthesis (type of study, sources, indicators, analytical techniques) multiple regression analysis are applied. Cross-sectional. Quantitative. The data used for ear 2013, or the nearest year. Data sources: the Economically Active Population Survey (EAPS2013); the Population and Housing Census 2011; the Living Conditions Survey (LCS-2006, 2013); the National Health Survey in Spain (NHS-2011); the European Health Survey in Spain (EHSE-2009); Health and Life Expectancy methology (HLE-Spain-2011); the Survey on Equipment and Use of Information and Communication Technologies in Households (ICT-H-2013). AAI Spain was computed based on the methodology of the AAI Europe. Cross-sectional. Quantitative based in qualitative meanings. 383 residents of 57 nursing homes took part in the study. Not reported year of the fieldwork. The Nursing Home Active Ageing (NHAA) survey,

Major findings

The distribution of AAI in the Spanish regions showed the difference between more built-up areas in the north, in addition to Madrid and the Balearic Islands, and the south, traditionally subject to more impoverished circumstances. The AAI showed a high correlation with income per capita, an average correlation with the human development index and a low correlation with QoL.

Residents in nursing homes appeared to have a positive QoL. The Nursing Home Active Ageing (NHAA) experience was positively related to QoL and explained 20% of its variance. Specifically, (continued)

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Language

Settings and participants

Summary of the objectives

composed of 61 statements grouped in 9 AA determinants (culture, behaviour, psychological, physical environment, social environment, economic, care, meaningful leisure, participation), and derived from a qualitative study by Van Malderen et al. (2013b). DV: AA as perceived by the residents of the nursing home; and the QoL of residents (using the Anamnestic Comparative SelfAssessment scaleACSA). NHAA score was computed as overall AA indicator. IV: sociodemographic features (gender, age, education level, previous profession-job), relationships among residents, length of stay in the nursing home, functional status. Cross-sectional. To construct an indicator of active Quantitative. AGEQOL (Aging, aging and assess its association with Gender and Quality quality of life and of Life) study (2012) was used to possible examine the active determinants ageing, quality of according to life and gender. gender. Sample size: 2052 participants.

what importance residents attach to these determinants. In addition, the residents’ QoL was assessed in order to examine its relation with the residents’ AA experience in the nursing home.

Viana Campos et al. (2015)

Portuguese Sete Lagoas in (state of Minas Gerais, Brasil); family housing. 60 years old and more; men & women

Methodological sinthesis (type of study, sources, indicators, analytical techniques)

Major findings psychological factors and participation related positively to QoL; except for the economical determinant, only educational level related negatively to the NHAA experience.

47% classified in the active ageing group and among then 58% were men. Physical and psychological factors as well as social participation are predictors of (continued)

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Authors and year

Language

Settings and participants

Summary of the objectives

91

Methodological sinthesis (type of study, sources, indicators, analytical techniques) DV: a binary active ageing variable (normal ageing, active ageing) based on: Activities of the Daily LivingADL, Instrumental Activities of Daily Living-IADL, family functioning, depression, cognitive functioning, selfperceived health status. IV: quality of life based on the WHOQoL-Bref (4 dimensions) and WHOQoL-Old (6 dimensions); sociodemographic variables, health, functioning, health services use, behavioural factors, personal factors, residencial environment factors, social factors, economic factors. Analytical techniques applied for each gender: bivariate statistical techniques, and multivariate analyses (cluster, discriminant analysis, multiple logistic regression analysis).

DV dependent variables, IV independent variables; CV control variables

Major findings active ageing for both sexes. Furthermore, the behavioral factors for men, and higher incomes and do not suffer falls for women had a better chance of belonging to the active aging group.

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Revista Española de Geriatría y Gerontología, 44(3), 124–129. https://doi.org/10.1016/j.regg.2008.12.008. Sanchis Sánchez, E., Igual Camacho, C., Sánchez Frutos, J., & Blasco Igual, M. C. (2014). Estrategias de envejecimiento activo: revisión bibliográfica [Active aging strategy: A review of the literature]. Fisioterapia, 36(4), 177–186. https://doi.org/10.1016/ j.ft.2013.04.007. Schalock, R. L., Keith, K. D., Verdugo, M. A., & Gómez, L. E. (2010). Quality of life model development and use in the field of intellectual disability. In R. Kober (Ed.), Enhancing the quality of life of people with intellectual disabilities. From theory to practice (pp. 17–32). Dordrecht: Springer, Social Indicators Research Series, vol. 41. https://doi.org/10.1007/97890-481-9650-0_2, Schlomann, A., Seifert, A., Zank, S., & Rietz, C. (2020 first online). Assistive technology and mobile ICT usage among oldest-old cohorts: Comparison of the oldest-old in private homes and in long-term care facilities. Research on Aging, https://doi.org/10.1177/ 0164027520911286 Slegers, K., Boxtel, M. P. J. V., & Jolles, J. (2008). Effects of computer training and internet usage on the wellbeing and quality of life of older adults: A randomized, controlled study. The Journals of Gerontology, Series B: Psychological Sciences and Social Sciences, 63(3), P176–P184. https://doi.org/10.1093/geronb/63.3.P176 Sutton, A., Clowes, M., Preston, L., & Booth, A. (2019). Meeting the review family: Exploring review types and associated information retrieval requirements. Health Information & Libraries Journal, 36(3), 202–222. https://doi.org/10.1111/hir.12276. Templier, M., & Paré, G. (2015). A framework for guiding and evaluating literature reviews. Communications of the Association for Information Systems, 37(6), 112–137. https://doi.org/10.17705/1CAIS.03706. The EuroQol Group. (1990). EuroQol—A new facility for the measurement of health-related quality of life. Health Policy, 16(3), 199–208. https://doi.org/10. 1016/0168-8510(90)90421-9. The WHOQOL Group. (1993). Study protocol for the World Health Organization project to develop a quality of life assessment instrument (WHOQOL). Quality of Life Research, 2(2), 153–159. https://doi.org/10.1007/ BF00435734. The WHOQOL Group. (1995). The World Health Organization quality of life assessment (WHOQOL): Position paper from the World Health Organization. Social Science & Medicine, 41(10), 1403–1409. https://doi. org/10.1016/0277-9536(95)00112-k. The WHOQOL Group. (1998). Development of the World Health Organization WHOQOL-BREF quality of life assessment. Psychological Medicine, 28, 551–558. https://doi.org/10.1017/s0033291798006667. UN – United Nations, Department of Economic and Social Affairs, & Population Division. (2019). World population prospects 2019, custom data acquired via website.

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Retrieved October 8, 2019, from https://population.un. org/wpp/DataQuery/ UNECE/EC – United Nations Economic Commission for Europe / European Commission. (2019). 2018 Active Ageing Index. Analytical Report: Report prepared by Giovanni Lamura and Andrea Principi, under contract with the United Nations Economic Commission for Europe (Geneva), co-funded by the European Commission’s Directorate General for Employment, Social Affairs and Inclusion (Brussels). Retrievde July 28, 2019, from https://www.unece.org/fileadmin/ DAM/pau/age/Active_Ageing_Index/Stakeholder_ Meeting/ACTIVE_AGEING_INDEX_TRENDS_ 2008-2016_web_cover_reduced.pdf Uysal, M., Sirgy, M. J., Woo, E., & Kim, H. (2015 first online). Quality of life (QOL) and well-being research in tourism. Tourism Management. https://doi.org/10. 1016/j.tourman.2015.07.013 Van Malderen, L., Mets, T., & Gorus, E. (2013a). Interventions to enhance the quality of life of older people in residential long-term care: A systematic review. Ageing Research Reviews, 12(1), 141–150. https://doi.org/10.1016/j.arr.2012.03.007. Van Malderen, L., Mets, T., De Vriendt, P., & Gorus, E. (2013b). The active ageing-concept translated to the residential long-term care. Quality of Life Research, 22(5), 929–937. https://doi.org/10.1007/ s11136-012-0216-5. Van Malderen, L., De Vriendt, P., Mets, T., & Gorus, E. (2016). Active ageing within the nursing home: A study in Flanders, Belgium. European Journal of Ageing, 13(3), 219–230. https://doi.org/10.1007/s10433016-0374-3. Vanleerberghe, P., De Witte, N., Claes, C., Schalock, R. L., & Verté, D. (2017). The quality of life of older people aging in place: A literature review. Quality of Life Research, 26(11), 2899–2907. https://doi.org/10. 1007/s11136-017-1651-0. Viana Campos, A. C., Ferreira e Ferreira, E., & Duarte Vargas, A. M. (2015). Determinantes do envelhecimento ativo segundo a qualidade de vida e gênero [Determinants of active aging according to quality of life and gender]. Ciência & Saúde Coletiva, 20(7), 2221–2237. https://doi.org/10.1590/141381232015207.14072014. Vilagut, G., Ferrer, M., Rajmil, L., Rebollo, P., Permanyer-Miralda, G., Quintana, J. M., et al. (2005). El Cuestionario de Salud SF-36 español: una década de experiencia y nuevos desarrollos [The Spanish version of the short form 36 health survey: A decade of experience and new developments]. Gaceta Sanitaria, 19(2), 135–150. https://doi.org/10.1157/13074369. Walker, A. (2002). A strategy for active ageing. International Social Security Review, 55(1), 121–139. https:// doi.org/10.1111/1468-246x.00118. Walker, A., & Mollenkopf, H. (2007). International and multidisciplinary perspectives on quality of life in old age: Conceptual issues. In H. Mollenkopf & A. Walker (Eds.), Quality of life in old age. International and

96 multi-disciplinary perspectives (pp. 3–13). Dordrecht: Springer, Social Indicators Research Series, Volume 31. https://doi.org/10.1007/978-1-4020-5682-6_1 WHO – World Health Organization. (2002). Active ageing: A policy framework. Geneva: World Health Organization. Retrieved July 22, 2008, from http://apps. who.int/iris/bitstream/10665/67215/1/WHO_NMH_ NPH_02.8.pdf Yesavage, J. A., Brink, T. L., Rose, T. L., Lum, O., Huang, V., Adey, M., & Leirer, V. O. (1982). Development and validation of a geriatric depression screening scale: A preliminary report. Journal of Psychiatric Research, 17(1), 37–49. https://doi.org/10.1016/0022-3956(82) 90033-4.

F. Rojo-Pérez et al. Zaidi, A., Gasior, K., Hofmarcher, M. M., Lelkes, O., Marin, B., Rodrigues, R., . . . Zólyomi, E. (2013). Active ageing index 2012. Concept, methodology and final results. Vienna: European Centre Vienna. Retrieved September 2, 2014, from http://www1. unece.org/stat/platform/display/AAI/Active+Ageing +Index+Home Zaidi, A., Harper, S., Howse, K., Lamura, G., & PerekBiałas, J. (2018). Towards an Evidence-Based Active Ageing Strategy. In A. Zaidi, S. Harper, K. Howse, G. Lamura, & J. Perek-Bialas (Eds.), Building evidence for active ageing policies. Active ageing index and its potential (pp. 1–15). London: Palgrave Macmillan. https://doi.org/10.1007/978-981-10-6017-5_1.

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The Life Course Construction of Inequalities in Health and Wealth in Old Age Michel Oris, Marie Baeriswyl, and Andreas Ihle

5.1

Health, Wealth and the Life Course

In this contribution we study health and wealth in old age as the outcomes of long life courses as well as crucial preconditions for the maintenance of activity and well-being. It is worth to note that all the main concepts we consider have a common history. All emerged in the late twentieth century M. Oris (*) Swiss National Centre of Competence in Research LIVES – Overcoming Vulnerability: Life Course Perspectives, University of Geneva, Geneva, Switzerland Centre for the Interdisciplinary Study of Gerontology and Vulnerability, University of Geneva, Geneva, Switzerland Institute of Demography and Socioeconomics, University of Geneva, Geneva, Switzerland e-mail: [email protected] M. Baeriswyl Swiss National Centre of Competence in Research LIVES – Overcoming Vulnerability: Life Course Perspectives, University of Geneva, Geneva, Switzerland Centre for the Interdisciplinary Study of Gerontology and Vulnerability, University of Geneva, Geneva, Switzerland e-mail: [email protected] A. Ihle Swiss National Centre of Competence in Research LIVES – Overcoming Vulnerability: Life Course Perspectives, University of Geneva, Geneva, Switzerland Centre for the Interdisciplinary Study of Gerontology and Vulnerability, University of Geneva, Geneva, Switzerland Cognitive Aging Lab, University of Geneva, Geneva, Switzerland e-mail: [email protected]

and have since known an impressive success in the scientific circles and beyond. In the 1980s, a growing discrepancy was observed between on one side the theory of disengagement, originally developed 20 years earlier to describe the retired withdrawal from social life associated with senescence and disability, and on the other side the growth of life expectancy and the improvements of the health and living conditions of the elderly (Baeriswyl 2016; Oris et al. 2017). The need for a new frame resulted in the theory of “successful aging” that since its first formulation by Rowe and Kahn (1987) became immediately highly influential. In this perspective, an appropriate lifestyle made possible to preserve good health and maintain active engagements. The approach of Paul Baltes and Margret Baltes (1991) was different since they defined the success as the capacity to self-regulate and even master the inevitable changes due to aging while maintaining a sense of self (see Bülow and Söderqvist 2014, for an in-depth comparison of the two models). Both Rowe and Kahn and the Baltes wanted to break with the dark visions of aging and with the stereotypes of elderly as passive. Both refused to see older adults as a burden for society and promoted quality of life in old age (Mendes 2013, p. 176). As strange as it could seem today, well-being as a personal objective has not an absolute value. Collinet and Delalandre (2014) showed how wellbeing became a political objective in the second half of the twentieth century, then how well-being

# The Author(s) 2021 F. Rojo-Pérez, G. Fernández-Mayoralas (eds.), Handbook of Active Ageing and Quality of Life, International Handbooks of Quality-of-Life, https://doi.org/10.1007/978-3-030-58031-5_5

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as personal self-realization has emerged in the 1990s. It immediately became a major topic. Indeed, a simple research in Google Scholar of the various spellings of wellbeing show a quasiabsence in the 1970s, a timid emergence in the 1980s, an explosion of interest and publications in the 1990s, continuing in the first decade of the twenty-first century, and still from 2010, although more slowly (Oris 2017). The centration on the micro-individual perspective similarly explains the parallel success of the life course analysis. Although some famous publications pioneered the field, this approach really became popular, diffused among all the social sciences, from the 1980s (Settersten 2018). Typically, the life course was central in Rowe and Kahn (1987) view since they saw successful aging as constructed all along life through adequate behaviors, while for Baltes the aptitude of managing aging depended on reserves constructed across the human development (see Cullati et al. 2018). The various conceptions of active aging also explicitly consider past life trajectories as a crucial factor.1 The simultaneous chronologies of the renewal in the researches on aging and well-being and of the life course analysis popularity are not a matter of coincidence. They reflect major sociological changes, mainly the individualization theorized by Anthony Giddens (1991) as the most recent chapter in the history of the “society of individuals” (Elias 1991). A new normative figure was imposing itself, the autonomous, responsible individual, implying according to Honneth (2004, p. 463) a “promise of freedom” supporting “an ideology of de-institutionalization”. Indeed, at the end of the twentieth century the neo-liberal context also played a role, but more cyclical than structural since rapidly, the emerging theories, models and approaches received severe critics. Among the most important, the first one was the implicit but strong elitism of the successful aging models which neglect social inequalities. Not everybody can afford a healthy living style or accumulate reserves (Katz 1996). Second, some 1

See especially the position of the World Health Organization: https://www.who.int/ageing/en/

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scholars denounced the discourse about prevention as a tool for “moralizing old age”, imposing “virtuous” behaviors to supposedly free individuals (Oris et al. 2015, p. 217). Third, successful implies unsuccessful and a stigmatization of the “losers”, guilty of inappropriate behaviors, without considering the many factors that are susceptible to affect disability in old age and are not under the individual control (Dannefer et al. 2019). The various answers to those criticisms are foundations for this contribution. First, the appreciation of what is a good aging by the older adults themselves was studied (Bülow and Söderqvist 2014). Second, the chance to “live a life you own value” (Sen 1999, p. 285) depends of a diversity of values but also, very concretely, of the resources or reserves that are available to the aging individual who has the freedom to use them, or not. Indeed, “well-being is characterized by the capacity to actively participate in work and recreation, create meaningful relationships with others, develop a sense of autonomy and purpose in life, and to experience positive emotions” (Hatch et al. 2007, p. 187). This is a support for “active aging”, a slogan that became dominant in the early twenty-first century because powerful international organizations and most of the States have adopted this objective. However, in the continuity of the debates about successful aging, and although the WHO (2002) vision explicitly consider individual wishes and capacities, the social norm promoted by the active aging discourses, the “duty” to be active, is vividly denounced because such pressure weights disproportionately on the disadvantaged (Mendes 2013; Van Dyk 2014; SAPEA 2019). Indeed, the unequal distribution of health and wealth resources or reserves in the elderly population defines unequal capacities to manage aging, to select and practice activities that are sources of well-being (Blane et al. 2004; Jivraj and Nazroo 2014; Baeriswyl 2016). This chapter is concentrated on the life course construction of those inequalities, in health and wealth, among the older adults, from the cradle to old age.

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The Life Course Construction of Inequalities in Health and Wealth in Old Age

Although the life course perspective uses the individual as unit of analysis, this individualism is only methodological since this approach locates individual agency within structures, these structures referring to different levels - macro (time and space), meso (social network and linked lives) and micro (past experiences) (see Elder et al. 2015, for an extensive discussion of the life course principles). In the following we borrow mainly to life course sociology results on the life antecedents of the unequal distribution of wealth and health in old populations. Although less systematically, we also include insights from life course epidemiology and lifespan psychology. Our objective is to look how have been accumulated (or not) the wealth and health reserves needed to be active actor in the preservation of wellbeing. Other resources are potentially important, especially the original genetic endowment of each individual, but are beyond the scope of this contribution. Family history and social relations are also crucial but would require a full chapter. In the next sections we start with the ages of life and follow with ongoing theoretical debates before concluding.

5.2

The Ages of Life

In the so-called developed world, the birth cohorts who are old now in the early twenty-first century, have seen their life trajectories structured by a process of institutionalization that has been amply studied by the European scholars (Brückner and Mayer 2005; Kohli 2007; Levy and Bühlmann 2016). The development of various welfare regimes resulted in a division in three stages associated with specific roles: youth until the age at compulsory schooling or legal majority, then adulthood to enter the labor force and settle a family, until a retreat also fixed by law and that defined old age. Most of the researches on the life course construction of active aging and wellbeing in old age use this structuration of life, looking at early life conditions, then at the mediating or moderating impact of adult life.

5.2.1

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Early Life Conditions

Early life even starts before birth. The importance of genetic is well-established in several fields, especially cognitive ability, and has an influence all across the life course (Richards and Deary 2013). However, heritability also concerns ascribed traits (like sex, skin color, ethnicity, etc.) that society can use to discriminate individuals all across their life. The medical doctor David Barker (1997) developed an influential theory about the onset of life, more precisely about foetal growth which is related to mother’s alimentation. In the western epidemiological regime where deaths are concentrated in old and very old age and are largely due to degenerative diseases, a lower cellular density of organs acquired during pregnancy and the very beginning of life has long-term impact on longevity and health in old age (mainly through hypertension and coronary heart diseases). This hypothesis has been confirmed by a flow of subsequent studies (see McEniry 2013, for a systematic review). In those researches, birth prematurity and birthweight are often used as proxy. Both are clearly dependent on the parental socioeconomic position but have an influence of their own on the development of cognition in childhood (Richards and Deary 2013). The developments of Barker theory provide a direct illustration of the embeddedness of the biological, psychological and socioeconomic dimensions and the difficulty to disentangle their respective influence. This challenge remains when we consider infancy and childhood that lifespan psychology, life course epidemiology and life course sociology all see as a critical (or sensitive) life period. Indeed, the earlier chapters of life are decisive in the formation of emotional capital, and also of the cognitive reserve that will be crucial in later life. This reserve will help, to protect from and cope with brain damage, contributing to reduce dementia development risk, delaying the onset of cognitive impairment or slowing decline (Stern 2002; Richards and Deary 2013; Ihle et al. 2015). In the initial constitution of cognitive reserve education in young age plays an important role,

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and is highly dependent on the socioeconomic position of the children family. Galobardes et al. (2007, p. 23) have shown that a surprisingly high number of indicators of socioeconomic positions have been used in a large number of researches. The dominant perspectives are the neo-Marxist inscription in social classes and the Weberian approach of power relations and life chances. Concretely all conclude to a high probability of social reproduction with children of disadvantaged background having low educational achievements and inversely (Keister and Southgate 2012). The long-term impact of this inequality in the distribution of human capital is striking. In a country like Switzerland, in 1979, 1994 and 2011, three times consecutively a low educational level implicated a multiplication by four of the risk of old age poverty, compared to those with a tertiary diploma. The persistence of this effect is remarkable since the proportion of older adults with a low human capital decreased from 66 to 18 percent during this period, without changing the statistical relation to poverty risk. Separately from the socioeconomic status, research has also considered the effects of adverse childhood experiences (ACE). Globally, life course research has well-established the role of non-normative events, or accidents of life. They have the potential to heavily impact individual trajectories and, in that case, to become a “turning point” in life trajectories (Oris 2017). Specifically, ACE include traumatic events experienced between ages 0 and 15 like parental death, parental mental illness, parental drinking abuse, period of hunger, property taken away, living in an orphanage (Cheval et al. 2019). For psychologists, they are proxies of the real explanations of long-term effects which could be the quality of the relationships between parents and child and between siblings, parenting styles, or attachment styles (Gale et al. 2013). For the epidemiologist Kelly-Irving and her colleagues (2013) the stress related to ACE is leading to diseases like cancer later in life. In a different perspective, Wilson et al. (2006) showed that ACE are associated with isolation in old age that explains low levels of wellbeing.

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Along the same logic, the LIFETRAIL project2 also studied “adverse childhood health experiences”, which basically reflected a poor health early in life that has been shown to negatively affect functional health (disability) (McEniry 2013) and more generally the frailty syndrome (van der Linden et al. 2019). However, health issues during childhood are disproportionately associated with poor socioeconomic conditions. Both act as “The long arm of childhood” (Haas 2008) and reduce the chances for successful aging as defined by Rowe and Kahn (see Brandt et al. 2012; Cheval et al. 2018).

5.2.2

Adult Age

If the long-term impact of early life conditions is well-established by a flow of researches from various disciplines, the importance of adult life is more debated. Pinquart and Sorensen (2000) conducted a meta-analysis based on 205 studies which highlighted a positive relation between adult SES and subjective wellbeing in later life, but this relation was weak and more specific for men than women. The limited robustness of these findings can be explained if we consider the factors behind wellbeing, with results which appear more scattered and also more complex. Of course, it is clear that people with a high social status are better equipped to cope with hassles and critical life events (Gale et al. 2013, p. 8), and that advantaged adults tend to reach old age in better physical and cognitive states than the others (Kuh 2007). However, this pattern has not an absolute value. Using SHARE data, Van der Linden et al. (2018) have just recently shown that the onset of overall cancer in old age was more frequent among the advantaged men and women. When looking by site they found this social pattern affecting breast cancer among women. A possible explanation is the higher survival of women of high social status (Bouchardy et al. 2006) who are consequently still alive, able to be surveyed and declare a cancer episode. Another hypothesis 2 https://cigev.unige.ch/recherches/research-l/ageing/ lifetrail/

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The Life Course Construction of Inequalities in Health and Wealth in Old Age

would refer to the historical evolution of an important behavior, smoking, usually initiated in early adulthood, which spread from men to women during the last decades (Janssen and Van Poppel 2015). Smoking has also a spatial pattern across the globe. Those elements of space and time are important in life course theories but relatively absent in studies of aging origins. Until now, much more frequent has been the identification of mediating and moderating factors. In statistical terms, do adult life conditions capture, reduce or increase the impact of childhood conditions? It is difficult to summarize many results that are sometimes inconsistent and depend heavily on both the studied outcome and the explanatory variable which is tested. As an illustration, a systematic review of Galobardes et al. (2007) showed that stomach cancer is associated only with early life socioeconomic conditions, while childhood-SEP and adult-SEP together increase the probability of chronic health diseases. Another example is provided by Landös et al. (2018) who studied the difficulties older adults are faced with in the activities of daily living. They show that both women and men were affected by childhood socioeconomic circumstances and that adult occupation and making ends meet have a mediating effect on this relation only for men. Cheval and his colleagues (2018) studied old age physical health using muscle strength as indicator, and demonstrated that the long-term impact of early life socioeconomic conditions remains even when controlling for adult socioeconomic conditions and unhealthy behaviors, especially among women. This is largely coherent with the results of Pakpahan et al. (2017) who also used SHARELIFE data and showed that the strong relation between childhood SES and old age health is mediated by education and adult SES while there is no midlife factor able to moderate the direct impact of childhood health on old age health. Among the potential later life modifiers, researchers have given some consideration to social mobility and its capacity to compensate for early-life disadvantages. Results are however

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mixed, sometimes positive, sometimes not, and even sometimes going in the unexpected negative direction (Vanhoutte and Nazroo 2016). It could be because frequency and perception of social mobility highly vary across countries, depending on their labor market and institutions (see Mayer 2004). Like in childhood, there is also a place for events of adult life in the explanation of unequal resources in old age. Pearlin et al. (2005) rightly noted that the events that have the strongest disruptive potential are those affecting the social roles attributed to adulthood, and consequently the identity of the affected individual: developing a career on the labor market and raising a family. Those events can be related by chains of adversity or spillover effects across life domains (Spini et al. 2017; Bernardi et al. 2019). Ben-Shlomo and Kuh (2002, p. 285) gives the example of a job loss leading to tensions in the family leading to physical abuse leading to divorce. They insist that the links have a probabilistic and not a deterministic nature. And that the final result, divorce, can result from the accumulation (additive effect) or only of the final episode which is physical abuse in this example (trigger effect). Pearlin and his colleagues (2005) and Oris (2017) insist on the characteristics of the events that can be traumatic, non-normative (typically a transition occurring before the proper social age, like a teenager pregnancy) and undesirable, and/or unexpected. In all the cases, both exposures and capacity to cope with those risks are unequally distributed among the social classes (Lantz et al. 2005).

5.3 5.3.1

Life Course Processes, Life Course Theories Accumulation or Continuity, Selection or Cause?

In this confuse landscape theories are needed. When adult-SEP captures the impact of childhood circumstances it could simply reflect the continuity of condition across the life course. Life course sociologists see the school system as a “phasing institution”: “By sequencing life courses and by

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regulating the ways and extent to which individuals can acquire life-course relevant resources an can use them in their biographical projects (. . .), phasing institutions have a particularly strong impact on life courses” (Levy and Bühlmann 2016, p. 34). Brückner and Mayer (2005, p. 29) underlined: “the expansion of secondary and tertiary education and training created career paths within and between educational institutions. It also moved young adults to labor market entry positions at different levels, thereby minimizing or decreasing initial search mobility and more securely launching them on employment trajectories”. In that perspective education tends to insure continuity in socioeconomic inequalities from the parental home to adulthood. Adverse health childhood conditions can play a similar role, initiating a causal chain linking early life and adulthood. Health problems can result in bad studies leading to limited professional opportunities. Or inversely the poor educational performances of children from disadvantaged households result in careers in precarious and/or risk jobs. These two pathways illustrate the debate between health selection and social causality (Palloni et al. 2009). Although the embeddedness of biological, psychological, and socioeconomic dimensions discussed in the preceding section does not help to disentangle, in the American context McLeod and Pavalko (2008) suggested that social causality is dominant in early life and that dynamic interrelationships are established subsequently. For Europe, Hoffmann et al. (2018) showed that in the transition to working age both social causality and health selection are equally weak while in the transition to retirement the social gradient in health is mainly due to social causality. The theory of cumulative (dis)advantage is for sure the most popular in social sciences and also well-known in epidemiology. It is defined as the “systemic tendency for interindividual divergence in a given characteristic (e.g. money, health, or status) with the passage of time” (Dannefer 2003, p. 327). As an illustration, Cooper et al. (2013, p. 10) observe that adult-SEP never completely captures the association between childhood-SEP and physical capability in old age. This is why

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they believe that there is more than continuity in SEP and instead that accumulation processes, or additivity, have detrimental impact on functional health. Clearly, continuity or persistence is not cumulative (dis)advantage that implies a growing magnitude of the disparities (Schafer et al. 2009). Such trends all along life can explain how, among members of the same birth cohorts, little inter-individual differences early in life expand to reach maximal amplitude among the “young old” (Dannefer 1987; Dannefer et al. 2019) (before the selection by social differential mortality changes the composition of the oldest old population). In lifespan psychology, the theory of cognitive reserve has more or less the same explanatory power since the initial consideration for education in young age has been completed with the theory of use or disuse (Richards and Deary 2013). The latter assumes that people with a high level of education (high cognitive reserve) are for the most engaged in professional activities where they will use their cognition, and consequently maintain or even increase their initial reserve. It could be intellectually demanding task but job complexity can also play this role (Kohn and Schooler 1978). Inversely those with a low level of education are more often engaged in manual repetitive works where disuse of cognition can even decrease their already lower reserve. Aartsen et al. (2019) recently provided a strong empirical support to this vision. Based on data from the Survey of Health, Ageing and Retirement in Europe, they revealed that the relation of adverse socio-economic conditions in childhood predicting late-life cognitive outcomes is partly explained by altered cognitive reserve accumulation pathways in terms of educational and occupational attainment. Specifically, adverse childhood socioeconomic conditions lead to unfavorable education pathways. This is then continued along working life with low-skilled jobs and finally in old age resulting in lower cognitive functioning. Ihle and colleagues also demonstrated that the processes of accentuation of initial differences can be amplified by socioeconomic differences in living styles (typically the social selection of leisure activities), in social relations (typically

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The Life Course Construction of Inequalities in Health and Wealth in Old Age

friendship), or in personality traits, all elements that are more or less susceptible to enhance cognition (Ihle et al. 2015, 2018, 2019). This model has been strengthened by research on vulnerability. Schröder-Butterfill and Marianti (2006) offered a convincing theoretical model of vulnerability demonstrating how low resources create additional exposure to risks and consequently to stress, a relation susceptible to degenerate in ‘vicious circles’ that could lead to psychological disorders and social exclusion (Schoon 2006; Spini et al. 2017; Oris 2017). Similarly, to associate conditions and events, Schafer et al. (2009) disentangled the onset, magnitude and duration of exposure as well as the dimensionality of adversity (specific or multiple; see also Ferraro and Schafer 2017). Together, those theoretical bodies about accumulation and vulnerability are appealing and appear robust. However, a prominent figure of the life course studies, Glen Elder et al. (2015, p. 23) observed that “there is surprisingly little evidence for cumulative processes” and “a wide variety of model specifications remain completely untested”). This is confirmed, among others, by a systematic review of self-rated health trajectories where Cullati et al. (2014) found only limited evidence supporting the cumulative advantage theory: “gender, ethnicity, education and employment status are only moderately associated with growing influences over time, and the cumulative influences of income, occupation, age and marital status are weak.” Other empirical results have been instructive. If there are ample illustrations that a favorable starting position is a resource that produces further gains across the life course (DiPrete and Eirich 2006; Burton-Jeangros et al. 2015; Ihle et al. 2018), the opposite can be true but not always. For example, research on old age poverty in Switzerland (Oris et al. 2017) do not support the notion of an accumulation of disadvantages for people who started low, who instead of facing a descending trajectory, exhibited “status maintenance, that is, life-course continuities in social status” (Dannefer 2003, p. 329). Similarly, in an analysis of 13 European countries based on SHARE data, Wahrendorf and Blane (2015,

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p. 584) concluded: “Results demonstrate that advantaged circumstances during childhood are associated with lower levels of labor market disadvantage and higher quality of life in older ages. Furthermore, results of multivariate analyses support the idea that part of the association between childhood circumstances and later quality of life is explained by labor market disadvantage during adulthood”. Those results suggest that the accumulation of advantages for the initially favored could coexist with “cumulative continuity” (Elder et al. 2015, p. 23) or more complicated processes mixing continuity and limited accumulation of disadvantages for those who grew in the low classes. And to increase the complexity, exceptional trajectories are not always exceptional. We noted above that low education was a strong predictor of old age poverty in Switzerland, multiplying the risk by four, but in 2011 a significant minority, about one fifth of older adults with a low human capital, were classified as wealthy (Oris et al. 2017). To understand why (dis)advantages do not always accumulate, or not as much as the theory would predict, Schafer et al. (2009) proposed a sociological conceptualization of the psychological concept of resilience. Their starting point is a distinction between disadvantage, which is a usually objective position in an unequal distribution of resources, and “adversity which is perceived misfortune” (p. 3). An appraisal of the situation, then the absence of resignation, the belief that something can be done, are preconditions for a reaction from the individual who can mobilize personal and social resources (if available) and solicit the various forms of social benefits in his/her welfare regime (if eligible) (Henke 2016). Psychological and more recently sociological researches try to understand why some individuals are deeply and durably affected by adverse conditions or traumatic events, with long-term scarring effects (Pearlin et al. 2007), while others are “forged” since they succeed to cope, gaining self-esteem and experience that will be precious assets if life tests them again (Martucelli 2006). In-between, other individuals just maintain their life trajectory, and we must keep in mind that preserving this continuity is

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usually highly demanding for the individual (Spini et al. 2017). It is quite improbable that resilience after facing a life risk could just be a psychological predisposition randomly distributed. Although further research is needed to understand the coping dynamics and processes, the long-term consequences in old age seem important. A prominent figure of the dialogue between sociology and psychology, Leonard Pearlin, studied the life course construction of mastery, which is the subjective evaluation by an individual of his/her capacity to control his/her life. His team identified the impact of early exposure to intractable hardships and of status maintenance, but showed that ultimately the feeling that one has kept the control of his/her past life, the appraisal (a subjective cognitive process in psychological terms) of his/her previous life course, was the most important determinant of mastery in old age (Pearlin et al. 2007). It is even more crucial if we consider the relation of mastery to selfregulation (Richards and Deary 2013), which is the core component of successful aging in Baltes view.

5.3.2

The Government of Life Course3

In the preceding section the search of explanation for non- or limited accumulation of disadvantages all along the life course until old age, adopted a very micro-individual perspective, although embedded in the socioeconomic structures. Time and space contexts have been considered only incidentally and deserve now to be integrated in our understanding of the life course construction of relevant resources in old age. Welfare regimes are crucial in that perspective since they heavily contributed to the institutionalization of the life courses (Kohli 2007), have at their core old age pensions and present a considerable spatial variation since they are national-state policies (Quadagno et al. 2011). This diversity is reduced thanks to the typological work of Gösta EspingAndersen (1990), which has been heavily 3

We borrow this title from Leisering (2003).

criticized, completed (Esping-Andersen 1999) and remains highly influential, although grouping national policies is controversial (Mayer 2005). For our purposes, it makes sense to consider separately two outcomes of those regimes, wealth and health. The fundamental rational of a pension system is to allow ending life in dignity. Some regimes have more ambition and aim to preserve the retirees’ standard of living. Whatever the pensions systems offer a powerful illustration of why processes of accumulation of advantages and process of accumulation of disadvantages are not necessarily the same. Indeed, through the pensions or through a variety of social benefits, the welfare regimes offer a safety net avoiding poor people to become destitute, resulting in the below continuity that was discussed previously (Oris et al. 2017). That said, old age poverty has been seen to be less likely in social-democratic and conservative regimes than in the liberal one (Tai and Treas 2009; Dannefer et al. 2019). These variations have several sources. A pension system is based on a life-course accumulation of contributions to constitute a capital, all along the working life, during 40–45 years. If the political logic is repartition, with the active paying for the retired, the benefits can be guaranteed. If individual capitalization logic applies, only those with a full career have a full pension. In Switzerland with a system aimed to secure basic needs in old age instituted in 1948, half of the 65 and over lived with incomes below the poverty threshold still in 1979. This figure decreased substantially in the following decades, just because more and more birth cohorts had the opportunity to accumulate during a full career (see Oris et al. 2017, and for the United-States the influential work of O’Rand 2006). Within these systems an important difference in the welfare regimes is if the state guarantees the capital, or not, when major financial crisis occurs like in 2008 (Quadagno et al. 2011). Additionally, the accumulation principle was based on the male breadwinner model, creating a structural penalty for women who have interrupted their career after marriage or motherhood, what has frequently been the case in the older birth cohorts (O’Rand

5

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2006). Vlachantoni (2012, p. 104) noted that “pension systems have generally been slow in mitigating ‘diversion’ from continuous and fulltime working lives”. The second fundamental rationale of pension systems was to allow an individual to retire without being constrained by disability. However social inequalities in health are observed everywhere and appear as a major failure of the modern welfare states (Mackenbach 2012). Bambra et al. (2010) observed educational differential in selfreported health using cross-sectional data from the European Social Survey that they stratified by birth cohorts to have a proxy of the length of exposure to various welfare regimes. They were surprised to observe larger differences among the older (who were in the 60s) instead of the opposite, and also that inequality was the smaller in the Southern and Bismarckian (conservative) regimes, not in the Scandinavian one. This was unexpected considering the large redistributions and egalitarian ethos of the latter while the Bismarckian regime is known for transferring adult socioeconomic inequalities into old age. The authors called for longitudinal analysis that was realized by Sieber et al. (2019) using SHARE data. The most robust result was that early-life conditions impact old age self-reported health, this relation being moderated by education and adult occupation in the Scandinavian regime, education in the Southern one and occupation in the Bismarckian one. Van der Linden et al. (2019) adopted the same data and methods but studied an objective measure of health, frailty. As we could expect (Mayer 2005; Raphael and Bryant 2015) the Bismarckian regime was the least able to compensate life course accumulation of disadvantages; Scandinavian but also the Southern regimes were the most efficient in that perspective. Obviously, more research on the South European policies is needed.

5.4

Conclusions

Changing individuals must be studied in a changing world. Ben Shlomo and Kuh (2002, p. 290)

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Research on the life course construction of wealth and health in old age has flourished during the last 40 years (Burton-Jeangros et al. 2015). Considering the space available, we have not completely made justice to the many results and the knowledge acquired. Several important questions requiring more investigation have been noted across the text. The most important remaining limitation is a concentration on the early old age as a “destination” of the life course. Gerontologists have amply documented how older adults, especially the oldest old, have the ability to cope with growing health problems while maintaining their level of wellbeing. Baltes and Baltes (1991) model SOC (selection, optimization and compensation) offered a key for understanding this paradox. It is curious that this wellknown phenomenon is not really considered in the research on active aging since it reflects a disconnection between activities which are necessarily declining and stable wellbeing (Ihle et al. 2017). On one side it demonstrates that this body of literature, considering as a core principle that aging well is staying active and in good health, hides the realities of very old age. On the other side, it is also fair to recognize that empirical evidence remains scarce since maintaining a longitudinal study with sufficient sample size (implying also enough survivors or sample renewals) is highly difficult. Recently the above mentioned LIFETRAIL project partly answered this criticism, combining SHARELIFE data and SHARE panel data to see how past life course conditions and events affect (inequalities in) health at a given point in time but also health trajectories in old age (Cheval et al. 2018, 2019; Sieber et al. 2019; Van der Linden et al. 2018). However, the panel time span is still short, only a few years, and SHARE samples are not stratified by age, with consequently a low proportion of oldest old. This research infrastructure is however by far the best we have. Developing the approach of linking early-life and adult-life trajectories with full old age trajectories could also help to better figure out the future of aging. Indeed the many birth cohorts who will reach old and very old age in the coming decades are already living with us. Not only they

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are already born, but they have already or are in the process of being phased by the school institution, they are growing or grew in changing families and face the challenges of flexible careers in a context of global competition. In that perspective it is worth to note that the welfare regimes (also exposed to reforms) reflect political cultures that also impact educational pathways and inequalities, the regulations of the labor market or the relationships between State and the family. Concretely many studies show that the transition to adulthood could become a new sensitive period where successes or failures will have long-lasting effects (Oris 2017). Recently, Dannefer et al. (2019, p. 46) observed that more wealth inequality, more experiences of precariousness in the late baby-boomers American birth cohorts suggest more health issues when they will reach old age, considering the stability of the social gradient. However, if there are many conditions, experiences, continuities or accumulations we could project on the future, we cannot assume that the processes, specifically the chains of risks or stress proliferation, will remain the same. Some researchers have suggested that in the “society of risk” (Giddens 1991; Beck 1992), life accidents are more frequent but as a consequence tend to become more normal, less disruptive (see Vandecasteele 2011). The future is living with us, for sure, but the future is not (completely) written. Acknowledgments This publication benefited from the support of the Swiss National Centre of Competence in Research LIVES—Overcoming vulnerability: Life course perspectives, which is financed by the Swiss National Science Foundation (grant number: 51NF40-160590). The authors are grateful to the Swiss National Science Foundation for its financial assistance.

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6

Lifelong Learning and Quality of Life Mª Ángeles Molina and Rocío Schettini

Traditionally, learning and study have been conceptualized as tasks linked to the first stages of life, and it is not until the 60s and 70s when learning begins to be given a function beyond simple literacy and professional development. Among other factors, the relationship of learning in advanced stages of life with personal wellbeing and quality of life promotes the development of lifelong learning programmes and activities for older people. In this chapter we will review the evolution of lifelong learning linked to the ageing process, as well its effect on quality of life and active ageing, with a special emphasis on university programmes for elderly people.

6.1

Lifelong Learning: Policy Development and Definition

Lifelong learning is proposed as a political, social and individual tool in response to an ageing population and the acceleration of ageing in a world transformed by the highly technology-based knowledge and information society. From a socio-political perspective, the aim of lifelong

Mª Á. Molina (*) Francisco de Vitoria University, Madrid, Spain e-mail: [email protected] R. Schettini Foundation of the Autonomous University of Madrid, Madrid, Spain e-mail: [email protected]

learning is to pursue, strengthen and support participation. From an individual standpoint, lifelong learning could be defined as a continuous and self-motivated search for personal and/or professional development, taken as a lifestyle of successful ageing with the intent to improve cerebral “fine-tuning” and cognitive reserve, to compensate for some physical or cognitive deficiencies and also to seek out social relationships and participation or simply to enjoy oneself (FernándezBallesteros and Molina 2016). Lifelong learning is not restricted to any specific stage of life; rather, it covers the entire life cycle. However, in this chapter we will focus on its implementation and benefits in old age. From the beginnings of the concept, lifelong learning has been understood from two perspectives that are reflected in a pair of reports, one by the UNESCO: Learning to be. The world of education today and tomorrow (Faure et al. 1972) and another by the OECD “Recurrent Education: a Strategy for Lifelong Learning” (Kallen and Bengtsson 1973). The first perspective is based on notions of solidarity of peoples, democratic principles, the complete development of humankind and the continually evolving need to acquire knowledge. From this first viewpoint, education is by and for the people in order to achieve their political, economic and cultural development. One year after the publication of Faure’s report, the OECD published its own report “to clarify the concept, main features and

# Springer Nature Switzerland AG 2021 F. Rojo-Pérez, G. Fernández-Mayoralas (eds.), Handbook of Active Ageing and Quality of Life, International Handbooks of Quality-of-Life, https://doi.org/10.1007/978-3-030-58031-5_6

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objectives” of the issue. Though from a more economics and productivity-focused perspective, this second approach recognises that lifelong learning has implications for education and socioeconomic policies and is related to the labour market and social security provision. These innovative reports articulated the principles of continuous learning. These trends remain in place today, and sometimes added to the emphasis on the economic benefits of lifelong learning are other more significant benefits such as improved mental and physical health over the course of a lifetime, or quality of life itself. Further to these original contributions, it is in WHO’s political documents on the definition of active ageing in which the relevance of lifelong learning in the aging process has been highlighted. Thus, the concept of lifelong learning has been closely related to advances in the concept of active ageing. Active aging has been recognised to prevent dependence and optimize the human capital of older people. Therefore, the objective of active aging is to improve the quality of life of the aging people. In the different developments of the concept of active aging, the importance of the educational dimension and its value has been recognised to achieve a better quality of life in old age. Table 6.1 highlights the political developments on the concept of active aging and how lifelong learning has been considered. The First World Assembly on Ageing was held in Vienna in 1982 and produced the Vienna International Plan of Action on Ageing (United Nations 1982). This document sets out recommendations for actions aimed at optimising old age and the ageing process. In this first paper, education and training revolve around old age and ageing and older individuals are highlighted as both agents and recipients of change. Various formal and informal education actions are identified. A reduction in negative stereotyping with regard to old age and ageing is noted as a benefit of education and learning, and the emphasis is placed on the need for education and learning regarding old age and ageing not at a

Mª Á. Molina and R. Schettini

particular stage of life, but rather from the perspective of the whole lifespan. The Second World Assembly on Ageing was held in Madrid in 2002 and produced the Political Declaration and Madrid International Plan of Action on Ageing (United Nations 2002). This document also explains the importance of training and education in old age. It describes education as “a crucial basis for an active and fulfilling life”, meaning it is necessary to adopt policies to ensure access to education and training throughout people’s lifespans, which the document links to the productivity of workers and nations. There is recognised that illiteracy or minimal literacy and numeracy among people arriving at old age “limit their capacity to earn a livelihood” and is an obstacle to enjoying health and wellbeing. Along the same lines, the document identifies a need to adopt measures to enable older individuals to access, participate in and adapt to technological changes and new technologies and points to training, retraining and education as “important determinants” of whether older workers can secure their value as part of the workforce. Two objectives are identified in this context: (1) equality of opportunities to continuing education, training and retraining throughout life; and (2) utilisation of the potential and expertise of older people, recognising the benefits of increased experience with age. This second paper proposes education and learning as a means to developing workplace skills and social integration, with older adults recognised as the main beneficiaries of these actions, but it also proposes education and learning as a means to ensure that the experience and knowledge accumulated by older people can be transferred. The World Health Organization contributed to this Second World Assembly on Ageing through the publication of the paper Active Ageing: a Policy Framework (World Health Organisation 2002). This document defines active ageing as “the process of optimising opportunities for health, participation and security in order to enhance quality of life as people age”. It describes active ageing as depending on a wide-ranging

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Table 6.1 Lifelong learning considerations in active ageing policies Active ageing Vienna International Plan of Action on ageing (United Nations 1982) Madrid International Plan of Action on Ageing (United Nations 2002) Active Ageing: a Policy Framework (WHO 2002) Active ageing: A policy framework in response to the longevity revolution (ILC-BR 2015) World Report on Ageing and Health (WHO 2015)

series of interrelated factors with regard to the actions can be taken to encourage active ageing in societies. The determinants that are referred to include gender and culture, economic factors, social factors, socio-healthcare services, behavioural determinants, personal factors and physical environment. Among the determinants related to the social environment are opportunities for lifelong education and learning. It is emphasised that a low level of education is associated with disability and death. The paper also states that opportunities for learning during early life and throughout one’s life enable people to develop the skills that can allow them to adapt to life and the requirements of the workplace and be independent. Furthermore, there is recognition of a need for older people to be trained in new technologies, as well as for intergenerational training. From the perspective of this paper, learning and training in old age are presented as a mechanism for adaptation to the requirements of a changing world as well as a catalyst to optimise wellbeing in old age. The concept of active ageing was reviewed in 2015 (ILC-BR 2015) and defined as “the process of optimising opportunities for health, participation, security and lifelong learning in order to enhance the quality of life as people age”. This paper no longer considers lifelong learning as a determinant of the ageing process; rather, it is represented as a fundamental pillar of that process. Lifelong learning is recognised as being necessary both in terms of employability and as a route to wellbeing. It is also identified as a pillar that underpins the others, by way of which health

Lifelong learning It covers the whole lifespan Includes formal and informal actions to reduce negative stereotypes about old age Enhance the potential of the old people Facilitates social and labor integration Determinant to achieve personal wellbeing Pillar to improve the quality of life of the aging people Fundamental component to achieve personal wellbeing

can be maintained, the perception of personal security can be improved and social participation can be developed. At a societal level, lifelong learning contributes to economic competitiveness, employment, social protection and citizen participation. Lifelong learning is considered in a fuller and more integrated manner in the 2015 paper, both in terms of expected benefits and the kind of learning taken into consideration. For the first time, moreover, it is related to a construct that is particularly important in this chapter: quality of life and wellbeing. In the same year, the World Health Organization published a report on ageing and health that features a conceptual return to healthy ageing, but which includes lifelong learning as a fundamental component (World Health Organisation 2015). In this regard, it describes it as essential to invest in training during later stages of life, which will lead to benefits across all the other areas necessary for healthy ageing, including personal wellbeing. Attention is also focused on the barriers that older people currently face in terms of enrolling in training activities, including physical, material and structural factors such as their attitudes toward training and learning and those of the professionals who work with them. In short, as stated, lifelong learning is not restricted to a particular phase of life but instead refers to all learning opportunities throughout the course of a lifespan. It can therefore take place in formal contexts as well as through cultural activities, hobbies, leisure and volunteering. Lifelong learning includes all forms of learning:

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formal, non-formal and informal. However, the scientific literature on lifelong learning with respect to old age has paid particular attention to one specific form of learning: university programmes for older people (Formosa 2010). As observed by Villar (2003), in Europe these programmes originated in France in 1973, with the creation of the first “university of the third age” in Toulouse. University activities specifically aimed at older people also began to be implemented in various forms in the United States during the 1960s and 1970s. Based on these two models, university programmes for older people have been rolled out in universities across the world. There is no single model for the implementation of university programmes for older people. They can include a variety of content and be structured in different ways (Serdio Sánchez 2015; Schettini 2017), but they do share the common objective of giving older people access to cultural and scientific training that foments personal development, as well as helping to improve their physical, intellectual and emotional abilities, offering an ideal framework to foster social participation and, all in all, giving rise to improved wellbeing and quality of life from a multidimensional perspective. Therefore, lifelong learning can be defined as “all purposeful learning activity, undertaken on an ongoing basis with the aim of improving knowledge, skills and competence” (Commission of the European Communities 2000). This conception of lifelong learning encompasses all learning experiences, whether formal, non-formal or informal, that take place throughout the life of the individual (BelandoMontoro 2017). Learning may be formal and structured, involving the award of a qualification or diploma. This was traditionally considered to occur during the early stages of life but it is increasingly common for it to happen in adulthood as well. Learning may be obtained in non-formal contexts, through workshops, seminars or short courses in which people acquire skills. And learning can also be informal or practical, forming part of daily life at all ages, in the home, in the workplace and during leisure activities.

Mª Á. Molina and R. Schettini

6.2

Quality of Life and Wellbeing

The lifelong learning conception adopted in this chapter has a clear personal, civic, social and employability perspective, which shows its relationship with the quality of life in all its dimensions. The term quality of life is broadly used in practice, in research and the development and implementation of public policies. There is a lack of consensus as to its definition, however, with various interpretations being suggested. Walker (2005) defines quality of life as “an amorphous, multilayered and complex concept with a range of components—objective, subjective, macro-societal, micro-individual, positive and negative—which interact together” (p. 3). This statement by Walker is indicative of the difficulty in defining a term that incorporates factors both subjective and objective, micro and macro, and positive and negative, all of which are interrelated and also directly and indirectly related to lifelong learning. In 1997, the World Health Organisation (1997) defined quality of life as an individual’s perception of their position in life in the context of the culture and value systems in which they live and in relation to their goals, expectations, standards and concerns. Therefore, although the World Health Organisation establishes that quality of life depends on an individual’s perception, this evaluation takes place from a perspective that is both objective and subjective. Objective indicators include access to basic needs, food, income, health, security and transport. But all these indicators must be weighted from the subjective point of view of the individual, in the context of the culture and value systems in which they are immersed and of their expectations. From this perspective, lifelong learning can be considered a tool to secure those objective indicators. Cummins (1997) argues that quality of life is as objective as it is subjective, proposing that the concept encompasses seven domains: material wellbeing, health, productivity, intimacy, safety, community and emotional wellbeing. For

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Cummins, the subjective aspect of quality of life emerges from the satisfaction with each domain, weighted by the importance that the individual accords to it. Schalock and Verdugo (2002) maintain that once an individual’s basic and more fundamental needs (income, health and social contact) have been met, improvements in quality of life are based on subjective factors, but mainly on “individual perception” as regards one’s “needs, choices and individual control”, as previously noted by the World Health Organisation (1997). Escuder-Mollon et al. (2014) explain that quality of life can be seen from a hedonic perspective (satisfying one’s own needs, pleasures and desires), and be related with the ownership of material goods, money, the pursuit of pleasure or the avoidance of pain. When someone is at risk of exclusion, is impoverished or has nowhere to live, quality of life can be improved through social and health services and public policies. But when basic needs are covered, the eudemonic perspective prevails. From this perspective, quality of life is conceived as a highly subjective long-term state that is related to attitude, motivation, integration, community, participation, perceived control and personal aims in life. From these perspectives, education can promote quality of life. Numerous definitions of quality of life have included wellbeing as a fundamental dimension forming part of the larger concept (Levy and Anderson 1980; Chaturvedi 1991). It has even been argued that the term wellbeing is interchangeable with that of quality of life (Fernández-López et al. 2010) when considered as its subjective dimension. While accepting that it is reductionist to assimilate subjective wellbeing with the construct of quality of life, wellbeing will be used in this chapter as a measure for the outcomes of lifelong learning.

6.3

Scientific Evidence for the Benefits of University Programmes for Older People

As stated above, although lifelong learning has been defined from a primarily political

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perspective, research has focused on its effect on the quality of life of those attending university programmes for older people. University programmes for older people are promoted as a superior form of training activity, enabling students to enhance their physical, cognitive, social and psychological wellbeing (Formosa 2014). From a perspective of encouraging an improvement in cognitive functioning, these programmes would be supported by three theoretical assumptions: 1. Neural plasticity is a structural and functional property of the central nervous system that is expressed via cognitive plasticity and modifiability (Fernández-Ballesteros et al. 2012a, b; Singer et al. 2003; Lindenberger and Reischies 1999). This modifiability is based on neurogenesis, the birth of new neurons and new cerebral connections, a property that is maintained throughout the lifespan (Boldrini et al. 2018), due to which the normal cognitive deterioration that occurs with age can be compensated through cognitive training (Schaie 2005a, b). 2. The expression of cognitive plasticity and modifiability requires an environment of enhancement over the course of a lifetime, as proposed by the activity theory (Havighurst 1960), according to which abilities that continue to be trained tend to remain stable, while those which are used less tend to decline. The neural basis for this theory may be found in apoptosis or programmed cell death, which occurs in the absence of a suitable context for the development of these newly-generated neurons (Benito-Sipos 2018). 3. Finally, the theoretical model of selection, optimisation and compensation proposed by Baltes and Baltes (1990), according to which individuals will have to select activities that enable them to optimise their abilities and resources and, when there is a deficit, should select those conditions that enable them to compensate for it. Based on these three theoretical assumptions, the positive effect of university programmes for older people on cognitive functioning can be

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perceived as undeniable. However, despite the large-scale implementation of these programmes and the benefits attributed to them at a theoretical level in all the factors involved in the ageing process, there is scarce research on this issue in Europe and more study is needed. Empirical research carried out in Europe on university programmes for older people has focused on describing the profiles of the people attending university programmes for older adults, their reasons for attending or the difficulties preventing them from doing so and the perceived benefits obtained by participants. With respect to the profiles of those completing university programmes for older adults, the majority of participants are women aged between 60 and 70 years, mostly married or widowed, with an average or high level of education and already in retirement. With respect to health and psychosocial conditions, the available evidence reports good physical and mental health and a positive association between perceived quality of life and variables such as sense of coherence, subjective assessment of health and level of education. Of note among the reasons reported for participation were acquisition of knowledge, personal development and the need to adapt to changing circumstances (widowhood or retirement). Barriers to attending are reported as health problems, the distance to travel to the centers where courses were available, being unaware of programmes and caring for family members. Increases in social relationships, acquired knowledge and personal wellbeing were all highlighted as perceived benefits (Menéndez et al. 2018). Based on the four-factor model of active ageing (behavioural health and fitness, cognitive functioning, emotional and motivational selfregulation and social participation; FernándezBallesteros et al. 2013b), positive effects of university programmes for older adults in each of its components have been found, although most studies have focused on psychological factors. Escolar Chua and De Guzman (2014) demonstrated that those who participate in these programmes obtain higher levels of satisfaction with life, higher self-esteem and lower levels of depression. In other research carried out at four

Mª Á. Molina and R. Schettini

universities (Spain, Chile, Mexico and Cuba) authors observed how attending a university programme for older people significantly improved participants’ self-perception of ageing, group stereotypes, negative affect and emotional equilibrium (Fernández-Ballesteros et al. 2013a). In a more complete research carried out by FernándezBallesteros et al. (2012b) comparisons between older students attending a university programme for older people (quasi-experimental group) and older people who did not participate in university programmes (control group) were made. Significantly, differences were found for cognitive performance, health, level of activity and positive affect. Focusing only on research that has tested the impact of university programmes for older people on quality of life, the results are positive too. Assessing the impact of university programmes for older people on quality of life, it has been identified that education influences on physical and psychological wellbeing, interpersonal relationships, attitudes toward daily life and intellectual energy (Escuder-Mollon 2012). People who attend university programmes for older people consider that the most important dimensions of quality of life are physical wellbeing, psychological wellbeing, independence, interpersonal relationships and support, and satisfaction. These people consider that attending university programmes for elderly people influences personal development with the greatest impact followed by enjoyment and psychological wellbeing. Meanwhile, adaptation was reported as having the least impact on the education received. Authors stood out that participants were convinced that their psychological wellbeing had improved due to the education they were receiving, and that the impact of perceived support on their physical wellbeing was limited, albeit with a high level of variance in responses. These results led the authors to conclude that education can have an impact on individuals’ quality of life as they age (EscuderMollon et al. 2014). In relation to the available evidence on wellbeing, the majority of articles find a positive relationship between education and wellbeing, although there is also some evidence pointing to

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the potential for learning experiences to generate stress and anxiety. In general, participating in learning experiences has positive repercussions for mental health, reducing the risk of depression. With respect to the dimensions of wellbeing taken into account, positive effects were found for trust, life satisfaction, coping ability, self-efficacy and perception of control over one’s own life (Field 2011). Beyond university programmes for older people, some studies evaluate the benefits of older adults participating in learning activities in terms of their wellbeing and quality of life. Narushima et al. (2018) suggested that continuous participation in learning contributes to the psychological

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wellbeing of adults by providing them with a compensatory strategy to strengthen their reserves, enabling them to be autonomous and meet the challenges of their daily lives. Åberg (2016) conducted a national survey of people aged over 65 years who participated in non-formal learning activities, concluding that participation in these activities has positive effects on the wellbeing of older people by fostering a sense of belonging and providing the opportunity to be part of a community that can function as a source of support to prevent social isolation and loneliness. In short, all the studies (Table 6.2) that examine the benefits of university programmes for

Table 6.2 Benefits obtained by attendees of lifelong learning programmes in terms of quality of life and active ageing components Authors Åberg (2016) Escolar Chua and De Guzman (2014)

Escuder-Mollon (2012)

Escuder-Mollon et al. (2014)

Fernández-Ballesteros et al. (2012b)

Fernández-Ballesteros et al. (2013a)

Field (2011)

Menéndez et al. (2018)

Narushima et al. (2018)

Benefits Sense of belonging To be part of a community (social isolation and loneliness) Satisfaction with life Self-esteem Mental health Physical wellbeing Psychological wellbeing Interpersonal relationships Attitudes toward daily life Intellectual energy Physical wellbeing Psychological wellbeing Independence Interpersonal relationships and support Satisfaction Personal development Cognitive performance Health Level of activity Positive affect Self-perception of ageing Stereotypes Affect Mental health Trust Life satisfaction Coping ability Self-efficacy Perception of control over one’s own life Physical health Mental health Sense of coherence Subjective assessment of health Level of education Psychological wellbeing

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elderly people on their participants’ quality of life focus primarily on subjective and psychosocial aspects. A minority of studies review such programmes’ effects on health and cognitive functioning, but also from an eminently subjective point of view. This means that there are many components of quality of life pending study.

6.4

Conclusions

A review of the evidence permits optimism as to the benefits of lifelong learning in terms of both quality of life and wellbeing of the older adults who participate in it. Despite the slowness in recognising the importance of learning among older people and its continued lack of sufficient permeation in society, the scientific evidence shows that the benefits of lifelong learning can go beyond mere participation and improvement of cognitive functioning. This is why further studies are required to examine the effects that learning at advanced stages of life can have on wellbeing and quality of life, from the multidimensional and multifocal perspective that the concept implies. Rather than designing specific programmes for the improvement of particular aspects of people’s lives, this is therefore a question of developing wide-ranging programmes that encompass each and every one of the dimensions underpinning the improvement of quality of life in old age. It was reported in a recent qualitative study (Schettini et al. 2019) that older adults themselves do not identify lifelong learning as one of the decisive factors in the improvement of their ageing process, despite its being positioned as a fundamental pillar at a social and political level (ILC-BR 2015). It is for this reason that the challenge facing professionals is to achieve wider recognition of the importance of continuing to learn throughout one’s life across all sectors of society, at both an individual and a social level.

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Fernández-Ballesteros, R., Botella, J., Zamarrón, M. D., Molina, M. A., Cabras, E., Schettini, R., et al. (2012a). Cognitive plasticity in normal and pathological aging. Clinical Intervention on Aging, 7, 15–25. Fernández-Ballesteros, R., Molina, M. A., Schettini, R., & del Rey, A. L. (2012b). Promoting active ageing through university programs for older adults. GeroPsych: The Journal of Gerontopsychology and Geriatric Psychiatry, 25, 145–154. Fernández-Ballesteros, R., Caprara, M., Schettini, R., Bustillos, A., Mendoza-Nunez, V., Orosa, T., et al. (2013a). Effects of university programs for older adults: Changes in cultural and group stereotype, selfperception of aging, and emotional balance. Educational Gerontology, 39(2), 119–131. Fernández-Ballesteros, R., Molina, M. A., Schettini, R., & Santacreu, M. (2013b). The semantic network of aging well. Annual Review of Gerontology and Geriatrics, 33 (1), 79–107. Fernández-López, J. A., Fernández-Fidalgo, M., & Cieza, A. (2010). Los conceptos de calidad de vida, salud y bienestar analizados desde la perspectiva de la Clasificación Internacional del Funcionamiento (CIF). Revista Española de Salud Pública, 84, 169–184. Field, J. (2011). Adult learning, health and well-being– Changing lives. Adult Learner, 13–25. Formosa, M. (2010). Lifelong learning in later life: The universities of the third age. Lifelong Learning Institute Review, 5, 1–12. Formosa, M. (2014). Four decades of universities of the third age: Past, present, future. Ageing and Society, 34 (01), 42–66. Havighurst, R. J. (1960). Successful aging. The Gerontologist, 1, 8–13. ILC-BR- International Longevity Centre Brazil. (2015). Active ageing: A policy framework in response to the longevity revolution. Rio de Janeiro: International Longevity Centre Brazil (ILC-BR). Retrieved from http:// www.ilcbrazil.org Kallen, D., & Bengtsson, J. (1973). Recurrent education: A strategy for lifelong learning. Paris: OECD. Retrieved from https://files.eric.ed.gov/fulltext/ ED083365.pdf Levy, L., & Anderson, L. (1980). La tensión psicosocial. Población, ambiente y calidad de vida. México: Manual Moderno. Lindenberger, U., & Reischies, F. M. (1999). Limits and potentials of intellectual functioning in old age. In P. B. Baltes & K. U. Mayer (Eds.), The berlin aging study: Aging from 70 to 100 (pp. 329–360). Cambridge: Cambridge University Press. Menéndez, S., Pérez-Padilla, J., & Maya, J. (2018). Empirical research of university programs for older people in

119 Europe: A systematic review. Educational Gerontology, 44(9), 595–607. Narushima, M., Liu, J., & Diestelkamp, N. (2018). Lifelong learning in active ageing discourse: Its conserving effect on wellbeing, health and vulnerability. Ageing & Society, 38(4), 651–675. Schaie, K. W. (2005a). Developmental influences on adult intelligence: The Seattle longitudinal study. New York: Oxford University Press. Schaie, K. W. (2005b). What can we learn from longitudinal studies of adult development? Research on Human Development, 2, 133–158. Schalock, R. L., & Verdugo, M. A. (2002). Handbook on quality of life for human service practitioners. Washington, DC: American Association on Mental Retardation. Schettini, R. (2017). Envejecer bien, definición mediante validación del modelo multidimensional y promoción del buen envejecimiento. Madrid: UAM. Schettini, R., Molina, M. A., & Gallardo-Peralta, L. P. (2019). Formación continua en el proceso de envejecimiento desde una perspectiva popular. In Fernández-Mayoralas, G. & Rojo-Pérez, F. (forthcoming). Envejecimiento Activo, Calidad de Vida y Género: una aproximación desde las experiencias académica, institucional y no profesional [Active ageing, quality of life and gender: An approach from the academic, institutional and lay-perspective]. Valencia: Tirant lo Blanch. Serdio Sánchez, C. (2015). Educación y envejecimiento: una relación dinámica y en constante transformación. Educación XX1, 18(2), 237–255. Singer, T., Lindenberger, U., & Baltes, P. B. (2003). Plasticity of memory for new learning in very old age: A story of major loss? Psychology and Aging, 18, 306–317. United Nations. (1982). Report of the world assembly on aging. Viena: United Nations. United Nations. (2002). Political declaration and Madrid international plan of action on ageing. New York: United Nations. Villar, F. (2003). Psicología evolutiva y psicología de la educación. Proyecto docente. Retrieved June 3, 2019, from http://www.ub.edu/dppsed/fvillar/ Walker, A. (2005). Growing older. London: Open University Press. World Health Organisation. (1997). WHOQOL: Measuring quality of life. Retrieved June 3, 2019, from http:// www.who.int/mental_health/media/68.pdf World Health Organisation. (2002). Active ageing: A policy framework (No. WHO/NMH/NPH/02.8). Geneva: World Health Organization. World Health Organisation. (2015). World report on ageing and health. Geneva: World Health Organization.

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Aging at a Developmental Crossroad The Case for Generativity in Later Life Feliciano Villar and Rodrigo Serrat

Quality of life could be improved by the active involvement of older persons in meaningful activities that contribute to the development of families and communities, such as grandparenting or volunteering. In this chapter, we will argue that the Eriksonian concept of generativity could help us to conceptually frame these contributions by older persons, providing a new approach to what we mean by aging well. The chapter is divided into three sections. First, we define the concept of generativity as originally formulated by Erikson and review subsequent theoretical developments. Second, we review the empirical evidence on the relationship between generativity and successful aging, and the expression of generativity by older persons in family and community domains. Third, we identify some strengths in generativity that could justify its usefulness and potential both in academic and policy arenas. We finish this chapter by mentioning some areas that deserve further research attention.

7.1

What Is Generativity?

Generativity is a concept introduced by Erik Erikson (1963) in his theory of psychosocial development. Erikson conceived the lifespan as divided by a series of discrete stages, involving F. Villar (*) · R. Serrat Department of Cognition, Development, and Educational Psychology, University of Barcelona, Barcelona, Spain e-mail: [email protected]; [email protected]

qualitative changes from one stage to the next. Each of the eight stages in Erikson’s proposal is anchored in a specific developmental stage within the life span and implies certain social challenges, also described as developmental crisis. The successful resolution of each challenge both strengthens the self with a new and unique competence, and increases the likelihood that the individual will be able to deal competently with the challenges of subsequent stages. Thus, Erikson’s theory is a proposal on how a person is able (or not) to master time-graded developmental tasks, and mature accordingly, from the cradle to the grave. Within this scheme, generativity is the challenge associated with the seventh stage, the one that individuals have to face once reaching middle adulthood. He defines generativity as “the concern in establishing and guiding the next generation” (Erikson 1963, p. 267). So, adults who have already consolidated their identity (the task of the fifth stage, in adolescence) and have committed themselves to long-term intimate relationships (the task of the sixth stage, in young adulthood), are confronted in midlife with the challenge of engaging in activities aimed at nurturing and guiding the next generation, promoting their development and well-being. The successful resolution of this challenge involves mastering the competence of care, and will facilitate leaving a lasting legacy that will transcend one’s own mortality. At the same time, the successful resolution of the generative challenge

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prepares the individual for the eighth stage, integrity, which involves feeling that one’s life has been full and worthwhile and accepting one’s death. According to Erikson (1963), having and raising children is the prototypical way of channeling generative needs and expectations. However, generativity also covers a broad range of activities, such as teaching and mentoring younger generations, or maintaining and strengthening the societal institutions and natural resources needed to assure the survival of successive generations (Erikson et al. 1986). Following Erikson’s work, the concept of generativity was largely ignored in the scientific literature for at least two decades until John Kotre, in the early 1980s, rediscovered the concept. Kotre redefined generativity by including two novelties. Firstly, he redefined generativity as “a desire to invest one’s substance in forms of life and work that will outlive the self” (Kotre 1984, p. 10). Such redefinition meant to expand the concept, which in Kotre’s view is not anchored to a specific age and does not privilege parenting over other roles in society. Accordingly, the second contribution of Kotre was to differentiate four types of generativity that manifest at different times across the life course: biological, parental, technical, and cultural. Biological generativity could be defined as the transmission of material substance from one generation to the next. It is related to the fact of conceiving and bearing children. Parental generativity is expressed in all the activities related to raising those children and initiating them into the family’s traditions. The third type is related to passing on skills to those who are less advanced than oneself. Finally, cultural generativity refers to the adult interest in transmitting cultural instruments and ideas to subsequent generations. The four types of generativity share a common core, the idea of ‘outliving the self’ by contributing to others, but that core could indeed be expressed by following very different avenues. Following Kotre’s contributions, the most relevant theoretical advance in the field of generativity was made by Dan McAdams. The relevance of his work lies in the proposal of a

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processual model of generativity that includes different types of motivations and expressions of the generative potential in adulthood (McAdams and de St Aubin 1992; McAdams 2001). In his model, the sources of generativity are based on two complementary motives. The first one is an inner desire, while the second implies social expectations. Regarding the first motive, McAdams and de St. Aubin (1992) identified two typical kinds of desires: a desire for symbolic immortality, which drives a need to leave a lasting legacy that survives the self and defies death, and a desire to be needed by others and being useful for other people who may need our help. The second motive for generativity is cultural demand. All societies provide age-graded expectations concerning the roles and behaviors of their members. The cultural demand for adult members of society indicates that they must take responsibility for the younger and less experienced members, providing support as parents, teachers, mentors or managers, and assuming leading roles in families, communities and social institutions. Such motives help to create a generative concern in adults, understood as a general disposition towards generativity. In turn, generative concern leads to the formation of and commitment to generative goals and plans to achieve them. Such goals, ideally, will be embodied in generative actions, the behavioral component in McAdam’s model. Such actions could be diverse, but they must involve creating (producing or giving birth to people or things), maintaining (preserving or nurturing people or things deemed worthy) or offering (passing on something or someone to the next generation as a gift) (McAdams and de St. Aubin 1992). The last component of the model is generative narration. As adults transform generative concerns into commitment to certain generative goals that sustain generative actions, they also construct stories to give meaning to these generative efforts. Eventually, if such stories are relevant enough, they become integrated into the larger autobiographical story that constitutes our narrative identity (McAdams 2013). Generative life stories tell how the person has made efforts to

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contribute to subsequent generations (by creating, maintaining or offering) and how these outcomes would ultimately outlive the self, connecting all the generative components of the model and, at the same time, giving meaning to the whole life span (McAdams and Guo 2015). McAdams has also made relevant methodological contributions, creating tools that have promoted the expansion of generativity as a concept that can be studied empirically. Among these tools (McAdams and de St Aubin 1992), the Generative Behavioral Inventory, which measures generative acts, and particularly the Loyola Generativity Scale (LGS), which measures generative concern, have been widely used in subsequent studies, and they have become a kind of standard for those approaches interested in including generativity in empirical models, both as a predictor or as an outcome of developmental phenomena.

7.2

Is Generativity Relevant in Later Life?

Although Erikson’s theory assigns life challenges to specific life stages, it has been argued that development is not linear and that the themes identified by Erikson, despite being key in psychosocial development overall, appear recurrently throughout the lifespan and are not restricted to single, discrete periods of life (Whitbourne et al. 2009). In the case of generativity this would mean that generative concerns and behaviors could appear in adolescence or early adulthood, and also that there is room for generativity beyond middle adulthood. Specifically, some authors claim that generativity may have an important role both in understanding the interests and activities in which older persons are involved and in promoting successful paths of aging (e.g. Ehlman and Ligon 2012; Rubinstein et al. 2015; Schoklitsch and Baumann 2012; Villar 2012). Perhaps the most obvious reason for this expansion of generativity to later life is the unprecedented change in life expectancy that has occurred during the past century. Older adults

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are living longer, and they represent an increasing percentage of the population, a trend that is expected to continue in the coming years. Older persons, as well as being more numerous, also differ from older persons in previous generations. Specifically, there are two aspects that may help to explain why generativity has the potential to play a more significant role later into adulthood: health and education. With regards health, older persons can expect to enjoy an optimum level of health, free of disabilities or severe chronic illnesses, for a substantial number of years after retirement. For instance, in the 28 countries of the European Union, the mean healthy life expectancy at age 60 was 10.1 years for females and 9.8 years for males in 2016, an improvement from the 8.8 for females and 8.7 years for males obtained just 6 years earlier (Eurostat 2019). In terms of educational level, there has been a dramatic change in recent decades. For example, in the 28 countries of the European Union, the percentage of people aged 55–64 who had received tertiary education increased by 6.5 points from 2005 to 2018. In contrast, the number of people who had only received primary or compulsory secondary education fell from 44.3 to 29.6% in the same period (Eurobarometer 2019). Such figures are key since health and education have been isolated as the strongest predictors of generative concern throughout adulthood (Carlson et al. 2000; Keyes and Ryff 1998, Kim and Youn 2002). Health and education are key resources that favor social inclusion, enhance one’s sense of connection to the wider world and promote selfconfidence, and these resources are argued to be the ones on which generative concern and generative activities are grounded (Son and Wilson 2011). Apart from the changing face of aging, there are also some conceptual arguments that justify the expansion of generativity to later life. Thus, while Erikson’s original proposal tended to focus generativity on ‘care for the next generations’ and favored parenting as the main generative role, subsequent developments of the concept enlarged that definition. For instance, as mentioned above, Kotre moved the core of generativity away from

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caring to the notion of legacy and contributions to others, in an effort to enable ‘outliving the self’. If generativity is a way of transcending one’s existence and achieving ‘symbolic immortality’ (Maxfield et al. 2014), it makes sense that older age, which implies an increasing perception of the future as something limited (Carstensen 2006), would induce ego-transcending goals in terms of generativity. Similarly, situations that potentially threaten the self and involve a reduction of future time, such as losses in subjective health (Kooij and Van de Voorde 2011) or intense social suffering (de Medeiros 2009; de Medeiros et al. 2015), may stimulate transcending desires that might be expressed in terms of generative concerns. The differentiation of multiple ways of expressing generativity (e.g. Kotre’s proposal of biological, parental, technical and cultural generativity) and multiple facets within the concept (e.g. McAdams’ proposal of generative concern, goals, behaviors and narratives) has also paved the way to expand generativity into later life. According to Kotre, different types of generativity could appear at different stages during adult life. Typically, biological generativity has a far earlier onset than cultural generativity. In a similar way, some component of generativity according to McAdams’ model, such as narrative generativity, is not only restricted to middle adulthood, but is likely to be particularly relevant later in life, when people are thought to be motivated to create a complete and meaningful version of their life story (Schoklitsch and Baumann 2012). In fact, Erikson himself, in his later writings (Erikson et al. 1986), also loosened the link between generativity and a specific life stage. He proposed that a transformed version of generativity, referred to as ‘grand-generativity’, may emerge and replace midlife generativity when people enter into old age. Grandgenerativity recognizes the fact that many older persons continue to show a strong commitment to the promotion and development of future generations, by acting as grandparents, mentors or advisers. Unlike midlife generativity, which implies taking direct and day-to-day responsibility for the next generation, grand-generativity

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represents caring for others and improving communities in a softer and more indirect way. It involves balancing such outward interest with an inward looking interest connected to the evaluative life review task that is salient in later life. It includes caring for others, but also the acceptance of being cared for, and doing so in a way that promotes generativity in the caregivers.

7.3

Empirical Support for Generativity in Later Life

As we have seen, the conceptual contributions to the notion of generativity that appeared after its initial proposal have facilitated its understanding as a lifelong endeavor that could be expressed in diverse ways at different points in life, not particularly tied to a stage or to a single activity (de St. Aubin 2013; Kim et al. 2017). However, beyond these concepts and theoretical models, the touchstone of the presence and importance of generativity in later life is empirical evidence. In that respect, at least two kinds of evidence are relevant: studies aimed at exploring the relationship between generativity, age and positive outcomes in later life; and studies aimed at exploring generative motives and experiences linked to specific developmental contexts, such as families and communities.

7.3.1

Generativity, Age, and Positive Outcomes in Later Life

According to Erikson’s proposals, we could expect generativity to emerge in young adulthood, peak in midlife, and progressively diminish as people enter later life. However, if generativity keeps on being key for older persons, such a decline would not take place. Available evidence on this issue, despite being mixed, indicates that at least some aspects of generativity do not show age-related declines and are still present in older age. In a seminal study, McAdams et al. (1993) found that, after an increase in generativity measures from young to middle adulthood,

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middle and older adults did not differ from each other in terms of generative commitment and generative narration, although generative concern and generative behaviors were lower in later life, a finding that was also reported by Keyes and Ryff (1998) and Whitbourne et al. (2009). However, other studies found that generativity remains stable from middle to older adulthood, both in cross-sectional (Sheldon and Kasser 2001) and longitudinal (Zucker et al. 2002) comparisons, and also when participants retrospectively evaluate their level of generative concern at different times in their life (Miner-Rubino et al. 2004). Although these findings suggest that some aspects of generativity maintain their importance beyond middle adulthood, the key to understanding this somewhat mixed picture concerning the relationship between generativity and age lies in two issues. Firstly, as Stewart and Vandewater (1998) suggested, different generativity types may have different importance over the course of life, which is consistent with Snarey’s (1993) findings in a longitudinal study, in which parental generativity preceded other more societal types (e.g. technical and cultural) of generativity. The particular importance of cultural generativity in later life has also been demonstrated in more recent qualitative studies (Rubinstein et al. 2015). Secondly, the differences in expression of generativity in middle and older adulthood, in quantitative but also in qualitative terms, may have something to do with the notion of cultural demand. As stated above, cultural demand represents the expectations concerning the timing of generativity. In that respect, cultural demand for generativity is not particularly high in later life, and the type of generative expression deemed appropriate for each age could vary. This aspect could be particularly relevant since, as Hofer and his colleagues found (Hofer et al. 2008, 2016), internalized cultural demand for generativity predicts the formation of generative goals motivating generative behavior, including in later life. Regardless of the relationship between generativity and age, the association of generativity with positive outcomes in later life could also demonstrate its relevance in this life

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stage. In this respect, there is a strong evidence that the presence of high generative concern and generative goals in midlife and in older age are related to satisfaction with life (McAdams et al. 1993; Serrat et al. 2018; Sheldon and Kasser 2001) and to eudaimonic well-being and satisfaction of the needs for relatedness, competence, and autonomy (Hofer et al. 2016; Serrat et al. 2018; Villar et al. 2013). Similarly, generative failure seems to be detrimental to life satisfaction both in midlife and in later life (Grossman and Gruenewald 2020). However, the evidence regarding generative behaviors is mixed, with some studies finding no relationship with satisfaction with life (e.g. McAdams et al. 1993), and others finding weaker relationships than when other types of generativity are considered (e.g. Cheng 2009; Villar et al. 2013). In this respect, cultural demand could also play a relevant role. Cheng (2009) found that the impact of generative behaviors on well-being was positive as long as older persons perceived that their contributions were valued by others and that their role was respected by younger generations. Other studies have also shown the relevance of generativity for successful aging (Fisher 1995; Versey et al. 2013). Specifically, older adults with greater self-perceptions of generativity tend to experience smaller increases in levels of disability and difficulties performing activities of daily living as they age (Gruenewald et al. 2012).

7.3.2

Generativity in Family and Community Contexts

A second strand of evidence to support the relevance of generativity in later life is its usefulness in understanding older persons’ participation in key developmental contexts. In this respect, two contexts have been the focus of attention: families and communities.

7.3.2.1

Generativity and Family Relationships In his original proposal, Erikson identified the family as the key context within which people

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express generativity, with parenting being the principal generative activity in midlife. Obviously, once generativity is expanded to later life, parenting diminishes in relevance. Research, however, has identified a good family role to take on for generative older persons: grandparenting. Erikson himself (Erikson et al. 1986) proposed that grandparenthood offers individuals a second chance for generativity. In his view, generative concerns may find in grandparenthood a particularly comfortable channel for expression, since grandparents may contribute to their grandchildren’s guidance and nurturing, but adopting a more relaxed, symmetrical and mutually respectful approach, without the sometimes burdensome disciplinary responsibilities that are attributed to parents. Hebblethwaite and Norris (2011) empirically support this view of grandparenting, since they found that leisure activities were a particularly frequent avenue for grandparents to express the generative themes of mentoring and legacy building. Subsequent studies seem to confirm the value of grandparenting in generative terms. For instance, Hoppmann and Klumb (2010) reported that grandparental generativity goals related to wanting to leave an imprint on others’ lives and wanting to feel needed boost grandparents’ desire to provide childcare. According to Thiele and Whelan (2008), caring for grandchildren fulfills generative expectations, since it is an activity that grandparents find significant, providing the opportunity to pass on family values and leave a legacy. Not surprisingly, in their study generativity was the factor that best predicted satisfaction with grandparenting. In turn, among non-custodial grandmothers, their level of engagement with their grandchildren was closely related to generativity scores (Moore and Rosenthal 2015). Villar et al. (2012) gave another twist of the screw by assuring that grandparenting could channel a double form of generativity. In their study, grandmothers who provided auxiliary childcare said that they did it for their grandchildren, but also to contribute to their children’s well-being, enabling them to combine

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work and family commitments. In other words, grandparenting could be, in some circumstances, an expression of good parenting, the continuation of a lifelong task that does not end once adult children leave home. Playing that role brought grandmothers satisfaction and reinforced their sense of utility and self-worth as a key element within the family. Obviously, not every grandparent can express generativity in their relationship with grandchildren. Custodial grandparents or those who provide non-voluntary intensive childcare, for instance, could experience the relationship as stressful and limiting (Choi et al. 2016), although even in these cases generativity could play a protective role (Song et al. 2015). Also, some authors suggest that in some cultures, rapid social and technological change could hamper grandparents’ attempts to be generative (Cheng et al. 2008). Aside from grandparenting, there have been few studies exploring the role of older persons’ generativity in family relationships. A promising line of research has to do with the role of generativity in the experience of providing care for a relative (e.g. a spouse) with severe chronic and/or degenerative illnesses. Thus, Fabà et al. (2017) showed how relatives taking care of people with dementia mention generativity (e.g. being a role model, desire to share learning with other people, or willingness to help other people in similar situations) as one of the benefits of their experience as caregivers. In a similar way, Grossman and Gruenewald (2017) found that generativity could not only be a positive consequence of caregiving, but might also play a protective role by helping to reduce some of the adverse health and well-being consequences of caregiving.

7.3.2.2

Generativity and Involvement in the Community As stated earlier, Kotre’s reformulation of the concept of generativity detached it from parenting, opening up new avenues for exploring the expression of generativity in later life in domains other than the family. One of these domains relates to older persons’ active involvement and

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participation in the life of the community through activities such as paid work, volunteering or political participation. Regarding paid work, although research from a generativity perspective has been scarce, there are some studies suggesting both that generativity may be a powerful motive for extending one’s working life, and that the working context may provide older adults’ with opportunities for the expression of generativity. In a seminal work published in the mid-1990s, Mor-Barak developed a scale to assess the meaning of work for older adult job-seekers. Among the four dimensions included in the scale (social contacts, personal satisfaction, financial needs, and generativity), generativity was especially relevant for older persons, suggesting that this age group values jobs that provide opportunities for interacting with and transferring experiences and knowledge to younger generations (Mor-Barak 1995; Zhan et al. 2015). Moreover, working for generative reasons has been positively related to greater work satisfaction and more positive attitudes towards retirement among older workers engaged in bridge employment (Dendinger et al. 2005). However, as Sanders and McCready (2010) showed, this depends on a workplace design that provides older workers with opportunities for decision-making, skill variety, and support from coworkers and supervisors, confirming that social expectations and demands for generativity are also key for its expression in the work domain. Research on the relationship between generativity and volunteering in later life has been much more extensive. For instance, there has been a large amount of research on the motivational aspects of volunteering, showing that generativity is one of the main reasons why older persons engage in this activity. Volunteering provides seniors with meaningful roles and fulfills their desires to give back to their communities (Narushima 2005; Warburton et al. 2006). Moreover, generativity is one of the factors underlying why volunteering contributes to active and successful aging (Warburton 2014). As a generative activity, volunteering has been positively related to many positive outcomes,

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ranging from increased psychological well-being (Choi and Kim 2011) to higher levels of cognitive function (Maselko et al. 2014). The expression of generativity through volunteering is especially appropriate via intergenerational programs (Warburton 2014). These programs not only provide older persons with opportunities to channel their needs to contribute to others and leave a lasting legacy, but also increase their levels of generative concern (Ehlman et al. 2014; Gruenewald et al. 2016), promoting a virtuous cycle in which the more they express their generativity the more generative they become. However, as well as in the case of paid work, this largely depends on cultural and societal expectations directed towards older persons. Tabuchi and Miura (2015), for instance, showed that young people’s reactions towards older persons when they perform an altruistic behavior change their self-perceptions of generativity, suggesting that only favorable interactions with younger generations have the capacity to trigger altruistic behavior and foster generativity among older persons. This mirrors the results of a study by Celdrán et al. (2018), who coined the concept of “generative frustration” to describe older volunteers’ withdrawal from mentoring young entrepreneurs as a result of the accumulation of negative experiences with them during the process. Finally, political participation represents a third arena for the expression of gene-erativity at the community level. Although research on this topic has been extremely scarce, there have been a couple of studies linking generativity with political participation and exploring its impact on wellbeing. Regarding the former, Serrat et al. (2017a) showed that older persons actively engaged in political organizations scored higher in several measures of generativity, including generative concern and generative goals, than those who were not engaged. Importantly, as in the previous cases of paid work and volunteering, cultural demands also played a role in this case, as those who were engaged in political organizations were more likely to perceive social expectations to act in a generative way than those who were not engaged. Regarding it impact on well-being,

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Serrat et al. (2017b) showed that politically active elders were more generative in comparison with inactive individuals, which, in turn, predicted higher scores for hedonic and eudaimonic wellbeing.

7.4

What Does Generativity Contribute to the Notion of ‘Aging Well’?

As we have seen in previous sections, an important consequence of the expansion of generativity into later life is the reinforcement of a new view of older persons that, far from the traditional images of disability, dependence, and frailty, recognizes their capacities, and potential to continue growing, while underlining their participation and contributions to society. In this respect, generativity is a new and fresh approach to the notion of aging well. However, generativity is by no means the only concept used to describe what aging well means. In fact, this is a field of scientific inquiry and political practice in which there are other widely used concepts, such as ‘successful aging’ (Rowe and Kahn 1997, 2015) or ‘active aging’ (WHO 2002; Foster and Walker 2014). If generativity in later life aspires to being consolidated as a useful concept, it must provide a different approach to the field, an approach enabling unique contributions not tapped by alternative concepts. In this respect, we have identified at least three strengths in generativity that could justify its usefulness and potential both in academic and policy arenas. Firstly, generativity in older age has its roots in developmental psychology, a discipline that has at its core a component related to growth and maturity. Thus, it implies situating the final decades of life within a more traditional developmental framework, contemplating later life from a radically optimistic perspective, as a period of life in which gains are possible, even if losses are also present. So, generativity could be an alternative way to find meaning in life and transcending values in later life. Concepts such as active aging or successful aging, which share with

generativity the emphasis on older persons’ contributions, lack the developmental edge underlining personal growth, a key that makes it easier to understand the motives for contributing and the benefits that sustain such contributions over time. Secondly, unlike active aging and successful aging, generativity in later life is a concept that locates intergenerational relationships at the fore of the aging process. With its emphasis on caring for the next generation and leaving a legacy, generativity places the interrelation between generations at the core of older age. Thus, it embodies the political call to construct ‘a society for all ages’ (e.g. UNECE 2012), in which we need different generations to interlink and support each other to build better integrated, stronger families, communities and societies. Generativity helps to understand why older persons may be motivated to create and feed intergenerational relationships (Villar and Serrat 2014), and facilitates the integration of the aging process into the whole life course, a goal that was also behind other similar concepts, such as active aging (WHO 2002; ILC 2015). However unlike active aging, generativity does so both by longitudinally explaining how generative concerns, goals and behavior appear, and are transformed through adulthood into later life, and by crosssectionally putting the focus on the bonds between different generations, the older ones being a key resource for the sustainability and improvement of societies. Finally, generativity links the person with the social context in which he or she participates and allows us to articulate the social and the personal (Villar 2012). Thus, the individual has a set of motivations, competences and skills enabling certain generative activities. If the activity is truly generative, it will be aimed at sustaining and improving the people, community, or social institutions that are the focus of the activity (Rubinstein et al. 2015). So, the generative individual helps to develop social capital and common goods. In turn, by acting in this way, the person develops himself or herself at the same time, finding satisfaction and meaning in life, as well as enhancing motivations, competences and

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skills. This interaction completes what we can call the ‘generative cycle’ (see Fig. 7.1), which relates personal and social development with generative activities. These two facets of generativity, personal and social, are two sides of the same coin and open up interdisciplinary approaches to account for phenomena that are intrinsically multifaceted and complex. The view of generativity as a win-win scenario gives some clues to design interventions that could trigger or reinforce the generative cycle, so that personal and social development is facilitated and reinforced. From a personal standpoint, training and education could open up new possibilities for starting generative activities, or for improving the generative activity in which one could already be involved. Education functions as a resource that makes individuals be more aware and capable of creating and maintaining generative activities. However, if we want education to become of the keys for stimulating generative activities, the kind of education that is offered to older persons should move from programs exclusively oriented to learning for the sake of learning, to others that are more instrumentally oriented, aimed at developing skills that could be applied in real-life social contexts. Accordingly, intergenerationality and partnership with community-based organizations are two crucial ingredients of generativity-oriented training programs (Villar and Celdrán 2012). From a social point of view, interventions to promote generativity in later life could be of a different scope. Some of them, for example, could be addressed at combatting ageism and the narrative of decline traditionally associated with aging. To be successful, such efforts should increase the cultural demand for being generative in later life, which, in turn, would facilitate generative activities among older persons. In more specific terms, we should make available as many slots as possible to mobilize generativity in later life, creating and promoting spaces where older persons who are motivated to keep on contributing by using their competences and expertise are welcome. Such interventions, which should represent new opportunities to leave a legacy or pay back

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their families or communities, might range from specific intergenerational or volunteering programs to the implementation of social policies in a generative direction (Peterson 2004).

7.5

Future Directions of Research

Research into generativity in later life has come a long way in recent decades. However, there are at least two areas that are still in need of development. First, we need more studies addressing the challenges that diverse and potentially marginalized groups of older persons may have to confront to behave in a generative way. Some of the ways of expressing generativity in later life that we have mentioned in this chapter, such as paid work or volunteering, may be extremely difficult or even inaccessible for some collectives of older persons. Although there are a number of emerging studies addressing the expression of generativity in those who suffer a chronic illness (e.g. Hannum et al. 2017), live in a long-term care institution (e.g. Doyle et al. 2015), are among the oldest-old (e.g. Kruse and Schmitt 2015), belong to a racial or ethnic minority (e.g. Lewis and Allen 2017), or have a migrant background (e.g. de Medeiros et al. 2015), among others, research in this area is still in its early stages. Second, more research is needed on the cultural aspects of generativity. Although Erikson conceived generativity as a cross-cultural phenomenon, since people care for the well-being of future generations and strive for the transmission of knowledge, practices, and experiences regardless of their culture, the universal validity of generativity is a contested issue. While some have argued that generativity is linked to the emphasis on individualism in Americans (Alexander et al. 1991), others have found that generativity is stronger in collectivistic rather than in individualistic cultures (Hofer et al. 2008). There is therefore a need for more studies exploring whether generativity and its components vary or present particular configurations across different cultural settings. In conclusion, we have tried to explore how generativity may help to enrich and broaden our

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Social development

Fig. 7.1 The generative cycle: How generative activity links social and personal development. Source: Villar (2012)

INDIVIDUAL Competences to participate

GENERATIVE ACTIVITY

SOCIAL CONTEXT Opportunities for participation

Personal development

view of later life, since it highlights older persons’ potential for development and, at the same time, underscores their resources, many times untapped, for benefitting families and communities. In other words, it is a big step towards understanding how making oneself better and pursuing common goods, far from being opposites, work together as a privileged path via which to enjoy a life worth living. Acknowledgments This study was funded by the Spanish Ministry of Economy, Industry and Competitiveness (grant PSI2016-77864-R). Rodrigo Serrat is a Serra Húnter Tenure-Track Lecturer at the University of Barcelona.

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131 Hofer, J., Busch, H., Au, A., Poláčková Šolcová, I., Tavel, P., & Tsien Wong, T. (2016). Generativity does not necessarily satisfy all your needs: Associations among cultural demand for generativity, generative concern, generative action, and need satisfaction in the elderly in four cultures. Developmental Psychology, 52(3), 509. Hoppmann, C. A., & Klumb, P. L. (2010). Grandparental investment facilitates harmonization of work and family in employed parents: A lifespan psychological perspective. Behavioral and Brain Sciences, 33(1), 27–28. International Longevity Center. (2015). Active ageing: A policy framework in response to the longevity revolution. Rio de Janeiro: ILC-Brazil. Retrieved April 17, 2019, from http://ilcbrazil.org/portugues/wp-content/uploads/sites/4/2015/12/Active-Ageing-A-PolicyFramework-ILC-Brazil_web.pdf Keyes, C. L. M., & Ryff, C. D. (1998). Generativity in adult lives: Social structural contours and quality of life consequences. In D. P. McAdams & E. de St. Aubin (Eds.), Generativity and adult development: How and why we care for the next generation (pp. 227–263). Washington, DC: American Psychological Association. Kim, G., & Youn, G. (2002). Role of education in generativity differences of employed and unemployed women in Korea. Psychological Reports, 91(3), 1205–1212. Kim, S., Chee, K. H., & Gerhart, O. (2017). Redefining generativity: Through life course and pragmatist lenses. Sociology Compass, 11(11), e12533. Kooij, D., & van de Voorde, K. (2011). How changes in subjective general health predict future time perspective, and development and generativity motives over the lifespan. Journal of Occupational and Organizational Psychology, 84(2), 228–247. Kotre, J. (1984). Outliving the self: How we live on in future generations. Baltimore, MD: Johns Hopkins University Press. Kruse, A., & Schmitt, E. (2015). Shared responsibility and civic engagement in very old age. Research in Human Development, 12(1–2), 133–148. Lewis, J. P., & Allen, J. (2017). Alaska native elders in recovery: Linkages between indigenous cultural generativity and sobriety to promote successful aging. Journal of Cross-Cultural Gerontology, 32(2), 209–222. Maselko, J., Sebranek, M., Mun, M. H., Perera, B., Ahs, J., & Østbye, T. (2014). Contribution of generative leisure activities to cognitive function in elderly Sri Lankan adults. Journal of the American Geriatrics Society, 62, 1707–1713. Maxfield, M., Greenberg, J., Pyszczynski, T., Weise, D. R., Kosloff, S., Soenke, M., et al. (2014). Increases in generative concern among older adults following reminders of mortality. International Journal of Aging & Human Development, 79(1), 1–21. McAdams, D. P. (2001). Generativity in midlife. In M. E. Lachman (Ed.), Handbook of midlife development (pp. 395–443). New York, NY: Wiley.

132 McAdams, D. P. (2013). The positive psychology of adult generativity: Caring for the next generation and constructing a redemptive life. In J. D. Sinnott (Ed.), Positive psychology: Advances in understanding adult motivation (pp. 191–206). New York: Springer. McAdams, D., & de St. Aubin, E. (1992). A theory of generativity and its assessment through self-report, behavioral acts, and narrative themes in autobiography. Journal of Personality and Social Psychology, 62, 1003–1015. McAdams, D. P., & Guo, J. (2015). Narrating the generative life. Psychological Science, 26(4), 475–483. McAdams, D. P., de St. Aubin, E., & Logan, R. L. (1993). Generativity among young, midlife, and older adults. Psychology and Aging, 8(2), 221–230. Miner-Rubino, K., Winter, D. G., & Stewart, A. J. (2004). Gender, social class, and the subjective experience of aging: Self-perceived personality change from early adulthood to late midlife. Personality and Social Psychology Bulletin, 30(12), 1599–1610. Moore, S. M., & Rosenthal, D. A. (2015). Personal growth, grandmother engagement and satisfaction among non-custodial grandmothers. Aging & Mental Health, 19(2), 136–143. Mor-Barak, M. E. (1995). The meaning of work for older adults seeking employment: The Generativity factor. The International Journal of Aging & Human Development, 41(4), 325–344. Narushima, M. (2005). ‘Payback time’: Community volunteering among older adults as a transformative mechanism. Ageing & Society, 25(4), 567–584. Peterson, B. E. (2004). Guarding the next generation: The politics of generativity. In E. de St. Aubin, D. P. McAdams, & T.-C. Kim (Eds.), The generative society (pp. 195–219). Washington, DC: APA. Rowe, J. W., & Kahn, R. L. (1997). Successful aging. The Gerontologist, 37(4), 433–440. Rowe, J. W., & Kahn, R. L. (2015). Successful aging 2.0: Conceptual expansions for the 21st century. The Journals of Gerontology: Series B, 70(4), 593–596. Rubinstein, R. L., Girling, L. M., De Medeiros, K., Brazda, M., & Hannum, S. (2015). Extending the framework of generativity theory through research: A qualitative study. The Gerontologist, 55(4), 548–559. Sanders, M. J., & McCready, J. W. (2010). Does work contribute to successful aging outcomes in older workers? The International Journal of Aging & Human Development, 71(3), 209–229. Schoklitsch, A., & Baumann, U. (2012). Generativity and aging: A promising future research topic? Journal of Aging Studies, 26(3), 262–272. Serrat, R., Villar, F., Warburton, J., & Petriwskyj, A. (2017a). Generativity and political participation in old age: A mixed method study of Spanish elders involved in political organisations. Journal of Adult Development, 24(3), 163–176. Serrat, R., Villar, F., Giuliani, M., & Zacarés, J. (2017b). Older people’s participation in political organizations:

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Quality of Life of Older People with Dementia Beatriz León-Salas, Maria João Forjaz, Carmen RodríguezBlázquez, and Pablo Martínez-Martín

8.1

Introduction

At the end of the twentieth century, as a result of the improvement in socioeconomic conditions, technologies and health, among other factors, aging in the population increased, motivated by delayed mortality and a decline in fertility. Despite advance in the increase in life expectancy, aging implies an increase in chronic disorders, such as dementia, and associated disability. Dementia is a consequence of various brain diseases: in 2015 it was estimated that there were a total of 46.8 million people with dementia in the world (Wimo et al. 2017). In addition, the number of people affected by dementia will double every 20 years to reach 66 million by 2030 and 115 million by 2050 (Prince et al. 2013). The impact of dementia is far-reaching. It not only affects the health and well-being of the patient but is also associated B. León-Salas (*) Canarian Foundation Institute of Health Research of Canary Islands (FIISC) and REDISSEC, El Rosario, Tenerife, Spain e-mail: [email protected] M. J. Forjaz National Centre of Epidemiology and REDISSEC, Carlos III Institute of Health, Madrid, Spain e-mail: [email protected] C. Rodríguez-Blázquez · P. Martínez-Martín National Centre of Epidemiology and CIBERNED, Carlos III Institute of Health, Madrid, Spain e-mail: [email protected]; [email protected]

with the burden for caregivers, an increased use of health services and long-term care needs, as well as a significant increase in social and personal resources (Hughes and Ganguli 2010). The prevention of disease and promotion of health are key in an aging society and, for this reason, active aging has become the focus of attention of organizations such as the World Health Organization, the World Bank, the Organization for Cooperation and Economic Development (OECD) and the European Commission. There is no doubt that we are witnessing an important population change that is demanding major social transformation. In chronic and disabling diseases for which there is no curative treatment, such as the vast majority of those that cause dementia, the promotion of well-being and the maintenance of patients’ quality of life (QoL) is a priority of care (Brod et al. 1999b; Lawton 1994; Whitehouse 1997). The knowledge of QoL and the study of how patients experience their illness are key when making decisions for the treatment and care of certain diseases. However, unlike the case of other chronic disorders, the QoL of people with dementia has been relatively little explored until very recently. Among the reasons that explain this is the potential interference that cognitive impairment can cause in people’s ability for self-evaluation or their ability to communicate (Rabins et al. 1999). Since the late 60s, the term QoL and, more specifically, the term health related quality of life

# Springer Nature Switzerland AG 2021 F. Rojo-Pérez, G. Fernández-Mayoralas (eds.), Handbook of Active Ageing and Quality of Life, International Handbooks of Quality-of-Life, https://doi.org/10.1007/978-3-030-58031-5_8

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(HRQoL), in reference to the field of healthcare, have been used in different fields of medicine and health sciences (for example, to obtain information on health in populations; to supplement clinical exploration; or as a measure of the results of clinical practice and therapy research) (Lucas Carrasco 2007). In general, every day there is greater theoretical and practical interest in including patient-reported outcomes within patient care, such as HRQoL, in order that we become aware of the impact of health problems from the patient perspective (Dixon et al. 2006). In recent years and in line with this interest, considerable progress has been made in the study of the conceptualization and evaluation of HRQoL in dementia. The objective of this chapter is to review the conceptualization, determinants and instruments for assessing QoL in dementia.

8.2

Methods

A narrative review was performed to respond to the objective of the study and summarizes the state of the evidence about QoL among older people with dementia. The following electronic databases were searched (March 2018): Medline (OVID), EMBASE (OVID) and Science Citation Index (Web of Science). Controlled vocabulary and free text terms were used including “quality of life”, “dementia” and “older people”. No date restrictions were applied. Language restrictions were applied: only Spanish and English publications were selected. Titles and abstracts of the references identified through the electronic search were screened. Results on the conceptualization, determinants and instruments for assessing QoL in dementia were qualitatively synthetized and summarized.

8.3

The Concept of Quality of Life and Quality of Life as Related to Health

Defining QoL is not easy, since it has been studied from different epistemological and

methodological viewpoints. This has led to very different theoretical conceptions (Cummins 1991). One of the most accepted definitions of QoL is the one proposed by the World Health Organization, that defined QoL as the “perception of the individual; their situation in life in the context of the culture and value systems they live in; and as related to their own objectives, expectations, concerns and rules” (WHOQoL Group 1993). There is majority agreement that the concept of QoL is multidimensional (Bowling et al. 2002; Fernández-Mayoralas et al. 2007; Gentile 1991; Katz and Gurland 1991; Lawton 1991; RojoPérez et al. 2009) and is built on objective or subjective domains or components (Lawton 1991; WHOQoL Group 1998). Traditionally, health has been a basic component of overall QoL and one of its most outstanding areas, especially in the case of the elderly, (Yanguas Lezaun 2006), however global QoL includes other components such as the family and social network, the quality of the environment, job satisfaction, economic situation, and spirituality, etc. HRQoL, on the other hand, has been defined as “the perception and evaluation by patients of the impact that disease and its consequences have had on their lives” (Martinez-Martin 1998). HRQoL refers to the impact that disability, pain, discomfort and frustrations cause on physical and psychological well-being, daily behaviors, roles, social activities, economic situation and other aspects that are important in subjects’ lives (Lawton 2001). HRQoL is also multidimensional and, in general, tends to include as components of HRQoL the domains related to the contents of the WHO definition of health (physical, mental and social well-being) (World Health Organization 2006): (1) physical function and symptoms; (2) cognitive function and psychological well-being; (3) performance or role and social welfare; (4) global health status; (5) perception of care and (6) personal constructs (Berzon et al. 1993; Fitzpatrick et al. 1998). For simplicity, we will use the term QoL from now on in the chapter.

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Quality of Life of Older People with Dementia

8.4 8.4.1

Quality of Life in Dementia The Concept of Quality of Life in Dementia

One of the biggest problems associated with chronic diseases is that many of these are associated with disability, and this has a major impact on daily functioning and the QoL of people who suffer from disabilities, as well as the QoL of their family members (Yanguas Lezaun 2006). Its impact is so great that there is an agreement since the 1990s between clinicians and social scientists on the importance of QoL evaluation in people who suffer from any type of chronic disease and are getting medical treatments or intervention to improve or maintain their QoL (Bowling 1996). Dementia is defined as a disorder characterized by acquired cognitive impairment of sufficient severity as to affect social and professional life (American Psychiatric Association 2000). This involves cognitive deficits such as amnesia, loss of learning ability, apraxia, aphasia, disorientation, sensory dysfunctions and inability to reason, abstract or solve problems. Other accompanying clinical signs are: delusions, hallucinations, identification errors, depressed mood, apathy, anxiety, aberrant motor activity, agitation and catastrophic reactions. In this context it seems inevitable and necessary to redefine the concept of QoL specifically for people with dementia. Initially, definitions of QoL in dementia have been derived from general definitions taken from the general population, extrapolated to the population with dementia (Brod et al. 1999a). At present, the concept of QoL in dementia lacks a universally accepted definition of its own and is questioned as a controversial and vague concept (Jennings 1999; Seymour et al. 2001; Welsh 2001). QoL in dementia has been defined as “the integration of cognitive function, the activities of daily life, social interactions and psychological well-being” (Whitehouse et al. 1997). The manifestations of dementia and changes in the

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physical and social environment of the person with dementia influence their QoL (Brod et al. 1999b). It is conceivable that the loss of mental abilities, functional capacity, independence, personal identity and family and social role, seriously worsen the QoL of those affected (Neumann et al. 1999). The impact of dementia on QoL is so important that it has come to be considered a state of health worse than death (Patrick et al. 1994). In a comparative study conducted by Struttmann et al. it was evidenced that cancer patients had better QoL than patients with dementia (Struttmann et al. 1999). However, the causal relationship between dementia and QoL is controversial, since several longitudinal studies have identified stability, including improvement, in QoL in the medium and long term in people with dementia (Beerens et al. 2015). On the other hand, a systematic review concluded that social relationships and functional capacity are related to a better QoL, whereas physical and mental health and poorer wellbeing of the caregiver are associated with poorer QoL for people with dementia (Martyr et al. 2018). The study of the factors that influence the QoL of people with dementia is essential, therefore, to understand the relationship between QoL and dementia. Given the self-evaluation problems inherent in the dementia situation, the subjective domains of QoL may be difficult to evaluate. For this reason, there is a tendency on the part of researchers to assess objective aspects that can be easily observed (Albert et al. 1996) or to resort to measurement instruments that can be answered by an interviewee. One of the most influential conceptual models of QoL in dementia is Lawton’s (Lawton 1994). This author considers that the global QoL is a multidimensional evaluation, both intra-personal and following normative social criteria, of the system that individuals live in (Lawton 1991). QoL in the general population would be made up of four areas or domains that form a continuum of objective and subjective dimensions: level of competence and objective environment (objective dimensions) and perceived QoL and psychological well-being (subjective dimensions) (Lawton

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1997). Psychological well-being refers to the subjective evaluation of everything that has to do with one’s own experience of global QoL. Affective state, happiness, morale or concept of self are examples of subjective aspects included in the psychological well-being domain. The level of competence represents the socio-normative evaluation of the person’s functioning with respect to their health, cognitive state, their use of time and other aspects of a social nature, such as socially appropriate behaviors. In dementia, Lawton suggests including aspects such as behavioral symptoms, agitation, depression, self-care skills, enjoyment of the use of time, social contact and emotional expression. The objective environment describes physical, social and economic indicators, that is, it includes objective indicators from the world outside the individual, such as physical safety, availability of support services, privacy, stimulation or aesthetic quality. Finally, perceived QoL refers to the evaluation by the individual of areas included in level of competence, including spirituality, satisfaction with care, family, friends, leisure time and residence. Table 8.1 shows other proposed models of QoL in dementia and their dimensions, including the one proposed by Lawton. One of the most interesting was proposed by Ettema et al., who define QoL in dementia as “the multidimensional evaluation of the person-environment system of the individual, in terms of adaptation to the perceived consequences of the dementia” (Ettema et al. 2005). They consider that the most important domains of the QoL of these people are: care relationship, positive and negative affect, behavior, self-image, social relations, social isolation, feelings at home and activities. The variability around the concept and the dimensions that make it up are emphasized more if we consider their significance during the different stages of development of dementia. The domains that make up QoL in mild dementia do not necessarily correspond to those of severe dementia. It is known, for example, that leisure and enjoyment of activities is a relevant domain in the early stages of dementia and not so much in serious dementia (Brod et al. 1999b). Given that the evolution of dementia may affect QoL

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domains differently, both the definition and the instruments for measurement used to assess it should reflect adaptation to all areas of life affected by dementia, depending on their severity (Ettema et al. 2005).

8.4.2

Determinants of Quality of Life in Dementia

Dementia itself and its severity, and especially neuropsychological disorders and associated disability, determine QoL (Conde-Sala et al. 2009; González-Salvador et al. 2000; León-Salas et al. 2011; Logsdon et al. 2002; Missotten et al. 2008). As mentioned before, the relationship between cognitive impairment and QoL is not clear. According to Martínez-Martín, this lack of relationship between cognitive impairment and QoL can be explained from the following arguments (Martínez-Martín 2004): (1) philosophical: wellbeing or happiness may not necessarily require intact cognition; (2) conceptual: the QoL model used in dementia may not be appropriate, or the constructs estimated by the measurements for mental state and QoL are not related to each other; (3) methodological: given cognitive deterioration, it is possible that self-evaluation by individuals with dementia is not reliable or that the measurements used to evaluate QoL in dementia are not valid in that context. CountSala et al. provide an element of interest that could be a mediator in the relationship between QoL and dementia—anosognosia—where neurology patients are not aware of their disease and its consequences (Conde-Sala et al. 2016). Anosognosia, and not cognitive impairment, could be responsible for patients with dementia not perceiving the impact of the condition on their QoL. According to Brod et al. (1999a) the determinants of QoL in dementia could be grouped into two broad categories: • Context determinants: context is defined as all those individual characteristics and life circumstances that help explain the subjective experience of QoL. This group would include

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Table 8.1 Different conceptual models of quality of life in dementia Author Lawton (1994, 1997)

Dimensions Subjective quality of life Psychological wellbeing Target environment or surroundings Competence level Characteristics of state of health Clinical characteristics Physical environment Social environment Socio-economic factors Personal autonomy Subjective satisfaction Personality Culture

Author Brod et al. (1999b)

Rabins et al. (1999)

Social interaction Self-perception Feelings and mood Activities Interaction with the surrounding environment

Terada et al. (2002)

Smith et al. (2005)

Daily activities and self-care Health and wellbeing Energy Cognitive functioning Social relations Concept of self Aesthetic sense

Ettema (2007) and Schölzel-Dorenbos et al. (2007)

Bond (1999)

Logsdon et al. (1999)

the following determinants: (1) signs and symptoms of dementia: mental state, ability to interact, degree of confusion, duration and type of dementia; (2) comorbidity: other physical conditions that affect QoL; (3) physical and social environment: external factors as a form of coexistence, social support and culture; (4) individual characteristics: age, sex, socio-economic status, education, values and beliefs. • Determinants of functioning and behavior: domains or dimensions that traditionally make up the construct “QoL in dementia” have also been considered as determinants

Dimensions Positive and negative affect Self-esteem Feeling of belonging Aesthetic sense Physical health Mood Energy Living conditions Memory Family, marriage Functional abilities Concept of self Interpersonal relations Economic situation Life in general Positive and negative affect Actions Communication abilities Insomnia Interaction with others Spontaneity Activities Care relationship Positive and negative affect Behavior Positive self-image Social relations Social isolation Feelings towards the home Activities

here. This is the case of functioning or disability and behavior, which are part of QoL, since these areas are analyzed to assess this but they can also be decisive for their impact on QoL. In a review of determinants of QoL in dementia the authors have classified these into socio-demographic, physical, psychological and emotional, social, spiritual, environmental and others (Jing et al. 2016). The determinants most often studied are those related to health and functioning, emotional state and social factors. Among the first, it is noted that a poorer state of health, the existence of other chronic diseases,

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pain and disability are associated with worse QoL. The main psychological or emotional determinant of worse QoL in people with dementia is depression. Social and family relationships, together with social and community participation are the main social determinants of good QoL (Jing et al. 2016). These authors have also described how these factors influence QoL differentially, depending on the living conditions of the person with dementia, the severity of the condition, and the type of informant person affected, family caregiver, professional caregiver).

8.5

Methods of Evaluating Quality of Life in Dementia

Due to cognitive impairment, people with dementia may suffer a loss of capacity for introspection and self-observation and forget recent experiences and feelings. In addition, due to anosognosia, these patients may be unable to recognize their disorders and disabilities. As cognitive deterioration progresses, there are more doubts about the validity of the responses of these people, it being necessary to use an alternative source to collect the necessary information, such as informants or caregivers. From a practical perspective and considering the consequences of cognitive impairment, there are three approaches to the QoL study on people with dementia: self-evaluation by the patient, evaluation through an informant and observation of behavior.

8.5.1

Self-evaluation

Self-evaluation emphasizes the subjective and individual nature of QoL and, when possible, this is the preferred approach. Usually, to collect individual subjective impressions related to QoL, self-completed or semi-structured questionnaires are used in an interview setting. Obviously, in the case of people with dementia their use is not always possible. According to several studies, self-evaluation seems to be reliable in the early stages of the

process, in mild and mild-moderate dementia (Brod et al. 1999b; Logsdon and Albert 1999; Ready et al. 2002; Selai et al. 2001a). However, other studies show that people with moderate and severe cognitive impairment are also able to answer certain QoL questionnaires reliably (Ankri et al. 2003; Brod et al. 1999b; Novella et al. 2001b; Thorgrimsen et al. 2003) and can express perceptions and expectations, and make judgments about their QoL, although direct evaluation of QoL in moderate-severe dementia is much more uncertain and difficult (Whitehouse et al. 1997). The main limitation of this approach is that, although the person is in a situation of mild dementia, their self-evaluation may already be influenced by cognitive deficiencies, such as memory loss, difficulties with spoken and written language, behavior or mood problems (depression), alterations that can hinder expressing judgement of QoL.

8.5.2

Evaluation by an Informant, Family Member or Caregiver

In moderate phases of dementia, difficulties of communication, understanding and memory increase. Behavioral problems, personality changes and neuropsychiatric symptoms increase, such as hallucinations and paranoia. In these cases, these people have difficulty making a reliable evaluation and other sources of information must be used, such as an informant, a relative, close friend or caregiver who lives with the patient, knows them or attends to them frequently (Selai et al. 2001b). This evaluation, which is theoretically valuable, is not completely without errors and it has been questioned as to whether informants can reliably assess the most private and personal feelings and perceptions of the patient (Andresen et al. 2001). The main disadvantages of this type of evaluation are two: (1) when the patient’s evaluation is not available, it cannot be ascertained to what extent the informant’s evaluation coincides with that of the patient; (2) the evaluation can be determined by the experiences,

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value system and subjectivity of the informant, as well as other aspects, such as the previous and current relationship with the person with dementia, and the burden of care and depression (Logsdon et al. 1999; Novella et al. 2001c; Snow et al. 2005). Studies have shown that, overall, these factors result in the evaluation of caregivers and patients being different. Caregivers tend to overestimate the deterioration and disability of patients, while people with dementia often underestimate their own limitations (Logsdon et al. 1999; Snow et al. 2005; Thorgrimsen et al. 2003). For these reasons, evaluation through an informant must always be considered with caution.

141

understand and determine the QoL concept at all stages of cognitive impairment. However, the approach to QoL will depend on the severity of the patients’ dementia (Ettema et al. 2005).

8.6

There is a large number of instruments (questionnaires, scales, indexes, profiles, etc.) to evaluate QoL. The simplest and most often used classification is one which divides the instruments into two groups: generic and specific (Table 8.2).

8.6.1 8.5.3

Evaluation Instruments for Quality of Life in Dementia

Generic Instruments

Direct Observation of Behavior

In severe phases of dementia there is significant loss of memory, the patient does not recognize objects, friends and family and there are difficulties of communication, understanding and interpretation. In addition, there is significant physical deterioration, with difficulty eating, urinary and fecal incontinence and permanence in a wheelchair or bed. In these cases, neither patients nor informants can provide a reliable evaluation. Given the difficulty in evaluating subjective aspects of the subject at that point, the only alternative is the observation of behaviors that may be related to QoL: facial expression, tone of voice, movements and other forms of nonverbal behavior (Lawton et al. 1996). In evaluation by observation there are two types of problems: (1) when determining certain behaviors that the researcher relates to the QoL in this phase of the process, it cannot be known whether or not what is observed is what the person with dementia would consider really important for their QoL, given that they cannot communicate this; (2) in this type of evaluations there may also be biases related to the observer’s own capacity for observation and perception, with their subjective emotions and value system. In the QoL study, the severity of the dementia should be taken into account and, whenever possible, these three evaluations should be made to

Generic instruments are applicable to the general population and specific populations, regardless of their characteristics. Generic measures, for example, determine the health status of a group, the comparison of patients with different diseases, and the effect of a disease or treatment on common aspects of the QoL of individuals. Due to their idiosyncrasy, they may show little sensitivity in terms of differences or changes in QoL when applied to populations with specific disorders that may not be adequately represented in a generic instrument. The two most widely used generic instruments in people with dementia are the SF-36 (Ware and Sherbourne 1992) and the EQ-5D (EuroQoL Group 1990). The impact of cognitive impairment on the ability to understand and respond to items can raise doubts about its validity (Geschke et al. 2013; Hounsome et al. 2011). The EQ-5D has also been applied for informants (Diaz-Redondo et al. 2013).

8.6.2

Specific Instruments

Specific instruments are designed to evaluate certain populations on the basis of a specific diagnosis or disease (multiple sclerosis, Alzheimer’s disease, etc.), symptoms (pain, hallucinations, etc.), states (dementia, disability, etc.) or

142

B. León-Salas et al.

Table 8.2 Quality of life instruments used in dementia Generic instruments (León-Salas and Martínez-Martín 2010a) Short Form Health Survey, versions with 36 (SF-36 y SF-12) and 12 items (Pettit et al. 2001) EQ-5D (Naglie et al. 2006; Karlawish et al. 2008a, b) COOP/WONCA CHARTS (Scholten and Van Weel 1992; Kurz et al. 2003; Ettema et al. 2007) Duke Health Profile (DHP) (Novella et al. 2001a, b) Health Utility Index 2 (HUI-2) (Neumann et al. 1999, 2000; Karlawish et al. 2008b) Health Utility Index 3 (HUI-3) (Neumann et al. 2000; Naglie et al. 2006) Health Status Questionnaire (HSQ) (Pettit et al. 2001) Nottingham Health Profile (NHP) (Bureau-Chalot et al. 2002) Quality of Well-Being (QWB) Scale (Wimo et al. 1995; Kerner et al. 1998; Naglie et al. 2006) Schedule for Evaluation of Individual Quality of Life (SEIQoL) (Coen et al. 1993; Schölzel-Dorenbos 2000) The Evaluation of Quality of Life (AQoL) Instrument (Wlodarczyk et al. 2004) World Health Organization Quality of Life 100 (WHOQoL 100/BREF) (Struttmann et al. 1999) Specific instruments (León-Salas and Martínez-Martín 2010b) Activity and Affect Indicators of QoL (AAIQoL) (Albert et al. 1996) Alzheimer Disease Related Quality of Life (ADRQL) (Rabins et al. 1999) Cornell Brown Scale for Quality of Life in Dementia (CBS) (Ready et al. 2002) Dementia Care Mapping (DCM) (Kitwood and Bredin 1992) Dementia Quality of Life instrument (DQoL) (Brod et al. 1999b) Instrument of the evaluation of Quality of Life of people with dementia living in residential settings (QUALIDEM) (Ettema 2007) Psychological Well-being in Cognitively Impaired Persons (PWB-CIP) (Burgener and Twigg 2002) Quality of life in Late-Stage Dementia Scale (QUALID) (Weiner et al. 2000) Quality of Life Evaluation Schedule (QoLAS) (Selai et al. 2001a) Quality of Life-Alzheimer’s Disease (QoL–AD) (Logsdon et al. 1999) Quality of Life for Dementia (QoL-D) (Terada et al. 2002) Quality of life instrument for people with dementia (DEMQoL) (Smith et al. 2005) The Community Dementia Quality of Life Profile (CDQLP) (Salek et al. 1996) The Vienna List (Porzsolt et al. 2004)

population characteristics (teenagers, seniors, etc.). Unlike generics, they are only applicable to the situations or target populations for which they were developed, but they have the advantage of being more sensitive to change, since they have been better adapted to the specific needs of a given population. Table 8.2 shows a summary of the specific QoL instruments developed for people with dementia and the most commonly used generic questionnaires in this population. In general, the psychometric properties of these instruments (validity, reliability, sensitivity to change) are satisfactory (Hughes et al. 2019). Due to the methodological problems presented by generic instruments in people with dementia (Bureau-Chalot et al. 2002; Novella et al. 2001a; Seymour et al. 2001), and the fact that the manifestations of dementia differ significantly from other states of health, there is agreement on the advisability of using specific measures to

evaluate QoL in dementia (Albert et al. 1996; Rabins and Kasper 1997; Selai et al. 2001). A recent systematic review on validity and utility of assessments of QoL and well-being of older adults with physical and cognitive impairments recommended two instruments for use: WHOQOL-BREF for self-evaluation and QUALIDEM for evaluation-by-proxy in case of severe dementia (Ballmer et al. 2019).

8.7

Conclusions

Measuring QoL in dementia is a conceptual and methodological challenge which researchers have responded to by reaching some agreements but with certain reservations and limitations. In recent years there has been a major advance in the study of QoL in dementia. Currently there is no consensus definition of QoL in dementia, however there is agreement on the

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Quality of Life of Older People with Dementia

multidimensional and subjective nature of the term. QoL is defined differently by different people, and the different measurement instruments used to assess QoL reflect different conceptual frameworks. In addition, the potential consequences of the disorder must be considered in evaluations. Due to cognitive difficulties, especially problems of communication, comprehension, introspection and reasoning, selfevaluation is only rarely possible. In general, usually used is information provided by a caregiver or close relative that can report valuable data through observation or closeness to the patient, although frequently of questionable validity as regards their QoL. Despite the complexity of conceptualizing the term QoL in dementia, the difficulty of defining a useful conceptual framework in all phases of severity, and the limitations of its evaluation, applying specific instruments created for its evaluation is increasingly frequent. These instruments are focused on the problems associated with dementia and can detect the changes that treatments, psychosocial interventions, or recommendations for active aging cause on the QoL of the subjects who suffer from this condition. The application and analysis of this type of evaluations serves as a complement to clinical evaluation and enables us to work out the impact of dementia on the QoL of patients and its most important determinants.

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B. León-Salas et al. quality of life is it anyway? The validity and reliability of the quality of life-Alzheimers disease (QoL-AD) scale. Alzheimer Disease & Associated Disorders, 17 (4), 201–208. Ware, J. E., Jr., & Sherbourne, C. D. (1992). The MOS 36-item short-form health survey (SF-36). I. Conceptual framework and item selection. Medical Care, 30(6), 473–483. Weiner, M. F., Martin-Cook, K., Svetlik, D. A., Saine, K., Foster, B., & Fontaine, C. S. (2000). The quality of life in late-stage dementia (qualid) scale. Journal of the American Medical Directors Association, 1(3), 114–116. Welsh, M. D. (2001). Measurement of quality of life in neurodegenerative disorders. Current Neurology & Neuroscience Reports, 1(4), 346–349. Whitehouse, P. J. (1997). Pharmacoeconomics of dementia. Alzheimer Disease and Associated Disorders, 11 (Suppl 5), S22–S32; discussion S32–S33. Whitehouse, P. J., Orgogozo, J. M., Becker, R. E., Gauthier, S., Pontecorvo, M., Erzigkeit, H., et al. (1997). Quality-of-life evaluation in dementia drug development. Position paper from the International Working Group on Harmonization of Dementia Drug Guidelines. Alzheimer Disease and Associated Disorders, 11(Suppl 3), 56–60. WHOQoL Group. (1993). Measuring quality of life: The development of the World Health Organisation Quality of Life Instrumento (WHOQoL). Geneva: Wold Health Organisation. Retrieved from https://www.who.int/ mental_health/media/68.pdf WHOQoL Group. (1998). The World Health Organization Quality of Life Evaluation (WHOQoL): Development and general psychometric properties. Social Science & Medicine, 46, 1569–1585. Wimo, A., Guerchet, M., Ali, G.-C., Wu, Y.-T., Prina, A. M., Winblad, B., et al. (2017). The worldwide costs of dementia 2015 and comparisons with 2010. Alzheimer’s & Dementia: The Journal of the Alzheimer’s Association, 13(1), 1–7. https://doi.org/ 10.1016/j.jalz.2016.07.150. Wimo, A., Karlsson, G., Sandman, P. O., & Winblad, B. (1995). Care of patients with dementia - a ticking bomb? Nordisk Medicinsk Tidskrif, 110(4), 123–126. Wlodarczyk, J. H., Brodaty, H., & Hawthorne, G. (2004). The relationship between quality of life, mini-mental state examination, and the instrumental activities of daily living in patients with alzheimer's disease. Archives of Gerontology and Geriatrics, 39(1), 25–33. World Health Organization. (2006). Handbook of basic documents. Geneva: World Health Organization. Retrieved from https://apps.who.int/iris/bitstream/han dle/10665/43637/9789241650465_eng.pdf; jsessionid¼514585414A97F0935C27DD2ABAA E959E?sequence¼1 Yanguas Lezaun, J. J. (2006). Análisis de la calidad de vida relacionada con la salud en la vejez desde una perspectiva multidimensional. Madrid: Instituto de Mayores y Servicios Sociales (IMSERSO).

Part II Social Policy Issues and Research Agenda

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Developmental Social Policy and Active Aging with High Quality of Life A Preventative, Life-Course-Oriented Approach Christian Aspalter

9.1

Introduction

The terms “social quality” and “high quality of life” have entered the realm of social policy discourse and policy making in the past, especially in the last two decades (see for example Lin and Herrmann 2019; Lin 2013; Bäck-Wiklund et al. 2011; Walker and Mollenkopf 2007; Beck et al. 1997, 2001; Nussbaum and Sen 1993). These two terms are often used side by side, and yet they propel one’s focus on quite different paths, as the former looks at society as the main level of analysis, and the latter at the individual. In postindustrial societies, social class-based social problems have been, by and large, replaced by individual, life-choices-based social problems (for example physical and mental health problems caused by food and drink choices, sedentary life styles; or educational choices, etc.) (see for example Veenhoven 1999). The difference of social quality and high quality of life (or “quality of life”) is one of perspective: the former emphasizes and draws much more attention to the societal level (the quality of society), while the latter focuses on individual level of quality of life. As post-industrial societies are marked by individualization, and hence differentiation, of people’s lives, life-choices, and actions (see Beck and Beck-Gernsheim 2002; C. Aspalter (*) Social Work and Social Administration Programme, BNU-HKBU United International College, Zhuhai, China e-mail: [email protected]

Beck-Gernsheim 1998, 2002), the author here focuses on the idea and outcomes identified with a high quality of life. In evaluating and prescribing major social policy solutions, one has to seek, foster and continuously improve multifaceted policy solutions, which has been the leading vision of Developmental Social Policy theorists (Midgley 2008, 2013; Aspalter 2015). This is particularly true in the case of social policy for a high quality of life, in old age or in one’s entire life (see, for example, Bowling 2007). The normative (that is evaluative and prescriptive) theory of Developmental Social Policy has been focusing on how to achieve a better (or best possible) outcomes in society in terms of human well-being, in all countries and societies on earth, for all people at all ages, and in different social groups and/or different life situations. How to get from here to there, where we want to go as a society, is the key question Developmental Social Policy is addressing. Thus, it is delivering key social policy strategies and social policy solutions based on empirical facts and findings, choosing what works best, or what works better, over what does not work or what does not work as well, in terms of effectiveness and efficiency on the ground. Developmental Social Policy is not a philosophy, not an ideology, it is simply a normative theory that is based on what works best (or better) in terms of helping to facilitate and helping to guarantee change of societal outcomes, from “what is” to “what should be”—i.e. “what

# Springer Nature Switzerland AG 2021 F. Rojo-Pérez, G. Fernández-Mayoralas (eds.), Handbook of Active Ageing and Quality of Life, International Handbooks of Quality-of-Life, https://doi.org/10.1007/978-3-030-58031-5_9

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we can achieved realistically with the available means at hand (through applying old and sometimes entirely new methods)”. Representatives of Developmental Social Policy, early on, insisted on science and empirical evidence (of for example particular practices and solutions on the ground, and of particular case studies) showing the way forward—not any kind of ideology, and not any kind political doctrines (of any place in the political spectrum). Empirical evidence must guide and determine what should be placed under the umbrella of the normative theory of Developmental Social Policy, and what needs to be applied on the ground and scaled up, and eventually across the globe, in both so-called developing and so-called developed countries alike (see Aspalter 2014, 2015, 2017a, b, c; Sherraden et al. 2014; Midgley 1984, 1986, 1995, 2003, 2010, 2013; Midgley and Tang 2001, 2008, 2010; Tang 2006a, b; Tang and Wong 2003; Sherraden 1991, 1997, 2005, 2008; MacPherson and Midgley 1987). The ideas of social quality and high quality of life (a concept which is used interchangeably with quality of life) can be seen, and have been used as, (i) concepts, (ii) theories, (iii) approaches, or (iv) policy instruments (see for example Beck et al. 2001: 148; cf. Walker 2013: 575; as well as van der Maesen and Walker 2005; Walker and Mollenkopf 2007; Lin and Herrmann 2019). Here, on the contrary, the theory of Developmental Social Policy is using the ideas of social quality and high quality of life as “outcomes”, i.e. aims of what needs to be achieved, as much as possible, as early as possible, in an as much as possible effective and efficient manner (see Midgley and Aspalter 2017; Midgley 2008). Building on the previous work of Aspalter (2015) that first applied the theory of Developmental Social Policy to the area of active aging policies, in a new comprehensive and yet very pragmatic manner, this chapter here also completely, from ground up, redefines the idea of high quality of life. This has become necessary, as the commonly used concepts and theories of social quality and

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high quality of life have become virtually all-encompassing, while highly politically liked (due to the popularity of new catchphrases like social cohesion, and social empowerment, etc.), but more often than not they de facto lacked particular usefulness in designing and calibrating social policies and welfare state systems on the ground (there are notable exceptions, see for example Calloni 2001; Bouget 2001; Phillips and Berman 2001). The concepts of social quality and high quality of life still need further “clarification” (Beck et al. 2001: 148). The largest limitations of both concepts and theories are (a) their “apparent open-ended nature” and (b) their “lack of theoretical foundations” (see Walker 2013: 573). This chapter sets out to address, and remedy, both of which. The main problems of the idea of social quality, concept and theory was, and still is, that it did not provide, or guide social policy making towards, practical solutions, but rather a complex compilation of several abstract concepts like social integration, social cohesion and social empowerment; with dozens of policy goals, and a myriad of related social indicators (see for example Beck et al. 2001; van der Maesen and Walker 2011). A theoretical foundation and rationale for the concept of quality of life being translated into and used in social policy is of utmost importance (see van der Maesen and Walker 2005: 9; Lin and Herrmann 2019; Walker and Mollenkopf 2007; for the general importance of theory when using social indicators, cf. Esping-Andersen 2000). Looking at the idea of high quality of lives, the author here prefers to employ the idea of high quality of life for all people—no matter where they live, and no matter how old they are. Developmental Social Policy is following a life-course perspective in social policy, and states that individual problems in later life, for the most part, are the product of cumulative causation of people’s life choices and life-styles over one’s lifetime (see Midgley and Aspalter 2017; Aspalter 2017a; as well as, Giefing-Kröll and Grubeck-Loebenstein

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Developmental Social Policy and Active Aging with High Quality of Life

2019; Walker 2018a, b; Mirowsky and Ross 2005; Kuh and Ben-Shlomo 2004; Darnton-Hill et al. 2004; Giefing-Kröll and GrubeckLoebenstein 2019)—especially when it comes to health problems, and problems, such as social isolation, loneliness, lack of social support, and economic deprivation. In this context, Developmental Social Policy proposes the development of individuals’ human capabilities (human capital), individuals’ social capabilities (social capital), and last but not least, individuals’ cultural capabilities (cultural capital) (see for example Aspalter 2010; Midgley and Aspalter 2017). In this study, high quality of life is defined as a “societal outcome”—that is, the expression and result, in the long-run, of all individuals’ life-time choices and long-term cumulative effects of their (one or more) life-style(s) they choose over their life courses, in any given society. This chapter will first partially avoid the problem “open-ended nature” of high quality of life, by not identifying all aspects of quality of life that there are out there. And second, it will avoid the void of theoretical foundation. In the following, we analyze the idea of high quality of life and what it means, as well as identify first major social policy strategies and social policy solutions to achieve high quality of life (as is the tradition of Developmental Social Policy to identify basic, guiding principles, policy strategies, and key solutions and key programs on the ground, see for example also Aspalter 2014, 2017a, b, c). For that reason, we will work out grand policy objectives for Developmental Social Policy for high quality of life to help find and recalibrate old and possibly also some very new ways (new methods and new policy and program designs) of achieving better social policy outcomes on the ground—that foster and/or ensure higher levels of quality of life for more people, while pursuing a universal strategy that can (and should) be practically applied in all corners of the earth, by all levels of governments, as well as NGOs. In addition by setting up these grand policy objectives, the author is integrating elements of and/or entire other theories, wherever they apply and contribute explanatory as well as other supportive value.

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Three Grand Objectives for Attaining High Quality of Life

The question of what needs to be aimed for (or chased down one’s path in life), what people value the most and look for the most, is perhaps best addressed and answered by looking at what people fear and what hurts people the most (see the role of dehumanization in social development theory, Aspalter 2006). Pain is the one thing that people try to do without (for the very most part), whenever they can, as much they can, and in whatever aspect. The absence of pain, by and large, is what enables “physical functioning” of people, which is a core ingredient of high quality of life (see Walker 2013: 576), as well as their “spiritual functioning”. There are of course different kinds of pain. There is physical pain: arthritis, for example, is one of the most severely disabling diseases; one which plagues the most number of people, rather a bit later than sooner in their lives, but one which yet is the outcome of one’s earlier life choices, life habits, and the life-style(s) one has pursued over the course of one’s life. Arthritis is one of the most debilitating diseases of all (there are about 100 different forms of arthritis) for older people in terms of overall societal (social, economic, as well as individual) impact. Arthritis, far from starting during old age, starts to develop and manifest itself often as early as one reaches 30 or 40 years of age. 1 in 3 people age 18-64 have Arthritis (Jafarzadeh and Felson, cited in AF 2019: 8).

Sugar, white flour, white rice, alcohol, tobacco, caffeine consumption and the lack of exercise are the main causes for arthritis (see WMD 2000). One has to tackle the problem early on, and one must not wait until walking becomes painful, or taking the staircase impossible, etc. That is why, Developmental Social Policy proposes a preventative, life-long approach to achieve and maintain high quality of life during not only old age, but for people of all ages (see also Walker 2018a, b; Giefing-Kröll and Grubeck-Loebenstein 2019).

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There is mental and emotional pain: such as, anxiety, depression, anger, isolation, and other forms of emotional distress (profound disappointment, estrangement, jealousy, etc. for example with the people closest to oneself in life, as they are also the ones who can, potentially, inflict the greatest and longest lasting levels of pain). In addition, there is financial pain (that is, economic deprivation) due to poverty, especially also during later stages of one’s life. There is social pain, in terms of social isolation, the lack of social and family support, the lack of love and/or beloved ones, and so forth. Last but not least, there is cultural pain, if one feels that he/she for example can only barely fit (or not well) in society, this could be due to different ethnic and cultural, linguistic or religious, background; or simply due to different socio-geographic backgrounds, for example rural migrants in an estranged urban environment, or technological/ digital estrangement. The second grand objective to achieve high levels of quality of life in social policy can be traced to the early works of Emile Durkheim (1997), where he described social integration, and with it, in detail, different kinds of social support, as the key factor that determines other social causes, which in sum leads to a series, if not myriad of social problems, with suicide being only one very last possible problem that can follow. There is to some minor extent an overlap between the first, the second and the third objective, to attain overall high levels of quality of life, as for example the ability of being physically highly mobile (according to one’s age category) is part of the instrumental quality of being able to develop and maintain good social network(s) and social support of all kinds, and for example having a strong social support and being strongly integrated in one’s family, community (city neighborhood or village). It may also very well already be an essential ingredient of one’s ability to achieve high levels of self-realization, which is the third grand objective to achieve high quality of life (see Fig. 9.1). Following the footsteps of the theory of Maslow (1943), the most difficult and the most

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seldom, fully at least, attained need or goal in people’s lives, is self-actualization, which can be very different from person to person, and is expected to be highly individualized of course, especially in post-industrial (and post-industrial) societies, where traditions and the traditional family system is fading away (Beck and BeckGernsheim 2002; Beck-Gernsheim 2002, 1998). Maslow stated the goal of self-actualization in essence to be the following: . . . to become everything one is capable of becoming (Maslow 1987: 64).

But, as it is with Maslow’s theory, without getting rid of one’s physical, mental, emotional, financial, social, cultural, et cetera pain one hardly can enjoy, build up and/or maintain one’s social support (i.e. social network and relationships) or not at all. Without having also a strong social and familial support one cannot, or hardly or to only a rather very limited extent, reach the goal of self-realization, or in other words, full-fledged personal or spiritual happiness. Amartya Sen (1999) hinted on selfrealization as a desirable development goal, in his philosophy-guided capability-based development model: The basic concern is with our capability to lead the kinds of lives we have reason to value. (emphasis added; Sen 1999: 285)

Interwoven into these three grand objectives for the attainment of high levels of quality of live are the concepts of Bourdieu’s human capital, social capital and cultural capital (see Bourdieu 1983, 1986). DSP, which is building on these concepts as defined by Bourdieu, has already focused on mental and physical health as being a fundamental part of individual human capital (or capabilities), social support and social networks, and the ability to make and sustain relationships, friends, and acquaintances—that is, social capital (or capabilities) (Aspalter 2015)—as well as the concept of cultural capital (or capabilities). Bourdieu’s concept of cultural capital (capabilities) is to a very large extent a facilitating and constituting ingredient to being able to achieve high levels of self-realization, at least to a high number of people.

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Fig. 9.1 The high quality of life pyramid

SelfRealization

Social Support & Mutual Aid

Absence of Pain (incl. physical, mental and emotional pain, social and cultural isolation, economic deprivation)

Whereas pain is more or less an easily identifiable concept and hence very fit to serve as a concise, concrete policy objective (particularly in preventative health policy, which should be carrying the main lead in preventing and reducing future levels of pain for whole generations of future older and mid-aged generations), social support and social integration is a bit more diverse in different cultural, social and individual contexts, but still very able to serve as a practical and very fundamental grand social policy objective. The third, and last (on the highest level that is), grand policy objective of enabling selfrealization, can for the very most part be only targeted in an indirect, contextual way by policymakers: for example by enabling cultural facilities, providing a safe, and a fully and freely accessible, environment that is full of opportunities for sports, exercise, social and cultural exchange (one that is freely accessible for all citizens) (see Fig. 9.1).

9.3

Key Policy Strategies and Key Examples for Designing Active Aging Policies: A Developmental Social Policy (DSP) Perspective

Normative theories in social science serve for the purpose of (1) evaluation of what is going on, or what has been going on in the past, and as a result of that (2) prescription of what to do (and what not to do) in order to (a) avoid problems (social problems, health and mental health problems, financial problems, lack of positive incentives, the presence of negative incentives and unexpected, unwanted, adverse side-effects), (b) achieve an envisioned or planned outcome, or (c) both of which. In the 1990s, under the early leadership of the World Health Organization, the concept of active aging began to conquer the world’s social policy

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agenda. This has become particularly important now, since today we know that countries like China and Japan by the years 2050–2055 will have over 40 percent of total population being 65 years or older, i.e. they are becoming “supersuper-super-aged” societies (super-aged societies are societies with at least 20 percent of the population being 65 or over) (Rapoza 2017; JT 2019). Active aging comprises aspects of health, participation, and security. “Active aging is not exclusively about prolonging working life . . . Rather it is a comprehensive way of organizing participation across the life course” (Walker 2008: 30; cf. also Walker 2002, 2005, 2006, 2015, 2018b; Walker and Maltby 2012). Both concepts of active aging and high quality of life are to be seen at from a lifetime, life-course perspective; and hence cannot be separately looked at only from the perspective of the aged populations alone (see for example Foster and Walker 2015). In order to get closer to the goal of attaining high levels of quality of live for all of the population, for all populations in the world, in a foreseeable, not too distant future, one has to deal with and do away with a number of large obstacles or roadblocks so to speak. The first of the three grand objectives for the attainment of high levels of quality of live, to avoid any major source and kind of pain, is such a roadblock that makes progress in the wanted direction (in terms of high quality of life) impossible, meaningless, and/or at least unable to enjoy the very same. In addition, one has also to facilitate or at least enable this lofty, but by far not unrealistic, goal of attaining high levels of quality of live by for example strengthening or bringing about enabling grand factors as shown in Fig. 9.1. Following the lead of Emile Durkheim (1997) and Pyotr Alexeyevich Kropotkin (1976), it becomes clear that social support and mutual aid are the two most enabling factors for attaining the goal of higher levels of quality of live, especially when seen from a holistic life-time perspective. The third goal of enabling, or at least making likely, self-realization in all kinds of forms is the most individualistic of all the three goals, whereas the first goal of preventing and reducing (as much

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as possible) any kind of pain is the most universalistic goal of the three. In fact, when looking at the relative differences of the three grand goals for achieving, in general, higher or highest levels of quality of life, there is a continuum from a high level of universal meaning of pain, to a high level of individual meaning (and definition) of what is self-realization based on each individual’s context of life experiences and expectations/aspirations (see for example Erikson 1993). While the goal of maximizing and/or optimizing (according to one’s own wishes and expectations, within the context of one’s cumulative life experiences) levels of social support and mutual aid is ranging somewhere in the middle of both ends of the continuum. The normative theory of Developmental Social Policy is to a very significant extent built also on the findings of French sociologist Pierre Bourdieu, and his interpretations and definitions of human capital, social capital and cultural capital (Bourdieu 1973, 1983, 1984, 1986, 2002; Bourdieu and Johnson 1993; Bourdieu and Passeron 1970). Aspalter (2007) first put forward the overarching concept of societal human capital (or societal human capabilities), which is composed of individual human capital (which includes, education, skills, training, attitudes, and most importantly here also physical and mental health), social capital (the ability to gather and maintain social support, as well as mutual aid), and cultural capital (one’s ability and habits/experiences in engaging in sport, exercise, nature, and of course cultural activities of all kinds) (see Table 9.1). Our three grand goals of attaining high quality of life are presented to different degrees in the concepts and goals of individual human capital (mental and physical health), social capital (social support and mutual aid), and spiritual capital (as one part of cultural capital) in the form of expected and aspired happiness and life-time satisfaction. When looking at general and particular social policy strategies and recommendations that we can draw from the existing theory of Developmental Social Policy and beyond, one can use a basic threefold classification of options to devise

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Table 9.1 Three types of human capital (i.e. human capabilities) Societal human capital Individual human capital Education, language skills, gardening skills, cooking skills, art skills, ability to swim or dance, general and professional knowledge, technological skills, professional skills and training, creativity, learning ability, adaptability, motivation, ability to control one’s emotions, other positive personal traits, etc.

Social capital Integration into family and community, family and community support, frequency and quality of interpersonal contact and communication, number of friends and acquaintances, strength of personal relationships, communication skills, social skills, emotional skills with others, etc.

Cultural capital Cultural and family traditions, customs, habits, moral code, religious believe and practices, filial piety, culture to live a healthy life (eating, drinking, exercise, work, and hobbies), culture to study, culture to save money, industriousness, entrepreneurial drive, multicultural understanding, openness to new ideas and the outside world, etc.

Source: Based on Bourdieu (1983, 1986) and Aspalter (2007)

and put forward social policies for active aging with high quality of life, and not just during old age, but in a preventative manner throughout the life course: 1. supply-side investments of any kind (these are the most straightforward items in terms of social policies to design and to implement), 2. the method of social policy marketing, which characterizes a much more direct way of influencing (guiding) individual behavior of millions of people (never a single or particular person) by way of using (a) communicational social policies, (b) environmental social policies, and (c) cultural social policies, as well as 3. general DSP strategies that change individual behavior by way of rather indirect, but yet very powerful, ways (for example the design and incentive structure of the social security system and its sub-systems in place). The policy fields of communicational, environmental and cultural social policy are strongly built upon the theory of social communication of Niklas Luhmann (1984, 1998)—that is his very own of social system theory (which features a very unique understanding and definition of what are social systems). The methods of communicational social policy and cultural social policy are built on the idea that all single pieces of social communication (for example, words, gestures, et cetera) form “the atoms of society”, and hence the

most important elements thereof. Environmental social policy, on the other hand, is derived from the dichotomy of the inside and the outside world of Luhmann’s system theory, where the outside world highly determines the inside world (outside system complexity, in the long run determines or highly influences inside system complexity, that is in our case, for example, a happy/favorable environment, such as flowers and trees, will eventually, sooner or later, impact a person’s happiness as well as physical, mental, social and cultural health). Aspalter (2007, 2010), on the contrary to Luhmann (1984, 1967, 1975, 1998), does not stop including a person’s feelings, thoughts, emotions and dreams, as part of a person’s social communication, as they themselves are merely the prolonged, refashioned, as well as over-andover-again nurtured expressions of past and other current social communication with the outside world (other people, as well as the environment, pieces of art, etc.). While these very same feelings, thoughts, emotions and dreams are also continuously ejected (or brought) into the social life (that is, the outside world) by way of new social communication that is being altered because of them. One has to see that Luhmann developed his theory mainly in the 1960s and 1970s, where the psyche of the human being was still a rather unexplored and inaccessible part of the human body for the sciences of biology, psychology, and sociology.

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9.3.1

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General DSP Strategies Pertaining to Supply-Side Investments

In the following, a wider selection of possible concrete and very pragmatic (i.e. feasible and realistic) social policy strategies, fields of action, and policy solutions is being put forward, since there is (due to the scope of this chapter) not enough space to fully sketch or discuss (explain in detail) all other major normative policy strategies that have been set up and developed over time by proponents of Developmental Social Policy (see for example especially Midgley 1999, 2008, 2013; Midgley and Aspalter 2017; Aspalter 2014, 2015, 2017a, b, c). This following section is hence focusing primarily on supply-side investments in physical and natural environmental social policy (for example by way of housing financing, and other investments in social, cultural, physical and natural infrastructure, universal public transportation, as well as investments in social and cultural events). A first major initiative in this right direction has been promoted by the World Health Organization (2019), the Global Age-Friendly Cities Project. While a great emphasis is placed on accessibility of services and the general public infrastructure, e.g. a first major step towards focusing on active leisure and socialization has been envisioned in the program. The program, however, is still lacking a life-course oriented approach. In the following hence we would like to deal with high quality of life issues from a lifetime perspective, to effectively and in a preventative way enable high quality of life, throughout all of one’s life, and especially at the later stages in life.

9.3.1.1

Investment in Universal Housing Finance The principle of cumulative causation triggers increased poverty and inequality during old age (see Crystal and Shea 1990). Hence, in order to have housing during one’s old age, a life-long policy focus needs to be applied. China is a very

apt example of what proper housing policy can achieve. In fact, measured by the amount of money and people involved (in absolute terms), the housing loan and housing regulation scheme is certainly the largest social welfare program in the world today, while it also creates the greatest amount of welfare (measured in terms of wealth, i.e. one very important form of welfare): i.e. China’s housing loan and housing regulation scheme (see for example Zhou 2015). Without much paying attention to (and without needing to do so) direct public housing provision, China has been able to solve the housing problem that has come to the fore with the abandonment of the iron rice bowl system (Leung 1994, 1998). Hundreds of millions of people in the past two to three decades have benefited from its generous low-interest housing loans, which in recent years exclusively focuses on first-time homebuyers. China has also set up a housing provident fund scheme, which plays a relatively minor, additional, role (see Lee 2014; Zhu 2014). In Singapore, on the other hand, a full-fledged cousin of the very same, the Central Provident Fund (a system of fully-funded savings accounts) is centered around its main function of financing housing—while also being able to provide a safety net catering to savings for medical needs and savings for maintaining old-age income and long-term care needs, as well as asset-building and wealth accumulation (Aspalter 2017b). These different functions of the Central Provident Fund, and flexibility of transferring from or using funds for one purpose or another, are in essence applying the principle of functional equivalence in social security provision. Aspalter (2017d) explained the major importance of the general principle of functional equivalence in the provision of social security: The “principle of functional equivalence” stresses the fact that different programs and system designs of social security systems can lead to same or similar social policy outcomes, strategies, and/or philosophies in social policy making. The principle of cumulative causation also applies to poverty, that is, economic pain. In addition to avoid economic pain throughout old age and with it throughout a lifetime (absolute

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Developmental Social Policy and Active Aging with High Quality of Life

and relative poverty, income insecurity), both China and Singapore have managed to (almost) perfectly address also the issue of social support—that is, especially mutual familial support—which in both countries is a central element of their housing policy strategies. That is to say, both countries support multiplegeneration households, they focus on the positive role of care-giving, from grown-up children to their parents, and from grandparents to their grown-up children by taking care of their grandchildren (either as a full-time responsibility, on a part-time basis, or in an additional capacity). In this way, both examples are great not only in boosting family support and mutual aid within the family (also with the help of legal and financial means, particularly in the case of Singapore, cf. Teo 2017; Lee and Vasoo 2008; Tan 2005), but also avoid and combat health and mental health problems, such as, loneliness that leads for example to depression, anxiety, and possibly suicide. Both Singapore and China have fully understood the concept of social support and mutual aid, and how to interweave it into the core of their respective welfare state systems, particularly into their housing policies. Hence, successful old age policies—such as active aging policies, healthy aging policies, and anti-poverty in old age policies—can only be achieved through a thorough, comprehensive and life-course oriented social policy approach that offers multifaceted strategies and preventative-cum-curative solutions (see Aspalter 2017c; Walker 2018a, b; Giefing-Kröll and GrubeckLoebenstein 2019).

9.3.1.2

Investment in Environmental Social Policy: Investing in Natural, Physical and Social Environment We can find good examples of environmental social policy everywhere around the globe. However, they are still very sparse in density, and not yet systematically and universally applied across the spectrum of possible policy designs, and being not yet universally applied across different regions, cities, and counties.

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China and Singapore, for example, pay a great deal of attention to the role of community facilities in the field of active aging policy: such as, day-care centers for the older citizens, as well as older people’s playgrounds, public parks and public squares, equipped with exercise and fitness machines (or installations) that are particularly designed for the needs (and wants) of older citizens, for example also with plenty of larger pavilions that protects them from rainfall (while they play cards or mahjong, talk to each other, babysit their grandkids, etc.), as well as the importance of short distances from their homes to recreational walking paths within and across housing communities, etc. (compare here particularly the findings of Rowles and Bernard 2013; Golant 1984, 2011, 2015). Half way around the world, in the state of Upper Austria in Austria, the state government for example bought several large lake-front realestates (for example, at Litzlberg, Weyregg and Attersee at the lake Attersee; Traunkirchen at lake Traunsee; Mondsee at lake Mondsee; or the Feldkirchen lakes next to the Danube, to name just a few of the larger ones) with additional large parking areas attached to them. There, swimming and sun bathing are for free for everybody (see LOӦ 2019). One could offer also public transport to the bathing areas for free, as well as free-ofcharge parking lots. This is a large-scale investment into the well-being of the people of Upper Austria, and not only the older people, but their entire families as well. Such an approach of the state government is not money-oriented, it is people-oriented. It not only focuses on old people, but on the whole family, and on old people of the future, that is, young and mid-aged people. These leisure activity centers can be combined with larger sports and other cultural events (like for example beach volleyball tournaments in Litzlberg, or music performances in Traunkirchen)—hopefully in a systematic and comprehensive manner (that is, frequently and with a great variety). The environment here serves as an investment opportunity for the development of well-being, health and happiness of people at large, being freely accessible, i.e. free of charge.

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When one is looking at an older citizen jumping into the a bit colder Attersee and swim out a hundred, two hundred meters, one comes to understand what active aging actually is all about, especially when one looks at the joy and satisfaction of the very same person when getting back on land. The same is true for the sheer countless hiking paths and routes (equipped with hundreds of fully-equipped Alpine huts, restaurants that offer sleeping facilities, see for example AV 2019) in all of the Alps, particularly for example in Austria, which caters to the entire population, but the offer is also particularly taken up by the elder citizens. Yet again on the other side of the globe, in Seoul, Korea, one can make the same observation, where many tens of thousands, if not hundreds of thousands, of people are going hiking within city limits (even right next to the city center) every weekend, especially in autumn and spring. In the South of Korea, or Austria, hiking is a national sport, a national passion, for people of all ages. Particularly the elder citizens are given the opportunity to keep extra fit due to lengthy and frequent hikes, often together with their entire families. Governments all around the globe, be it national, state/provincial or local governments, need to approach environmental social policy as an investment opportunity into people’s wellbeing and multiple perspectives of health (including social and cultural aspects)—a main way to prevent health care costs and a major source to trigger and foster social and familial bonding, common social and familial activities, and with it, also, social support and mutual aid. Only people (be it elder people, or people of any other age) that engage with one another, frequently and on an in-depth level—and continuously so over a lifetime—will help one another in times of dire needs (rather than calling on the government to help out, or looking at the expensive offers for retirement homes for older citizens). Environmental social policy uses the environment and public investment into environmental infrastructure (like for example free-of-charge

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bathing sites and hiking paths, national parks, wildlife parks, zoos, camping sites, etc.) as a major means for social policy—especially for example for taking up the function of: (a) preventative health policy in the fight against sedentary lifestyle and/or obesity and overweight, asthma, hypertension, prediabetes, diabetes, cardiovascular diseases, Altzheimer’s disease, cancer, different kinds of arthritis, etc., and (b) increasing people’s physical mobility during older age, as much and for as long as possible, whenever and wherever possible, as well as (c) enhancing and maintaining social capital (social capabilities) family capital (family capabilities), and cultural/sports capital (cultural and sports capabilities).

9.3.1.3

Investment in Universal Public Transport System, as Well as Social and Cultural Facilities Free universal public transport at local and/or regional level, and plenty and frequent public transport, as well as full coverage thereof, is not only a smart environmentally friendly thing to do, but at the same time a must for the development of active aging, for mainly two reasons. First, this allows citizens of all generations, particularly the older generation (and here again the poorer and more isolated individuals) to get around, to visit places, to visit friends, family, relatives, and acquaintances, to join family and community gatherings: such as, weddings, anniversaries, funerals, and seasonal festivals. Family and social networks must be maintained and nurtured over all of one’s lifetime, not just starting in old age. It is important to apply here the principle of life-course perspective in social policy (see OECD 2007; Bovenberg 2008; Walker 2018a, b), especially the accumulation and maintenance of human capital, social capital and cultural capital (e.g. in form of health and health knowledge), which is especially prominent in the theory of Developmental Social Policy. For example, annual festivals are especially important in China (especially the New Year

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Developmental Social Policy and Active Aging with High Quality of Life

Festival, Mid-Autumn Festival, Ching Ming Festival). They help form and sustain the backbone of the family and community system. More often than not, in China, one’s whole life’s efforts go into these celebrations—including financial and other preparations, all vacation time, and most money saved during the year. Second, comprehensive universal coverage of free public transport also allows all citizens (not just the older citizens) to develop the habit of doing exercise, going hiking, going swimming, joining cultural, religious and sports festivals, as well as to maintain their social skills, physical agility and strength, and cognitive skills— namely, to keep fit socially, physically, as well as mentally (that is, for example, being able to, as easily as possible, and getting used to find one’s way in a train station and being able to change buses, etc.). Taking the case of, for example, Austria, a lot of tax money is invested in the development and maintenance of cultural and social infrastructure, like theatres, opera houses, concert halls, ballrooms, etc. Most of them are located in the capital cities of the federal states, and of course in Vienna. The same truth holds for France, the United Kingdom and the United States. In these countries, the countryside and the small towns almost entirely miss out on this kind of public investment in social and cultural facilities, this situation is being mirrored in most countries across the world. On the contrary, the Russian Federation for example has a very strong commitment to investment in cultural facilities and performances all across its territories, reaching even the most remote, most poor corners of Siberia (such as Kyzyl in Tuva Republic). Developmental Social Policy, so Midgley, has its historical roots far away from the urban centers of world powers, but rather contrarily so, in the hearts of developing countries throughout for example especially former British colonial territories in Africa and Asia (Midgley 2008: 15; cf. Midgley 1993, 1995, 1996; MacPherson and Midgley 1987; Midgley and Sherraden 2000). It is for this reason, that DSP proposes a much greater focus on social policy initiative in poor developing countries, but also in poor and

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neglected rural areas of all countries, including the rich developed ones. Investing in social and cultural facilities in the countryside includes public investment in community facilities and community events: such as, community festivals like village festivals, farmers’ festivals, local fashion festivals, fair grounds, agricultural trade shows, and so forth. Hence, investment in an aging society has to be a wholesome approach, focusing on all population groups, and not just the older population (see Walker 2018a, b).

9.3.2

9.3.2.1

DSP Strategies that Directly Change Behavior of People at Large: The Method and Key Instruments of Social Policy Marketing

The Case of Preventative and Curative Health, and Mental Health Care Due to the limited space available here, the author chooses to first and foremost, and exclusively so, focus on preventative health policy, including preventative mental health policy. Unfortunately, in the past, these two fields of health policy (and with it social policy) have been analyzed and treated separately in policymaking. Today, we know or we are supposed to know better. That is, in essence, health policy and mental health policy are inseparable. Both physical and mental health problems are intrinsically intertwined. For example, the newest research findings have revealed that Alzheimer’s disease is nothing more, and nothing less, than yet another type of diabetes, it is nowadays identified as type 3 diabetes (MC 2017). Type 3 diabetes (Alzheimer’s disease) is regularly the continuation of Type 2 diabetes, and Type 3 diabetes refers to insulin resistance in the brain (HL 2019). For this reason, when looking at the larger picture, Alzheimer’s disease can be referred to as stage 3 diabetes, with prediabetes forming stage 1 diabetes. In recent years, a whole new arm of medical research linking food and drinks (i.e. food

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consumption) to most major modern mass diseases has become very prominent—be they physical diseases or mental health diseases (diabetes, cardiovascular diseases, cancer, arthritis, Alzheimer’s disease, etc.). Consuming the wrong kinds of foods (and drinks), is even being considered more harmful and causing greater levels of mortality across the globe as either smoking tobacco or alcohol consumption alone (IHME 2019). In order to shift the primary focus of health policy to preventative health policy, in the perspective of new integrated physical cum mental health policy, Developmental Social Policy proposes to implement a new concept of social policy itself: that of behavior-changing social policy. Social policy marketing is the method of altering in advance—as much as possible that is— people’s behavior, life choices, habits and lifestyles (see for example Aspalter 2014, 2015, 2018) with conventional marketing techniques, when looking at the behavior of millions of people, and never that of a single person, at a time. Social policy marketing is, just like any well perceived and well applied marketing campaign, telling people want they want, what they should do, when, how, and how often. People want to live a healthy long life without pain. But they also want to smoke, they also want to drink plenty of alcohol on mostly a daily basis, people like to eat lots and lots of meat, they love French Fries, and they, by and large, developed a much lesser taste (and graving) for vegetables, healthy beans and lentils, herbal teas, etc. The older we get (that is, the longer we indulge in a habit, or the lack of it), the more each of our habits gets stronger, and hence more difficult to change (for the better). For this reason, a life-long approach is the only true effective way to change habits of all people, especially older people. Therefore, social policy experts (including health policy experts) need to come to devise marketing concepts and strategies, design marketing campaigns to tell all people how they achieve what they want most, to live a painless healthy long life, and what they, now, do not want, and do not love, and do not like (at least not so much as

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before) anymore; and what they now want instead, the healthy vegetables and spices, and (importantly) why. Social policy marketing addresses the problem of shortage of information, as most scientific findings regarding health benefits and health damages of different kinds of foods and drinks, and spices, are unknown to the public. Developmental Social Policy has taken on the past practice of Advertisements in the Public Interest as practiced by the government of Hong Kong (ISD 2019). Even though (unfortunately) the whole system of Advertisements in the Public Interest in Hong Kong is not very well coordinated (but rather mostly divided into different government departments brewing their own soup, so to speak), the system of using intensively and over long periods of time Advertisements in the Public Interest to change people’s behavior is a very promising one. In Hong Kong, there were very positive examples of these public advertisement campaigns in the past: for example in case of active aging (where for example an older citizen is joining a kids’ birth day party, going for a swim in a public swimming pool, meeting friends, etc.), or in case of spousal abuse of elder citizens, or preventing hillside fires, or internet crimes, etc. Advertisements in the Public Interest have the greatest potential to change the face of social policy down the road yet deeper into the twenty-first century. Communicational social policy is capturing this new way of doing social policy—which may, and should, exist side to side with conventional, even though updated, social policy programs and social security systems, as well as completely new programs and systems. Communicational social policy is in essence social policy by way of using media, communication and education to achieve social policy objectives, i.e. the right outcomes, as much as possible and as early as possible (Midgley and Aspalter 2017). On top, there is cultural social policy, which is using for the very most part cultural activities and events to achieve social policy objectives, as well as public investment in the physical and natural environment, in order to achieve people’s

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Developmental Social Policy and Active Aging with High Quality of Life

well-being, for example active aging with high quality of live (Aspalter 2014, 2015, 2017c). In order to really change the massive epidemic of modern mass diseases, one has to “change the culture of everything” (see Havel 1992). That is to say, preferring for example to take a walk instead of using a car, a motorcycle or a Segway, or taking an elevator is part of this new culture. And so is, the culture of going for a walk after lunch, in the lunch break, and after dinner going a couple of rounds in the neighborhood, or joining a community dancing class (as in China, where for example women love to dance together in a public square and on empty car parks, putting a ghetto-plaster to a very healthy purpose). People need to learn how and how much to cherish vegetables, spices and herbs, and which ones have what major health benefits, so that they can prevent their likely, or mitigate (and eventually perhaps get rid of) their currently developed and accumulated, health problems and diseases. This kind of learning cannot merely start during old age, or at the time one enters old age, but instead, it has to be developed, nurtured and groomed over a lifetime, from the very young ages onward. Bad daily life habits need to be changed even before they have a chance to manifest themselves in form of health problems and diseases—long before the diagnosis of a major debilitating, life-altering and in the short or long run life-threatening disease (that is, long before one loses one’s limb or eyesight due to diabetes, long before the first heart attack and/or cancer diagnosis). In the same way good daily life habits need to be established, nurtured and groomed, long before the first symptoms of diseases appear or the first diagnoses are being made (see Tello 2018; Simon 2019; Walker 2018a, b; GiefingKröll and Grubeck-Loebenstein 2019). Cultural social policy can be in charge of bringing about and nurturing a national hiking culture (by way of more and free-of-charge hiking paths and national parks), an outdoor culture (by way of free camping sites, bathing sites, etc.), a sports and exercise culture targeting all age groups, and in particular targeting intergenerational activities of families and communities alike.

9.3.3

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General DSP Strategies that Change Behavior of People at Large

9.3.3.1

Smart Universalism: Taking the Case of Health and Mental Health Care Policy The principle of universalism in social policy and welfare state system design has become a strategic principle in the normative theory of Developmental Social Policy (see Midgley 2008). Far from being only a dominant principle within the playbook of Developmental Social Policy, universalism has become widely recognized of constituting a very effective and efficient policy design instrument across the field, as well as superior also in terms of the quality of entitlement, being fair and based on people’s rights (see for example Kwon and Kim 2014; Cecchini and Madariaga 2011; Mkandawire 2005; Townsend 2002). Rather than seeing universalism as the universal cure for all pitfalls in social security and social policy designs, Developmental Social Policy, however, proposes a much more accentuated approach, by proposing smart forms and smart practices of universalism (i.e. smart universalism), rather than demanding social policies to be universal all the time and/or the more universal the better. This is so, because sometimes there are downsides to an over-emphasis on universalism, especially in the context of universal health policies. Today we know that up to 95 percent of modern mass diseases are being caused by lifestyle choices and personal habits and/or the lack thereof (see for example CRUK 2018; PCRM 2018; Noone 2018; Galaviz et al. 2018; Marsa 2018; NCI 2017; BC 2017; BBHFL 2015; Asif 2014; Anand et al. 2008): especially for example choosing one’s food, making daily choices like taking the stair case or the elevator (every day on the way to and from office, etc.), going for a walk in the evening or directly go to one’s couch and start watching one’s favorite TV shows and series almost every day after work, ordering a hamburger with or without French Fries and a Coke on the side, drinking too much alcohol and that too many times a week

162 or not, smoking or being exposed to second-hand smoke every day or not, etc.

From an economic (i.e. micro-economic) point of view, universal health care provision if covering all of the population and all health problems across all of a lifetime does has negative side effects: 1. subsidizing lack of good behavior and the presence of bad behavior (in terms of health outcomes), as well as punishing good behavior (by way of not returning a large share of one’s lifetime savings/social security contributions), and at the same time 2. giving one’s lifetime savings/social security contributions away to other citizens, who, when looking at the behavior of millions of people at a time, for the very most part do a lot or everything wrong regarding their lifetime choice and lifestyles. It is for this reason that DSP has developed the idea and concept of smart universalism (see Aspalter 2017a: 106), that is, for example offering full-fledged free-of-charge (no matter how high the costs) universal health care services to: 1. all children and young adults (e.g. up to age 20, 25, or 30, up to the government to decide, depending also on the context of a country’s government finances) with 10 years of phasing out from e.g. 20–30 years of age (where public coverage for health care treatments and medicines drop e.g. by 5 percentage points every half a year), 2. all pregnant women and birth-giving mothers, 3. all senior citizens (e.g. of age 85, 80, or 75 years of age), with 10 years of phasing in e.g. from 70 to 80 years of age (where public coverage for health care treatments and medicines increases e.g. by 5 percentage points every half a year), 4. all people suffering from rare disease, 5. all people with handicaps (including services and equipment, etc.), as well as 6. all dental care expenditures for children up to age 12, 14, or 16 (to avoid subsidizing children eating the wrong kind of foods, e.g. candies, and not brushing their teeth; thereafter

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non-economic targeting can still play a major role). For those between 20/25/30 and 75/80/ 85 years of age, provident fund systems shall be in place that provide sufficient funding for health care and long-term care needs of all kinds. In addition, a severe accident insurance system (public, or private with for example tax exemption) needs to be installed. In general, any kind of social insurance systems (be they Beveridgean, i.e. universal, or Bismarckian, i.e. occupationally and/or geographically divided) punishes—unreasonably and heavily—positive lifestyle choices and rewards negative lifestyle choices, and should be therefore avoided in the future. Instead, these should be transformed into notional/non-financial defined contribution schemes, or other provident fund systems, (either being phased in over time, or directly converted into a provident fund system at once). In this way, the health care system can avoid all negative effects of negative incentives mechanisms (and structures), as well as missing positive ones (see for example Aspalter 2017c; Preker and Harding 2019; Lagarde et al. 2010). Healthy life choices, and lifetimes, therefore, must be rewarded and must not be punished in any way, especially though social security system design and overall mechanisms in the tax system. To the same extent, negative life choices and lifestyles (in terms of health outcomes, determined by medical science), must not be supported and subsidized in any form, i.e. any financial means, be the direct or indirect.

9.3.3.2 Non-Economic Targeting Developmental Social Policy is not the only source of support for individual behavior changing strategies, policies and programs on the field. Ever since 1995, a new wave of innovative social assistance programs that are designed to change individual behaviors of tens of thousands and indeed hundreds of millions of people’s behavior in the short- and mid-term has started spread around the globe, with its origin in local and

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later on national conditional cash transfer programs (so-called CCTs) in Brazil. According to Aspalter (2017a), there are “good CCT programs” and “bad CCT programs.” The good CCT programs are made up by usually two good components: individual behaviorchanging and behavior-creating conditions and/or categorical conditions (for example household targeting, etc.), both of which are two forms of non-economic targeting (NETs) methods in public social assistance and social service provision. On the contrary, bad CCTs also feature the bad component of asset- and means-testing (AMTs) or proxy asset- and means-testing (proxy AMTs) apart from other good NET-based components. AMTs and AMT elements have disastrous side-effects, as they almost always cause most severely the phenomena of poverty trap, savings trap and unemployment trap (all at once), not only increasing the incidence of poverty, but also the severity and length thereof. That is to say, in 99.99 percent of cases, asset and means-tests (AMTs) led to horrendous side-effects—the only exception of which being a one-time payment, with the income and wealth test is focusing on recent past income and wealth owned (this kind of program was devised and implemented for example by the former Ma Ying-Jiou Administration in Taiwan, see Hsueh 2015). The good CCT programs are a mix of both forms of NET elements, while not evolving any kind of assetand means-testing (AMT element). Hence, most CCT programs in that we can find in the world today are bad CCTs. Only Bolivia, El Salvador, and partially Mexico, for example, have (probably by accident or by way of pragmatism) implemented good CCTs that abstain from using extremely harmful AMT mechanisms in determining eligibility, and entirely rely on conditional and/or categorical forms of non-economic targeting (NETs). The good conditional cash transfer programs (good CCTs) target welfare and social service eligibility by any other way and economic targeting (income or wealth): (a) for example by age, (b) gender, (c) number of children in household,

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(d) average living space for each household member, (e) household conditions, such as, having running water or not, having a toilet or not, having a fixed roof or not, having walls made out of a concrete structure or not, etc., (f) ethnic background, (g) geographic location (using poverty maps), (h) school attendance (for example 75 percent of time per semester), (i) work status, (j) labor market participation (length of years), etc.—and, importantly, (k) any combinations thereof. In the wake of the rampant spread of unfortunately mostly bad CCTs, and only sparsely good CCTs, across the globe, social policy experts working for the World Bank among others have stressed the importance of scaling up supply-side investments in for example health care facilities, educational facilities, employment opportunities, and transport and other public infrastructure (see for example Cecchini and Madariaga 2011; Ferreira and Robalino 2010; Fiszbein and Schady 2009; Lindert et al. 2007; Rawlings 2004; Rawlings and Rubio 2003). National and local governments around the world need to (Aspalter 2017b): 1. abandon the practice of applying any kind of asset- and means-testing (AMTs), which trigger large-scale poverty-increasing, poverty-spreading and poverty-lengthening side-effects that spans the globe (most countries in the world are using the extremely harmful method of AMT for assessing social assistance and service eligibility), 2. set up a great deal more categorical cash transfers, be it universal benefits and services or non-economically targeted benefits and services based on categories (i.e. “categorical NETs”), and/or 3. set up a great deal more behavior-based conditional cash transfer programs and systems (“conditional behavior-based NETs”, that is, the good CCTs).

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NETs can be applied across the board, especially in social assistance policy (i.e. anti-poverty policy) and health care policy (incl. mental health care policy)—to eradicate physical, mental, economic pain in particular, and hence, to make possible further achievements with regard to the attainment of high levels of quality of life (gaining and enjoying social support, mutual aid, as well as any form and degree of selfrealization) not just during old-age, but—in order for this to work—in all of our lifetime. The conditions that are responsible for poverty during old age are long set in stone, long before the onset of old age. That is why the practice of poverty-increasing asset and means-testing needs to be stopped for people of all ages: the old ones, the not so old ones, and the young ones. New anti-poverty policies and instruments as highlighted by the Developmental Social Policy approach in social policy need to replace all sorts of asset and means-testing. Universal and non-economic targeted benefits and services need (and readily can) take their place entirely (Midgley and Aspalter 2017).

9.4

Conclusions

This study breaks new ground in the sense that a new definition of high quality of life is being used, one that sees high quality of life as a social, as well as lifetime “outcome”. Hence, in a nutshell, high quality of life can be achieved by avoiding the main sources of its obstruction and absence, that is: (i) different kinds of pain (centering around physical, mental and emotional pain, but also wandering into new fields of inquiry, such as, how pain translates to fields like lack of social and cultural capital, as well as economic deprivation), (ii) the lack of social and familial support, as well as lack of mutual aid, and (iii) any sort of restrictions on enabling and encouraging numerous individuallyanchored aspects of people’s self-realization (for example, lack of facilities and natural infrastructure, lack of access to nature, etc.).

In devising social policies for active aging with high quality of life, the normative (evaluative and prescriptive) theory of Developmental Social Policy serves as a theoretical base that has been highly missing in the past, since “the absence of a theoretical rationale for quality of life [otherwise] tends to undermine its usefulness in the policy world” (van der Maesen and Walker 2005: 9). The above analysis has demonstrated that not descriptive or explanatory theories, but normative theories must be the answer to address the rising global interest in individual perspectives on high quality of life, as well as its societal outcomes and context. According to Midgley (1995: 38) “social development involves a process of change which is fostered through deliberate human action.” Developmental Social Policy, hence, not only collects and evaluates positive, not so positive, as well as negative examples (since they also contribute explanatory and empirical value), but also rolls out a broad empirically-cum-theorybased normative theory that is highly apt to cater to different fields of social policy, as well as different societal and developmental contexts of all countries, regions, and societies on earth. This includes also the most developed countries and societies, as they also do not stop developing into many new directions and into many unknown territories in the immediate, and not so immediate, future (see Midgley 2008, 2013). The theory of Developmental Social Policy is based on empirical practices, especially employing the method of comparative social policy (be it case studies, in-depth historical case studies, or comparative studies analyzing social indicators, comparative surveys, etc.). Developmental Social Policy is built to render pragmatic models, strategies, and best practices and, apart from that, to warn against not so good models, bad and worst practices on the ground—for the purpose of pushing ahead social policy and humanity all the way down the road into the twenty-first century and beyond and in all (no matter how rich or how poor) corners of the earth.

9

Developmental Social Policy and Active Aging with High Quality of Life

Active aging with high quality of life can be brought upon and strengthened by: not holding people back from an active, joyful and healthy life (pursuing the grand goal of avoiding all kinds of pain), and encouraging and enabling high qualities of social support and mutual aid, as well as self-realization. The study above has put forward numerous social policy strategies to pursue (and those not to pursue), as well as given, time and again, prime or good examples of how to achieve the wanted outcome of high quality of life in pursuing active aging policies for the whole population, thus implementing a life-course perspective in the field of active aging policy. We have seen above that Developmental Social Policy, in more than one way, has rang the opening bell for preventative social policy, as well as preventative health policy (see Holland et al. 2018: 2, 42). True preventative social policy is exceedingly effective and efficient at the same time. Down the road further into the twenty-first century—with the coming of hyper-aged societies, and having already entered the stage of “third modernity,” where artificial intelligence and (yet another) digital revolution are from ground up altering life as we know it—preventative social policies are the only available way out from (otherwise inevitable) financial downfall of welfare state systems, governments and economies alike. Developmental Social Policy—with its pro-active, preventive, and life-course-oriented approach—is (as of today) the only normative theory out there that has the potential to address the social questions of the times ahead of us, not only with regard to active aging policies paired with high quality of life, but also in the entirety of all social and public policy.

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“Active Ageing”: Its Relevance from an Historical Perspective

10

Julio Pérez Díaz and Antonio Abellán García

10.1

Introduction

After several decades of gestation and increasing relevance, Active Ageing received definitive support as a strategy of the international policy on ageing in an official World Health Organisation (WHO) document presented at the World Assembly on Ageing of 2002 in Madrid. Its title was eloquent: “Active Ageing: a Policy Framework” (World Health Organisation 2002). The United Nations health agency thus became the concept’s principal guarantor and promoter, as well as its main reference when today seeking its definition (“the process of optimising opportunities for health, participation, and security in order to enhance quality of life as people age. Active Ageing applies to both individuals and population groups. It allows people to realise their potential for physical, social and mental wellbeing throughout their lives and to participate in society according to their needs, desires and capabilities, while providing them with adequate protection, security and care when they need assistance”). However, in 2015 the WHO itself has begun to give abundant evidence that its future strategy abandons this concept. It did not mention Active J. Pérez Díaz (*) · A. Abellán García Institute of Economics, Geography and Demography (IEGD), Spanish National Research Council (CSIC), Madrid, Spain e-mail: [email protected]; antonio.abellan@cchs. csic.es

Ageing in its “World Report on Ageing and Health” (World Health Organisation 2015), which bore a status similar to the 2002 document. Nor did it do so in other strategic documents in this area, such as the “Strategy and Action Plan on Ageing and Health 2016-2020”, or the scheduled “Decade of Healthy Ageing 2020-2030” (Clare 2019). Such a radical change in the WHO’s dialectic leads to a variety of questions: what has happened? Has the concept already served its purpose? If so, with what results? Is this abandonment exclusive to the WHO or is it common to the other actors who plan for a better old age in the future? (always taking into account that these actors belong predominantly to the part of the world where mortality has already decreased significantly and the aged persons begin to exceed 20% in population pyramids, often higher percent than infant population). These unknowns have suddenly been added to the ambiguity and polysemy always inherent to the Active Ageing, unknowns that the 2002 document had been able to curtail by turning the concept into an international and interdisciplinary reference. Until then, the progressive, spontaneous spread of its use in planning or research had also increased the need to delimit which of its multiple uses would be adopted in each specific case, and how it would be distinguished within the great family of concepts that always sought to characterise “good” ageing (healthy ageing, participatory ageing, ageing without ceasing labour

# Springer Nature Switzerland AG 2021 F. Rojo-Pérez, G. Fernández-Mayoralas (eds.), Handbook of Active Ageing and Quality of Life, International Handbooks of Quality-of-Life, https://doi.org/10.1007/978-3-030-58031-5_10

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activity etc.). In fact, during the first decade of the twenty-first century, when Active Ageing attained the peak of its adherence and popularity, the task of clarification and delimitation of the concept itself became a relevant goal of research. The study proposed in this chapter is also an attempt at conceptual clarification. Its specificity lies in the fact that the path chosen is not semiological, bibliometric or document tracked (the existing literature is so plentiful today that it proves almost overwhelming). Rather, it is a broad interpretation of the historical development in the construction and use of Active Ageing, embracing too its present and surprising abandonment by the WHO. We know that Active Ageing has had different impacts and developments as observed in its political/instrumental dimension or its theoretical/conceptual dimension. In the former, it has generated increased practical regulatory activity (entities, financing, legislation, etc.) during the past two decades. However, in “scientific” terms, together with the aforementioned problems of definition and classification (Moody 2005) it has also brought operationalisation and measurement difficulties. The question arises whether its abandonment by the WHO is a response to the poor results of Active Ageing in one or another dimension (or in both). Or whether, despite its usefulness and effectiveness, there has been a change in the historical or institutional context that has caused it to be left behind. The response obliges clarification of its origins and trajectory in any of its areas of application. What follows is a proposal for a temporal map of the major landmarks that have marked its historical evolution by setting it against the backdrop of the interest in treating population ageing and the way to do so. Our hope is to contribute to greater understanding of Active Ageing as a tool and its present situation following the WHO’s shift.

10.2

The Origins

Ever since literature about old age has existed, there have been references, of varying degrees of

vagueness, to principles or practices that lead to good ageing. These have been enunciated by thinkers of all times, but especially those who, from the field of medicine, have suggested keys to good health throughout life (food, exercise, medications etc.), and their historical recapitulation is a recurring part of early major treatises of geriatrics (Nascher 1914). However, a significant degree of precision and theorisation on the keys to good ageing was not reached until the psychosocial and geriatric discourses of the 1950s. These were far of be adopted in public policies as a planning tool. What they proposed, from a highly medical and sectoral perspective, were the first gerontological theories, closely related to daily practice in rest homes. The aim was to find a general guideline for action that promoted “good ageing” for those institutions. One of the earliest, that of “disengagement” (Cumming and Henry 1961) considered ageing as an irreversible process of function, capacity and social relationship loss. It therefore led to a gerontological practice that promoted social detachment and abandonment of previous activities, in “harmonious” preparation for the inevitable (a theoretical framework, incidentally, that was highly favourable to the institutionalisation of old age). In contrast, the same period saw the proposal of “active ageing” (Havighurst 1954; Maddox 1963), a direct forebear of today’s concept. A polar opposite to Cumming and Henri, it understood that maintaining links, activities, even new learning, held the key to a successful old age. Theories about the nature of ageing and the best way to intervene in it continued to develop and proliferate during the 1970s. These employed very different approaches, but particularly “psycho-social” ones, such as role theories (Rosow 1970), subculture (Rose and Peterson 1965), continuity (Atchley 1971) or age stratification (Riley 1971). However, our focus here is the final structuring of the policies to optimise the ageing process around the concept of Active Ageing. In reality, the policies about old age in this period were developed with very different bases: since the end of the nineteenth century, medical care for workers and their financial insurance in front to retirement had been the structural topics

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“Active Ageing”: Its Relevance from an Historical Perspective

with regard to State protection for old age, within the context of incipient social welfare policies. This political orientation responded in large part to a long history of worker and trade-union struggles, but additionally to the usefulness of the pact implicit in liberal parliamentary governments to halt workers’ expansion, that was revolutionary initially, and Soviet later. In this way, old age as a State issue had always been linked to overwork, the right to rest and the protection of the worker from illness and poverty once working life had ended. In short, the core of the social policy about ageing was set in the ability or inability to work (Walker 1980, 2016). Therefore, the first theories of Active Ageing, psychosocial ones, had little impact on the manner of State understanding and treating of old age. Active Ageing was a politically marginal issue during the years in which developmentalism reached its zenith, years of fast economic growth and expansive policies in public spending. Policy on old age continued focusing on and delving into “worker welfare”, with different translations according to the most developed major regions where demographic change was already very visible, especially Europe or the US. Further afield, in most of the rest of the world, health remained a subject that was linked to over-mortality in the ages prior to old age, especially children, while the numbers of older persons were still at traditional lows (around 4–5% of the population). Indeed, after the Second World War, European States had been forced to adopt reconstruction and welfare policies. The onus was on them to present their own political bloc advantageously against their opponent (in this point the two Europes, Eastern and Western, are convergent and competitive). In the US, on the other hand, the War had given way to a period of unprecedented expansion, with very rapid growth of the middle classes and with generations of young people who decades later would have the chance to retire in better conditions than ever before (Marmor 2017); the universal health protection system for American old age, Medicare, was launched during the Johnson administration (1963–1968).

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In addition to these two vectors, the theoretical one and that of State policies, the picture would be incomplete without adding demographic evolution itself (MacInnes and Pérez Díaz 2009). Much less circumstantial and dominated by long-range trends, the numbers of older people in the richest countries was progressively increasing. By the end of the 1970s, the proportion of the over-60s, around 5% in all historical human populations, reached 16% in the US and 17% in Europe (while on continents such as Africa, the figure barely exceeds 6% today) (United Nations 2017). This factor was still little in evidence in the political discourse on old age. Despite the increase in life expectancy, the baby boom of the 1950s and 1960s had greatly reduced concern about the population pyramid, which still showed a very broad base, far from what began to occur in the 1970s. Transfer of the emphasis on protection policies, from worker’s health to general health, began to take place after the Second World War, although old age was not yet its central theme. The focus was on general mortality, summarised in the indicator “life expectancy at birth”, which in a good part of the world remained at the archaic value of under 40. In developed countries, it was already around 60. Indeed, in the subsequent quarter-century, there was notable progress but health and old age remained separate as two main lines of political concern. Their merger into a single strategic objective only occurred after the economic and political earthquake that hit in the 1970s.

10.3

The Crisis of the 1970s and the Change in the Conditions for Considering Old Age

The 1970s began with a very similar situation, which could be termed post-war or developmentalist. However, profound changes soon took place worldwide that completely subverted the picture we have just drawn. In 1973, the price of crude oil rose dramatically on international markets, triggering a chain

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of effects. By the end of the decade, the economic development model, based on industrial production and employment, and supported by cheap oil, had already begun to decline. The deficit of the leading States soared, without Keynesian policies appearing of any use on this occasion. The second oil crisis, in 1979, led definitively to a rethinking of policies, public spending and the relationship between State and market. As regards old age, a paradox was produced. For the first time, and only in the most developed countries, an international economic crisis had found older people minimally protected in their income. Never before had an aged generation attained a full, uninterrupted working life, in paid employment and in a principally urban and industrial economy. Combined with the fact that public retirement systems had been deployed intensely after the Second World War, it would be seen that this crisis had very different effects on different ages than before. Any previous economic crisis had forced workers to prolong their working life indefinitely, even to the point of total exhaustion and death. By contrast, the effect of this crisis was the mass early retirement of workers of mature age. Not only was there huge destruction of employment, but this was concentrated in occupational sectors where increasing proportions of workers had become consolidated and mature, until they had become the majority. In the face of the collapse of a complete production model, closure or reduction in workforce was facilitated by States resorting to the funds accumulated by contributors, allowing and even encouraging the early retirement of a large number of workers (this was justified by the need to pave the way for their substitution by the young, which was mere rhetoric because their entry into the labour market was also significantly blocked in those years). The effects were so great that they significantly brought forward the average retirement age (Guillemard 1993). The period’s economic and productive slump interacted with the demographic point in time: mass generational survival during adulthood, limitation of births by couples who had already completed their family projects in the 1960s and

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70s, at unusually early ages, the commercial emergence of “the pill” that provided the youngest with a cheap and effective method to dissociate the forming of a couple from a first child and sizeable relative surpluses of youth labour in a market that had shut its doors (Easterlin 1968; MacInnes and Pérez Díaz 2008). The baby boom was coming to an end. Fertility rates in the wealthiest countries again began a downward path, which this time led them to minimums they had never experienced before. Although this demographic drift was not a mechanical reflection of the slow progress in improving life expectancy and of the increase of survivors in old age, the rapid decline in the number of births helped to draw public attention to demographic ageing, which was accelerating. Finally, the demographic weight attained by old age forced the issue of good ageing away from strict care or geriatric practice, or from trade union programmes and social democratic policies on good retirement. Instead, it was placed in a much more general medical and social perspective. In fact, the watchwords began to be “epidemiological transition”, rather than the traditional “demographic transition” (Omran 1977). The mere evolution of the population pyramid modified the map of the principal pathologies and causes of death, or of health policies. Care systems created around maternal and child health and the fight against infectious diseases, began to confront the need to adapt to the new majority profile of beneficiaries, who were now much older, and of their principal medical conditions (cardiovascular, degenerative diseases etc.). In this evolution, a milestone was the creation in 1975 of America’s National Institute of Aging (NIA), within the general framework of the National Institute of Health. In summary, the question of how to grow old moved during the 1970s from geriatric practice to a much more general medical-health perspective, one that responded simultaneously to a serious international crisis, to new trends in economic management by States, and to an unprecedented demographic shift.

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“Active Ageing”: Its Relevance from an Historical Perspective

10.4

The 1980s and New Economic Policy: Old Age as a Problem

The internationally generalised politicaleconomic formula for dealing with the crisis included a profound revision of the role of the State and public spending in their economies. The mandates of Ronald Reagan (1981–1989) and Margaret Thatcher (1979–1990) were emblematic of the new economic policy, but their momentum could also be found in the new recipes of institutions such as the World Bank or the International Monetary Fund (Stiglitz 2002). These were applied inflexibly in the other, less industrialised, part of the world where the crisis was concentrated in an external debt that had become impossible to pay, or in the dismembered Soviet bloc, in a brutal shift towards the free market. The reduction in public spending was preached in highly different spheres (except in no-go areas, such as defence). This meant that social and old age protection and, in fact, the very change in the age structure were subjected to profound “revision.” In this tidal shift, academic research and think tanks played a significant role. The crisis and subsequent adjustments bolstered one of the most literal meanings of Active Ageing, which referred to the maintenance of labour activity and economic productivity (Foster and Walker 2014). Paradoxically, the crisis led to “employment restructuring” (obligatory in companies, but promoted too by States), whereby a significant proportion of workers in the final stages of their working lives, saw their definitive departure from the labour market abruptly brought forward. The aggregate result was a significant reduction in the average age of effective retirement, which had always been above 65 and which fell to under 60 in many developed countries. In this way, support for adjustments and early retirement co-existed in the 1980s with conflicting support for the prolongation of the years of work activity (Active Ageing in labour terms). Also quickly evident was the lack of preparation with which huge numbers of workers

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saw their working life terminate without their having planned for the moment or the life strategies they were going to adopt. Therefore, the crisis produced an important precedent of what we now consider Active Ageing; not in the discourse on the prolongation of working life, but in the early preparation for retirement in order to enjoy an equally active and satisfactory life subsequently. In the 1990’s, the average effective retirement age stopped decreasing. However, there was divergence with the US, where it stayed very stable at around 65, while in Europe it reached much lower levels before stabilising. This may explain why in the US during this decade the discourse about good ageing placed less emphasis on work activity and more on health, while in Europe remaining in work was much more the focus. With regard to pensions, there was a proliferation of “actuarial” studies announcing the unsustainability of public systems. Such studies lacked originality in methodological terms and were supported by population projections by the classic component method, but also by new economic theories such as those of the Chicago School (Friedman 2002). The best example of this academic-financial synergy was the privatisation of the Chilean pension system in 1981, personally led by Milton Friedman. It was soon imitated by other countries, such as Mexico. The surge reached Europe which, although reluctant to privatise, witnessed an extending of the State’s promotion of voluntary, or even obligatory, complements to public pensions through other private savings products. Although take-up was slower, this was made explicit in the EU White Paper on Pensions (European Commission 2012a, b). The social sciences also saw the deployment of a “sociological/political” discourse that re-examined the State’s historical role towards the family with regard to welfare. It was claimed that the traditional protective functions of the family had been “usurped” by the insatiable public services, with negative results, and that such protection would improve if this were returned to the family (Kertzet and Laslett 1995). Although

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this discourse was applied to multiple facets of State intervention (some even extended it to children’s education), it was especially geared to the old age that needed personal care. These were the years that saw the emergence of language about “formal” and “informal” care (Froland 1980). In demography, finally, the focus of the discipline began to shift. Since its birth in the late nineteenth century, it had as its central theme “low fertility” and the fear of demographic decline (for ideological reasons and international competition, even in war, because in reality these were years of unprecedented population growth) (Teitelbaum and Winter 1985). After two World Wars and the baby boom that the developed world experienced right at the end of the second, the focus had changed from the low fertility of the wealthy world to the “excessive fertility” of the barely advanced world, especially the Asian continent, a vector for the spread of communism. Only after the baby boom had concluded, the USSR decomposition and the return of a sustained decline in fertility, coinciding with the industrial crisis and new economic policy, was the attention of demographers finally drawn to changes in the age pyramid. The best illustration of this thematic breakdown of the discipline itself was provided by a survey that IUSSP (the world association of demographers) conducted of its members in 2009, canvassing their opinions and attitudes about their field of work, their research topics, their applications, the biggest current problems to be solved or the policies required to confront them. When the analysis of the almost one thousand completed questionnaires was published, the thematic and political predominance of “ageing” was overwhelming (Van Dalen and Henkens 2012). But the major emergence of the subject of old age during the 1980s, in addition to showing up in the social sciences, economics or demography, was observed especially in the field of health. It was there that a first global review on public strategies on old age appeared, a precedent of what would be articulated around the concept of Active Ageing.

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10.5

Adding Life to Years, the Strategic Shift of the WHO

The accumulated changes that led to this first emergence were highly diverse and some of them have already been stated. They included truly disruptive political, ideological and economic factors, beyond the abandonment of Keynesian policies, which were replaced by policies of adjustment, expenditure control or liberalisation of the public sphere. In general terms, advanced societies moved abruptly from a principally industrial economy to one of services, in which the care of people occupied a central place. However, the demographic and health situation was also regarded as a key focus of the major collective problems in which old age and its growing significance was always indicated as a threat. Terms such as “demographic winter” or even “demographic suicide” were coined, attributing the new population pyramid as leading to an imminent health crisis, the collapse of the public pension systems and the unsustainability of the Welfare State in general. Perhaps the best example of this change in perspective was to be found in the general strategy of the WHO, this time with regard to mortality. Since the Second World War, life expectancy had been the indicator with the greatest presence, and the one that made the results of development and health policies visible. There could be said to be a real international race, especially between the two major political blocs, to show the greatest progress in years of life. Indeed, such progress occurred in a significant, sustained manner. However, the new climate that followed the industrial crisis and the change in the political and economic paradigm coincided symptomatically with a radical rethinking of the international health strategy with regard to two crucial issues: the possibility of continuing to improve mortality, and the importance of disability for collective health. This shift was already evident in the Action Plan that arose from the First World Assembly on Ageing in Vienna, organised by the United Nations in 1982 (United Nations

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“Active Ageing”: Its Relevance from an Historical Perspective

1982), and in the First International Conference on Health Promotion, organised by the WHO in 1986 in Ottawa (https://www.who.int/ healthpromotion/conferences/previous/ottawa/ en/). In short, the transition from mortality was regarded as having come to an end. In strict demographic terms, it began to be affirmed that the maximum life expectancy had already been attained by reducing or eliminating premature mortality, especially that of children. It could now not be improved much more in that direction, but it was not even worth making the effort; in line with Ricardo’s reasoning about the diminishing yields of cultivated land, when infant mortality is already so low, the costs of any additional improvement grow exponentially and tend to infinity. The other large age group where mortality remained high, old age, could have been the beneficiary of the efforts to continue increasing life expectancy. However, budgetary stability and the reduction in the public debt demanded by the new economic orthodoxy were accompanied by two presumptive convictions about the inconvenience of making that effort: (1) high mortality in old age was “natural”, the limits of life expectancy were predetermined in each species and in the human species they had already been reached (Olshansky et al. 1990), and (2) even if the death affecting the old could be postponed, this artificially-prolonged life would only increase the years lived in poor health; it would be a pyrrhic victory. In short, the 1980s marked a critical rethinking of growing health spending on old age. Its most radical exponent is Callahan (1987), who stated directly that the concentration on health care and resources in old age was immoral and should be decisively slowed so as not to harm the other ages. Others, who were less radical, proposed the existence of an epidemiological and health transition associated with the new demographic situation, in which the primacy of infectious diseases, acute problems and early mortality had been replaced by degenerative diseases, chronic problems and late mortality (Omran 1983). Those warning of a pandemic of senile disease if the effort to extend the years people lived were

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maintained received the response that serious morbidity did not extend to all the years of old age but that it was “compressed” in the moments before death (Fries 1980). Others predicted a future “dynamic” balance between health and morbidity, as these advances occur. In any case, the decade signalled the end of self-satisfaction about the progress against mortality. From then on, the aim was to improve the quality of life achieved rather than to keep adding on the years. Secondly, this change in aspirations obliged health to be conceived in a more complex manner. Disability entered the public agenda as a problem that proved beyond the traditional medical framework. Since people’s abilities did not depend exclusively on their physical or mental functionality, being also determined by the environment, resources and their interaction with other people, future ageing strategies could not focus solely on a person’s functional state. They had also to embrace the conditions that surrounded them and that helped or hindered them from undertaking activities. This new conception of health was not individual. But, in addition to being social i.e. collective, it posed a new problem in measuring people’s own health. It was no longer possible to resort to medical or clinical data to build a general picture, information was needed on the health of the whole population and not only those who attended the doctor’s surgery or were hospitalised. The aim was to establish their relationship with age and whether it had changed. It was necessary to be able to empirically determine the effect of the increase in life expectancy on collective and individual health. Therefore, States and the scientific community were required to make a significant effort to generate knowledge. This was expressed in three main and complementary directions: 1. A call for proper statistical operations. In fact, the 1980s saw major surveys on health and disability (a notable paradigm shift, as this was no longer a question of medicallydiagnosed health, but of subjective responses in which self-perception was crucial). In addition to large national surveys (the first Spanish

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one, for example, was conducted in 1986), this effort even shifted to the international statistical agencies, as occurred in the European Union with the creation of SHARE (Survey of Health, Ageing and Retirement in Europe, see http://www.share-project.org). It should be added that the new sources increasingly sought knowledge that was longitudinal, of the life cycle, rather than transversal and exclusively devoted to a “snapshot” about each age. Contributing to this were statistical advances such as panel and biographical surveys, together with methodological ones, such as “event history analysis” (Courgeau and Lelievre 1989). 2. A notable effort was also made to conceptualise and classify the various health problems and abilities affected, which gave rise to the International Classification of Functioning, Disability and Health, the ICF (WHO 2001). Just as a century earlier through the international classification of causes of death, a fundamental tool for achieving comparability and unity of criteria in the political and scientific effort being made was thus achieved, 3. Building on the progressive achievements in the first two points, the aim was to create indicators that measured which part of the life expectancy achieved was translated into years of good health or, conversely, into years affected by disability and morbidity. This would provide an international comparative picture, one that would also be seen over time [these were years of abundant technical and methodological proposals for measuring “life expectancy in health” (Robine et al. 1991), which culminated in the 1990s with major reports like the “Global Burden of Disease” (Murray and Lopez 1996)]. Parallel to the effort to improve the knowledge of old age and the process by which people grow older, the other visible result of strategic change was a progressive attention to the individual’s own role in their way of ageing and optimising the way to do so. Epidemiological and health research revealed the growing importance of “lifestyles” or of a healthy environment to reach

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old age in optimal conditions, without the need for medical or pharmacological treatments. Consequently, the various facets with which the general objective of “good ageing” was pursued were translated into equally diverse labels, which were often too vague and undefined (successful, healthy, active ageing). It was not until 2002 that the concept of Active Ageing received decisive support.

10.6

Finally, the Summit of 2002

The process by which health became the focal point of old age policies culminated in the Second World Assembly on Ageing, which was organised by the United Nations and held in Madrid in 2002. This combined the political interest and two decades of conceptual, scientific and strategic change with regard to old age (Sidorenko and Walker 2004). The Assembly also took place in a far less restrictive economic context than that of Vienna in the early 1980s. The ambition contained in the objectives had only grown, but it also served to disprove that the transition from mortality had been concluded. On the contrary, precisely since the 1980s, in the countries advanced in this transition the possibility of death had only receded in the advanced ages, exactly the opposite of what was predicted. This unexpected good news had, however, its troubling side because it raised renewed challenges in all the areas where the alarm bells had been ringing two decades earlier (Pérez Díaz and Abellán García 2016; Bárrios 2015). Thus, international consensus was sought to structure the measures to meet the challenge of ageing and the result was the approval of the Madrid International Plan of Action on Ageing (United Nations 2002). It happened that this document faithfully adopted the definition of Active Ageing that the WHO had just proposed the same year in its document Active Ageing: A policy framework (available at https://www.who.int/age ing/publications/active_ageing/en/). From then on, the primacy of active ageing became overwhelming. It was adopted by national, regional and international policies, in

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their respective agendas, in funding lines, in strategic and research plans, until it became part of the official language. That orthodoxy may be seen from the fact that the EU declared 2012 as European Year of Active Ageing and Intergenerational Solidarity. It seemed that the multitude of proposals for conceptualising good ageing (healthy, successful, good life, productive, optimal etc.) had been left behind and a unitary vision and a common definition finally achieved. But the difficulties did not disappear. It became urgent, as had happened two decades earlier with regard to disability, to discover the data and methods to quantify Active Ageing and determine its evolution over time and the degree of success of the measures undertaken to achieve it. Otherwise, the unification represented by the new WHO paradigm was in danger of only being a rhetorical proposal without any real usefulness. In fact, the United Nations Economic Commission for Europe created the Active Ageing Index, which is multidimensional and bares great conceptual ambition. It brought together 22 different indicators grouped into four major domains: work, social participation, independent living and the capacity for Active Ageing. The first three measured the individual’s degree of achievement, while the latter sought to measure their readiness to achieve them (Zaidi et al. 2017; Rodriguez-Rodriguez et al. 2017; Lamura and Principi 2019). However, compared to the situation in the 1980s, the attention now devoted to old age had become much more diverse and holistic. Active Ageing was actually an “umbrella” slogan with which WHO wished to guide States towards comprehensive and very broad policies on old age, including health, but also economic security and participation in society, which embraces political and citizen participation. All this significantly hindered quantification, despite the fact that the initial studies on the index were presented in 2012, coinciding with the European Year on Active Ageing and Solidarity between Generations. The subsequent sustained statistical effort was enshrined in the Second International Seminar on the Active Ageing Index UNECE

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2018 (the studies presented may be viewed in full at https://www.unece.org/index.php? id¼49105) and the European Centre for Social Welfare Policy and Research was especially prominent (https://www.who.int/ageing/events/ world-report-2015-launch/en/) in it. However, so far there has been little international implementation of the index, despite the satisfaction its authors showed in presenting it.

10.7

Abandonment in 2015

The second decade of this century began with Active Ageing apparently consolidated as a global objective and political concept, a theoretical paradigm around which action and research were structured. However, to the surprise of all the scientific community dedicated to clarifying, conceptualising, measuring and discovering the most effective keys to promoting Active Ageing, or for all the types of bodies determined to use it as a reference for their own activities, the newest official WHO documents suddenly began to drop the term (Fernández-Ballesteros 2017). Once again, they replaced it with some of its other variants and, particularly, with “healthy ageing.” This was already manifest in the World Report on Ageing and Health 2015 (https://www.who.int/ ageing/events/world-report-2015-launch/en/), but above all in the Global Strategy and Action Plan on Ageing and Health 2016-2020, approved at its 69th World Assembly in 2015 (https://www. who.int/ageing/global-strategy/en/). Unexpectedly, the international organisation that since 2002 had become the main driving force behind the concept, and an obligatory reference when providing it with a definition accepted by all, had stopped using it. The change must have occurred sometime in 2014, when the studies were commissioned to organise the following year’s Assembly where the new action plan was to be approved. However, the reasons have never been made explicit. Active Ageing has disappeared from the most important documents that the WHO drafts today, but at no time has the organisation issued an official statement or a

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document that we can use to find an explanation for the term being dropped. With the perspective provided by the cumulative silence that has appeared since then, it is worth considering the possible reasons that, either separately or in combination, could explain this odd turn of events: • The apparent international unity hid important differences. Europe had adopted and promoted the approach approved in 2002 (visible in the inclusion of Active Ageing as the objective of its research framework programmes, and in particular in the creation of the FUTURAGE and similar networks) (Rodríguez Rodríguez et al. 2012). However, in the US, where the medical and hospital industry carries significant weight and a lesser connection to State policies, there is still a preference for the terms “healthy ageing” and “successful ageing”, which display a greater tradition and special emphasis on individual achievements. In American gerontology, there is a long tradition of publishing and revised re-editing of large reference “Handbooks”, which are true encyclopaedias on the state of the field, such as Springer’s The Encyclopedia of Aging: 2-Volume Set: (Noelker et al. 2006), The Encyclopedia of Aging (Maddox 2013), or the monumental Handbook of Aging and Social Sciences (eighth edition) of Academic Press (Ferraro and George 2015). After a review of the main ones, we have verified that the degree of implementation of Active Ageing in these manuals is practically nil. Even the Futurage researchers, the promoters of the Active Ageing Index and those who were convinced of their good analytical results, systematically avoid addressing its limited international implementation (Zaidi and Howse 2017). • After the apparent consensus after 2002, the truth is that operational problems persisted. Polysemy continued to hinder unambiguous definition and the breadth of the concept hindered its measurement. Holistic and transversal ambition, which had removed it from the strict medical and health field, did not produce

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the same positive results as in the precedent of the International Classification of Functioning, Disability and Health, the ICF-2001 (WHO 2001). It is therefore unsurprising that there was no consolidation of the way to measure the weight of the different risks that affect Active Ageing (e.g. non-participation), as opposed to the success achieved by measures of the risk of disease or disability (Pérez Salanova 2016). • The economic crisis that began in 2008 significantly hindered the viability of action plans on Active Ageing in Europe too. Unemployment and the consequent shrinkage in contributions again made public finances a priority compared to the mere change in the population pyramid and the needs it raised. The issue of pensions again gained in uncertainty in the face of the approved purposes of greater economic protection. This was visible even in the European Year for Active Ageing, 2012, in keeping with the European Commission publishing a White Paper on Adequate, Safe and Sustainable Pensions (European Commission 2012a, b), which followed on from the Ageing Report 2009 in recommending increasing the retirement age, limiting access to early retirement, and linking what would be received to what had been contributed. This consolidated a perverse use of the “active” concept as a literal synonym for the postponement in the age at which the active working life ends. This was the case in the Spanish reform of 2013, approved under the following label: “Royal Decree-Law 5/2013, of March 15, on measures to encourage the continuity of the working life of older workers and promote Active Ageing” (Jefatura del Estado 2013) (highlighted by the author). The contrast with the concept defined and promoted by the WHO was very visible. • Without the WHO being able to anticipate it in 2002, much of the research work on old age has been diverted to new technology companies that will save in health spending in the future thanks to information and communication technologies (ICT). This

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unforeseen reorientation is enshrined in the statement of priority research topics to be funded by the EU in Horizon 2020, where ageing only appears unless in relation to the development of these ICTs (https://ec.europa. eu/programmes/horizon2020/en/news/hori zon-2020-work-programme-2018-2020). • The WHO is in reality reinforcing its strategy embodied in the ICF-1991 by now placing the emphasis on health and healthy ageing, defined as that in which functional capacities are maintained (Rodríguez Mañas 2016). The current replacement of Active Ageing with “healthy” occurs with a much broader conception of health than was covered in the 1980s. Internal dynamics have certainly influenced the WHO itself; the sectors that are less satisfied by the great breadth and vagueness inherent in the concept of “active” in reference to ageing have never gone away. These sectors are more likely to circumscribe the general strategy of good ageing in its facet of health. It is even possible that behind the big issues, strategies, international agreements and action plans, the action and ideas of individuals within the WHO itself carry significant weight in the most recent change. We may, for example, speculate on how this coincides with the retirement of Alexandre Kalache, the Director of the WHO’s “Ageing and Life Cycle” programme until 2008. He was one of the most involved and influential supporters of Active Ageing as a lynchpin of strategies and the promoter of the work document Active Ageing: a Political Framework, which was presented at the Second World Assembly on Ageing in Madrid in 2002. The founder in 2012 of the International Longevity Centre Brazil (ILC-BR) and Co-Chair of the Global Alliance of ILCs and prominent promoter of the WHO Friendly Cities project in 2007, even in 2015 he stood out for initiatives like the inclusion of a fourth pillar of Active Ageing -lifelong learning-, adding to the three proposed in the 2002 document (health, participation and safety) (ILC-BR 2015; Bárrios 2015).

10.8

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Discussion and Conclusions

Whatever the reasons why the WHO has suddenly stopped using Active Ageing as the axis for its action plans with regard to old age, we need to take stock of the results obtained after over a decade of its promotion, an indispensable element for judging why the term has been dropped. Even if this leads us into an area that might be open to subjectivity, the authors of this chapter believe that the expectations generated have not been properly satisfied. From the conceptual and scientific viewpoint, unification and clarification remain a challenge. On the one hand, the notable institutional and financial support for research has been made from a political and dirigiste conception of the topics to be funded. The result has been that for years practically the only way of receiving financial support for research into old age has been to propose studies that included the Active Ageing label. Paradoxically, the result has been to increase heterogeneity and noise, and hinder conceptual and methodological unification. Another trend observed whose results were surely not expected is the intensification of holism in official discourses. Until the 1980s, old age and health were separate as public policy objectives, but since then they have tended to become a single issue that encompasses increasingly more dimensions (health, well-being, participation, quality of life etc.). The problem is that the change from “old age” to “ageing” becomes a black hole that drags everything in. Ageing is a process that embraces practically all life and all its spheres, so that since 2002, by subsuming issues as different as pensions, work, disability, political participation or social and family relations, the conceptual framework of Active Ageing has ended up including the full life cycle. However stimulating it may be, this globalising effort makes it very difficult to implement the strategies and actions to be taken. On the other hand, and with regard to the recent changes observed in old age, which include a marked improvement in its life expectancy both in terms of years and living conditions,

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these can hardly be attributed to policies associated with Active Ageing. More than the recent recommendations on individual behaviour or public strategies, and with the same logic of the life cycle that sustains the perspective of Active Ageing, it should be acknowledged that improvements were gestated many decades earlier, in the earlier stages of life, including childhood, of the successive generations to have now entered old age. Long before, that is, the strategy of Active Ageing was formalised. In the light of the above, Active Ageing has probably been ambiguous in sustaining a strategy on old age, understood as a part or type of the population, while appealing to the dynamic concept of ageing as a universal life process. On many occasions, what in theory were proposed as new ways of ageing, directed by public policies, were really only new ways of treating those who are now aged. But this criticism can be made even more insidious and general. In this chapter, we have attempted to clarify the present state of Active Ageing as a concept with differing degrees of implementation and possible uses, drawing a broad historical picture of its evolution. Observing its origins in the specialised practices of the healthcare facilities for the older persons, and its conversion into a tool of international strategies since the 1980s, it might be asked whether its underlying engine has not always been to reduce public spending. Throughout this process, and despite the official rhetoric of national and international bodies, it is possible that Active Ageing has always served to shift a growing burden imposed by the weight of good ageing onto individuals themselves, onto their families and social environments, and onto the market. If this general criticism were substantiated, then the labels and theories employed to denominate this strategy would have been merely instrumental for the institutional, political and scientific actors involved; each would have done so for their own reasons (the need to finance their work in the case of researchers, the need for administrations to give themselves an innovative sheen etc.).

J. Pérez Díaz and A. Abellán García

Among all the uncertainties that the WHO has generated in recent years when reverting to the term “healthy ageing” instead of Active Ageing, the most obvious is whether this change will become generalised and signal the end of the concept. In any case, if the change of label entails the abandonment of the aspirations of the 2002 action plan, based on the trilogy of healthparticipation-financial security, to reduce everything again to the first, it seems clear that we are talking about a backward step. Beyond the concepts on which the strategies regarding old age and health are based, the challenges to which the initiative on Active Ageing attempted to respond remain very much with us. It would have helped for the WHO to explain to some degree its terminological and conceptual change, because it is also possible that, far from a retreat towards a more health-based conception of strategies to promote good ageing, the explanation lay in the broadening of the concept of “health” to extend it to the other two areas, participation and security. Even former proponents of Active Ageing as a strategic lynchpin are currently reclaiming other terms (healthy, successful etc.) without experiencing any difficulty in continuing to support the same strategic proposals. Fernández-Ballesteros et al. (2019) provide a manifest example of this attitude. In any case, the need for a global, coordinated response to the revolutionary change in dynamics and demographic structures has not gone away. Rather, it will become increasingly urgent. The baby-boom generations will soon be reaching the age of 65 but there also will be a rapid expansion of life beyond 100 years, a radical modification of traditional human population survival. We are at the threshold of super-longevity, and this must begin to be raised seriously as a challenge (Araújo et al. 2016) beyond the simple increase of old age in age ranges as a whole. Acknowledgments This study was funded by: i) SURVIVAL-APC project (MICINyU, Retos Investigación 2018; ref. RTI2018-097812-B-100; 20192021); ii) ENVACES project (MINECO/FEDER/UE; ref. CSO2015-64115-R; 2016-2019); iii) ENCAGE-CM Program (Comunidad de Madrid/Fondo Social Europeo; ref. S2015/HUM-3367; 2016-2019).

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“Active Ageing”: Its Relevance from an Historical Perspective

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Transnational Aging and Quality of Life

11

Vincent Horn

11.1

Introduction

In this chapter, two concepts in the field of aging that thus far have not been systematically connected are brought together: Quality of Life (QoL, thereinafter) and transnationalism. Both concepts lack a common definition and no consensus exits on their meaning, operationalization and measurement. What definition is used and how the concepts are measured are largely contingent upon the field of research and research questions addressed. In studies on older people’s QoL, both quantitative and qualitative approaches have emerged, drawing on objective measures and subjective accounts of older people, respectively (Bond and Corner 2006). Quantitative approaches usually use indexes and scales developed to capture different dimensions considered to be relevant to older people’s QoL, such as health, social relationships or economic situation (Diener and Suh 1997). Qualitative approaches emphasize that older people should define QoL for themselves, as their accounts can incorporate more and different dimensions than traditional quantitative approaches (Bowling et al. 2003). In this chapter, it is argued that transnational contexts and processes will become increasingly relevant to the study of older people’s QoL, demanding a careful and systematic consideration V. Horn (*) Institute of Education, Johannes Gutenberg University Mainz, Mainz, Germany e-mail: [email protected]

of transnational aspects in the development of research designs, theoretical reasoning and political interventions. Initially, transnationalism was defined as “the process by which transmigrants, through their daily activities, forge and sustain multi-stranded social, economic and political relations that link together their societies of origin and settlement” (Basch et al. 1994: 6). Since then, ‘transnationalism’ and ‘transnational’ have become widely used terms in migration studies to refer to all kinds of connections between individuals, networks and communities across national borders (Vertovec 2009). It is due to this indistinct use and the variety of conceptualizations and typologies, that transnationalism remains a fuzzy concept. Consequently, Boccagni (2012: 120) concludes that “the prospects for operationalizing transnational processes—or even to measure them in terms of intensity, extent, frequency or degree” are still limited. Despite its theoretical and methodological flaws, a particular merit of transnationalism is that it shifts our perspective to phenomena which may have existed but were not being seen and conceptualized as transnational before (Smith 2003). Another particular use of transnationalism is to question the methodological nationalism deeply rooted in social sciences, according to which nation states are the quasinatural frame for social practices (Wimmer and Glick Schiller 2003). Methodological nationalism still characterizes most research on aging (Torres

# Springer Nature Switzerland AG 2021 F. Rojo-Pérez, G. Fernández-Mayoralas (eds.), Handbook of Active Ageing and Quality of Life, International Handbooks of Quality-of-Life, https://doi.org/10.1007/978-3-030-58031-5_11

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2013; Toyota and Xiang 2012), including studies on older people’s QoL. Transnational aging provides a methodological lens to explore the intertwining between transnational processes and older people’s lives (Horn and Schweppe 2017). It asks questions about the types and scope of older people’s transnational involvement and the significance of transnationalism for older people’s self-concepts and everyday lives. As a multi-level concept, transnational aging seeks to disentangle the relationships between different, often interlinked levels of analysis (Horn and Schweppe 2015). At the micro level, transnational aging focuses on biographical projects, everyday routines and practices, life experiences, identity formation, individual and family histories and relationships (Dossa and Coe 2017; Treas 2008; Zontini 2015). At the meso level, transnational aging is concerned with migration, labor market and social security systems, social institutions and social services and their implications on older people’s behaviors, decision-making and transnational family arrangements (Lunt 2009; Montes de Oca et al. 2013). Finally, at the macro level, transnational aging explores how global politics, welfare state development and ideologies of aging relate to older people’s life (Horn et al. 2013). The facets of transnational aging are manifold and comprise both tangible cross-border activities such as travels and the sending of gifts or remittances and abstract types of border-crossing such as nostalgia, longing for distant kin or imagined co-presence (Baldassar 2008; Laubenthal and Pries 2012). The type and intensity of transnational involvement in old age varies over the life course and over life events such as birth, death or retirement. Thus, rather than a constant mode of being, transnational aging can be more relevant during some phases of life than during others (Kobayashi and Preston 2007). In addition, no individual can be purely transnational, as many vital needs have to be satisfied locally and immediately. Hands-on care, for instance, can be organized but not provided from a distance. Despite all advancements in the field of new information and communication technologies (ICTs), place still plays a pivotal role (Baldassar

V. Horn

2016). Mobility rights, transportation infrastructures, access to the Internet, time and financial means are therefore of particular importance for an individual’s capacity to be present in two or more localities in different countries more or less at the same time (Horn 2019). The question of how transnational aging relates to QoL in old age has been addressed more implicitly rather than explicitly thus far. This chapter shows that the two are inherently linked with each other. A transnational approach to old age can be seen both as a strategy to improve QoL and as an undesired condition in which older people involuntarily find themselves. To illustrate the relationship between transnational aging and QoL, this chapter begins with an overview of different fields of research in which transnational aging emerged as a lens for studying older peoples’ lives. Against this backdrop, different domains are identified in which transnational aging touches upon dimensions relevant to QoL, including social relationships, social roles, health and dependency. Finally, the potential and methodological implications of a transnational aging perspective in research on older people’s QoL are discussed. The chapter builds on an analysis of selected literature from the field of transnational aging, including an ample body of studies published over the last two decades. It covers literature that emerged in different areas related to aging in transnational contexts, such as aging migrants and international retirement migrants. The studies selected touch upon at least one of the dimensions of QoL defined above in the broadest sense. Subsequently, the studies were assigned to one (or more) dimensions of QoL and their main concepts and findings were identified. For a better understanding of outcomes and possible shortcomings, attention was paid to the data and methods used. Finally, studies with similar objects of inquiry were grouped together and analyzed regarding their potential associations with the dimension(s) of QoL to which they had been assigned.

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Transnational Aging and Quality of Life

11.2

Transnational Aging: Fields of Research

Transnational aging is a young but growing research field which has evolved in different areas of study more or less in parallel. According to Horn and Schweppe (2015), different broad and often overlapping strands of research in the field of transnational aging can be identified. A first strand developed in research on aging migrants in industrialized countries. Studies on aging migrants tend to focus on their vulnerabilities originating from the risks of migration and the accumulation of disadvantages through their life course (Ciobanu et al. 2017; Treas and Batalova 2009). Accordingly, these studies examine the stressors older migrants encounter in their country of residence, analyzing the relationships between ethnicity and social disadvantages, e.g. in terms of health, housing etc. Due to the host country focus, studies on aging migrants’ QoL only rarely control for the effects of transnational dimensions and their associations with the dependent variable. However, a growing body of literature can be found which approaches aging migrants from a transnational vantage point. Researchers in this strand examine aging migrants’ transnational family ties and practices such as pendular migration, the sending of remittances or long-distance communication (Fokkema et al. 2015; Hunter 2018). This research reveals how aging migrants develop strategies to maintain access to health care and social services in the host country while simultaneously maintaining close ties with family and friends in their country of origin (Burholt 2004; Palmberger 2017). Even when no longer able to travel, aging migrants still long for past places and transnational social ties (Mellingen Bjerke 2017). Drawing on Levitt and Glick Schillers’ (2004) differentiation between “ways of being” and “ways of belonging,” Zontini (2015) shows that although transnational practices (“ways of being”) may diminish with advanced age (e.g., because of reduced mobility), the same does not apply to identities and sense of self (“ways of belonging”).

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Whilst most of this research is on migrants who have spent a substantial part of their lives abroad, recently a research strand has emerged in which more attention is given to those who migrated or became mobile at an advanced age. Migration can take place throughout the life course, not just at earlier stages in life (Blakemore 1999). Nedelcu (2009) introduced the term of “zero generation” to conceptualize older people who (permanently or temporarily) join family members abroad and/or stay in frequent contact through the use of ICTs (King et al. 2014; Nedelcu 2017; Zickgraf 2017). Treas and Mazumdar (2004) described the principal reasons for older family members joining their children in the US as follows: “Children encourage aging parents to come here to help out with their children, to share the benefits of life in the US, or to be nearby so that they can receive care” (Treas and Mazumdar 2004: 244). Although pulled to another country, these older people maintain multiple ties with their country of origin while simultaneously transferring their cultural and social capital (e.g. language, traditions, and cuisine) to their grandchildren in their new country of residence, hence becoming “truly transnational” (Treas 2008: 472). Another type of migration or mobility in old age is known as international retirement migration (King et al. 2000), also referred to as lifestyle migration (Benson and O’Reilly 2009). This third stand of research explores the motivation, adaption strategies and residence patterns of retirees from relatively wealthy countries moving to countries with better climates, more attractive leisure options and lower living costs (Breuer 2005; Toyota 2006). This research shows that older people often develop transnational life-styles, characterized by periodic changes of residence (multilocality), engagement in transnational socio-cultural and political activities, transnational health care use and the formation of transnational identities (Gustafson 2008; O’Reilly 2000; Rodes García and Rodríguez Rodríguez 2018). Whilst the early focus of this research was on Spain, a diversification of destination countries for international retirement migration can be observed, including Latin America

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(Croucher 2018; Hayes 2014) and South East Asia (Green 2015; Wong and Musa 2014). As retirement migrants in Spain and elsewhere are aging, another shift in the research can be observed, from younger to older retirement migrants and to questions related to social support networks, transnational care strategies and so on (Hall and Hardill 2016; Gavanas 2017; Oliver 2017). With older people moving abroad for the consumption of health and long-term care services, a new nuance of mobility in old age has recently been emphasized (Horn et al. 2015; Schwiter et al. 2019). However, older people do not necessarily have to be mobile themselves in order to be involved in or affected by transnational processes. A fourth strand of research therefore emerged on older people ‘left behind’ by emigrated kin. Older people ‘left behind’ have become a common phenomenon in regions with high out-migration, mainly in relatively poor countries throughout Africa, Asia, Europe and Latin America (Timmerman et al. 2018; Zimmer et al. 2014). With the family often being the principal or even the only provider of care and support in old age, older people ‘left behind’ are at particular risk of neglect and abandonment (King and Vullnetari 2006; Van der Geest et al. 2004). These risks can be reduced by the presence of other relatives but also accentuated, for example, when younger family members are absent or forced to leave because of wars or conflicts. In sum, the different strands of research show how older people’s social and geographical frames of reference are remodeled due to their own or others’ cross-border mobility. However, the circumstances and motivations for aging transnationally are highly diverse, as are the subjective experiences of the older people involved. Thus, while for some transnational aging may be a deliberate option, others may opt for a transnational approach in old age to cope with social, emotional and economic problems faced in their current environment (Horn and Schweppe 2017). Others may get involved in transnational ties and practices to cope with loss and spatially ruptured social relationships.

V. Horn

11.3

Transnational Aging and Quality of Life

According to the World Health Organization Quality of Life Assessment (1995: 1405), QoL can be defined as “individuals’ perception of their position in life in the context of the culture and value systems in which they live and in relation to their goals, expectations, standards, and concerns. It is a broad-ranging concept affected in a complex way by the person’s physical health, psychological state, level of independence, social relationships, and their relationship to salient features in their environment.” Reading transnational aging literature in light of this definition, several interrelated factors affecting older people’s QoL can be identified: social relationships, social roles, health, and dependency. These will be discussed below.

11.3.1

Social Relationships

The quality of social relationships plays an important role for an individual’s perception of QoL (Peplau 1994). Good quality ties with family members and friends tend to be positively associated with better QoL in old age. In transnational contexts, social relationships are particularly affected as individuals tend to move away or be ‘left behind’. Studies on older people ‘left behind’ point out how the disruption of close ties leads to experiences of loneliness and vulnerability (King and Vullnetari 2006; Sun 2017). Feelings of loss are particularly strong, when emigrated kin cuts ties periodically or completely (Horn 2019). However, as shown by Conkova et al. (2018), older people ‘left behind’ develop mechanisms to cope with their situations. In their study, older Albanians and Bulgarians left behind began to strengthen ties with neighbors and lowered their expectations about the relationship with their children abroad. Similarly, MarchettiMercer (2012) showed that South-African older people found it helpful to establish relationships with other people to fill the gap left by the emigration of family members. In particular, contact

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Transnational Aging and Quality of Life

with people in a similar situation helped to create a “sense of universality” and mutual support (Marchetti-Mercer 2012: 384), which was perceived as comforting. Another set of studies emphasizes that intergenerational solidarity and obligations are not dissolved in transnational family configurations but undergo transformation processes (Baldassar et al. 2007; Baldock 2000). These studies show how emigrated children organize and engage in caring activities across national borders and large geographic distances. Restricted in their capacity to regularly providing hands-on care, emigrated children “generally acquire the responsibility for monetary support, while those children remaining in the country of origin take charge of the practical tasks” (Díaz Gorfinkiel and Escrivá 2012). Besides return visits and emotional and financial support (Baldassar 2015; Krzyzowski and Mucha 2014), a sense of togetherness is created through a variety of modalities, including ICTs (virtual co-presence), photos, gifts (proxy co-presence) or shared dreams (imagined co-presence) (Baldassar 2008; Nedelcu and Wyss 2016). This research reveals the potential of polymedia environments (Madianou and Miller 2012) to buffer feelings of loss and to improve intergenerational dynamics and relationships (Baldassar 2016), and thus to enhance older peoples’ QoL. In a similar vein, research on aging migrants reveals that older migrants engage in a variety of transnational practices to maintain close ties with friends and relatives in their country of origin (Burholt 2004). Relatively frequent back-andforth movements between the countries of residence and origin, often referred to as pendular migration, have become a widespread practice among aging migrants who seek to balance their physical presence in different countries (Bolzman et al. 2006). Frequent visits in the country of origin have been shown to be closely linked to the geographic location of family members (Baykara-Krumme 2013; Horn 2019). Although seemingly combining the ‘best of two worlds’, not all aging migrants “have a relaxed time during their stays in the home country” (Fokkema et al. 2015: 150). In particular, migrant women’s visits to the country of origin often seem to be

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motivated by family and community commitments such as childcare, household chores or the attendance of meaningful events like weddings or funerals. Felt obligations and unmet expectations on the part of the migrants and their significant others harbor potential for conflicts and may lead to disappointment and ambivalent feelings about social relationships (Horn 2018; Pustulka and Slusarczyk 2016). Older people who temporarily or permanently join their emigrated kin abroad later in life often do so to provide care to their grandchildren and to receive care once they are in need of care themselves (Lie 2010; Treas and Mazumdar 2004). When spending extensive hours providing childcare and doing household chores, older people’s possibilities to establish social contacts beyond the family can be limited. Language barriers and the seclusion of suburban areas are factors that can contribute to social isolation and reinforce dependency on their children (Barros 2006; King et al. 2014). At the same time, older people’s children may feel overburdened by the responsibility to organize care and daily lives for both their children and parents, placing a strain on social relationships and through this negatively affecting their QoL. This indicates that social relationships in these contexts have to be re-negotiated because of intergenerational systems of reciprocity being challenged by the norms and values of the social and economic environments in the host society (Lamb 2002). In contrast to older people moving abroad for family reasons, the search for a better QoL is at the core of the retired migrants’ decision to move abroad (Benson and O’Reilly 2009). At the same time, moving abroad in old age changes older people’s context of social integration as significant ties such as with children, friends or neighbors are no longer available on a frequent basis (Gambold 2013). This could also explain why retirement migrants tend to develop patterns of dual-residence, spending periods abroad and in their country of origin (Böcker and Balkir 2015; O’Reilly 2000), favored by the economic capacity to maintain two different houses (Rodes García and Rodríguez Rodríguez 2018). In so doing, retirement migrants are able to maintain

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local as well as transnational social ties (CasadoDíaz 2009; Gustafson 2008; Oliver 2008). According to Gustafson (2001: 391), such life in two different countries may be a “highly positive experience and contribute substantially to their perceived quality of life”. However, establishing meaningful social relationships in the new environment can be challenging as local communities may be closed and/or closer contact to co-nationals may be not available or desired, resulting in marginalization and social exclusion (O’Reilly 2007). Maintaining or intensifying ties with friends and relatives in the country of origin can be one way to cope with the lack of social relationships abroad. Still, transnational social ties do not necessarily exist or may not be strong enough to function as significant social relationships in everyday life. Finally, a relevant question is to what degree retirement migrants’ local and transnational ties serve as social support structures in times of crisis, such as sickness or long-term care (Hardill et al. 2005; Kaiser 2011).

11.3.2

Social Roles

Closely related to social relationships, transnational aging also influences older people’s roles within transnational aging contexts. Research on transnational families has shown that older people ‘left behind’ often slip into the role of mother and/or father surrogates, taking care of their grandchildren’s basic needs and education (Levitt 2001; Yarris 2017). In her study on Honduran transnational families, Schmalzbauer (2004) revealed that grandmothers in particular could help children to cope and develop positive feelings towards their physically absent parents. Studying multigenerational Peruvian families, Leinaweaver (2010) found that childcare is not the only function of these arrangements, as the grandparents also benefit from the company and support of grandchildren, especially when becoming frail and dependent elderly. Besides the local provision of care, older people ‘left behind’ have been shown to engage in various modes of distant caregiving, such as emotional and financial support (Baldassar 2008).

Through “reverse remittances” (Mazzucato 2010), they support their children at the beginning of the migration project or during times of crisis (e.g. unemployment). Nevertheless, the reverse economic support is not always free of frustration and discomfort among the providers and receivers “as they challenge the usual direction of support, anchored in social and cultural representations of migration, where the figure of the (successful) migrant is a provider of support for family members in origin countries” (Palash and Baby-Collin 2018: 8). In light of this, migrants’ perceiving the pressure to send remittances as too high may undermine contact with family members in the country of origin (Mazzucato 2008). Another type of support older people ‘left behind’ provide is care for their grandchildren abroad. In other words, they turn from a sedentary into a mobile actor (Nedelcu 2017). Older people who engage in more or less frequent trips to their children’s country of residence have been defined as “flying grandmothers” (Goulbourne and Chamberlain 2001) or “transnational travelers” (Deneva 2012). As suggested by a study on older Peruvians within transnational families, being able to travel is of particular importance as it enables grandparents to at least temporarily comply with the cultural norm of being co-present grandmothers and grandfathers (Horn 2019). Similarly, Vullnetari and King (2008: 161) pointed out that what ‘left behind’ older people are missing above all “is their ‘natural right’ to be grandparents with their grandchildren living close at hand: the emigration of their children denies them this aspect of care-giving, nurturing the new generation, with devastating emotional consequences.” A different constellation can occur when older people join family members abroad. Whilst implicitly or explicitly expecting to spend time with their children and being treated according to the cultural norms in their country of origin, they might find themselves in situations of prolonged parenthood and ambiguities. Studies revealed older people’s dissatisfaction with the attention received from their children after moving abroad (Díaz Gorfinkiel and Escrivá 2012; Zhou 2013),

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as family norms valid in their country of origin are no longer binding in their new environment. Zhou (2013: 59) points to this discrepancy in the case of Chinese families in Canada: whilst Chinese “seniors’ transnational care and later immigration were driven by the traditional notion of family, such a notion has become increasingly selective for adult children and ‘abstract’ for the grandchildren’s generation” (Zhou 2013: 59). Other studies showed how older people struggled with dependency and—especially in case of older men—their primary role as caregivers (Deneva 2012; King et al. 2014). Studying Bulgarian families in Spain, Deneva (2012) points out that Bulgarian men in their 50s and 60s moved to Spain to care for their grandchildren but rapidly took up jobs in agriculture or construction. Consequently, they limited their childcare activities to minor tasks such as picking their grandchildren up from school. Through earning their own money, these older men could slip back into their role as working individuals and reduce the shame they felt for performing a ‘female activity’. The older women in this study also felt ashamed, not because of providing childcare, but because of neglecting their family responsibilities in their country of origin. These findings indicate that gendered social roles and norms are neither easily transformed nor complied with in the transnational aging context. Social roles play an important role among aging migrants as well. In his study on aging migrant workers in France, Hunter (2018) showed that for some of the older men, retaining their social role as breadwinner after retirement was very important. Instead of returning to their country of origin, they stayed in France and sent remittances to support their families financially. However, while being able to uphold their social role as breadwinners, they lost part of their patriarchal authority within their families due to prolonged periods of absence. Accordingly, gaining enough money to be able to afford being frequently present in their earlier communities is crucial for aging migrants to maintain their status and social roles within transnational families. As Montes de Oca et al. (2013: 74) point out: “The growth of the family, including grandchildren and

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great-grandchildren, plays a substantial emotional part in the lives of elderly Mexican migrants. The hierarchy and prestige associated with the revered roles of grandfather or great-grandfather are very important to Mexican families. This is an important aspect that influences the subjective wellbeing of the elderly.”

11.3.3

Health

Health is a key factor for an individual’s QoL. However, the knowledge about the relationship between transnational ties and practices for older people’s well-being is still limited. Thus far, findings from studies on the effects of transnationalism on older people’s health and well-being are mixed, partly because of methodological reasons. Different dependent variables are used, as well as different measurements of transnational ties and practices, making comparisons difficult. Moreover, transnational involvement can have a complex bearing on older people’s health. Remittances, for example, may improve physical health through better access to health care services and improved access to food and better nutrition. However, the positive effect of remittances may not offset the increased level of stress and depression caused by spatial separation from close family members (Ivlevs et al. 2018). Some of the studies in this field explore the relationship between different family types and different dimensions of older people’s well-being. Analyzing data from two Mexican surveys, Antman (2010) and Arenas and Yahirun (2011) found that older people with children who migrated to the US reported poorer psychological well-being than their counterparts with all children living in Mexico, they did not find any for overall depressive syndrome, wishes to die, or anxiety. Yahirun and Arenas (2018: 986) therefore argue that the emigration of children “triggers very specific emotions” for older people staying behind. In contrast, exploring data from a sample of 550 older people in China, Guo et al. (2018) did not find a significant statistical relationship between family type and older peoples’ well-being. Their findings showed that older

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people in non-migrant, internal migrant, transnational, and hybrid (with both migrant and non-migrant children) families had similar levels of depression and life satisfaction. Other studies focus the relationship between transnationalism and loneliness of older migrants in different countries. Klok et al. (2017) measured the association between loneliness and transnational belonging among older migrants in the Netherlands, finding that a sense of transnational belonging is associated with more loneliness. Similarly, Park et al. (2019) studied loneliness and social isolation among older Asian migrants in New Zealand. In their qualitative study, they reveal that social isolation and loneliness in this group is closely related to their transnational family context: “it is fair to conclude that aging in a foreign land involves a range of challenges, among which are social isolation and loneliness mainly caused by the lack of family contact or support in a transnational family setting” (Park et al. 2019: 746). This indicates that public interventions against loneliness should both take into account older people’s local and transnational ties. Another set of studies analyzes the transnational consumption of health care among older migrants. Older Chinese migrants in New Zealand, for instance, have been shown to travel to China for health checks, dental services, and cancer treatments or to consume traditional Chinese medicine (Li and Chong 2012). Similarly, Sun (2014) reveals how older Taiwanese migrants try to maintain their health and wellbeing by accessing the benefits of public healthcare available in their country of origin rather than in the USA. However, transnational health care strategies can be a risk, for example, if medications and treatments in different countries are not coordinated. Other studies show that older migrants opt against definite return in order to maintain access to health care services in the country of residence due to the high quality of these services (De Coulon and Wolff 2010; Hunter 2018). According to survey data on Southern-European older migrants in Switzerland, the quality of health services is the second most important reason not to return after

V. Horn

retirement (the first is living close by children and grandchildren) (Bolzman et al. 2016). Health is also relevant to retirement migrants, as a motivation for their mobility but also an issue that can become important during their stay abroad. Numerous studies show that retirement migrants expect the warmer climate in the destination country to better their health conditions (Blaakilde 2013; Huber and O’Reilly 2004). The relatively low costs of health care services in some of the popular destination countries (e.g. Mexico, Spain) is another often cited reason for motivating retirees to move abroad (Ackers and Dwyer 2002; Sunil et al. 2007). Despite the relatively low costs for health care services abroad, many retirement migrants seek to maintain access to public health care systems in their countries of origin and keep consulting medical doctors during visits, phone calls or through the Internet (Gehring 2016; Lardiés-Bosque et al. 2016). Language barriers, lack of trust or unfamiliarity with health care systems abroad can contribute to these transnational health care strategies. Moreover, in the event of deteriorating health conditions and more severe care needs, returning to the country of origin is a widespread practice among retirement migrants (Haas 2013; Hall and Hardill 2016), although not all are able to do so (Kaiser 2011). In contrast to this are movements of older people to care facilities established in low-income countries like Thailand, Malaysia, Poland or Bulgaria (Bender et al. 2014). These care facilities specifically target older people from wealthier countries by promising not only cheaper but also more personalized and holistic care than supposedly available in the older people’s countries of origin (Horn et al. 2015). The precise reference to the care situation in wealthier countries indicates that the operators of these care facilities are well-informed about the criticism levelled towards the provision of long-term care in those countries (Bender et al. 2014; Großmann and Schweppe 2018). Empirical insights about the quality of care provided in these facilities are still scarce and point to very diverse experiences and practices, varying from one facility to another (Horn et al. 2015). Future

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research will have to analyze how older people’s QoL is affected by moving to another country in health conditions impeding social integration and self-determination in the receiving context. What if local and transnational networks and safety structures do not protect older people from abuse and neglect?

11.3.4

Dependency

Dependency in contexts of transnational aging is another aspect relevant to older people’s QoL. As in other contexts, dependencies in transnational contexts come in various forms, including financial, practical and emotional. Financial dependency in the form of remittances is a common feature among older people ‘left behind’ in poorer countries. In their study on older Albanians ‘left behind’, Vullnetari and King (2008) found significant differences in the material well-being between those receiving remittances from their emigrated children and those who did not. Those not receiving remittances from abroad “had to forage for survival on a near-starvation diet, making broth from grass and weeds” (Vullnetari and King 2008: 139). Compared to this, older people receiving remittances from their children enjoyed a better standard of living but generally described their emotional wellbeing as poor due to the absence of their children and grandchildren (see point about health above). To a certain degree, the pain of separation might be alleviated by the use of ICT-based communication which allows manifold ways of (instant) virtual connectedness (Baldassar et al. 2017; Madianou and Miller 2012). Different studies show how older people adapt to and incorporate different modes of ICT-based communication in their daily lives (Ivan and Fernández-Ardèvol 2017; Nedelcu and Wyss, 2016). Nonetheless, there are several limits to ICT-based communication, such as the inability to intervene quickly in risk situations (MarchettiMercer 2017; Parreñas 2014) or the lack of an adequate Internet-infrastructure, like in Cuba (Brandhorst 2017). In addition, ICT-based communication entails a heightened risk of conflicts

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and misunderstandings. Thus, while facilitating a space for intergenerational cohesion, ICTs “can also exacerbate the emotional distance between generational groups as well as generational distance” (Tarrant 2015: 295). Older people who are not as familiar with the use of ICTs may feel excluded or dependent on the younger family members’ willingness to help them participate, thus creating new dependencies. ICT-based communication can also be the source of new expectations of virtual connectedness and intergenerational solidarity, generating constraints and frictions as well as the necessity to justify unavailability (Licoppe 2004). Finally, physical and cognitive impairments due to old age can hamper the older peoples’ capacity to participate and may ultimately lead to their (involuntary) withdrawal from virtual communication (Heikkinen and Lumme-Sandt 2013). Hence, the relationship between ICT-based communication and QoL is complex as it entails the potential to both enhance and diminish older people’s well-being. Dependencies also exist regarding family visits abroad. In this regard, migration regimes and their entry rules play a pivotal role. Oftentimes, travel or visitor visas are required when travelling from countries in the Global South to the Global North (Guild 2009), unless the traveler holds a ‘first-world’ passport. To successfully apply for a short-term visa, older people have to meet several requirements regarding income, property, health insurance etc. They also may have to submit a letter of commitment according to which their children are willing and able to cover their expenses during their stay abroad. Children with insufficient income or without a regular residence status are likely unable to provide their parents with such a document. Older people ‘left behind’ not capable to travel themselves are highly dependent on their children’s and grandchildren’s visits to share times of physical co-presence. However, long-distance trips with various persons are expensive, at the same time that the children’s living costs abroad increase with every child born (Horn 2019). Additionally, not all children might be disposed to travel, e.g. because of a conflictive relationship with their parents. Being deprived of seeing or

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establishing first contact with their grandchildren may be particularly harmful to the older people’s QoL. Similarly, before older people can permanently join their children abroad, several requirements have to be met. In Australia, for instance, family reunification is only available to older parents who—among other things—have reached a certain age (e.g. retirement age in the receiving country) and pass the obligatory health examination. In countries like Spain or the United Kingdom, a key requirement is that the older parents depend mainly on their children’s financial support, which is not always easy to prove. In addition, the applicants’ children (or grandchildren) generally have at least permanent residence status and dispose of sufficient financial means to sponsor their parents (or grandparents). Still, many countries do not include older parents in their family reunification programs, which are often limited to parents and their minor-aged children. Those who do offer the possibility may find other ways to prevent older people from entry such as by “discretional procedure in applications resolution” (Escrivá 2014: 163). A principle reason to hinder older people from settling is that they are seen as a burden for the welfare-state which, according to policymakers, needs young and well-educated migrants to be sustained. In sum, older people’s mobility and the mobility of their children and grandchildren are oftentimes beyond their own control and highly dependent on the political contexts surrounding their transnational family lives. The lack of control and the related feeling of powerlessness can be assumed to have a strong bearing on their QoL through its impact on health, social relationships, roles etc.

11.4

Conclusions

During the last decade, transnational aging has emerged as a methodological lens for gaining a deeper understanding of older people’s everyday lives in an increasingly globalized and transnationalized world. In this sense, transnational aging seeks to expand the traditional layers

of analysis in the study of older people and their environments by introducing a transnational perspective. Within old age research, there is still a widespread belief that older people’s geographical and social spaces gradually shrink over time. This becomes evident in one of the disciplines’ focal concepts, aging in place, (Horn and Schweppe 2017). However, as shown by an ample literature on transnational aging phenomena, being sedentary by no means adequately describes later stages in life. Older people are entangled in transnational social spaces in different ways and contribute to their maintenance through a variety of modes, including crossborder travels and ICT-based communication. Using the concepts of social relationships, social roles, health and dependency, this chapter aimed to shed light on the relationship between transnational aging and older people’s QoL. It has been shown that within transnational contexts, social relationships are remodeled without obligations and commitments being dissolved. New routines and rituals are developed, as everyday practices of ‘doing family’ can no longer be practiced in the same way as before. Moreover, within transnational contexts, older people’s lifestyles and social roles can be transformed, with consequences for their QoL. This may be the case, for example, when older people take on the role of transnational grandparents and gain by establishing intimate relationships with their grandchildren at a distance as well as during periodic stays abroad or in the country of origin, respectively. In so doing, older people may feel that they are fulfilling their socially ascribed role as physically present and caring grandparents, with positive implications for their self-concepts and social identities. At the same time, geographic distance from grandchildren and the (everyday) demands of care obligations may “serve to enhance relationships and increase the grandparents’ ability to provide other forms of help. In other words, it may give them a better sense of control over the intensity and forms of grandparental support” (Repetti and Calasanti 2019: 14). Hence older people in transnational family contexts may experience enhanced independence and a higher quality in relationships,

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due to a more facultative way of grandparental support. However, as indicated regarding older people’s health, the relationship between transnational aging and QoL is complex. Improving one aspect of QoL can impoverish other areas, leading to ambivalent outcomes. Aging in transnational contexts can improve the material dimensions of older people’s QoL, e.g. through remittances. It may also have a positive effect on their health, for example when emigrated children purchase medicine or organize care arrangements from abroad (Díaz Gorfinkiel and Escrivá 2012). Such positive associations between transnational aging and QoL are highlighted by studies which find that older people with children abroad tend to be better off in health and economic terms than their counterparts without children abroad (Böhme et al. 2015; King and Vullnetari 2006; Kuhn et al. 2011; Nguyen et al. 2006). At the same time, older people may experience emotional strains and a lack of practical support in everyday life. In addition, the children’s transnational support practices may create new dependency relations which older people may not desire or could even reject (Skornia 2014). Older people may depend on their children’s financial support, and also on their control of access to and information about grandchildren abroad (Horn 2017). Experiences of loss, dependency and powerlessness may increase the risk of mental health problems such as depression or anxiety. Exploring the simultaneous impact of factors that are enhancing and/or diminishing different dimensions on older people’s QoL will be a crucial task for future research. In sum, the examples suggest that transnational aging may affect multiple interrelated dimensions of QoL. Still, the implications of transnational aging for QoL in old age are yet to be fully explored. Future research on QoL in old age should incorporate a transnational perspective in their research designs to expand our knowledge on the relevance of transnational ties and practices. This includes a revision of standardized measures as well as exploratory research designs and the analysis of older people’s narratives in qualitative research. More empirical evidence is

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needed for a better understanding of QoL and the development of political interventions tailored to the needs of older people in times of mobility. This requires awareness of the pivotal contribution of older people to the well-being of transnational families and as enablers of younger migrants’ labor market participation and social reproduction in wealthier countries.

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What Should Guarantee Pensions Systems Designed with a Human Rights Approach?

12

Sol Minoldo and Enrique Peláez

12.1

Introduction

The population ageing generates huge transformations which require an overhaul of economic and social institutions in order to meet the demands and challenges of a new conjuncture. In this context, analyses of the characteristics, limitations and challenges faced by social welfare systems for the elderly take on particular importance as qualitative determining factors shaping the conditions under which ageing progresses. Particularly, economic security constitutes an essential basis for autonomy and, consequently, an important side of active aging approach. One often problematized question regarding social security systems around the world is the institutional restriction of contributions-based protection which systematically excludes those who have not fulfilled a given period of contributions payments before reaching retirement age. Another issue less discussed, also related to the contributory model, is the stratification of the protection around ‘earnings replacement’: whether as part of an actuarial logic based on contributions made, or as an income defined according to the rate of salary replacement, most pensions systems distribute benefit payments which are unequal in terms of purchasing power among beneficiaries, on the basis of their income S. Minoldo (*) · E. Peláez Centre for Research and Studies on Culture and Society, National Council for Scientific and Technical Research (CIECS-CONICET) (UNC), Cordoba, Argentina

during their economically active life (Gomez Sala 1994; Piffano et al. 2009). This distributive model around which social security is structured is consistent with a particular view of the social function of these systems, the rights which they aim to enshrine, the subject of said rights, and specific criteria related to distributive justice. The way in which these concepts have been defined is connected to the two traditions which constitute the main precedents and benchmarks for the development of large scale systems of state welfare: namely, the Bismarck (implemented in Germany by Otto Von Bismark at the end of the nineteenth century) and Beveridge (recommended to the English parliament in the “Beveridge report” in 1942) models. Over the last few decades the human rights based approach has acquired particular relevance both for orienting public policy and for academic analysis. This approach identifies a guidance framework in international law, comprising various international treaties and, mainly, human rights instruments. Far from being a list of static prescriptions, international law is in a state of constant growth, developing new instruments every decade. Since “progressive realization and non-retrogression” is one of the principles of that development, the trajectory always inclines towards the expansion of rights. In this light, it is worth inquiring whether the coincidence of social security traditions which arose simultaneously with the first human rights treaties

# Springer Nature Switzerland AG 2021 F. Rojo-Pérez, G. Fernández-Mayoralas (eds.), Handbook of Active Ageing and Quality of Life, International Handbooks of Quality-of-Life, https://doi.org/10.1007/978-3-030-58031-5_12

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remains valid and suitable for the current period, when we take into consideration the rights that those treaties promoted many decades later. In this chapter we propose to explore the current implications of approaching social protection, and in particular the elderly social security, from a human rights approach. To that end, we examine how different human rights instruments approached to two main questions: Firstly, how ‘the subject’ with social security rights in particular is defined, and how ‘the subject’ of old-age protection in general is defined. Is the rightsbearing subject the worker? Or the older person? In this sense, it would be useful to identify whether the right to protection and social security is conditioned by fulfilling certain “criteria” (in terms of certified number of working years or the compliance with periods of contributions), by the existence of a “need”, or by the recognition of a citizen’s right defined by age. Secondly, how is the right which must be guaranteed defined and, as a consequence, what are the criteria of distributive justice which must guide the implementation of income transfer systems for older people? We will attempt to establish how the definition of ‘economic security’ for older people, which pensions systems are aimed at guaranteeing, is conceived of and understood. Is it understood as meaning the preservation of the living standards and consumption levels that were enjoyed during working life? Or is the security of access to material resources at a level established collectively (in other words, one that is guided by criteria as the amount necessary to “guarantee autonomy”, a “dignified standard of living”, or that guarantees “participation in the benefits of development”)? In order to determine how these questions are dealt with from a human rights perspective, in this chapter we perform a content analysis of all the human rights instruments that relate to the elderly economic and social rights. Our aim is to establish whether those concepts have undergone any transformations and what the current definition of who the subject of old-age rights protection is, what the priorities of that protection are, and what the main distributive characteristics and quality are. As part of the analysis, international instruments will be included as well as those of

S. Minoldo and E. Peláez

the Inter-American Human Rights system, which are especially relevant for a region experiencing an accelerate ageing process while lacking the social and economic institutions of developed countries. After explaining the two fundamental principles which structure the distribution of protection under contributory systems of social security, and commenting on their main social implications, we will briefly outline their conceptual foundations: the Bismarkian and Beveridgean traditions which laid the groundwork for the main precedents of public policy design. Next, the methodology employed in the research for this chapter is presented along with our findings and our analysis of the content of the human rights instruments. Finally, in the conclusions we reflect on the implications of our findings for the design and evaluation of social policies for the elderly protection, and more specifically for social security systems.

12.2

The Distributive Model of Contributory Social Security

The fundamental criterion for the distribution of protection is related to the very definition of access to the right, which primarily covers paid workers in the formal sector, in other words those with a history of contributions payments on the labour market, excluding (or providing a lower quality protection to) older people who fail to meet those criteria. Within the framework of contributory systems, informal employment means that social security contributions are not made, and therefore the employment activity is not registered in the contributions history which eventually activates the right to retirement (Beccaria and Maurizio 2014). On the other hand, although the unpaid work encompasses activities related to preserving well-being and social reproduction, the tasks involved are ones whose economic value is invisibilized and, in turn, excluded from social protection recognition. Unpaid workers are those whose work does not result in earning an income (Neffa 2003) and who therefore produce outside

12

What Should Guarantee Pensions Systems Designed with a Human Rights Approach?

of the sphere of commercial exchange. Their activities do not constitute “work” in statistical or legal terms. Although the International Labour Organization (ILO) has begun to refer to work for self-consumption—part of invisibilized labour— as economic activity, the statistical instruments do not yet consider it as such (ILO 2012, p. 52). However the tasks they perform are considered to be “work” when they are carried out by people who offer their services on the market and are remunerated for them. These activities are mostly performed by women in the private sphere and although it does not necessarily imply a complete absence of a history of paid work, engagement in work not recognised as such can affect the continuity and duration of women’s employment history. So, the sexual division of labour perpetuates a discriminatory gender system which, disregarding domestic labour and care work, limits women’s chances of securing access to social protection. The design of contributionsbased social security access therefore implies a disadvantage for women’s protection, whose old-age tends to be for a more extended period (due to their longer life expectancy), as a result of which they are exposed to long periods of economic and social vulnerability. The second fundamental criterion for the distribution of contributory protection is that it generates gaps in the quality of that protection, not only between those who gain access in the first instance through complying with the contributions regulations, and those who may eventually be included outside of the main regulations, but also among those who gain access to coverage by meeting the contributory conditions. The gaps are produced either through actuarial relations with the contributions made, or through the implementation of a rate of income replacement around which the benefits are set. The replacement payments mean that the quality of protection, understood as its “capacity to satisfy needs”, will be greater for those who had earned higher wages during their economically active life. Thus, “in terms of equity, in these countries, the paradox of protection strongly emerges, in the sense that the least vulnerable

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groups are the ones that have access to more and better protection” (Bertranou 2006, p. 16–17).

12.3

The Right to Social Security in the Main Traditions

When the first social security system was established in Bismarck’s Germany, which would be the key precedent for all other pensions systems in the Western world, it was as a part of a range of instruments aimed at guaranteeing workers’ rights (Durand 1991). It was specifically a right of paid formal workers who registered their working history through a record of contributions. “The social insurance preferentially addressed occupational risks, so social insurance policy was fundamentally concerned with the working life cycle, and not particularly with other persons and groups. Therefore, the protection was aimed at [. . .] compensating for the loss of productive capacity” (Monereo-Pérez 2008, p. 57). In this way social welfare was instituted as a right, not for older persons as rights-bearing subjects, but for workers as future older people. Accordingly, the objective of social security benefits was to provide insurance to workers in case of loss of earnings on the labour market and, as a consequence, it was consistent with the criteria of income replacement used to stipulate the characteristics and level of benefits. Thus, in this model, the contributions became in turn the condition of access and a parameter for the benefit level. The latter point means that a proportionality was expected between contributions made to the fund and the benefits received (Fleury and Molina 2002). The solidarity in these systems was above all linked to an intergenerational dimension (in other words, it was produced by vertical transfers between generations, but not necessarily between the members of the same generation living in unequal material conditions). The emergence of the ‘Beveridge’ paradigm of social security entailed the expansion of rights to other workers (i.e. beyond paid formal sector workers). Although Beveridge’s proposal promoted social security as a “citizenship right”,

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the break with the right being understood in terms of “labour” was not complete: for those who were not protected as a result of their condition as paid formal workers, the protection was grounded in considering them to also be workers who, in spite of their intention to work on the labour market, were not able to for reasons beyond their control (Durand 1991). People who were engaged in domestic work, whom Beveridge referred to as “housewives”, were also considered to be workers inasmuch as they were recognised to have the right to non-contributions-based pensions. However, as they were considered “semi-workers”, their right was conditional on the specific circumstance that there was no retired man in the home (Durand 1991). In this model, although contributions lost their absolute centrality as a determining factor of access and a contribution from the state budget was included in the financing of the scheme (Venturi 1994), the coverage still centered around the contributions paying worker, and the other (non-contributions paying) workers were included as a complementary part of the system. In the Beveridge model the benefits payments were not salary replacements, but rather homogeneous for all contributors regardless of the amount contributed. But while the Beveridge model had a significant influence on the historic design of social security, the elimination of the replacement calculation for benefits payments hardly had any impact (Mesa-Lago 2004). In any case, it is worth noting that the Beveridge system did not create a total break from the idea of maintaining a relationship between contributions made to the fund and the level of benefits paid out, given that it defended the segmentation of benefits between those who had contributed and those who gained access without having made contributions. Thus, the logic of “rewarding” or “compensating” contributions with a differential level of benefits was not altogether abandoned. Almost eight decades after the publication of the Beveridge report and from the first Human Rights declaration in 1948, several human rights instruments have been created which relate to the question of social policies. While it is to be

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expected that the first documents, historically proximate to the Beveridge report, would to a great extent be inspired by a precedent whose influence on welfare states for the majority of the twentieth century is undeniable, it could also be expected that redefinitions and considerations would arise which could affect the priorities and characteristics of social security systems in order to adapt these rights for the challenges of the twenty-first century. However, debates around social security remain tied to the principles of the two main traditions mentioned above, and the scholarly literature has not given an account of any alternative tradition consistent with the human rights instruments currently available. It is therefore of great interest to advance an analysis that enables us to identify what, from a human rights approach, are the concepts and priorities that should guide the design, implementation, and evaluation of the elderly social protection and, in particular, the systems of income transfer for older persons.

12.4

Methodological Design

For the purposes of research for this study firstly we identified broad areas of competence. An initial pre-selection of human rights instruments was made, only excluding those which clearly related to other types of rights (for example political or civil), or to other age groups. Next we defined key words of interest on the basis of our object of study, and selected documents for analysis through a title and content search. The key words chosen were: quality of life; coverage; contribution/contributory; dependency; decent/dignity; distribution; age; ageing; equity/ equitable; structured; gender; hunger; equality; informal; pension; social justice/justice/just; older people; minimum; women; living standards; benefits; social welfare; social protection; retirement; economic security; social security; solidarity; sufficient; universal/universality/ universalism; old age. We should clarify that the content analysis was originally conducted in Spanish, being the authors’ mother tongue. So, it is worth keeping in mind that the key words

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presented here in English may not be the direct equivalents of those which we searched for in the official Spanish version of the different instruments. As a result, we initially chose 19 international human rights instruments and 11 regional instruments (from Latin America). During the course of the analysis we incorporated an additional five documents referred in the contents of pertinent human rights instruments. Finally, after analyzing the content of these instruments, we found that 20 of the 35 instruments analyzed were relevant to our study (5 of them with a regional scope covering Latin America, set in italics to identify them): 1. The Universal Declaration of Human Rights (1948). 2. Social Security (Minimum Standards) Convention n○ 102. Convention concerning Minimum Standards of Social Security (1952). 3. International Covenant on Economics, Social and Cultural Rights (1966). 4. Declaration on Social Progress and Development (1969). 5. World Population Plan of Action (1974). 6. World Plan of Action for the implementation of the objectives of the International Women’s Year (1975). 7. Convention on the Elimination of All Forms of Discrimination against Women (1979). 8. Vienna International Plan of Action on Aging (1982). 9. Declaration on the Right to Development (1986). 10. United Nations Principles for Older Persons (1991). 11. Proclamation on ageing (1992). 12. Programme of Action of the International Conference on Population and Development (1994b). 13. Integration of older women in development (1994a). 14. United Nations Millennium Declaration (2000). 15. Political Declaration and Madrid International Plan of Action on Ageing (2002). 16. Brasilia Declaration: Second Regional Intergovernmental Conference on Ageing in Latin

17.

18. 19. 20.

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America and the Caribbean: towards a society for all ages and rights-based social protection (2007). San José charter on the rights of older persons in Latin America and the Caribbean (2012). Montevideo consensus on population and development (2013). Inter-American convention on protecting the rights of older persons (2015). Asuncion Declaration. Building inclusive societies: Ageing with dignity and rights (2017).

In order to perform the content analysis, we selected the relevant passages from each instrument, detecting these in the first instance with the key words, and then selecting or discarding them on the basis of the context in which the key words appear. Finally, once the extracts from each document had been selected and codified, we proceeded to analyse the content, paying special attention to how certain predefined questions of interest were addressed: • We paid particular attention to the rightsbearing “subject” for social security and pensions systems. • We were particularly interested in whether, when economic security was referred to, any definition was provided or whether any indications or clues existed with which to interpret the way that concept was used. We examined whether any mention of this acknowledged the implicit or explicit existence of a market and individual logic or alternatively a collective logic of solidarity. We explored any expression which could indicate whether the objective of the protection provided by the income transfer systems was to guarantee prior levels of individual earnings, or to guarantee access to determined social or collective benchmarks for consumption (as sufficient, decent, etc). • We aimed to identify the underlying criteria of social justice: Was distribution “according to efforts” made in terms of contributions/work, prioritizing the criteria of income replacement,

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•

•

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understood as just? Or were there references to criteria of equity? How was the question of gender as a problem of social security approached, and what possible solutions were offered? How was unpaid work traditionally performed by women understood in relation to rights to protection? We looked into whether the question of work in the informal sector was discussed, along with its exclusion from contributions-based protection. We examined the proposals that mentioned the universalization of protection, identifying the modes suggested and foundations underlying them, and when minimum protection was mentioned we explored whether this took a residual/assistance form or used another framework (for example, as a temporary response to an emergency, with limited resources). The method of financing social security, particularly that based on contributions, and what role it played in the definition of its objectives and characteristics.

Certain questions also arose which focused our attention during the work of reading and interpretation of the contents, such as the modification of some terms which refer to the systems of protection based on income transfer. Due to space limitations it is not possible here to include the complete analysis of the contents, however we will describe our main findings and present some general considerations.

12.5 12.5.1

Findings Social Security from the First Human Rights

Social security was first mentioned as a right in the Universal Declaration of Human Rights in 1948 of the United Nations (UN) (1948, art. 22). From then until 1982 different instruments incorporated considerations that could be relevant to socio-economic protection of older persons,

and social security in particular. In these instruments we find no explicit mention of the right to receive an income which would meet the level of individual pre-retirement earnings. In contrast, despite bearing no relationship to social security, we found specific references to distributive justice, in an equitable sense, to protect the most vulnerable.1 On the other hand, in terms of a gender perspective, from the mid-1970s instruments dedicated to women’s rights were introduced. These sought to account for the disadvantages women faced in terms of income and protection as a result of the sexual division of labour, the undervaluing and lack of protection for domestic labour and carework, and the wage gap when women enter the labour market.2

1 For example, in the Declaration on Social Progress and Development (UN Human Rights 1969) there are references to a distributive model based on equity of income distribution, which operates as a guideline for the distributive and redistributive role of the state. In article 7 there is mention made of what is considered the foundation of “social progress” and the concerns which should be priorities for all states and governments, referring to the “equitable distribution [of the national income and wealth] among all members of society”. Later, in article 10.c (in Part II), “the elimination of poverty; the assurance of a steady improvements in levels of living and of a just and equitable distribution of income” is established as one of the main objectives for progress and social development. Next, when discussing the means and methods by which to achieve the objectives for progress and social development (Part III: means and methods), in article 16.c, the “achievement of an equitable distribution of national income, utilizing, inter alia, the fiscal system and government spending as an instrument for the equitable distribution and redistribution of income in order to promote social progress” is promoted. While these criteria allude to social policies as a whole and not particularly to social security, the World Population Plan of Action (UN 1974) stipulates that “all countries should carry out as part of their development programmes, comprehensive, humanitarian and just programmes of social security for the elderly” (art. 66). In order to grasp the sense in which ‘just’ is used here, it is important to note that the plan mentions the promotion of social justice as an objective, “particularly by means of a wide participation of the population in development and a more equitable distribution of income, land, social services and amenities” (art 32.c). 2 In 1979 the Convention on the Elimination of All Forms of Discrimination against Women (UN Human Rights

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12.5.2

1982: Older Persons as a Group with Rights

Eventually, in 1982 a specific human rights instrument for older persons was designed: the Vienna International Plan of Action on Aging (UN 1982). This instrument incorporated a large number of benchmarks and specifications for the conceptualization and operationalization of economic protection for older people: • In relation to the gender question, the limitations of social security are recognized, as it is not capable to protect older women by taking into account the wage gap as well as the consequences of the sexual division of labour for reducing or interrupting women’s trajectories on the labour market. It literally states “particular attention should be paid, in social security and social programmes, to the circumstances of the elderly women whose income is generally lower than men’s and whose employment has often been broken up by maternity and family responsibilities” and recommends that “policies should be directed towards providing social insurance for women in their own right” (item 72). This implies a break with the typically ‘indirect’ protection for women provided by social security frameworks centred on the male breadwinner, which indirectly protects women who, as a result of the sexual division of labour, perform

1979) explicitly states concern for effective equality between men and women in the enjoyment of their rights, and recognizes that full equality requires “a change in the traditional role of men as well as the role of women in society and in the family is needed to achieve full equality between men and women” (introduction). In other words, the existence of gender roles which hinder equality of access to rights is acknowledged. Among the rights explicitly mentioned as those for which effective equality should be achieved is “the right to social security” (art. 11.e). Additionally, in the subsection above this article (art. 11. d), the right to equal remuneration in respect of work of equal value is mentioned, implicitly acknowledging the gender problem known today as the wage gap. This is particularly relevant to the inequities that are eventually transferred into social security in the context of systems which aim to replace income.

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reproductive work, child-rearing, and care work. • In relation to the issue of the protected group, it recommends that “the social security system and if necessary by other means, respond to the special needs of income security for older workers who are unemployed or those who are incapable of working” (Recommendation 36. d). It is worth noting that this does not refer to older persons in general, but rather to older workers. Furthermore, the recommendation refers to responding to a special need consisting of ‘incapacity to work’. Likewise, it indicates the importance of creating or extending social security systems, in order to contribute to the duty of governments to “ensure to all older persons an appropriate minimum income” (Recommendation 36). A Beveridgean view of welfare seems to be asserted here, in which all workers, including those who could not work for reasons beyond their control, must be protected and, at the same time, the extension is conceived of on the basis of “minimum” levels. • In relation to the sum of benefits provided by social security, certain specifications are introduced as regards the level of minimum benefits: “[they] will be enough to meet the essential needs of the elderly and guarantee their independence” (Recommendation 36.b). It is important to point out that nowhere is it stated that the level of purchasing power of the personal earnings obtained during active life should be maintained. However, the document refers to the Convention n○ 102 of the ILO (1952), concerning Minimum Standards of Social Security, which does include the criterion of income replacement (as we will discuss in greater depth below). Moreover, although it is not mentioned when specific reference is made to social security, it establishes that “the aim of development is to improve the well-being of the entire population on the basis of its full participation in the process of development and an equitable distribution of the benefits therefrom” (II Principles, 25.a). And, following on from that, stressing the

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concept of equity it declares that “individuals, regardless of age, sex or creed, should contribute according to their abilities and be served according to their needs” (II Principles, 25.a). • Additionally, the concept of equity is introduced from a generational perspective, stating that “the development process must enhance human dignity and ensure equity among age groups in the sharing of society’s resources, rights and responsibilities. Individuals, regardless of age, sex or creed, should contribute according to their abilities and be served according to their needs” (II Principles, 25.a). Next it adds that an “age-integrated society” and “solidarity and mutual support among generations” are “an important objective of socio-economic development” (II Principles, 25.h). • Finally, concern is expressed for the impending impact of population ageing. In this sense, it is stated that “changing dependency ratios are bound to influence the development of any country in the world, irrespective of its social structure, traditions or formal social security arrangements” (item 35). Said changes in dependency ratio are described as “the gradually deteriorating ratios between the economically active and employed sectors of society and those dependent for their sustenance on the material resources provided by these sectors” (item 34). Confronted with this scenario, “countries with established social security systems will depend on the strength of the economy to sustain the accumulated charges of incomebasis and deferred retirement benefits for a growing elderly population and the costs of maintaining dependent children and of ensuring training and education for young people” (item 34). This suggests that the deterioration of dependency ratios is not considered to be sufficient to jeopardize the sustainability of social security, but rather that this sustainability is bound up with economic performance.

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As mentioned above, the plan underlines the importance of other instruments. One of them in particular merits closer attention: the Convention n○ 102 of the ILO (1952), concerning Minimum Standards of Social Security, which came into effect in 1955. The Convention introduced specific considerations about the characteristics of benefits that social security systems should provide. With regards to old-age benefits, some definitions are provided identifying the “persons to be protected” on the basis of four criteria. Two of these consist of certain categories of employed workers. Another stipulates that the protected group represent certain categories of the economically active population. The last encompasses all residents whose resources during old-age do not exceed certain pre-established limits. Thus, in three out of the four alternatives, the protected subject is the worker or the economically active working population. In contrast, the stipulation directed at residents is compatible with a type of citizenship right, although as we will explain below it constitutes an inferior quality of protection in comparison with the others, consistent with a Beveridge model of social security. Additionally, the convention specifies how the benefit payments should be calculated, describing criteria of income replacement: • When the protected population is defined by one of the three aforementioned criteria (i.e. falls within certain categories of employees or categories of the economically active population), a mechanism of proportionality is established as regards prior earnings, putting in place some considerations in which some benchmarks are individual (the personal earnings of each worker), and others are collective (the earnings of a particular category of workers). Thus, the rate of the benefit shall be such as to attain at least the percentage indicated [40%] of the total of the previous earnings of the beneficiary (art. 65.1). This criterion is established for a “standard beneficiary”, which in the case of contingency for old-age is defined as a man with a wife of pensionable age and two children. For all other beneficiaries “the benefit shall bear a

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reasonable relation to the benefit for the standard beneficiary” (art. 65.5). The stratification of beneficiaries may, however, be subject to limits: “a maximum limit may be prescribed for the rate of the benefit or for the earnings taken into account for the calculation of the benefit” (art. 65.3). This maximum limit should be at least 40% of the benchmark earnings of a skilled manual male employee. As article 65.9 stated “the wage of the skilled manual male employee shall be determined on the basis of the rates of wages for normal hours of work fixed by collective agreements, by or in pursuance of national laws or regulations, where applicable, or by custom, including cost-of-living allowances if any”. Thus, the upper limit permitted is established on the basis of a collective, rather than individual, guideline. • When the protected population is defined by the last criterion mentioned above (residents whose resources during old-age do not exceed certain pre-established limits), the total of the benefit and any other means “shall be sufficient to maintain the family of the beneficiary in health and decency” (art. 67.c), and must be at least above 30% of the benefit payments that would be provided in the case of an “ordinary adult male labourer”.

12.5.3

The 1990s: The Rights of Older Persons During the Neoliberal Boom

In 1991 the United Nations Principles for Older Persons (UN Human Rights 1991) were established. One year later the Proclamation on Ageing (UN 1992) was implemented. Both instruments mention family responsibilities and an as yet unmentioned social actor: non-governmental organizations. It would seem that in this period rights are proclaimed as a responsibility whose guarantee of implementation falls to a lesser extent on the state. While the delegation of responsibilities

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- attributed in the first instance to the family, establishing the role of the state as being one of “support”—concentrates on the question of care for the elderly, it also appears in relation to income security. With regards to economic security, the United Nations Principles for Older Persons (UN Human Rights 1991) referring to independence, establishes that “older persons should have access to adequate food, water, shelter, clothing and health care” by different means: the first being “the provision of income”, and proceeding to mention “family and community support and self-help” (item 1). Following on from that certain principles are added which discuss the possibility for older people to continue working if they should so desire. In this way, the principles related to social protection and economic security which are elaborated in the document seem to distribute the responsibilities to guarantee the social protection of older persons among other actors, besides the public sector. The Proclamation on Ageing (UN 1992) notes that “the ageing of the world’s population represents an unparalleled, but urgent, policy and programme challenge to Governments, non-governmental organizations and private groups to ensure that the needs of the aged and their human resource potential are adequately addressed”. It should be noted that neither of these instruments made any explicit reference to the principles of distributive justice that underpin income replacement systems for older persons. In relation to the gender question, the Proclamation on Ageing (UN 1992) mentions the development of policies and programmes “which respond to the special characteristics, needs and abilities of older women” (2.g). Furthermore, the lack of recognition given to traditional female labour is acknowledged, considering it to be of importance that “older women are given adequate support for their largely unrecognized contributions to the economy and the well-being of society” (2.h). Along the same lines, resolution 44/76 of the UN General Assembly concerning the “integration of older women in development” (UN General Assembly 1994a), recalls resolution 44/76 from 1989, in which it pointed out that sex

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stereotyping “makes the social and economic problems of elderly women even more acute, and that they are often viewed only as beneficiaries and not as contributors to development”. With that in mind, the resolution calls attention to “the urgent need to develop and improve the publication of statistics by sex and by age, and to identify and evaluate the different forms of activities of older women which are not normally recognized as having an economic value, in particular in the informal sectors”. Thus, recognition was made of the social and economic value of the typically unremunerated work which many women perform, while being excluded from direct and unmediated access to welfare. Until the production of the next instrument specifically addressing the rights of older persons, it is worth examining two relevant instruments which deal with the social and economic rights of older people. Firstly, in Cairo in 1994 the Programme of Action of the International Conference on Population and Development (UN 1994b) was outlined. Concerning the measures with which to enable its objectives to be met, it urged governments to “develop social security systems that ensure greater intergenerational and intragenerational equity and solidarity” (6.18). Apart from once again ascribing primary responsibility for care to the family, describing the role of the state as “support”, it designated the provision of long-term support and services to the most vulnerable older persons as a public responsibility. In any case, among the measures described, emphasis is again placed on the importance of collaboration between the public sector and “non-governmental organizations and the private sector”, in order to “strengthen formal and informal support systems” for elderly people (6.20).

12.5.4

The Rights of Older Persons in the Twenty-First Century

At the turn of the millennium, in the year 2000, the United Nations Millennium Declaration (UN Human Rights 2000) was published. In this

document a clear expression of the distributive principle was made: including “solidarity” as one of the “fundamental values to be essential to international relations in the twenty-first century” it stated that “global challenges must be managed in a way that distributes the costs and burdens fairly in accordance with basic principles of equity and social justice. Those who suffer or who benefit least deserve help from those who benefit most” (I.6). In the year 2002, the Political Declaration and Madrid International Plan of Action on Ageing (UN 2002) was adopted. This instrument was a landmark in the treatment of social protection for the elderly, introducing guidelines that would define a new approach from human rights in the twenty-first century: • The first issue worth noting is that, instead of referring exclusively to “social security”, it simultaneously and consistently refers to “social protection/social security”. That is consistent with the expansion of rights emphasized through the whole declaration. • In contrast with the documents of the previous period, the idea that protection depended on the market or families, and not on formal systems of social protection/social security, was identified as problematic. In this light we can interpret the statement that “in developing countries with limited coverage formal systems of social protection/social security, populations are vulnerable to market shocks and individual misfortunes that strain informal family support” (item 50). • Additionally, the document highlights the importance of wide-reaching protection that safeguards at least “sufficient” minimum income. In this sense, objective 2 of “Issue 7: Income security, social protection/social security and poverty prevention” consists of “sufficient minimum income for all older persons, paying particular attention to socially and economically disadvantaged groups” (item 53). In turn, it establishes that one of the recommended measures is to “organize, as a matter of urgency where they do not exist, social protection/social security systems to

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ensure minimum income for older persons with no other means of support” (item 53.b). • For the first time an explicit concern is raised about the lack of protection which the traditional social security systems entail for workers in the unstructured sector, stating that this is a particularly significant problem “in developing countries and countries with economies in transition”. There, “most persons who are now old and who work are engaged in the informal economy, which often deprives them of the benefits of adequate working conditions and social protection provided by the formal sector economy” (item 24). The issue is raised again when the declaration recommends ensuring “that social protection/ social security systems cover an increasing proportion of the formal and informal working population” (item 52.c) and that they “consider innovative social protection/social security programmes for persons working in the informal sector” (item 52.d). • A concern is also reaffirmed for protection that does not exclude older women. The declaration highlights the existence of “institutional biases in social protection systems” that are detrimental to the economic situation of women, as they are aimed at protecting subjects with “uninterrupted work histories” (item 46). In this regard, it notes that “gender inequalities and disparities in economic powersharing, unequal distribution of unremunerated work between women and men, lack of technological and financial support for women’s entrepreneurship, unequal access to, and control over, capital, in particular land and credit and access to labour markets, as well as all harmful traditional and customary practices, have constrained women’s economic empowerment and exacerbated the feminization of poverty. In many societies, female-headed households, including divorced, separated and unmarried women and widows, are at particular risk of poverty. Special social protection measures are required to address feminization of poverty, in particular among older women” (item 46). In

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this way, acknowledgement is made of gender inequality rooted in the sexual division of labour, the lack of recognition for social tasks assigned to women, and the inequalities that have an impact on women’s position in the labour market. To address this, further on it recommends to “strive to ensure gender equality in social protection/social security systems” (item 52.b). This issue is raised again in a passage which refers to the responsibility placed on families for their role in care-giving, in contrast with the documents from the 1990s. It states that “family care without compensation to caregivers is creating new economic and social strains. The cost to women, in particular, who continue to provide the majority of informal care, is now recognized. Female caregivers bear [the] financial penalty of low pension contributions because of absences from the labour market, foregone promotions and lower incomes. They also bear the physical and emotional cost of stress from balancing work and household obligations” (item 102). • Equity as a principle of distributive justice for social protection was ratified upon affirming, in reference to development, that the “sustained legitimacy of the process requires the introduction and maintenance of policies that ensure the equitable distribution of the benefits of economic growth” (item 17). • One last question worth examining from the declaration is that interest is revived in reducing compulsory retirement (especially in developed countries where the population ageing is more advanced), and encouraging continuing employment for older persons when they choose it. In this sense the declaration highlights the economic benefits that continuing employment for older persons could bring in populations with population ageing, due to the fact that “labour shortages are likely to occur resulting from the decline in the pool of young persons entering the labour market, the ageing workforce and the tendency towards early retirement” (item 24). Therefore, “policies to extend employability, such as flexible retirement, new work arrangements,

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adaptive work environments and vocational rehabilitation for older persons with disabilities are essential and allow older persons to combine paid employment with other activities” (item 24). Subsequent to the Madrid Declaration no further human rights instruments relevant to this question were produced on a global level, but there was a wide-ranging development of regional instruments in Latin America. Thus, Madrid is the last human rights instrument at an international level that can be taken as a guideline, at least until another is produced. Latin America: The Elderly Rights in the Twenty-First Century

In 2007, the Brasilia Declaration: Second Regional Intergovernmental Conference on Ageing in Latin America and the Caribbean “towards a society for all ages and rightsbased social protection” (ECLAC 2007) explicitly states the objective of incorporating “greater solidarity” in social protection systems, broadening coverage levels and the quality of the protection. In addition, the importance of intergenerational solidarity is reiterated, and it refers to the right to protection in more of a “citizen” sense than strictly “employment” based when it states that “entitlement to human rights signifies that the subject effectively belongs to the society, since it implies that all citizens, men and women alike, are include in the development dynamic and can enjoy the well-being that it promotes” (p. 6). In 2012 the San José charter on the rights of older persons in Latin America and the Caribbean (ECLAC 2012) was published, which reaffirmed a concern for gender equity of access to protection when it established the objective to guarantee “equal access of older women and men to social security and other social protection measures, particularly when they do not enjoy retirement

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benefits” (item 12.d). In 2013 the First Session of the Regional Conference on Population and Development in Latin America and the Caribbean was held which produced the Montevideo Consensus on Population and Development (ECLAC 2013). Among the general principles were highlighted “the need for a cross-cutting, universal, comprehensive, inclusive and equitable approach, based on equality, solidarity, and respect for dignity and human rights in order to address the needs of all vulnerable groups” (p. 12). In relation to the question of “ageing, social protection and socioeconomic challenges” the signatories to the consensus agreed, among other things to, “promote the development of allowances and services relating to social security, health and education in the social protection systems targeting older persons to improve their quality of life, economic security and social justice” (p. 19). Besides mentioning the criterion of social justice in general, in particular it asserts the importance of a gender perspective—promoting a broadening of rights in the sense of increasing the scope of protection and social security in order to incorporate “those women who have devoted their lives to productive work, whether as domestic workers, women in rural areas or informal workers” (p. 19). In this manner the document includes in the concept of “work”, which should be protected, those tasks which were traditionally invisibilized under the restricted definition of work that only considered the labour inside the market. In 2015 the Inter-American Convention on Protecting the Rights of Older Persons was held (OAS 2015). It stated that “all older persons have the right to social security to protect them so that they can live in dignity” (art. 17). In this way the rightsbearing subject is identified as the older person and not as the working person or person of working age who will eventually (continued)

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be elderly. It is worth pointing out that “gender equity and equality” are also established as principles of the Convention, as well as “solidarity and the strengthening of family and community protection” (art. 3). Lastly, in 2017 the Asunción Declaration (ECLAC 2017) was drafted, which ratified the objective of eliminating poverty, and mentioned in particular concerns about “the worrying incidence of poverty among older persons in the region” (item 5). Encouraging governments to “implement specific policies for older persons”, it underlined an approach that recognizes gender inequalities and promotes the “autonomy and independence [of older persons], as well as intergenerational solidarity” (item 5).

12.6

Final Reflections

As we have discussed, in the contributory social welfare models, protection of older persons is a right, the access to which is mediated by access to the formal labour market during the span of economically active life and by the recognition (or lack) of certain tasks as work (from which are principally excluded domestic labour, childrearing, and care of the sick or otherwise dependent persons). Thus, a history of incomplete or non-existent contributions can lead to exclusion from social protection. This means that pensions systems are systemically incapable of guaranteeing protection to workers from the informal sector, and reinforce the gender gap due to the shortfalls in protecting people who perform unpaid work and the sexual division of labour. Furthermore, in contributions-based social security the prevailing principle is that old-age benefits bear some relationship with earnings during economically active life, while noncontributions-based benefits tend to represent a reduced portion of the contributions-based benefit payments. In this way the systems provide

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stratified protection: in other words, benefits with different capacities to meet needs, favouring those who were able to contribute more during their working life. These characteristics are underpinned by the long tradition of the Bismarck and Beveridge models, which has resulted in a generalized understanding of social security being a labour right, that is to say, of the worker, being deeply culturally entrenched. Hence, certain inequities and exclusions from the sphere of employment were transposed onto welfare: while some work is performed in conditions of informality, and unpaid work has traditionally been overlooked with regards to its economic and social value, the stratification of earnings often reflects the disadvantages that are crystallized in more precarious and vulnerable working conditions. On analysing the contents of the human rights instruments we found that during the twentieth century references to social security in particular, and the economic security of older persons in general, were consistent with these paradigms. Even though social security is mentioned without too many specifics in relation to distributive criteria, references in some treaties to the ILO’s Social Security (Minimum Standards) Convention n○ 102 implies an endorsement of protection aimed at replacing certain prior rates of income for workers with a history of uninterrupted contributions, and providing lower quality benefits for other workers. However, it is worth pointing out that within the text of these human rights instruments, from the very first treaty, there are references to the importance of protecting the most vulnerable sectors. So, a concern to provide minimum levels of protection to those sectors not covered by the social security, and to reduce poverty, is expressed early on. Furthermore, the instruments include statements about equitably distributing the fruits of development and the role of public policies geared towards equitable social justice, which create internal tensions around the restrictive characteristics that the elderly income protection acquires when it focuses on labour rights. The production of specific documents for rights of older persons sharpens these tensions,

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inasmuch as the worker as a rights-bearer is undermined, and they are explicitly aimed at the rights and needs of older persons. On the other hand, the various instruments which introduce a gender perspective also generate tensions with labour rights based on a view of labour which does not include the contribution made by tasks assigned to women. While the lack of recognition given to these tasks is acknowledged, as is the disproportionate allocation of these tasks to women, to the detriment of their protection and economic autonomy, it is necessary to consider social security itself as an institutional model with a gender problem. The ‘90s seems to be an atypical period in terms of the understanding expressed in the human rights instruments regarding public policies, introducing non-state actors such as families, non-governmental organizations, and even private groups as protagonists in the provision of protection and welfare. During this period the various tensions and inconsistencies can be observed principally in relation to the gender question, due to the responsibility in the first instance being allocated to the family (which should receive “support”), and to social policies less centred on citizens’ rights, while the instruments with a gender perspective continued to highlight the inequitable consequences of the sexual division of labour and asymmetrical value attributed to that labour. The human rights approach commenced the twenty-first century making confident strides in a direction which is summarised in the United Nations Millennium Declaration, asserting that “those who suffer or who benefit least deserve help from those who benefit most”. We find that the human rights-based approach of the twentyfirst century reduces the aforementioned tensions by moving towards expanding rights and strengthening the principles of equity in social policies. Bearing in mind that human rights instruments have the principle of Progressive Realisation and Non-regression, those elaborated this century have greater validity, due to being most contemporary and also incorporating a broader understanding of rights. For this reason the Political

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Declaration and Madrid International Plan of Action on Ageing should, for the time being, be the principle benchmark for defining the economic rights of older persons. The Political Declaration and Madrid International Plan of Action on Ageing in its very articulation implies an expansion of rights, as it always refers to social security along with social protection. The document questions the restricted sense that contributory social security provides protection, drawing attention to its institutional bias which results in a lack of protection for people, predominantly women, who work outside of the labour market. For this reason, one stated objective is the public assumption of familial care roles which women are principally burdened with. Additionally, it underlines the limitations of these systems to protect workers in the formal economy. It emphasizes the particular importance of protecting the poorest and most disadvantaged groups. Ultimately it produces an affirmation of the the protected subject and the principle of equity, condemning the inequity which leads to lack of protection. In Latin America the regional instruments have reaffirmed and expanded the principles expounded in the Madrid declaration. These findings show that adopting a human rights approach today does not fully align with the priorities and criteria that guided the design and development of the social security of the past. Therefore, the parameters for evaluating social impact which revolve around indicators and benchmarks from the twentieth century may not be suitable for the current period. This is not a question of establishing the superiority of some goals over others from the academic sphere. Rather than aiming to provide a “scientific” answer to this question, our claim is that complying with a human rights-based approach requires the definition of objectives consistent with certain frameworks of rights, and also outlining what institutional and distributive characteristics are consistent with those objectives. To that end, it is crucial to establish whether there are tensions, correspondences, or transformations in the concepts regarding their primary function, the central right that the systems should protect, the rights-bearing subject, and the criteria of

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What Should Guarantee Pensions Systems Designed with a Human Rights Approach?

justice which must prevail to ensure its funding and distribution. Insofar as there are transformations in our cultural notions of rights related to social security, that will affect the parameters for assessing the effectiveness of those systems, as well as what recommendations emerge in terms of potential reforms and designs of effective mechanisms aligned with their objectives and priorities. Taking our findings into consideration, we might suggest, for example, that the human rights approach of the twenty-first century requires indicators of socio-economic and gender equity in order to assess the quality and concentration of protection, and to be equipped to monitor their progress. Similarly, placing greater emphasis on protecting a whole life cycle rather than occupational risks, means that the object of protection should be defined to a large extent by the economic security of older persons rather than that of a worker. In this context, it may be more appropriate for a human rights approach to define the level of benefits payments not on the basis of individual earning during working life, but instead on collective benchmarks defined by the consumption needs of older persons to guarantee their “autonomy”, a “dignified life”, and also their participation in the fruits of development. We should note that the increase of inter and intragenerational solidarity of retirements systems, without colliding with rights acquired by individuals and groups, will always require adequate transition measures, and sometimes elucidate the hierarchy of rights in tension. Therefore, the ILO Convention No. 102 has to be consider for any incrementation of benefits equity in retirement systems. Thus, although a scheme fully consistent with the principle of equity establishes higher protection to the most vulnerable, an equal benefits system could be the most equitable that the legislation allows (without colliding with previous regulations). As we explained, the Convention establishes earnings replacement criteria, it while allow to limit inequalities through establishment of maximum and minimum benefits. So, fulfilling both the Convention No. 102 and the principle of equity would imply providing benefits of the highest possible level to all people

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equally, always above the level admitted as maximum ceiling. This could be implement by setting maximum ceilings within the permitted framework and not increasing them until the minimums have practically reached them. Ultimately, universal access to protection along with an increase of solidarity within the systems, moving away from replacement payments, should be investigated as a direction which is possibly more consistent with the rights established in our era.

References Beccaria, L., & Maurizio, R. (2014). Hacia la protección social universal en América Latina: Una contribución al debate actual. Problemas del desarrollo, 45(177), 37–58. Bertranou, F. (2006). Envejecimiento, empleo y protección social en América Latina. Santiago, Chile, Organización Internacional del Trabajo (OIT). Durand, P. (1991). La política contemporánea de seguridad social. Madrid, España: Ministerio de Trabajo y Seguridad Social. ECLAC. (2007). Brasilia declaration: Second regional intergovernmental conference on ageing in Latin America and the Caribbean: Towards a society for all ages and rights-based social protection. Santiago, Chile: ECLAC. ECLAC. (2012). San José charter on the rights of older persons in Latin America and the Caribbean. Santiago, Chile: ECLAC. ECLAC. (2013). Montevideo consensus on population and development. Santiago, Chile: ECLAC. ECLAC. (2017). Asunción declaration. Building inclusive societies: Ageing with dignity and rights. Santiago, Chile: ECLAC. Fleury, S. & Molina, C. G. (2002). Modelos de Protección social. 3–6. Washington, DC: Inter-American Development Bank, inter-American Institute for Social Development (INDES). Design and management of social policies and programs. Gomez Sala, S. J. (1994). El largo camino hacia la racionalización de la pensiones públicas. Cuadernos de Ciencias Económicas y Empresariales, 26, 47–69. International Labour Organization. (1952). Social security (minimum standards) convention n○ 102. Convention concerning minimum standards of social security. Geneva, Switzerland: ILO. International Labour Organization. (2012). 2012 Labour overview. Latin America and the Caribbean. Lima, Perú: ILO/Regional Office for Latin America and the Caribbean. Mesa-Lago, C. (2004). Las reformas de pensiones en América Latina y su impacto en los principios de la

216 seguridad social (p. 144). Santiago, Chile: ECLAC, Financing for Development Series. Monereo-Pérez, J. L. (2008). Ciclos vitales y Seguridad Social: trabajo y protección social en una realidad cambiante. Revista del Ministerio de Trabajo e Inmigración, 74, 49–134. Neffa, J. C. (2003). El trabajo humano. Contribuciones al estudio de un valor que permanece. Buenos Aires, Argentina: Trabajo y Sociedad -CEILPIETTE/ CONICET, Lumen-Humanitas. OAS. (2015). Inter-American convention on protecting the human rights of older persons. Washington, DC: OAS. Piffano, H. L. P., Lódola, A., Silva, H., Sánchez, D., Ohaco M. C., et al. (2009). El Sistema Previsional Argentino en una perspectiva comparada. La Plata, Argentina: Departamento de Economía, Facultad de Ciencias Económicas, Universidad Nacional de La Plata. Retrieved June 20, 2019, from http://sedici.unlp.edu.ar/ bitstream/handle/10915/44322/Documento_completo. pdf?sequence¼1 United Nations. (1948). The universal declaration of human rights. New York: United Nations. United Nations. (1966). International covenant on economics, social and cultural rights. New York: United Nations. United Nations. (1969). Declaration on social Progress and development. New York: United Nations. United Nations. (1974). World population plan of action. New York: United Nations.

S. Minoldo and E. Peláez United Nations. (1975). World plan of action for the implementation of the objectives of the international Women’s year. New York: United Nations. United Nations. (1982). Vienna international plan of action on aging. New York: United Nations. United Nations. (1986). Declaration on the right to development. New York: United Nations. United Nations. (1991). Principles for older persons. New York: United Nations. United Nations. (1992). Proclamation on ageing. New York: United Nations. United Nations. (1994a). General assembly resolution 44/76. Integration of older women in development. New York: United Nations. United Nations. (1994b). Programme of action of the international conference on population and development. New York: United Nations. United Nations. (2002). Political declaration and Madrid international plan of action on ageing. New York: United Nations. United Nations Human Rights. (1979). Convention on the elimination of all forms of discrimination against women. New York: United Nations. United Nations Human Rights. (2000). Millennium declaration. New York: United Nations. Venturi, A. (1994). Los fundamentos científicos de la seguridad social. Madrid, España: Ministerio de Trabajo y Seguridad Social, Secretaría general para la Seguridad social.

Civil Society Organizations’ Discourse and Interventions to Promote Active Ageing in Relation with the Quality of Life in Latin-America

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Vicente Rodríguez-Rodríguez, Verónica Montes de Oca Zavala, Mariana Paredes, and Sagrario Garay-Villegas

13.1

Introduction

Active ageing and quality of life are concepts of frequent interest in terms of research and the social agenda. These concepts are defined in diverse ways and not easily implemented, but they are also accepted in official and public discourse as goals to be achieved for a society that wishes to improve the circumstances that older persons face. The World Health Organization (2002) originally defined three pillars of active ageing: health, participation, and security. A fourth pillar has since been added: lifelong learning (ILC-BR 2015). Based on the recognition of human rights of older persons and on the United Nations V. Rodríguez-Rodríguez (*) Institute of Economics, Geography and Demography (IEGD), Spanish National Research Council (CSIC), Research Group on Ageing (GIE-CSIC), Ageing Network of the Latin American Population Association (ALAP), Madrid, Spain e-mail: [email protected] V. Montes de Oca Zavala Institute of Social Research, National Autonomous University of Mexico (UNAM), Mexico City, Mexico M. Paredes Interdisciplinary Aging Centre, University of the Republic, Montevideo, Uruguay e-mail: [email protected] S. Garay-Villegas Faculty of Social Work, Autonomous University of Nuevo León, San Nicolás de los Garza, Mexico

Principles of independence, participation, dignity, care and self-fulfillment (Huenchuan 2013), active ageing remains a strategy for action on an individual, local, national and global scale to respond to the challenge of longevity. It can be interpreted in diverse forms, some based on a research-related perspective and others normative and institutional in nature (López-López and Sánchez 2019). The scientific literature has thoroughly shown that a form of active ageing has positive consequences in terms of quality of life (Ahmed-Mohamed et al. 2015; Lardiés-Bosque et al. 2015). However, and despite its integrating and inclusive character (Rojo-Pérez et al. 2015; RodríguezBlázquez et al. 2017), active ageing often clashes with other concepts such as healthy, successful, productive and robust ageing (FernándezBallesteros 2011a), which have diverse meanings with multiple dimensions. These related concepts often make it more difficult to have a clear understanding of active ageing (Fernández-Mayoralas et al. 2014; Montes de Oca et al. 2014; Rodríguez-Rodríguez et al. 2018). Some reviews highlight the complex structure of active ageing (Annear et al. 2014; Arbesman and Lieberman 2011; Van Cauwenberg et al. 2011; Cosco et al. 2014; Harris et al. 2013; Martinson and Berridge 2015; Moran et al. 2014). Other studies place particular emphasis on its components such as health (Fernández-Mayoralas et al. 2015), participation (Ahmed-Mohamed et al. 2015), social and

# Springer Nature Switzerland AG 2021 F. Rojo-Pérez, G. Fernández-Mayoralas (eds.), Handbook of Active Ageing and Quality of Life, International Handbooks of Quality-of-Life, https://doi.org/10.1007/978-3-030-58031-5_13

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residential environments (Fernández-Mayoralas et al. 2015; Rodríguez-Rodríguez et al., 2017) and financial security. The literature does not tend to include examples relating to Latin American/IberoAmerican countries (Fernández-Mayoralas et al. 2014), and studies do not adopt a standpoint that recognizes the role of older persons as “agents” of social transformation (a lay perspective). However, there is wide-ranging and substantial evidence regarding aspects that are central to ageing in terms of the three dimensions studied in this chapter, showing the importance of many of the parameters analyzed for Latin American research. Health, for example, emerges through two fundamental aspects. The first is the individual sphere, in which health is recognized as having a moderating role for individual wellbeing (Gallardo et al. 2018), always bearing in mind that the older population is a heterogeneous group as regards gender, ethnicity and social relationships (Mendoza-Núñez et al. 2018), all of which facilitate increased social participation and activity (Pérez-Cuevas et al. 2015). The second is associated with the national socio-political environment, in terms of the caregiving and health’ assessment and the role that women play in the provision of healthcare, as well as the burdens that this task implies for them (Gonzálvez 2018). This perspective is directly related to the difficulties that Latin American countries face in providing healthcare as a recognized right (Peláez and Ferrer Lues 2001), in extending the social protection of older persons (Lathrop 2009) and in providing sufficient resources to ensure that the right to receive care is consolidated in order to prevent discrimination (Perlingeiro 2014). When these processes occur (all too often), there is also a link to problems involving financial insecurity (poverty, exclusion) (Peláez and Ferrer Lues 2001). Financial insecurity is undoubtedly another reference point that can be studied in the Latin American literature, again from a dual perspective. First are the financial circumstances of individuals and their families. Older persons clearly face difficult financial conditions in many countries within the region as a result of

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their precarious and informal positions in the workplace during their working lives (Nava et al. 2016) and the ensuing failure to accumulate resources (Flores-Payan and Salas-Durazo 2018). Added to this is the scarcity of public social security coverage, linked to national economies that restrict financial payments to the population (Ortega González 2018) and to the (im)balances between the job market and the benefits employees receive by right (Camarano and Pasinato 2007). All of this gives rise to a lack of effective recognition of the right to financial security in old age (Nava Bolaños and Ham Chande 2014). Various studies recognize the heterogeneous nature of the older population as a key point in generating a lack of financial coverage: gender (male), educational level (high) and position in the home (head of the house) are differentiating factors (Yáñez Contreras et al. 2016; Ortega González 2018), as well as one’s history of employment (Bauer García 2016; Nava et al. 2016) and of access to pension benefits (Flores-Payan and Salas-Durazo 2018). The future remains to be seen, but the trends point towards a reinforcement of the (a better) sustainability of pension systems (Silva 2016) and the extension of working lives (Texeira 2018), which does not fit well with the current situation in many Latin American countries. As regards the environments in which the older population is living, the evidence points to the existence of a general perspective that promotes the provision of support services to individuals and families, family arrangements that secure the best conditions for the care of older persons, and the creation of circumstances that are favorable to health in living settings. Another trend in the literature is to confront negative views regarding the older population to prevent situations of discrimination and mistreatment (Phelan 2013; Daichman and Giraldo 2013; Ruelas-González et al. 2016). This latter aspect is notably present in studies as a response to the heterogeneous nature of the older population (Ortega González 2018) both in the family context, conditioned by factors such as gender, educational level, income and social status, and in the residential sense (Lathrop 2009).

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Civil Society Organizations’ Discourse and Interventions to Promote. . .

Evidence has also recently emerged from environmental gerontology (Sánchez-González and Rodríguez-Rodríguez 2016) and the policy of age-friendly cities (WHO 2007) with regard to the role played by the city, as the environment in which most older persons live, with recognition that residency in a city carries with it a right to age-friendliness of one’s surroundings. This is the case due to the symbolic and vital meaning of the city (Sánchez-González et al. 2018), the need for residential adjustments (García-Valdez et al. 2019) and the public policies to ensure age-friendliness (Monteiro et al. 2015). Also highlighted are the impacts on quality of life for older persons who live in cities, particularly in certain groups differentiated by gender, educational and socio-economic level or state of health (Bustamante et al. 2017). The conceptual association between active ageing and improvement in quality of life is a well-known fact, although it has not been analyzed as frequently as might be expected even in the Anglophone world. Quality of life is most commonly associated with physical and/or mental health, social participation and social relationships or environments, all as components of active ageing (Rojo-Pérez et al. 2020), with quality of life hence being understood as an effect of these various factors (Rojo-Pérez 2020). In both strictly academic studies that measure quality of life via indicators and those based on the opinions of older persons (Wilhelmson et al. 2005; Fernández-Ballesteros and Santacreu 2011), the same reality is observed: quality of life is not defined and it is therefore difficult to clarify its content (Boggatz 2016) or to reduce its dimensions to a single index (FernándezBallesteros and Santacreu 2011; FernándezBallesteros 2011b). It is not anchored to specific theories; instead, there are references to multiple dimensions of active ageing (Rojo-Pérez 2020). Quality of life is also commonly used as a recommendation for evaluating public policies and intervention programs (Campos et al. 2014; Santacreu et al. 2016). It may therefore be expected that this chapter will include references to quality of life in the civil society organization (CSO) documents subject to analysis, though it

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may also be anticipated that they will not contain a strict definition of the concept but will instead describe it by reference to the main dimensions of active ageing. In short, the potential and limitations of research concepts such as active ageing and its association with quality of life, both studied in depth, point to a need to extend the focus of analysis of their definition and use by older persons and their social organizations when lobbying for their inclusion and implementation in public policies. The aim of this work is specifically to examine how CSOs (previously referred to as non-governmental organizations, or NGOs) in the Latin American context position active ageing and its link to quality of life in their documents as tools to exert political pressure over public policy design. The analysis will focus on three essential dimensions to achieve this aim: health, financial security and physical and social environments.

13.2

Materials and Method

The documents used to prepare this chapter correspond to the various declarations by CSOs. The first is the outcome of a gathering in Madrid in 2002: the NGO World Forum on Ageing. Although this assembly did not take place in Latin American and the Caribbean, it sets a significant precedent because CSOs participated in this forum only days before the holding of the Second World Assembly on Ageing (United Nations 2002). This produced the Madrid International Plan of Action on Ageing (MIPAA), one of the guiding forces in subsequent intergovernmental and CSO forums in the Latin America region. CSO declarations in Latin America and the Caribbean resulting from forums coinciding with regional ageing conferences to follow up on the MIPAA are examined in addition to the initial document resulting from the NGO World Forum on Ageing. These declarations are from Santiago (Chile) in 2003, Brasilia in 2007, Tres Ríos (Costa Rica) in 2012, San José (Costa Rica) in 2013 and Ypacaraí (Paraguay) in 2017. Other

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supplementary CSO documents have been used to support some proposals. The content of the various CSO declarations has been analyzed from a chronological perspective in relation to regional intergovernmental conferences in Latin America and the Caribbean. This strategy has permitted an examination of the main lines that have fleshed out the three selected dimensions (health, financial security and physical and social environments), largely following an interpretative framework based on the components of a social protection system for older persons (Huenchuan 2019b). As expected, not all lines develop consistently over time. Rather, they are reformulated as they are addressed by international guidelines on ageing populations. In the case of health, the aim is to identify the references that examine this dimension as a component of the physical and mental wellbeing of a person in relation to their quality of life. References sought are essentially healthcare and caregiving processes, health and social participation as individual rights, the consideration of older persons as a heterogeneous population group albeit with specific rights that are not always recognized, and shortfalls linked to a lack of preventive healthcare and discrimination in terms of the access to health services that is also recognized as a right. In terms of financial security, the intention is to identify textual references to the financial circumstances of older persons, social security coverage and retirement (neither of which are recognized as rights), the employment conditions of older workers, and social protection of older persons (recognized as rights). Finally, and as regards the dimension of physical and social environments, the aim is to identify references in the documents to the physical environment relating to housing, residential arrangements, transport and access to urban settings. With respect to social environments, the analysis also seeks to identify household structures and social support networks, as well as situations of discrimination and mistreatment in the social environment, the provision of support services to individuals and families, the creation of conditions that are conducive to health in

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living settings, and the confronting of negative perspectives regarding the older population that give rise to discriminatory situations.

13.3

The Positioning of CSOs with Regard to Health

Health is generally mentioned in all the documents relating to policies on older persons. But it is a very broad and multifaceted concept, and can be related with ageing from various perspectives. Indeed, there has been a dramatic shift in the relationship between old age and health influenced by other key concepts such as active ageing. The definition of active ageing by the WHO (2002), and the WHO document on ageing and health (2015), change the focus for practitioners specializing in geriatric medicine, who move from being “mere witnesses to and perhaps prophets of deterioration to promoters of a preventive and proactive approach” (Gutiérrez Robledo 2017: 31). From the traditional perspective, old age is justly linked to deterioration in health, declining capacities, a sense of deterioration of the body and of the person, and a resulting isolation from social life. Policies revolving around this paradigm have generally been focused on caregiving and “medicalized” attention, and on the partial repair of ailments, illnesses and declining capacities. So, old age is hence associated with a deficit of capacity and hence a lack of independence, hindering the consideration of older persons as citizens with rights (Huenchuan 2013). The Second World Assembly on Ageing (2002) gave rise to a transition from this understanding of health toward one that is oriented around physical and mental wellbeing, with health being recognized as a right and being linked in turn to social participation and to environments (United Nations 2002). It is in this spirit that the World NGO Forum proposes that “ageing must not be synonymous with declining health” (World NGO Forum on Ageing 2002:61) and that health is often associated with living conditions that particularly affect older women, given their longer lifespans. Its approach is aimed

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Civil Society Organizations’ Discourse and Interventions to Promote. . .

at identifying the specific conditions affecting older persons due to their difficulties in accessing healthcare and at recognition of the discrimination that older persons suffer in terms of their right to health protection. In the context of Latin America, as mentioned, the MIPAA was crystallized at the first forum held in Santiago (Chile) in 2003, where the MIPAA Regional Implementation Strategy was designed. CSOs made a general and not areaspecific declaration on this occasion, with demands above all in the field of social protection (CEPAL 2003). Five years later, at the second MIPAA follow-up forum held in Brasilia (2007), the concept of “quality of life” was included in the CSO declaration within the context of the Latin America and Caribbean Regional NGO Forum on Ageing. This concept is linked to two fundamental pillars that are key elements in the active ageing paradigm: the exercise of rights and participation in social life (Fernández-Mayoralas et al. 2014). CSOs recognize the progress generated on the basis of the MIPAA, but inequalities continue to arise that affect quality of life for specific groups of older persons, such as women, people in rural areas and those belonging to certain ethnic groups. This situation is currently profound in the Latin American context, where there are many acute inequalities in the healthcare area in countries whose social protection systems do not offer high levels of coverage (Huenchuan 2018). Based on the ascending participation approach suggested by the United Nations to generate participation by older persons, this document proposes specific reinforcement actions in this respect and the participation of CSOs throughout the entirety of the public policy process, from formulation to evaluation (United Nations 2006). The need for legally binding frameworks to protect the rights of older persons is mentioned for the first time here. The Madrid+10 Regional Civil Society Forum on Ageing was held in Tres Ríos (Costa Rica) in 2012, during the third MIPAA follow-up cycle. The resulting declaration specifically mentions the population groups of older persons who, due to their displaced, refugee or migrant status, were

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living in border areas and in vulnerable circumstances. In this specific case, access to health services is described as highly limited, with impediments even in terms of securing care for primary needs (s. 6, p. 2). Specific reference is also made to the insufficient care provided by public healthcare services and the resulting direct impact on functionality and independence (s. 7, p. 2). The issue of caring for older persons emerges for the first time here, the burden of which is often assumed by the persons themselves without this being recognized as a contribution to social security. The care agenda has been growing in the region, and it has now become a key issue (Bidegain and Calderón 2018). The Tres Ríos forum sets the precedent for CSO contributions in terms of the implementation and follow-up of the San José charter on the rights of older persons in Latin America and the Caribbean (Regional CSO Network in Latin America and the Caribbean 2013), which specifically refers to an increase in the prevalence of chronic illnesses, disability and dementia. Also reiterated is the commitment to a process involving the dynamic participation of older persons with regard to “dignified, active and healthy ageing within the framework of human rights” (s. 11, p. 5). This document contains an effort to conceptualize what CSOs believe it necessary to consider: there is a specific description of physical and mental health as a human right and the concept of a “comprehensive approach to health” is defined as encompassing prevention, cure and rehabilitation; this is particularly to be taken into account in the care given to older persons as a vulnerable group (s. 22, p. 7). Finally, this document recognizes a paradigm shift in the concept of health, with the incorporation of the dimensions of mental health and caregiving, and the idea of participation by older persons in the exercise of the right to health. This right to health extends into the following section of the document (s. 8), with the inclusion of certain determinant factors such as access to water and sanitation, food and nutrition, education and housing, all linked to the vulnerability of the older population in many Latin American regions. There is also an advance toward a broad

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concept of health that is also related to the physical environments in which older persons live. This involves two central elements of the MIPAA (health and environments) and would later be revisited by the WHO in its most recent strategy on ageing and health (WHO 2015). There are specific recommendations in this area, entailing the incorporation of a rights-based approach across all health systems and the implementation of a comprehensive healthcare protocol with an interdisciplinary approach that also includes training for people involved in caring for and attending to older persons. Finally, there is a mention of the monitoring of progress in this exercise of the right to health. This and other references take into account the recommendations made by the Special Rapporteur on the right to health based on a specific study of the right to health. The Madrid+15 Regional Civil Society Forum was held in Ypacaraí (Paraguay) in 2017, coinciding with the Regional Conference on Ageing in Asunción. The corresponding declaration contains a specific section on health, which recognizes the progress made in terms of legal and structural reforms to healthcare systems but identifies a continuing shortfall in preventive healthcare and the existence of discrimination as a barrier to healthcare access and to quality services. It also recognizes the increased costs of medication and treatment, in addition to the problems arising with relation to the “commercialization of old age as a disorder” (Ypacaraí Declaration 2017: 2). Failures in mental health terms are also mentioned, insofar as depression and dementia are considered public health problems, with recognition of the imbalance between the need for treatment, the provision of services and respect for rights. This is fundamental in relation to the epidemiological transition and structural changes in the causes of death, among which there is significant growth in those associated with mental health (Huenchuan 2018; Gutiérrez Robledo 2017). The Ypacaraí Declaration also refers to shortfalls in terms of care and caregivers, as well as long-term residential care. The culmination is a demand that governments protect the right to give

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care, be cared for and care for oneself via the development of integrated and inter-sectoral systems, in addition to a call to “safeguard the right for older persons to be properly and suitably care for through health services, including the possibility of access to optimal healthcare, in order to have a dignified death” (Ypacaraí Declaration 2017: 5). On this topic and based on the 2030 Agenda’s Sustainable Development Goals, it has been noted that health systems are being adapted very slowly in response to the demand that is arising out of demographic and epidemiological changes and that this is causing insufficient access to quality services. There is also an indication of the need to use long-term care (Huenchuan and Rovira 2019) as a key pillar of new regulation aimed at developing the protection of older persons’ rights (Huenchuan 2018), with recognition of the importance of care provision in the family environment and the limitations that this represents for families, and particularly for women (Huenchuan 2019a).

13.4

Financial Security from the CSO Perspective

The 2002 World NGO Forum on Ageing was notable for contextualizing the financial circumstances of older persons in the world, including in developing countries, using a macroeconomic perspective as a guide to its recommendations. The general features of the forum included recognition of the poverty, social exclusion and undignified living conditions that older persons face, the limited coverage of their pensions, a lack of social services to attend to them, and housing shortcomings, among other difficulties (Huenchuan 2018). This panorama extended to families, who are the main source of support for their older members but also face conditions of poverty (Enríquez et al. 2008). In this respect, the forum proposed “the right to a retirement with sufficient income to ensure security and dignity” (2002 World NGO Forum on Ageing), as well as the provision of sufficient resources to families to enable them to support

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their elderly family members (Guzmán et al. 2003; Saad 2005). Emphasis was placed on the importance of caring for older persons who are more fragile, or in situations of poverty or dependency (Saad 2003). The 2002 NGO Forum document describes the economic circumstances upon which action is conditional when focusing on the world’s economies and particularly those of developing countries. References are made to foreign debt payments that restrict the economic resources countries can allocate to policies for improving the wellbeing of older persons and to capital flight due to economic uncertainty, all of which creates a lack of investment in social infrastructure, as well as to diminished purchasing power due to inflation, contributing to deteriorations in people’s quality of life in debtor countries (CEPAL 2019). Various actions are proposed in this respect, such as guaranteeing that pension resources will not be used for other economic ends, cancelling foreign debt to free up economic resources that could be allocated to benefiting older persons, collaborations between Northern NGOs and International NGOs who should provide economic support for the microprojects of Southern NGOs, and the inclusion by governments of adequate spending in public budgets taking into account the proportion of older persons making up their national population (2002 World NGO Forum on Ageing). In relation to work for older persons, it is proposed to promote retirement as a right that can be voluntarily, gradually and flexibly exercised (Camarano and Pasinato 2007; Nava et al. 2016). There is also mention of the importance of equal wages, with no discrimination on grounds of gender or age, of improving workplace environments to foster worker health and safety, and to encourage businesses to change the way in which workplaces are organized, considering the demands of an ageing workforce to facilitate the transmission of experiences, knowledge and professionalism from old to young (Huenchuan 2018; Mejía-Guevara et al. 2019). Unlike the proposals made at the 2002 World NGO Forum on Ageing, the CSO Declarations in Latin America and the Caribbean are less

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extensive in terms of addressing the region’s economic circumstances and refer instead to the specific situations of older persons. The Santiago Declaration of 2003 recognizes that the crises afflicting countries in the region are the outcome of the development models implemented, which have given rise to social and income inequality and poverty. There is continued recognition that a high proportion of older persons do not receive pensions or other income (Nava et al. 2016; Nava and Jiménez 2017). In this scenario, it is proposed to improve quality of life by “promoting and driving changes that allow social security to be extended and made universal, and fostering social transfers toward the older adult population. In other words, each person should have a minimum base of material and social support that allows them to have a dignified life; States should take urgent measures to enable the current workforce in our countries to have access to social security systems that guarantee they can reach older age with better living conditions and free from poverty” (CSO Declaration 2003; Camarano and Pasinato 2007; Texeira 2018). The Brasilia Declaration of 2007 expresses the same ideas as in Santiago 2003 with regard to the exclusion, inequality and poverty experienced by older persons, emphasizing that up to that point there had not been a satisfactory response in terms of social security and pension systems (contributory and non-contributory). This document called on governments to adopt the strategies identified at the Second World Assembly on Ageing, such as the importance of drawing up an international Convention on the Rights of Older Persons. It also proposed that States and governments create the conditions that would permit social security to be made a universal human right, as well as guaranteeing that the current workforce of our countries can have access to an old age with better living conditions and free from poverty (Brasilia Charter 2007: 4). In a supplementary document, the CSO Network in Latin America reiterated the need for a Convention on the Rights of Older Persons in 2009. Concern continued to be expressed at its forum regarding the increase in circumstances of poverty affecting older persons, in addition to a

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recognition that social security systems attempt to resolve the problems of the present but are not thinking of the future (Huenchuan and Guzmán 2007; Mejía-Guevara et al. 2019). It was proposed for governments to implement a strategy involving comprehensive social protection systems with service networks that respond to the real needs of older persons, the improvement of benefit systems in countries in the Latin America region, workplace inclusion in private businesses and companies, and the promotion of employability of older persons through the region’s countries regulations (Regional CSO Network of Latin America and the Caribbean 2009). In 2012, the CSO participation in Tres Ríos (Costa Rica) raised similar concerns to those presented at previous forums, identifying conditions of inequality and poverty affecting Latin American older persons, limitations on access to dignified work, and continuity of employment as a right to cover their basic needs, rather than due to a desire to remain in the labour market. The recommendations made to States and governments were aimed at developing universal and permanent policies targeted at the older adult population, without being restricted merely to measures for overcoming poverty such as guaranteeing social security by developing systems both contributory (shared between government, business and workers) and non-contributory, promoting intergenerational solidarity, and developing laws that guarantee protection of older persons’ assets (Tres Ríos Declaration 2012; Camarano and Pasinato 2007; Texeira 2018). The CSO Declaration in the San José Charter (Costa Rica 2013) emphasized the importance of advancing with the Inter-American Convention on the Protection of the Human Rights of Older Persons. It also ratified the need for States to consider a human rights-based approach to attempt to reduce inequalities and conditions of poverty afflicting older persons. As at previous forums, particularly important aspects were identified as areas for action, including a reform of benefit systems that would entail the participation of CSOs and associations of retirees and

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pensioners from each country, as well as procedural improvements in the administration of pension, retirement and other social services systems. Finally, the most recent CSO forum was held in Ypacaraí (Paraguay) in 2017. The InterAmerican Convention on the Protection of the Human Rights of Older Persons had been approved by this time, under the auspices of the Organization of American States (OAS), and CSOs recognized this as a great step forward, though lamenting the restriction on CSO participation in the process of drafting the Convention. The Ypacaraí Declaration shows the concern at policies with little social focus and measures lacking a rights-related vision. Among other issues, it notes that a high proportion of people are still excluded from benefit systems, that the vast majority of indigenous peoples and ethnic communities are a productive workforce that is exploited and invisible, working in precarious and informal conditions that mean they do not have retirement benefits or pensions when they withdraw from the labour market, and, finally, that a large proportion of older persons continue to work out of necessity, in informal conditions and for very low pay (Flores-Payan and SalasDurazo 2018; Gallardo et al. 2018). The Declaration also reports that older women tend to receive lower pay than men, that poverty in old age persists as a structural and multidimensional problem and that it affects the nuclear family, since when illness occurs, financial difficulties increase and people’s living and emotional conditions deteriorate. The document concludes with a demand for governments to “combat poverty with efficient policies and programs that secure the effective enforcement by older persons of economic, social and cultural rights; to change the economic paradigm that is underpinning countries’ progress” (Ypacaraí Declaration 2017: 5). It is clear from the analysis performed that considering the economic circumstances of older persons is a priority issue. This appraisal is reinforced with an eye to the future as a priority in the 2030 Agenda. Although older persons are not specifically mentioned as beneficiaries of the

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Civil Society Organizations’ Discourse and Interventions to Promote. . .

measures established, some of the sustainable development goals (SDG 1, on poverty, and 8, on decent work and economic growth) outline the path to follow. Improvement in financial security is associated with an improved labour market, as well as with the availability of economic means and resources for older persons to retire, in the form of benefit systems (pensions) and social provision (services) (Cecchini 2019; Huenchuan 2019a). The main goal will be to achieve a comprehensive reduction of the various dimensions of poverty (Huenchuan and Rovira 2019) in order to make progress on social inclusion and overcome discrimination. The goals established act as guidelines for States to improve the quality of life of society in general, and of older persons in particular.

13.5

Supportive and Enabling Physical and Social Environments from the CSO Perspective

The third dimension arising out of the MIPAA and addressed at the World NGO Forum on Ageing held prior to the Second Assembly in Madrid in 2002 is that of supportive and enabling social and physical environments. The concept of “enabling environments” was taken from the World Summit for Social Development 1995, held in Copenhagen (United Nations 1995), due to its importance in the context of this global forum. The World NGO Forum on Ageing debated social environments as elements related with security of social relationships and respect for older persons, essentially to be achieved through the elimination of any form of discrimination and mistreatment, with recognition that the age factor can give rise to discrimination (Word NGO Forum on Ageing 2002). This security is necessary in environments including family and the home, community, State activities and the market. This issue has permeated public policy in various countries and emphasis has been placed on the importance of reinforcing human rights alongside action to eliminate discrimination (Vázquez

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2006; Phelan 2013; Montes de Oca and Gutiérrez Cuellar 2018). As regards physical environments, calls were made to improve transport, housing and accessibility of urban settings in order to promote increased participation by older persons in safe and accessible settings. Reference was made to the need to adapt the physical environment to the characteristics and needs of older persons, including in relation to urban settings (World NGO Forum on Ageing 2002). These aspects were included in the MIPAA (2002), which argued for the elimination of all forms of violence, abuse and mistreatment against older persons and for the development of a strong line of research in the Latin America and Caribbean region aimed at identifying the prevalence and most commonly occurring types of mistreatment (Giraldo 2006; Daichman and Giraldo 2013). Secondly, the MIPAA also established as a priority the need to consider housing preferences in terms of adaptation and location (Garay Villegas et al. 2017), stressing the links to the accessibility and improvement of transport. As a result, in 2007 the WHO proposed the Global Age-Friendly Cities strategy in relation to the promotion of active ageing, with the intention of addressing two phenomena: population ageing and urbanization (WHO 2007; Plouffe and Kalache 2010). Increasing importance has been placed more recently on research into social and residential environments, with an emphasis on residential satisfaction in terms of quality of life (RojoPérez and Fernández-Mayoralas 2002), but also on new forms of habitation in old age, with non-family housing in cooperative formats (Rojo-Pérez 2020), as well as market offerings. In the framework of these discussions, residential settings are key aspects for the quality of life of older persons. Most importantly, they do not merely include family arrangements but also go beyond familyist centrality to encompass other forms of co-residence, as family behaviours tend to be diversified. Environmental gerontology is a consistent research line assessing the link between physical and social environments, as well as focusing on

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the concerns about the exhaustion of natural resources, the global consequences of climate change and its effects on older persons (Di Véroli and Schmunis 2008; Cárdenas and González 2014; Sánchez-González and Rodríguez-Rodríguez 2016; Giorguli and Muñoz 2016). A third issue relates to old-age support services and the promotion of support for those who provide care to older persons, and particularly to women who reach very advanced ages. It is no less important to address the active intellects of older persons, for which purpose there are proposals for the public recognition of their knowledge and contributions to society. There was ample opportunity to develop these major issues raised by CSOs in Madrid at subsequent forums held in the following years in the Latin America and Caribbean region (CEPAL 2003). From the Brasilia forum held in 2007, proposals were made to eliminate abusive conduct toward and mistreatment of older persons and to adapt physical environments to their characteristics and needs. This is a central issue and has been repeatedly identified by CSOs up to the Ypacarai Declaration (2017). At the same time, there was a reiteration of the idea of eliminating the negative image of old age in advertising and the media, which to an extent created ideas that affected respect for the elderly. These aspects were included in the CSO Brasilia Declaration (2007), which promoted a view of active, participative and healthy old age. This declaration notes the influence of the concept of active ageing, proposed 5 years previously by the WHO (2002), Brasilia Charter (2007). A further aspect was also introduced to the debate, and remains central to quality of life for older persons: the creation of conditions that are favorable in terms of health, housing, nutrition, education and public services. It should be highlighted that since the World NGO Forum on Ageing and the Brasilia forum, the recognition of education in old age has been constantly identified as fundamental for older persons, representing a break from the previously existing educational paradigm. Faber strengthens the concept of active ageing with the incorporation of

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lifelong learning as one of the former’s pillars (ILC-BR 2015). The CSO forums held in various countries across Latin America and the Caribbean have frequently emphasized family arrangements, relationships with children and between spouses, with a focus based on family stages including the “empty nest”—the departure of children and partners living alone (Arriagada 2018). This outlook was influenced by two important aspects: a family-based perspective that made much of the action in the lives of older persons dependent on various family arrangements and in turn made their families responsible for their lives in old age. This “family-based ideology” influenced many of the initial discussions that took place with regard to ageing, with families placed at the center for older persons, on one hand, but on the other hand being responsible for their lives (Huenchuan and Guzmán 2005; Redondo et al. 2015). In recent years, older persons in the Latin America and Caribbean region have seen a transition from this family-based view, central for so long, toward other more critical approaches that do not seek to place further responsibilities on the shoulders of families. This discussion regarding families and care has gradually gained prominence in the Latin American forums, as it has in Europe. For example, the Tres Ríos forum in 2012 and the Ypacaraí forum in 2017 both saw ample references to the issue of caregiving, a concept that has been transformed by the care work performed by caregivers (mainly women), but with the need to develop social homecare programs for older persons. This is essentially a matter related with the dimension of supportive and enabling social and physical environments— and also connected with health, as has been seen—and one that has now gained great prominence (Durán 2018; ONU MUJERES 2018). To summarize, it is possible to identify four main dimensions with relation to supportive and enabling physical and social environments: (a) eliminating all forms of violence, abuse and mistreatment in the public and private spheres; (b) respecting housing preferences, providing access to public spaces and improving transport; (c) eliminating the negative image of old age that

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reproduces stereotypes and publicly recognizing the contribution and knowledge of older persons; (d) promoting socio-healthcare support and services for people who provide care or support to older persons, particularly women. For the future and alongside the 2030 Agenda, it is necessary to reinforce the human rights and gender approach. But the role played by physical and social environments and their accessibility for older persons should also be emphasized (Cisternas 2019), as well as respect for residential habitats, whether urban or rural, especially where indigenous and Afro-descendant people are living, and these do not appear in the guidelines of this Agenda. It is in the spatial dimensions and those related to the environment and climate change where the 2030 Agenda must integrate their effects on people’s quality of life and in that regard, there is a need to safeguard the environmental rights of ageing populations (Huenchuan 2018).

13.6

Final Reflections

The consideration of the dimensions of active ageing and their relationship with quality of life seen in the debates held and documents produced by CSOs in Latin America and the Caribbean in connection with regional forums on ageing and as a follow-up to the MIPAA offers a complementary perspective to that set out in governmental documents. In the last 20 years, CSOs have strengthened their position as actors recognized by national and international bodies, with a voice that carries increasing weight. However, and along the same lines, CSOs are aware that they have a limited influence in terms of the content of policy documents and even more so with regard to the implementation of policies and programs. Nonetheless, they do attempt to perform the function of defending the needs of older persons by attempting to play a part in the design of those documents. The signature and ratification of the Inter-American Convention on the Protection of the Human Rights of Older Persons in the OAS by an increasing number of countries in the region lends credibility to this role, giving CSOs

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equivalence to governments, international bodies and other social actors. What, then, is the fundamental approach taken by CSOs? Society in general and its associative dynamic (CSOs) have evolved since the MIPAA to be more sensitive to the main parameters of the ageing process, which have been gaining importance and interest in terms of being implemented in national public policies in order to improve the quality of life and wellbeing of individuals. In contrast to other general concepts and dimensions, the idea of quality of life does not come through with sufficient strength in the documents to be able to appreciate its evolution over the last 20 years. It always appears in relation to various parameters (health, participation, environments, wellbeing, etc.), fulfilment of which entails an improvement in the living conditions of the older population. To take a high-ranking legal example, the Inter-American Convention does not consider quality of life as an essential reference point in the construction of the body of law it establishes. Article 2 of the Convention describes quality of life together with active and healthy ageing, which permits the focus to be placed on three dimensions: health, financial security and the role of physical and social environments. Health is of key importance in the documents in terms of facilitating the move away from a perspective linked to illness, physical deterioration and decline in functional, which leads to restorative care that revolves around medical treatment, toward a different, comprehensive and preventive way of understanding health as an individual right that enables people to live with autonomy, facilitates their social participation and makes it possible for them to establish social relationships in their living environment. As an aim to be achieved for the entirety of the older population, health appears in the documents as a parameter that causes inequality among the older population given that it is not a homogenous group. This means that CSOs have to make repeated references to the groups that are most disadvantaged in terms of attaining the best health conditions. In relation to this, access to health services also emerges as a trend that critically

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oscillates between the private sphere—families and their women as the custodians of a caregiving social role, and the public arena, in which the State must assume its role as provider of a right that belongs to the population. Based on this understanding, the integrating approach of caring for health problems is linked not only to illness and care but also to other factors that influence health (nutrition, water, healthy environments). As the concept of health becomes broader and more diverse, new aspects appear that are reflected in the Inter-American Convention (art. 19, right to health; art. 12, long-term care) and in the 2030 Agenda (SDG 3, Good Health and Wellbeing). The financial security of older persons is undoubtedly one of the aspects that has been addressed throughout the various CSO texts. Their proposals have changed from an approach focused on the conditions of poverty and inequality experienced in developing countries as a consequence of the economic models they have adopted, foreign debt acquired and economic crises, toward a standpoint that revolves more around individual rights, such as the need for income and dignified work in old age and the inequalities faced due to ethnicity, sex, employment history, and so on. During this development, sight has not been lost of the limitations of benefit systems, the participation of older persons in informal employment, their need to remain in work in order to obtain income, and the intensification of conditions of poverty among ill, dependent and disabled people. Seventeen years after the World NGO Forum on Ageing in Madrid and 16 years after the first CSO Declaration in Latin America and the Caribbean, it can be affirmed that the same concerns persist with regard to the financial security of older persons, and although there has been some progress in implementing universal non-contributory pension programs, these pensions are of an amount that is not sufficient to secure a dignified life. It is to be hoped that the implementation of article 17 of the InterAmerican Convention on the right to social security will give effect to the aim of attaining a dignified life for older persons by securing their

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basic financial resources. SDG 1 of the 2030 Agenda (No Poverty) also reflects this target. Along the same lines, adequate social and residential environments represent another way to secure a dignified life for people, preventing discrimination and enabling the development of family and social relationships. Some of the range of points that emerge from the CSO documents are fundamental to this end, including a safe physical environment that offers the best conditions for the enjoyment of housing, transport and access to urban settings. Other fundamental points are eliminating discrimination and mistreatment in these environments and combating the negative stereotypes of the older population that lead to discriminatory situations, encouraging family arrangements that favor caring for older persons, and providing support services for people and families in their living spaces. CSOs have been making some of these proposals for long periods of time, and they have been enshrined in the Inter-American Convention (art. 9 on personal safety, art. 24 on housing, and art. 26 on accessibility and mobility). SDG 11 (Sustainable Cities and Communities) also incorporates these specific demands for the older population. To conclude, there is a trend in the CSO Declarations in Latin America and the Caribbean that indicates a firm interest in constructing a general policy on older persons as holders of rights that States are obliged to respect, thereby overcoming previous situations that have seen a negative impact from the traditional and deeprooted social, cultural and political practices of many countries in the region. Aknowledgments This work was supported by the project ‘Active ageing and citizenship. Government mechanisms for social inclusion, poverty reduction and inequality in older persons in Mexico’ (UNAM-PAPIIT IN300517) and by the Network ‘Active Ageing in Ibero-America’ (ENACTIBE) (MINECO, CSO2015-71193REDT). Our thanks also to the specialized translator and the reviewers who enriched this work.

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Outdoor Green Spaces and Active Ageing from the Perspective of Environmental Gerontology

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Diego Sánchez-González and Carmen Egea-Jiménez

14.1

Introduction

The world today is undergoing a process of demographic ageing within the context of increasing urban growth and climate change. It is estimated that in the year 2050 four out of every five people over 60 on the planet will live in Third World cities (UNFPA 2007). This has led to increased interest on the part of governments to discover the socio-spatial implications of urban spaces in the health and quality of life of older people (Rioux and Werner 2011; Rojo-Perez et al. 2016; Garcia-Ballesteros and Jimenez 2016). At the same time the scientific community is helping to reveal the excesses of the process of global urbanization, and the effects of pollution and environmental deterioration on the morbidity and mortality of the aged (Simoni et al. 2015). The World Health Organization is promoting the idea of age-friendly cities and communities, as one of the most effective mechanisms for local policies wishing to address the ageing of the urban population (WHO 2007; Moulaert and Garon 2016). This program has arisen out of the need to promote active ageing, as a process for optimizing the opportunities for health, D. Sánchez-González (*) Department of Geography, National Distance Education University (UNED), Madrid, Spain e-mail: [email protected] C. Egea-Jiménez University of Granada, Granada, Spain e-mail: [email protected]

participation, security and lifelong learning in order to improve the quality of life as people get older (WHO 2002). Open-air spaces such as green areas, gardens and public parks have an important impact on the mobility, independence and quality of life of older people in our communities and in institutions and must therefore be a key factor in the design of friendly cities and the promotion of active ageing (Plouffe and Kalache 2010; Buffel et al. 2014). Research in recent decades has indicated that green areas contribute to the physical and mental wellbeing of the ageing population, by fomenting outdoor activities, safety and social interaction (Yung et al. 2017). It is also reported that access to and the quality of outdoor spaces contribute to the residential satisfaction of senior citizens (Rojo-Perez et al. 2007; Yeo et al. 2019). Various interesting contributions have been made to the study of natural settings and their implications on active ageing by approaching it from the perspective of environmental gerontology (Peace et al. 2006; Yung et al. 2016). It has been found, for example, that having green spaces in the neighborhood is important for maintaining outdoor activity (walking, social relations) and improves the probability of older adults being able to remain in their homes so avoiding the risks involved in relocation (Annear et al. 2014). It has also been suggested that daily exposure to elements of the natural landscape has therapeutic and symbolic benefits associated with memories and experiences, which strengthen their feelings

# Springer Nature Switzerland AG 2021 F. Rojo-Pérez, G. Fernández-Mayoralas (eds.), Handbook of Active Ageing and Quality of Life, International Handbooks of Quality-of-Life, https://doi.org/10.1007/978-3-030-58031-5_14

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of attachment to a place and of belonging to the community (Bedimo et al. 2005; SanchezGonzalez et al. 2018). However, there is still limited research based on empirical evidence on the implications of nearby physical-natural environments on the promotion of the pillars of active ageing (health, participation, security and lifelong learning) (WHO 2002), a fact that has tended to restrict the design of intervention programs. Researchers have tried to find the answers to two key questions: (1) How do outdoor green spaces influence active ageing? (2) Which attributes and functions of green public spaces help consolidate the pillars of active ageing? The objective of the chapter is to conduct a systematic review of the international literature, from the theoretical and methodological approach of environmental gerontology, to understand the influences of outdoor green spaces (green areas, gardens and public parks) on the promotion of the pillars of active ageing (health, security, participation and lifelong learning). As a complementary objective, they are identified key elements and strategies to favor a basic proposal outline, that contributes to the development of a future intervention model on active aging in natural environments. The methodology is based on a review of the bibliography obtained by consulting databases such as Web of Science and Scopus. The results indicate that exposure to outdoor green spaces promotes active ageing by encouraging physical activities, social relations and active participation in the community. The discussion suggests that via the control of the attributes and functions of these natural settings it is possible to strengthen or weaken the pillars of active ageing. Likewise, key elements and strategies are identified to favor a initial proposal for a future intervention model on active ageing, such as the optimal adaptation of the specific characteristics of outdoor green spaces to the competences and preferences of older people. It is recommended to develop new research from interdisciplinary and longitudinal perspectives, that use mixed methods in the assessment of the characteristics of natural environments, so as to be able to adapt and improve them within the

D. Sánchez-González and C. Egea-Jiménez

design of the future intervention programs to encourage active ageing. It also is important to encourage the active participation of older adults in the design and planning of friendly cities, in which natural elements can promote lifelong healthy lifestyles.

14.2

Method

Our research is based on a systematic review of international literature via the consultation of scientific articles from journals indexed in the Web of Science and Scopus databases. The criteria used to limit the search were research published in English, Spanish and Portuguese between 1985 and 2019. We also used combinations of the following terms and their synonyms: active ageing, aging, ageing, aging population, old age, grow old, older people, older adult, elderly, seniors, natural elements, green areas, natural environment, public open spaces, public space, public park, natural landscape, gardens, outdoor space, building, age-friendly cities, elderfriendly, friendly cities, friendly community, aging in place, liveable city, healthy cities, healthy ageing, walkability, mobility, accessibility, sustainable, neighborhoods, planning, urban, urbanisation, urban aging, built environment, environmental factors, environmental indicators, environmental attributes, environmental functions, facilitators, barriers, evaluation tool, settings, health, supportive environment, social environment, policy, empowerment, governance, participation, security, safety, quality of life, and wellbeing. The initial search produced a total of 2310 potential articles. However, after carefully reviewing the title, keywords and summary of each one, this was reduced to 253 articles of interest, 87 of which were included in this review because they were directly linked and relevant to this subject. The review was completed by consulting books and reports. In the review of the selected articles, we found that most of the research was based on quantitative methods, while qualitative or mixed methods were used in only a limited number of studies (McCormack et al. 2010). Another dominant

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Outdoor Green Spaces and Active Ageing from the Perspective of Environmental Gerontology

feature is transversal design while there are relatively few studies based on a longitudinal approach. We also observed that in the quantitative studies, the participants were normally selected using probabilistic sampling techniques and were asked to respond to questionnaires. Another interesting finding was that the most frequently used methods in the qualitative studies were in-depth interviews and focus groups, while other ethnographic methods such as photovoice and mental mapping were only used in a minority of cases (Garvin et al. 2012; Sanchez-Gonzalez et al. 2018). As regards studies of the variables in the natural environment, the most frequent were studies based on dimensions defined by the researchers themselves and to a lesser extent on the basis of the perception of the users. Nonetheless, we found few examples of research based on data obtained by measurements in the field using environmental sensors and checklists (SanchezGonzalez and Cortes-Topete 2016). Another methodological aspect was the conceptualization and delimitation of the study areas. In this article, an outdoor green space is conceptualized as a publicly managed outdoor space with natural features, such as a green area, neighborhood garden or public park. In the literature, however, there is a lack of consensus in the definition of these spaces (Koohsari et al. 2015), which are normally associated with urban land use units (such as the free spaces used for the provision of public services) or with administrative units established by governments (census districts). Some studies even go so far as to include subjective definitions of green spaces proposed by the residents within the particular context of their neighborhoods (Fadda et al. 2010).

14.3 14.3.1

Results Outdoor Green Spaces and Their Implications on Active Ageing from the Perspective of Environmental Gerontology

Our review of the literature has confirmed the growing interest amongst the scientific

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community in the influence of nature on active ageing in place (Annear et al. 2014). The term active ageing is also a source of some confusion in terms of its definition and is normally linked to wellbeing and quality of life, which limits its practical application in the assessment of public policies (Fernandez-Mayoralas et al. 2015; Rodriguez-Rodriguez et al. 2018). Environmental gerontology seeks to understand, analyze, modify and optimize the relation between the ageing person and their physical, natural and social environments, from a range of interdisciplinary perspectives and approaches (Wahl et al. 2012; Rodriguez-Rodriguez and Sanchez-Gonzalez 2016). In recent decades this branch of gerontology has made important theoretical contributions to the study of natural settings and their influence on active ageing in place, which has been found to enhance the spatial independence and autonomy of older adults in their homes and neighborhoods (Wahl and Oswald 2016). However, little is known about how older people experience the natural environment around them, and its influences on the opportunities for dealing with everyday challenges in ageing (Sugiyama and Thompson 2008; Garcia-Valdez et al. 2019). The active behavior of an ageing person depends on their functional and cognitive capacities and on the characteristics of their environment, such as the presence of natural elements (Sanchez-Gonzalez and Cortes-Topete 2016) (Fig. 14.1). Proponents of the ecological theory of ageing (Lawton and Nahemow 1973) explained that during the ageing process we experience a reduction in our functional and cognitive capacities, which results in spending more time in the residential setting of the home and neighborhood. Nonetheless, it has been suggested that natural environments can contribute to create mechanisms for adaptive coping, by increasing suitable, stimulating choice opportunities, optimizing learning and experience, and compensating for the individual losses and deficits produced by ageing (Baltes and Baltes 1990). Open spaces, such as neighborhood gardens and public parks are urban recreation facilities (NarvaezMontoya 2012) whose specific characteristics (accessibility, safety, comfort) can enhance healthy lifestyles amongst older adults (Finlay

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Fig. 14.1 Outdoor green spaces and its implications for active ageing. Source: Adapted from Sallis et al. (2006), Yung et al. (2016), Sanchez-Gonzalez et al. (2018), by authors

et al. 2015; Duan et al. 2018). For example, large outdoor green spaces have been linked with more frequent physical activity and better health amongst users (Paquet et al. 2013). The frequency with which older people use green areas may depend on their personal capacities, biography and physical social context, such as the availability of a private garden, walking the dog and access to parks over the course of their lives (Maat and De Vries 2006;Dalton et al. 2016; Cherrie et al. 2018). At the same time the absence or deterioration of green areas can have a negative effect on active ageing, by discouraging everyday open-air activities, such as leisure, recreation and social relations (Kaplan and Kaplan 2003; Peace et al. 2006; Kemperman and Timmermans 2014). Different studies have indicated that daily exposure to outdoor green spaces and bodies of water (rivers, lakes) have potential benefits for the health and quality of life of older adults and are determining factors in the promotion of active ageing (Finlay et al. 2015). In fact, gardens and

public parks stimulate physical activities such as walking and cycling, which generate tangible positive effects for the physical and mental health of the older people, and a lower risk of cardiovascular diseases and dependence (Maas et al. 2009). In this case, because outdoor green spaces are perceived as attractive, enriched settings, they can stimulate the improvement of the cognitive capacities of older adults and increase positive feelings and residential satisfaction, as well as reducing the risk of environmental stress (Bengtsson and Grahn 2014; Cassarino and Setti 2015). Green areas can contribute to improving environmental adaptation to climate change in an ageing urban society, by mitigating the effects of pollution and the impact of natural dangers such as floods and heat waves (De Vries et al. 2003; Chavez and Sanchez-Gonzalez 2016). Green public spaces, as ecological elements of social cohesion and of high economic, historic, cultural and symbolic value (Chiesura 2004), can contribute to environmental justice, reducing the

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Outdoor Green Spaces and Active Ageing from the Perspective of Environmental Gerontology

effects of the segregation of impoverished neighborhoods and the social inequality of the vulnerable ageing population (Sanchez-Gonzalez and Egea-Jimenez 2011). For example, it has been noted that in neighborhoods with large amounts of green areas older adults residents on low incomes showed significant benefits in their health and a lower risk of mortality (De Vries et al. 2003). Active ageing is linked to the spatial experience of growing old in place, and is influenced by a sense of belonging, the significance of the home (house and neighborhood), and the life story of each person (Sanchez-Gonzalez 2009). Older people tend to live in the same place for many years. The long time spent in the home enables the person to establish cognitive, affective and social links with the everyday spaces and elements of their home and its outdoor surroundings, such as gardens and parks. In fact, during ageing these outdoor green spaces become important for their significance in the configuration of a sense of identity, of attachment to a place and of belonging to a neighborhood, all key factors in reducing the risk of relocation (SanchezGonzalez et al. 2018). Green areas are also spaces where people can spend time together, meet others and improve social relations, so strengthening neighborhood support networks and reducing the risk of loneliness and depression during ageing (Gaikwad and Shinde 2019). Some differences in the use of nearby green spaces have been noted according to the age and sex of the users, in that older women tend to get involved in spontaneous social conversations and enjoy shared activities such as sewing, while men prefer games such as cards, dominoes or bowls (Noon and Ayalon 2018). It has also been observed that green areas with trees promote altruistic behavior aimed at helping other people in the community (Takano et al. 2002; Gueguen and Stefan 2016). According to the theoretical approach of environmental proactivity (Lawton 1989), older people can become agents for change in their physical-natural and social environment. This involves both compensatory and adaptive behavioral strategies at an individual level, such as the maintenance, modification and optimization of

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the places in which they live. In the last decade various government initiatives have promoted a proactive approach to environmental optimization, in which older adults play an active role in the search for solutions in their residential environment and contribute to the design of outdoor green spaces, which are key factors in the promotion of friendly cities (Wahl et al. 2012; Buffel et al. 2014). This active participation of older people in the design and planning of friendly cities can prevent or correct the adverse effects of exclusive town planning (as seen in some gentrification processes), by preventing the disappearance of open spaces and elements, such as tree-filled areas that have high symbolic value for the community (Buffel and Phillipson 2019). In this case, the proposals made by older adults in relation to friendly cities and neighborhoods respond to a decision-making process based on their own spatial experiences of environmental comfort and control, and the search for residential normality over the course of their lives and in particular during old age. At the same time, the decisions taken by this social group may be motivated by a need to optimize their residential environments in a selective way, assigning specific resources to compensate for potential losses linked to old age and to promote active ageing (Golant 2015).

14.3.2

Environmental Attributes and Functions in the Promotion of the Pillars of Active Ageing

In recent decades there have been a number of different theoretical and methodological attempts to define and stratify the objective and subjective dimensions of the environment in ageing (Takano et al. 2002; Yung et al. 2016). The objective dimensions or attributes of the physical-natural environment refer to all the objective and material aspects of the environment, expressed in decimal metric units, which can be measured on the basis of their functionality. These include accessibility, mobility, orientation, security, privacy, control and comfort. The subjective dimensions or functions are linked to all the subjective aspects

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of the environment and can be measured via their usability. These include maintenance, support and stimulus (Lawton 1989; Wahl and Weisman 2003; Sanchez-Gonzalez 2015). Various different studies have argued that via the control of the attributes and functions of outdoor green spaces it is possible to influence the behavior and interaction of older people with their environment, so strengthening or weakening the pillars of active ageing (Yung et al. 2016; Sanchez-Gonzalez and Cortes-Topete 2016) (Table 14.1).

14.3.2.1 Health Health is a key pillar of active ageing which refers to the complex state of physical, psychological and social wellbeing throughout one’s life. Scientific evidence indicates that the various components of healthy lifestyles, such as physical and social activity, a healthy diet, effective accompaniment (i.e. that which brings benefits in terms of health and general quality of life) and a meaning to life, can promote autonomy and independence, so preventing or delaying the risk of incapacity and dependence in old age (WHO 2002). Different studies have tried to establish which objective and subjective characteristics of green spaces influence the performance of outdoor physical activities, health and general quality of life (De Vries et al. 2003; Milligan et al. 2004; Sallis et al. 2006). On this question, the most important environmental aspects related with health include accessibility (the presence of architectural barriers, distance), mobility (walkability, connectivity) and security (risk of falling, crime). These influence the level of use of green areas and the frequency of open-air activities, as well as the prevalence of illnesses and functional and cognitive decline in old age (Maas et al. 2009). The various attributes of control, (street furniture, sports equipment) and comfort (maintenance of green areas, cleanness and temperature) are also related with the daily practice of physical activity, residential satisfaction and the physical and psychological wellbeing of older adults (Hartig et al. 2003; Kwok and Ng 2008; Cervinka et al. 2012). Changes in the weather can influence the

D. Sánchez-González and C. Egea-Jiménez

perception of natural environments and their potential dangers, which in turn can affect one’s mood and the choice as to whether to visit outdoor places such as parks (La Gory and Fitpatrick 1992). The environmental functions include stimuli (sounds and smells of nature, diversity of trees, flowers and animals) associated with the encouragement of leisure and recreation activities (art, music, games), and improvements in mood and concentration capacity (feeling more relaxed, spiritual recovery), as well as the functional and cognitive activation of dependent people (Rappe and Topo 2007; Wen et al. 2018; Bell et al. 2018). However, the benefits for the mental health of older people of exposure to natural elements may be influenced by the degree of conservation of the vegetation, their sociodemographic characteristics and the emotional links with the natural environment around them that arise from these spatial experiences (Artmann et al. 2017; Lawton et al. 2017; Sanchez-Gonzalez et al. 2018).

14.3.2.2 Security Security, as a pillar of active ageing, is associated with the absence of risks and has important implications in healthy lifestyles, health and physical and psychological wellbeing at both a personal and a community level (WHO 2002). The environmental attributes of security, accessibility and mobility help enhance both objective and perceived safety in active ageing, as they influence the degree to which natural environments protect users from falls, injuries or other dangers (crime) (Zeisel et al. 2003). In fact, the proximity to green areas is an excellent resource for improving perceived safety and facilitates open-air activities, social interaction and peaceful coexistence (Kaplan and Kaplan 2003; Villanueva et al. 2015). Likewise, environmental control and comfort (maintenance of green areas, cleanness) influence the perception of safety, and therefore the use and the frequency of everyday activities such as physical activity and social relations (Stedman 2002; Kwok and Ng 2008).

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Table 14.1 Attributes and functions of the outdoor green spaces that determine active ageing

References Takano et al. (2002), Fadda et al. (2010), Sanchez-Gonzalez et al. (2018)

Kurniawati (2012), Annear et al. (2014), Yen et al. (2014)

Sanchez-Gonzalez and CortesTopete (2016) McCormack et al. (2010), Finlay et al. (2015)

Outdoor green spaces

Pillars of active ageing

Attributes Accessibility

Health ✓

Mobility

Orientation Security

Artmann et al. (2017) Gaikwad and Shinde (2019)

Privacy Control

De Vries et al. (2003), Bjerke et al. (2006), Kemperman and Timmermans (2014)

Comfort

McCormack et al. (2010), Annear et al. (2014), Yung et al. (2016), Duan et al. (2018), Keijzer et al. (2019)

Functions Stimulation

Variables Removal architectural barriers Proximity to services and activities Information (urban signage) Topography (flat, smooth) Walkability Connectivity Accessible public transport Limitation to traffic Low concentration of people Inclusive design (legibility) Low risk (falls, disorientation, crime) Optimum lighting Low pollution (air, noise, water, soil) Intimacy Public toilets Public seats Drinking fountains Sports equipment Cleaning Maintenance of green areas Environmental temperature Intensity of the wind Humidity Shaded areas Vegetation (trees and flowers) Wildlife (birds, squirrels)

Security ✓

✓

Participation ✓

Lifelong learning ✓

✓

✓

✓

✓

✓ ✓ ✓

✓

✓

✓

✓

✓ ✓ ✓

✓

✓

✓

✓

✓

✓

✓

✓

✓

✓

✓

✓

✓

✓

✓

✓

✓

✓

✓

✓

✓

✓

✓

✓ ✓ ✓ ✓

✓ ✓ ✓

✓ ✓ ✓

✓ ✓ ✓

✓ ✓ ✓

✓ ✓ ✓

✓

✓

✓

✓

✓

✓

✓ ✓

✓ ✓

✓ ✓

✓ ✓

✓

✓

✓

✓

✓

✓

✓

✓

✓ (continued)

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Table 14.1 (continued)

References

Outdoor green spaces

Pillars of active ageing

Attributes

Variables Bodies of water (rivers, streams, lakes, ponds)

Health

Sounds and smells of nature Varied trails Aesthetics of design (colors, textures, materials) Versatility (leisure time) Pleasure (favorable experiences) Gardens and urban gardens Place attachment Identity Familiarity (friendships) Social interaction Family spaces Intergenerational relationships

✓

Kweon et al. (1998), SanchezGonzalez et al. (2018)

Maintenance

Lachowycz and Jones (2013)

Support

Participation

Lifelong learning

✓

✓

✓ ✓

✓ ✓

✓

✓

✓

✓

✓

✓

✓

✓

✓

✓ ✓

Security

✓

✓ ✓ ✓

✓ ✓

✓ ✓ ✓

✓ ✓ ✓

✓ ✓ ✓

✓ ✓ ✓

✓ ✓ ✓

Source: Adapted from the references cited; by authors

The environmental functions of stimulus, maintenance and support are crucial in the perception of the safety of natural environments and the promotion of active ageing. The exposure to natural elements helps increase the proactive strategies of older adults against the pressures in their surrounding environment, providing an improved sense of safety and fomenting outdoor activities, socializing and a feeling of identification and empathy with their natural surroundings (Mitchell and Popham 2007; Deplege et al. 2011). It has also been observed that older people who are familiar with their daily natural environment are more independent, as they more inclined to engage in physical activity, so improving their functional and cognitive competence and giving them a stronger sense of safety (SanchezGonzalez 2015).

14.3.2.3 Participation Participation is a key pillar of active ageing, which is linked to social, intellectual and spiritual commitment and to positive social relations and a sense of belonging. It also boosts the physical and mental wellbeing of older adults and their social inclusion and reduces the risk of dependence (WHO 2002; Dufouil et al. 2014). This participation can be voluntary, for example via involvement in non profit making organizations and associations; and active, in decision-making political processes (town planning), which can enhance their empowerment. Environmental attributes play an important role in promoting participation. These include accessibility, mobility and security due to their influence on the use of green areas and the holding of activities organized by the community

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(walking groups, community gardens), so improving social relations, social inclusion and a sense of belonging (Milligan et al. 2004). For example, the density of the vegetation in parks can affect the recreational preferences of older users as it limits their mobility (Bjerke et al. 2006). Similarly, environmental control and comfort can facilitate sociocultural participation and social commitment, improving self-esteem and reducing the risk of isolation (Kweon et al. 1998). The provision of benches, public toilets, and drinking water fountains allows older people to spend more time outdoors, so increasing their opportunities for participation and social interaction (Gaikwad and Shinde 2019). The environmental functions of stimulus, maintenance (identity, attachment to place) and support (social interaction) increase the degree of affectivity towards the everyday natural surroundings, by means of ecological actions, and promote the active and altruistic participation of older adults in environmental protection programs (Gueguen and Stefan 2016). In green spaces the support linked to social interaction foments participation in group activities, such as walks and games, which have beneficial effects on the health and quality of life of older people (Lachowycz and Jones 2013; Duan et al. 2018). Likewise, participation in gardening and horticulture programs fosters social relations, attachment to place, identity, aesthetic pleasure and physical, psychological and spiritual wellbeing (Cooper and Barnes 1999). This environmental identity is created by means of a symbiotic interaction between the natural setting and the spatial experiences of the people who are ageing in place (Cuba and Hummon 1993; Rowles 2006; Tofle 2009). In the same way, attachment to place motivates the active participation of older adults in the defense and promotion of everyday green spaces, through altruistic, strongly committed actions linked to voluntary work and associationism, as well as in urban design and planning exercises which help bring about social inclusion and empowerment (McCormack et al. 2010; Sanchez-Gonzalez et al. 2018). For example, environmental voluntary work can have therapeutic benefits for older people who want to be in

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contact with nature in everyday public spaces and relate with other people, but who require specific stimuli and supports in order to be able to join programs of this kind (O’Brien et al. 2011).

14.3.2.4 Lifelong Learning Lifelong learning is a pillar that supports the other pillars of active ageing, in that it is based on the acquisition of knowledge and skills to produce lifelong healthy lifestyles, key factors for remaining healthy, competent and committed in old age (WHO 2002). Little research has been done from a longitudinal approach regarding the influence of natural settings on the promotion of lifelong learning. However, results indicate that the environmental attributes of accessibility, mobility, security, control and comfort, foster the acquisition of knowledge and skills over time, by enhancing open-air training activities and social relations that improve self-esteem and empowerment (Kweon et al. 1998). The environmental functions of stimulus and support also enable the perceived natural setting to become part of the memory and of experiences, key issues in lifelong learning and in the design of environmental adaptation strategies that can enable senior citizens to deal better with important changes at a personal and social level (such as worsening health or losing a spouse) (Grahn and Stigsdotter 2003).

14.4 14.4.1

Discussion and Recommendations Empirical Evidence and Limitations of this Research

Over the course of recent decades, the results obtained by researchers from the perspective of environmental gerontology can be considered hopeful due to the lines of research opened, although the results must still be treated with caution due to the limited empirical evidence gained from longitudinal research approaches. This academic effort has produced various different studies which indicate that exposure to the natural elements in outdoor spaces provides

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potential benefits in active ageing (Beard and Petitot 2010; Annear et al. 2014; Yung et al. 2016). Similarly, through the management of the attributes and functions of natural environments it is possible to strengthen or weaken the pillars of active ageing. In the gerontological approach to active ageing from the field of health sciences, the lines of research which offer the most empirical evidence have focused on the benefits of physical-natural settings in encouraging physical activities (walking, cycling), health and wellbeing. However this empirical evidence is insufficient to support the development of intervention programs given the need for new longitudinal studies which help perfect the evaluations of the attributes and functions of the environment, so enabling the optimization of the environment and improved adaptation to the functional and cognitive capacities of the heterogeneous older participants, as well as to the different sociocultural contexts. Various contradictions can be observed in the literature when comparing the results of different studies in relation to the attributes of the physical and natural environment, such as connectivity, which in some cases is considered a factor that facilitates mobility and physical activity and in others a limiting factor associated with a loss of safety (Yen et al. 2014). Others question whether visiting parks is related with improvements in health and wellbeing and reduction of the problems of loneliness in old age (Noon and Ayalon 2018). Some researchers have pointed out that exposure to the natural elements can have adverse effects (allergies, insect stings, disorientation) on fragile dependent people (Brawley 2007). However, it is possible that the presence of green areas, even in cases in which there are problems of size and quality (accessibility), can have benefits for health and inspire older people to participate in physical activities outside their homes (Dalton et al. 2016). For example, a park can be observed and enjoyed from the window of one’s home and offers numerous opportunities for restoring the mental health and wellbeing of older adults (Kaplan and Kaplan 2003).

D. Sánchez-González and C. Egea-Jiménez

Other emerging lines of research which received more attention from the social sciences field discuss the potential benefits of outdoor green spaces in the promotion of participation, security and lifelong learning (Cunningham and Michael 2004). Nonetheless, these kinds of research offered little empirical evidence in the assessment of the objective and subjective characteristics of the physical-natural and sociocultural environment, and their implications in terms of attachment to place, perception of safety, altruistic, caring behavior and the acquisition of knowledge and skills to create lifelong healthy habits. At the same time, the results are still inconsistent and are the product of the prevalence in the literature of transversal, descriptive and relatively unanalytical studies based on small samples that are difficult to extrapolate (Parra et al. 2010). In this branch of gerontology, it has been argued that one of the problems lies in the lack of consensus in the definition and stratification of the objective and subjective dimensions of the physical-natural environment (Wahl et al. 2012; Sanchez-Gonzalez 2015). In addition, the dominance of transversal studies based on interventions aimed at small groups has limited the obtaining of empirical evidence and the establishment of ecological theoretical models, which are key factors in the design and application of active ageing programs.

14.4.2

Considerations in the Design of Intervention Programs on Active Ageing in Outdoor Green Spaces

The literature is dominated by research focusing on wealthy English-speaking countries (United States, United Kingdom) and based on limited empirical evidence. The proposals for intervention in active ageing in outdoor green spaces in these studies have nothing to do with the socioenvironmental and cultural reality of the ageing population in cities in developing regions such, as Latin America (Sanchez-Gonzalez 2015). Another key issue in the discussion is related to

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the need to reach an interdisciplinary complementarity and consensus (Seah et al. 2019) in the design of intervention programs on active ageing, based on optimization of the environment and its adaptation to the capacities and preferences of older participants. It has also been suggested that the design of these programs could be determined by personal (functional and psychological capacities), environmental (constructed and natural), sociocultural (culture, religion), and political (laws, rules, regulations) factors (Paoletti 2015; Bauman et al. 2016). The formulation of these programs must be adapted to each sociocultural context, designing strategies that can improve the social inclusion and empowerment of older people, and address the potential threats of discrimination due to age and the negative effects of cultural stereotypes (Fernandez-Ballesteros et al. 2017). Organizational aspects and the training of personnel are important in the design of intervention programs, so as to ensure the provision of activities and the availability of services for older adults in outdoor green spaces. At the same time, the continuation of the participants in the programs will could depend on their level of satisfaction and that of their families, in which a key role is played by the activities that foment intergenerational altruistic relationships between the different members of the community (Sanchez-Gonzalez et al. 2018). One example is community gardening programs for older people in public parks. The participation of both professionals and users (dependent or not) is important in the design of these activities. It is also important for the program to be based on the diagnosis of the capacities and sensibilities of older participants, of the characteristics of the sociocultural and political context, and of the specific characteristics of the outdoor green spaces, in order to be able to optimize the environment and adapt it as well as possible to the individual preferences of participants. As a result, the park and the gardening program have been adapted to promote the long-term active participation of older adults, so strengthening their contact with nature, lifelong learning and social relations (Milligan et al. 2004), and benefiting

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their relaxation and recovery, and their physical, psychological and spiritual wellbeing. As a result of the review of the scientific literature (Sallis et al. 2006; Paoletti 2015; Bauman et al. 2016), key elements and strategies are identified to favor a basic proposal outline, that contributes to the development of a future intervention model non-pharmacological on active aging in outdoor green spaces (Fig. 14.2). This initial proposal, which needs to be operationalized and empirically validated through future research, would be based on a diagnosis of the functional and cognitive capacities of the potential participants; of the characteristics of the physical-natural and sociocultural environment, of the political and juridical framework (laws, rules and regulations), and of the training of personnel (interdisciplinary). Likewise, it would be analyzed the attention needs and preferences of the participants (health, wellbeing and control), as well as the available support in the physical-natural and social environment. The possible program would be implemented offering activities and services aimed at fomenting personal skills and adaptive conduct, so as to ensure the best possible person-environment fit. Finally, an evaluation of the intervention program implemented could be carried out and improvement alternatives would be proposed. The initial proposal could strengthen the opportunities for choice, identifying the environmental support available (accessibility, security, privacy, stimulation) that the best fit personal competences and preferences of users. Also, the promotion of active ageing and healthy lifestyles (physical activities and social relationships) would be associated with the optimization of the characteristics of the outdoor green spaces, as the environmental stimulation (selection and care of vegetation, nature sounds) and the safety of the participants (elimination of physical and social barriers).

14.4.3

Recommendations

Research into the influence of exposure to outdoor green spaces on the promotion of active

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Fig. 14.2 Basic proposal outline of key elements and strategies to favor a future intervention model on active aging in outdoor green spaces. Source: Adapted from Paoletti (2015), Bauman (2016), by authors

ageing has so far been dominated by transversal studies. This has led to weak results and limited empirical evidence, which has made it difficult to develop specific guidelines for designing and optimizing the parks and gardens that can inspire an active life, above all in old age (Koohsari et al. 2015). This is why, from the interdisciplinary perspective of environmental gerontology, there has been a call for longitudinal research which can produce empirical evidence of the benefits over time of natural environments in active ageing, mental health and lifelong learning (Cherrie

et al. 2018). There is also a need to promote longitudinal studies about the influence of green public spaces on the prevention and or delay of situations of incapacity and dependence (Artmann et al. 2017). We also recommend continuous assessment of the therapeutic and restorative effects of natural elements for the physical and psychological health of people with dementia (Alzheimer) and of their carers, both institutionalized and in the community, in order to try to improve the intervention programs in active ageing (Bell et al. 2018). The optimization

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of parks and public gardens can contribute to normalize their use by people with dementia, and to improve social awareness of this condition (Furness and Moriarty 2006). The diversity and complexity of the attributes and functions of physical natural settings for the promotion of active ageing requires the incorporation of mixed methods and new tools for environmental analysis and evaluation such as photovoice, mental mapping, checklists and environmental sensors. The incorporation of virtual environment technologies (virtual reality) which can simulate different environmental situations, such as parks and gardens, could be used to control factors of confusion and identify the scenarios that provide optimum environmental stimulation and facilitate cognitive performance in old age (Cassarino and Setti 2015). Similarly, Global Positioning Systems (GPS) and Geographic Information Systems (GIS) could be used to support studies of the mobility of older adults and of the spatial-temporal location of stimulating spaces. The progressive incorporation of new cohorts of more active and more aware older people could help increase the demand for outdoor green spaces, which would encourage healthy lifestyles and promote active ageing. This would also help to reduce the high costs produced by the health problems of an ageing, sedentary society, in which dependence is on the increase. However, accelerated urban growth, globalization and climate change are causing the disappearance of outdoor green spaces, above all in cities in the developing world, such as Latin America and Africa (Garcia-Valdez et al. 2019). This obliges us to rethink our urban model and our relationship with nature, and to reassess the viability of Age-friendly Cities and Communities programs. To this end there is a clear need to research the repercussions of environmental deterioration and the loss of these nearby natural landscapes on the quality of life and the pillars of active ageing, as well as the discouragement of lifelong healthy lifestyles, negative behaviors produced by poor adaptation to the setting and the deterioration of physical and psychological health.

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In the construction of age-friendly cities, it is vital that professionals and public sector managers become aware of the importance of environmental gerontology in the planning and design of outdoor green spaces. It would also be a good idea to increase research on the attractiveness of green public spaces, so as to bring about their optimum fit with personal needs, which is determined by the functionality of the attributes of the physical-natural environment (quality and quantity of green areas) and the usability of the functions of the social setting, all key factors in the promotion of active ageing in place (SanchezGonzalez and Cortes-Topete 2016). It is also crucial that local governments encourage the active participation of older adults in the planning of their neighborhoods, in which green areas are essential for the construction of lifelong healthy ecological societies (McCormack et al. 2010; An et al. 2013; Duan et al. 2018). The participation of this collective in decision-making about their communities could contribute to their social integration and empowerment and could facilitate the optimization of their green spaces within the design of intervention programs on active ageing. Natural environments are places in which identity is shaped and people can thrive at both a personal and social level, so improving the way in which we live and grow old in an active and healthy manner. To this end it is essential to highlight the key role that will be played by future outdoor green spaces in the construction of a resilient society that can grow old well despite the demographic, social and climate challenges facing the world today. Acknowledgments This research is part of the research project “Natural therapeutic landscapes, environmental identity and healthy aging in the place. The case of Monterrey, Mexico” (RC-DI-PA-07-003), PAICYTUANL (Mexico).

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Active Ageing and Quality of Life

15

An Agenda for Scientific Research Alan Walker

15.1

Introduction

This chapter examines the role of science in achieving active ageing and enhancement of the quality of later life. It takes as axiomatic the essential nature of the contribution of scientific research to respond successfully to the global challenges of ageing because it provides the evidence upon which policy, practice, product and service innovations should be based. It is one of the keys to ensuring that the positive potential of ageing is realised for both individuals and societies. This crucial role of research as well as the necessity for multi-disciplinarity have been emphasised well by the European Commission: “Ageing research is an area of great social, political and economic importance for the European Union . . . I want to re-focus research and innovation policies very clearly on developing a coherent strategic research agenda which will tackle the grand societal challenges, which include both the promotion of healthy living and healthy ageing . . . These challenges can only be confronted if innovative and multi-disciplinary approaches are taken” (Geoghegan-Quinn 2010). Accepting the essential role of scientific research in the achievement of active ageing, the question what should be the main research priorities is the main focus of this chapter. It A. Walker (*) Department of Sociological Studies, University of Sheffield, Sheffield, UK e-mail: a.c.walker@sheffield.ac.uk

draws on the Road Map for European Ageing Research (Futurage 2011) but adapted for a global audience with reference in particular to the Madrid International Action Plan on Action of Ageing (UN 2002).

15.1.1

A New Vision of Ageing

As well as prioritising research to promote active ageing, and with it the quality of later life, much more fundamentally these goals also rest on the development and application of a new vision of what ageing could and should be. This new vision is essential because the present dominant paradigm is outdated in the global north and rapidly becoming so in the south as the less developed countries age rapidly. In the previous sociodemographic era retirement took place for a majority at state pension ages and post-retirement years were relatively short, in the developed countries that is. Changes in the labour market and social behaviour coupled with a remarkable extension in longevity, associated in some countries with a pushing further up the age range (or ‘compression’) of morbidity, have transformed the experience of later life for many. Of course deep-seated inequalities remain and while 70 may be the new 50 for some, it is but a distant dream for others even in the more developed world. This is one reason why inequalities in health and healthy life expectancy (HLE) must be a central feature of any research agenda on

# Springer Nature Switzerland AG 2021 F. Rojo-Pérez, G. Fernández-Mayoralas (eds.), Handbook of Active Ageing and Quality of Life, International Handbooks of Quality-of-Life, https://doi.org/10.1007/978-3-030-58031-5_15

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ageing. While the transformation of ageing and old age are far advanced in some of the world’s richer countries, in the global south the picture is much more mixed. These less developed countries will see the most rapid ageing of their populations over the current century and, with this increase in longevity, will come similar pressures to those experienced already by the more developed ones. But the big difference between them is that the latter developed before they aged while the former are ageing while they develop economically. This means that they will not necessarily have the same levels of resources as the more developed countries to spend on infrastructure to support active ageing. This deficit must be born in mind by researchers and especially by policy makers. Regardless of levels of economic development there is an obstructive ‘structural lag’ between socio-demographic change and the adjustment of societal institutions and attitudes, for example in the labour market and media (Riley 1994). This time lag of up to 20 years is a major factor in the need for a new vision of ageing and old age. This should be a positive vision in which all older people, regardless of competence and capability, are included in society as full citizens, expected to contribute and participate, and in which they feel empowered. The reality of the plasticity and diversity of old age must replace the outdated model of inevitable decline and disability. Later life is but one part of a life course which is characterised by lifelong development. Although there are well known problems with terminology, the concept that best captures this life course perspective is ‘active ageing’ (Walker 2018). Alongside this new vision of ageing there is a need for new scientific approaches. More multidisciplinary perspectives are required in order to reflect the fact that the ageing process and its experience are holistic. But research funding regimes have not always been open to such multi-disciplinarity, again with important exceptions that have blazed the trail in this respect. This new science of ageing also includes a life course perspective, pays attention to personenvironment interaction and is user engaged

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(Walker 2015). Moreover the changing demographic context increases the need for a greater focus on chronic conditions. The non-communicable diseases (NCDs)—strokes, cancer, heart attacks, lung disease and dementia—are increasing and, by 2020, will be the top four causes of death globally. Three in every four deaths from NCDs occur in people age 60 and over and their incidence rises with age. For example dementias affect 12% of those over 65 and 30% of those over 85. Moreover increasing numbers of older people are living with multiple chronic conditions, or multi-morbidity (in the UK one-fifth of those aged 80 and over have four or more chronic conditions).

15.1.2

Making Active Ageing a Research Priority

As the European Road Map argued powerfully active ageing is a concept that, like a red thread, connects all of the major ageing research priorities. In scientific terms active ageing is used as a helpful umbrella term to encompass various combinations of quality of life essentials such as continuous labour market participation, active contribution to domestic labour (caring, housework), active participation in community life and active leisure. It is valuable too in being able to synthesise strands of research on ageing and developmental science which traditionally have not had much in common. For example the need to combine research able to drive social policy or cultural investments with that concerning the individual level of ageing, such as in regard to health, cognitive functioning and motivation. The concept of active ageing is also valuable in social gerontology in linking the macro, meso and micro perspectives of ageing research. Active ageing requires a social-ecological view of ageing. Different levels such as evidence-based policy action (macro), community and neighbourhood arrangements (meso) and individual intervention (micro) must go hand in hand in order to effectively promote active ageing. In addition, the social-ecology

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perspective implies a contextual view to be imposed on active ageing, because active ageing outcomes are significantly driven by the interplay between persons and environmental resources and constraints. A social-ecology view also comes with a purposefully wide understanding of environmental levels including the physical, spatial, social, economic, cultural legal and value context and the ‘chronosystem’, that is, the flow of individual and historical time as a context of active ageing (Bronfenbrenner 1979). This also means that the concept of active ageing must be multi-disciplinary including, for example, sociology and social policy research, psychology, biogerontology and economics in order to acknowledge its holistic nature. Because of its integrative potential the construct of active ageing can nurture the bridge-building between the different scientific disciplines and research themes. To maximise the integrative research potential of the concept of active ageing, as well as its broader impact in terms of policy and practice, it is crucial to ensure that the paradigm is as comprehensive as possible. (Too often ‘active ageing’ is interpreted narrowly to mean ‘working longer’). It should, above all, reflect the need for a life course approach to ageing (in science, policy and practice) which transcends the traditional age segregation into three life stages—education, work and retirement—and adopts an age-integrated approach in which all three concurrently span much of the life course. The foundations for a comprehensive approach to active ageing exist already (WHO 2002). The WHO’s emphasis on well-being and participation is highly important, as is the life course focus. Also ‘activity’ must consist of all meaningful pursuits (mental and physical) that contribute to the well-being of the individual concerned. Because of the dangers of exclusion active ageing should not be focussed only on the young-old. For all age groups, it should be participative and empowering and, in public health terms, preventative. To these essentials must be added a division of labour and responsibility to underline the fact that active ageing depends on a wide range of different actors and cannot simply be a top-down imposition by policy makers. For example age

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management in enterprises, to improve opportunities for workers as they age, should be largely a matter for organisations themselves. Furthermore, we should not assume that active ageing exists as a fully developed entity but, rather, it should be seen as an aspiration. Thus it might be defined as: “a comprehensive strategy to maximise participation and well-being as people age. It should operate simultaneously at the individual (lifestyle), organisational (management) and societal (policy) levels and at all stage of the life course” (Walker 2009, p. 90).

15.2

A Research Agenda for Active Ageing

A comprehensive multi-disciplinary research agenda for active ageing (also defined in broad terms) is clearly going to be a complex undertaking. We should not shy away from this complexity because ageing itself is a complex phenomenon yet is often placed in narrow, age-oriented, confines. In purely practical terms it is impossible in one chapter to describe this complexity in detail. So I will sacrifice the fine detail to convey the range of research required and, again, the European Road Map is a major source. The Road Map identified seven major priority themes the five most relevant of which (in italics) will be the main focus of the remainder of this chapter: • Healthy Ageing for More Life in Years • Maintaining and Regaining Mental Capacity • Inclusion and Participation in the Community and in the Labour Market • Guaranteeing the Quality and Sustainability of Social Protection Systems • Ageing Well at Home and in Community Environments • Unequal Ageing and Age-Related Inequalities • Biogerontology: from Mechanisms to Interventions

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15.2.1

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Healthy Ageing for More Life in Years

While in less developed countries there is a continuing emphasis on extending life expectancy and reducing mortality, because deaths from infectious diseases and maternal mortality remain relatively high, as those causes of premature death are reduced attention shifts to ensuring the quality of life at older ages and the need for healthy ageing. The key aim is for the gain in healthy years to outpace increases in life expectancy so as to ensure a reduction in unhealthy years, a goal that has not been achieved consistently even in European countries (Jagger et al. 2008; Deeg et al. 2019). It has been increasingly recognised that the ageing process is shaped throughout the entire life course, not only in old age, and that events in childhood, youth and early adulthood increase the risk of early occurrence of chronic disease, which in turn increases the risk of premature disability. A life course approach to healthy/unhealthy ageing is therefore essential but research should also recognise that newer cohorts may behave differently. Prospectively a life course view requires a long-term commitment and vision but seeds must be sown soon if we are to fully understand the influence of early and midlife physical and mental health, attitudes and lifestyle. Future studies also need a more comprehensive and holistic approach to delineating the biological, social, psychological, clinical, behavioural, economic, cultural and technological factors that drive healthy/unhealthy ageing at the individual level as well as the wider societal, public health, health and social care delivery and environmental reforms which may also impact positively on reducing unhealthy life years. Although there is continuing debate about terminology the major approaches to healthy ageing were developed from a researchers’ perspective. There is an urgent need to explore through multidisciplinary and multi-country studies, involving both qualitative and quantitative components, how older people themselves define healthy ageing, including the oldest-old with multimorbidity, and whether healthy ageing means

the same for people from different socioeconomic, cultural or ethnic backgrounds and for different age cohorts and genders. This would not necessarily cover all countries but should comprise broadly representative samples covering geography and a range of differences in life expectancy, including by gender. A similar challenge exists for the definition of frailty. If we are to fully understand how frailty manifests itself and progresses and how physically frail older individuals can maintain high levels of daily functioning and well-being, a consensus on its definition must be reached taking into account a range of possible research designs to capture this syndrome. Biogerontology in particular can contribute here through a number of avenues: by identifying biomarkers of frailty; through the use of systems biology to gain understanding of progressive, irreversible alterations in systems that are a feature of ageing; by clarifying molecular biological profiles (muscle protein breakdown, oxidative stress and accumulation of modified proteins) in sarcopenia, a universal, age-related, loss of muscle mass which is a major factor leading to frailty. Research evidence has demonstrated that physical activity/exercise, social ‘interaction’ and good nutrition are strongly associated with healthy ageing whilst smoking, alcohol consumption and poor diet/obesity are related to increased mortality and poor health. All these factors have formed the basis for health promotion activities, yet even where evidence is strong, gaps remain that limit ability to design, organise and deliver effective interventions to promote healthy ageing. Exposure to these determinants is related to measures of advantage across the life course, for instance education, social class, wealth, deprivation, although the manner in which social factors hinder healthy lifestyles is not fully understood. Moreover multi-disciplinary research encompassing the underlying biology with clinical and social and behavioural science is rare.

15.2.1.1 Physical Activity With regard to physical activity, future research should include: whether the timing of physical activity/exercise over the life course is important

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and the conditions under which the exercise is done; the relative merits of different forms of physical activity (habitual exercise, sustained aerobic exercise, strength and balance training); and whether there are gender differences in the way physical activity influences healthy ageing. While sarcopenia is inevitable with ageing, it can be mitigated through physical, nutritional and pharmacological intervention. Strong evidence exists that regular resistive exercise slows down the ageing associated decrease in muscle mass, and its possible role in protecting against the loss of motor units should be further explored.

15.2.1.2 Nutrition As the number of obese persons in Western populations is growing, optimal nutrition is an important area for future studies on healthy ageing yet no consensus exists on the types of nutrition to be recommended in midlife and old age to maintain health. Neither is there a detailed understanding of the social factors linked to healthy eating. However, advances in biogerontology increasingly point to metabolism as a determinant of ageing and health. Research shows that factors such as diet and exercise can produce changes in metabolism that profoundly affect ageing and health, but it is difficult to determine the underlying mechanisms as most known mechanisms of ageing are affected. Studies of metabolism, how it changes with age, and how interventions can slow ageing and increase healthy lifespan could also provide a deeper understanding of the biology of ageing and improve late-life health. The role of immunity is important here also since circumstantial evidence from a very small number of longitudinal studies mostly limited to the oldest-old humans, have begun to reveal clusters of parameters increasingly recognised as an ‘immune risk profile’ (IRP). Establishing whether the IRP is a general characteristic of human populations and understanding the mechanisms responsible for its emergence would allow the design and validation of interventions to reverse the effects of immunosenescence. In addition understanding the interaction between IRP and nutrition could provide the evidence needed to

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develop personalised interventions to extend healthy lifespan.

15.2.1.3 Social Interaction Research on social interaction has additional problems due to the host of interrelated concepts: social interaction; social activity; social integration; social engagement; social participation, and because social interaction can be operationalised on a number of discrete levels: frequency; density; quality; type; purpose. Reinforcing links between psychosocial and biological sciences pertinent to old age should become an urgent priority to clearly conceptualise a highly complex area and determine the exact element or elements of social ‘interaction’ that determine healthy ageing. Positive and negative lifestyles also affect healthy ageing through mutual action which requires an integrative approach to understanding drivers of healthy ageing as well as how late in life gains can be made. But as well as population based and behavioural approaches to prevention of age-related disease and ill health, there is also the possibility of pharmacological preventive interventions. In particular, a combination of recommendations in terms of lifestyle and nutrition, with appropriate drugs can be a powerful means of promoting healthy ageing, although the risks of polymedication should not be forgotten. Targets for prevention should include mental fitness, cognitive function and processes and promotional strategies for all levels of health and fitness. 15.2.1.4 Behavioural Change A further overarching issue is to develop a comprehensive and multi-disciplinary understanding of the science of behavioural change, determining interventions (individual/social/public health) that lead to behaviour change, the maintenance of behaviour change following cessation of intervention, and how behaviour change is moderated via individual (self-images of ageing), social, cultural and environmental barriers and facilitators. Research here should be framed within a life course perspective to understand how behaviour change and change maintenance in later life

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relates to cognitive and behavioural development over the life course and, how physical, social, cultural and economic environments impact upon the person and influence behavioural development. Helping people to change their behaviour is the most relevant public health and social action in which a community could invest to decrease the avoidable burden of risk, harm and disease among older people and to fully empower older people to participate to their own salutogenesis process thereby increasing the chances for active and successful ageing.

15.2.1.5 Older People’s Perspectives It is important that older people’s views are incorporated into the design of services as many interventions and public health messages are developed by policy-makers, researchers and practitioners with little account of the cultural and social diversity of the population and are all too frequently ‘top-down’. It is extremely important to tap the ideas of older people for innovative but often ‘low tech’ interventions in the future as well as including older people as experts during the implementation and/or evaluation of specific programmes and interventions. As yet little is known on more innovative types of intervention, e.g. individual educational programmes for older people and educational programmes via email, Facebook, cell/mobile phones. Specific population subgroups are particularly vulnerable in this respect, for instance the socially disadvantaged, ethnic minorities, new widow(er)s, newly discharged from hospitals, and it is important to ensure these are included to prevent and reduce the already existing ‘digital divide’ affecting most of these groups. Moreover future cohorts will have very different experience and expectation of technology-based interventions. 15.2.1.6 Early Markers For primary prevention it is important to be able to identify individuals at high risk for unhealthy ageing before disability or frailty has occurred by characterising early markers which are not in themselves manifested as diseases or pathological conditions. Such early markers may be biological indicators, physiological markers, physical

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performance, behavioural indicators, or measures of early frailty and include those termed as biomarkers of ageing and may be able to predict the future onset of age-related disease and/or residual life expectancy more accurately than chronological age. In addition, if we are to intervene in the ageing process, it is important to understand the main drivers of biological ageing to identify possible targets for intervention, whether this be via health practices, pharmacological or societal change. A further urgent research topic is vascular ageing since ageing is the major risk factor for cardiovascular disease, which itself is one of the most important public health problems in ageing populations. Vascular ageing is a phenomenon where biology, lifestyle and social factors converge to accelerate a pathophysiological process resulting in both subclinical and clinical events, ranging from cognitive decline to heart failure and stroke. Current therapeutic interventions do not tackle the manifestations of vascular disease specifically related to the underlying organismal ageing. To address this situation there is an urgent need to gain a detailed understanding of the complex interactions between the molecular, biochemical, morphological and functional aspects of vascular ageing. Although there has been varying amounts of research in this area, gaps in knowledge remain, specifically how different social groups and genders transition through disease to mental and physical functioning and through to participation in society, the role of the environment and how these relationships will play out in future healthy life expectancy. Cognitive impairment and dementia especially in advanced old age as well as transitions from normal to pathology are also addressed in the next section. Understanding how individuals progress through disease to disability and frailty is important to inform policy makers for planning for ageing populations. Since the same level of disease may impact differentially on disability in different environments or countries and the context and indeed the transitions may differ between countries, such differences will assist in our understanding of the disablement process.

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This area of research requires longitudinal studies in representative groups of countries. Long-term, large scale, strategically designed longitudinal studies are of utmost importance. This is particularly relevant to the European countries, where population heterogeneity and environmental diversity has been shown to influence the ageing process and play a critical role in disease prevention. Moreover a long-term approach is required since any longitudinal studies set up in the near future will require adaptation and improvement as knowledge advances.

15.2.1.7 Education Attributes of the individual are known to have implications for healthy/unhealthy ageing. Education is not the least of these, and over the last decade in developed countries there has been a rise in both formal education and training and informal educational opportunities resulting in the concept of ‘lifelong learning’. Whilst we know with some certainty that early life education differences contribute to inequalities in mortality, morbidity, disability and healthy life expectancy, the mechanisms whereby education and indeed lifelong learning affect their influence requires clarification. This includes in particular to better understand how education and lifelong learning are interrelated with other socio-economic measures (such as for instance: occupation, income and material circumstances), and their multiple effects on healthy/unhealthy ageing. To what extent can lifelong learning mitigate the impact of key life events: negative health events; the successful restoration of functioning/the decline into frailty; the negotiation of the transition from autonomy to dependency; work, retirement, and withdrawal from the labour force; migration; and widowhood and bereavement. A relevant issue in this respect is the identification of the most effective and economically sustainable forms of education and lifelong learning, in order to ensure that the largest segments of population as possible can benefit from them to reduce unhealthy ageing behaviours.

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15.2.1.8 Environmental Conditions for Ageing Well Traditionally, research on ageing mainly focuses on the ageing individual and population—much less on environments and even less on the interaction between the person and the environment. Independence in daily functioning and the well-being of older citizens in the future will be significantly enhanced through an improved understanding of the interrelations between ageing persons and their physical- social environments in areas such as home environments, out-of-home environments, and technology and products. Making the best out of environmental potential is critical to decrease inequality among older citizens within and between countries. As with other research areas, multi-disciplinary work is key, although this has not, as yet, included the breadth that it might. For example, interrelations between environment and the neurosciences of ageing, may lead to new insights on whether and how living environments of older adults may impact on brain ageing trajectories. More recognition should be made of the fact that environmental conditions act at both micro and macro level, thereby adding complexity in analysis as well as concepts. Multi-level analyses can ascertain whether and how the interrelation between the person and their environment is driven by contexts such as urban versus rural environments, community contexts such as deprived neighbourhoods, or wider country legislation and social policy values. Environmental research must also focus on the question of whether such interrelations and outcomes depend on the societal, cultural and/or political context, and may therefore be different across global regions and whether future cohorts will behave differently.

15.2.2

Maintaining and Regaining Mental Capacity

Mental capacity comprises a collection of abilities and behaviours that ageing individuals possess and apply in aligning their lives most closely to

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their needs. Mental capacity also refers to the capability of ageing individuals to share their competence, life experiences, and world views with others, particularly the younger generations. As a consequence, mental capacity certainly encompasses the entire spectrum of cognitive functions such as memory processes, speed of information processing, or executive functions as addressed by traditional cognitive ageing research as well as geriatric medicine and geropsychiatry. However, this topic also addresses more general competencies such as knowledge important to master daily life, skills to maintain and secure one’s social integration, coping abilities that enable ageing people to deal with critical transitions and major life experiences, and the regulation of positive and negative emotional functioning and forms of psychological resilience. In this wide sense, mental capacity is central to day-to-day health and functioning, independent and rational action, societal participation and personal meaning in the last stages of the human lifespan. Depression including sub-threshold depression and anxiety-related disorders are other major conditions, which undermine mental capacity greatly. The European Road Map identified six relevant priorities for future research on mental capacity. Making optimal use of the existing plasticity of the human mind is critical in terms of maintaining independence, societal participation, as well as the reduction of the burden put on family caregivers. There is therefore a strong need to replicate and extend in a European context randomised control trials in cognitive training, such as the ACTIVE study in the United States (US). Going further, new intervention research targeting the full range of primary and secondary outcomes of physical exercise is needed, including multi-component designs. Such research may consider specific conditions in different countries and should allow for data integration and analysis across different training strategies and countries involved (see REACH study in the US for such an approach). Especially important is more research on the short- and longterm impact of cognitive training and physical exercise in middle adulthood, including the

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important target area of the ageing workforce. Indeed, work environments can it itself have an intervention-like effect and can support the longterm maintenance of cognitive functioning and mental capacity at large.

15.2.2.1 Social and Environmental Context Contextual conditions have always been argued to be of critical importance for the development of mental capacity across the life course. However, a focussed research programme targeting this issue in a broad perspective is still needed. Systematic research is needed on the role of contexts such as social relations, home environments, neighbourhoods, out-of-home environments and leisure activity settings for cognitive engagement and cognitive outcomes in the longer run. It is interesting to observe in this context that, considering the highly encouraging research on the relationship between cognitive functioning in normal ageing or Alzheimer’s transgenic rodents and the role of Enriched Environments (EE), that there is little analogous research at the human ageing person-environment interaction level. For example, there is no rigorous research which brings together old and new housing solutions and their possible impact on the course and outcome of cognitive functioning or research that systematically manipulates housing and neighbourhood features in order to test for possible effects on cognitive ageing. Similarly, the role and influence of social engagement deserves much more rigorous research attention. 15.2.2.2 Life Course Dynamics Although there are good reasons to study mental capacity from a life course perspective, a rigorous description of such a view is still rare. First, new investment into a theoretical account based on the existing conceptual ideas and empirical evidence on life course trajectories of mental capacity is needed. Second, existing longitudinal data as well as long-term data to be generated in the future are needed to better understand the life course dynamics of systems such as early life education, physical activity, disease over the life course, social engagement, labour force and leisure time

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involvements on the outcome of mental capacity later in adult life. In addition, the role of major person-environment transitions such as relocation to various forms of long-term care or ‘new’ housing solutions are not well researched so far. Such research is highly important to exploit preventive potentials toward maintaining mental capacity into very old age to the best possible.

15.2.2.3 Transitions The need to increase and improve research targeting transitions from normal cognitive ageing to various forms of pathological ageing, particularly dementia-related processes, is obvious. Research efforts must be focussed to learn more about the mechanisms, risk and protective factors involved from the biological and clinical to the social and behavioural level. It is reasonable to expect that the outcome of such research will significantly contribute to evidence-based early intervention strategies with the possible ability to counteract possible pathological trajectories in the area of mental capacity.

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inter-disciplinary pathways, such multidisciplinary synergies should also be spelt out and tested out more comprehensively and systematically in the future. This includes for instance the strengthening of research collaborations between psychology and biogerontology, neurosciences of ageing, health and physical exercise sciences, sociology, occupational therapy, architecture and urban planning. In particular, spelling out and conducting more research on the linkages between cognitive and emotional development at the behavioural level, differential environmental influences, and cortical processes seems a highly promising area in terms of pure research as well as practical outcomes. Such multi-disciplinary research must also include intervention research. Indeed, better understanding of the malleability of the human ageing process may be a core bridge between key disciplinary areas such as health sciences, social sciences, psychology and biogerontology.

15.2.3 15.2.2.4 Societal Responses The theme of mental capacity related to ageing brings huge challenges to ageing societies at various levels. For example, European societies must address the question, what kind of societal and political role large portions of cognitively impaired citizens are able or should play and which models (e.g. in terms of assistance) may be promising. In addition, dementia has risen nearly to the top of the most feared diseases among those 50 years and older, and societies must deal with such new highly prevalent fear. Going further, there is robust evidence pointing to the fact that age stereotyping and age discrimination may undermine mental capacity to a considerable degree via self-stereotyping. Therefore, more research targeting the issues of social participation, societal assistance, dementia worries and the functional undermining role of age stereotyping and age discrimination is needed. 15.2.2.5 Multi- and Inter-Disciplinarity Although much of the research described above has to strongly follow multi-disciplinary and

Inclusion and Participation in the Community and Labour Market

Increasing the level of people’s participation in society and ensuring that this contribution can continue along the whole life course represents today a widely shared policy target. The extent to which societies facilitate participation and promote inclusion at all ages is a key component of people’s access to their inalienable rights as citizens, and has implications for society as a whole from an economic and social point of view. At a micro level, participation represents a crucial element for active ageing, since being involved in social and professional activities is positively associated with several indicators of socio-economic status and well-being, including better health as well as mental and physical functioning. At a macro level, the positive impact observed on socio-economic institutions and public resources when participation is facilitated shows that stronger efforts will be needed in the coming years, in order to implement welfare policies able to reach and maintain both financial

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sustainability and quality of the social protection system. At an intermediate, meso level, the facilitating or inhibiting role played by social institutions such as families, companies or other social networks is also relevant in affecting people’s inclusion and participation along the life course, and will therefore need to be closely monitored by future research efforts. Participation in the community and in the labour market is a broad concept that embraces different dimensions of human life. It can be described as the sharing of individual resources in socially-oriented as well as economic activities, i.e. the complex set of behaviours and relationships that people activate with other individuals, groups or organisations. In this sense, it refers to different social networks in which people are embedded and interact during their life: families and kinship, friendships, peer groups, companies, non-profit organisations, political parties, and so on. Clearly, participation cannot be merely defined by the number of contacts between people and these social networks, but it should necessarily include also the quality and scope of such interactions. Inclusion (and its counterpart exclusion) can be understood as the extent to which existing social, economic, political and cultural norms, institutions and environments facilitate or inhibit participation. Uncovering the mechanisms and processes of inclusion/exclusion in our societies is crucial to better define the prerequisites and enablers for participation, taking into account also the psychological structure of ageing individuals and their behaviours and attitudes toward different forms of social interaction.

15.2.3.1 Ageism One of the most entrenched barriers facing appropriate participation and inclusion of people during their life course concerns the phenomenon of ageism. This term encompasses the attitudes, prejudices, behaviours and social structures that result in discrimination against individuals or groups on the basis of their age. Ageism is manifested as exclusionary practices throughout all areas of the community and labour market, creating barriers to participation. This can take

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place at a micro level (e.g. during interactions between individuals), meso level (e.g. in form of discriminatory practices in businesses and other organisations) and macro level (e.g. in policy planning and delivery). Perceptions of ageing and of older people, and the stereotypes that arise from them, are the root of the problem of ageism. Research has established that older people are perceived positively as more friendly, moral or admirable than younger people, but at the same time also as less competent or capable (Biggs and Lowenstein 2011). Although less overtly hostile than many other stereotypes, this form of prejudice nevertheless leads to discriminatory behaviour. In order to tackle ageism at its roots, we must therefore do more to understand and change perceptions of ageing. For example, stereotypes are often formed early in life and are resistant to direct change. However, evidence suggests that positive contact in the form of close friendships between people from different age groups can be a very powerful tool to overcome age stereotypes. Given the current high levels of ageism and the diversity of circumstances and contexts in which this phenomenon is taking place across the globe, it must be considered a priority to expand this evidence base and build up a wide range of potential interventions (appropriate to the context in which discrimination is taking place). A particularly significant priority for future research in this area is to help tackle the development and perpetuation of ageist attitudes and prejudices through the media. The latter play a central role in societies, both informing and reflecting public attitudes. Emerging evidence suggests that older people are under-represented in the media and, where represented, they are often portrayed negatively. Research targeted at interventions to change perceptions and portrayals of age and ageing within the media industry are therefore key to breaking the cycle which perpetuates ageist stereotypes and attitudes. Finally, research designed to fight ageism must not only focus on perceptions and individual behaviour, but also seek to develop interventions to change discriminatory practices and processes

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at an institutional level. This is a key area for meso and macro level research, in order to tackle entrenched and often subtle ageist structures (such as organisational policies and procedures), that lead to discriminatory and exclusionary outcomes for older people in the community and in the labour market.

15.2.3.2 Lifelong Learning Lifelong learning is fundamental not only for macro competitiveness and economic prosperity, but also for the social inclusion, active participation and personal fulfilment of its citizens. In particular, in the context of demographic change, employing the full potential of adult learning has a key role in extending the participation of older workers in the labour market and allowing their better integration into all spheres of life in society. However, the age of individuals has a clear impact on their propensity to take up or have access to opportunities for training and lifelong learning. Research is therefore needed to identify the types and number of non-formal and informal learning opportunities in which older people participate as well as the specific issues they face in accessing formal training and educational programmes. Particular attention should be paid in this respect to the gender, ethnic and disability dimensions as well as to the needs of older people living in rural or remote areas, in order to facilitate a widespread implementation of lifelong learning strategies and the modernisation of existing training systems. Further studies are also required to assess how to transfer know-how and experiences among generations, within and outside the labour market. On the one hand, knowledge transfer from the younger to the older generations plays a key role in fostering intergenerational understanding and re-skilling older workers. On the other hand, the transfer from the older to the younger generations can preserve older workers’ skills and help older workers and retired people maintain a sense of meaning and purpose, preventing their social exclusion. Therefore, research in this field is crucial to better understand how mentoring schemes and other intergenerational exchanges can

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promote solidarity between generations and competitiveness.

15.2.3.3 Migration A further research challenge derives from the strong migration phenomena currently taking place globally. In this regard, more attention should be paid to the mechanisms facilitating the integration of ageing migrants in destination countries, by analysing the impact of migration trajectories over the individual life course and on society itself, on the background of local cultural and societal mediators. In this field, crucial research issues to support the development of policy and practice are the integration of migrants into their host countries’ communities and labour markets, and a better understanding of how migration can contribute to tackling the challenges associated with the societal ageing. There is also a key need to understand the experiences of ethnic and racial discrimination faced during the life course by many migrants in their destination communities, in order to identify which measures can best contribute to prevent this occurring. A further area of interest is that of transnational families, with a more specific focus on the relationships between the ageing migrants and their left-behind kin in the countries of origin. 15.2.3.4 ICTs Access to ICT will increasingly be key to active ageing across all age groups including older adults. The uptake and use of ICT is still much lower among older age groups, and increasingly a ‘digital divide’ is observed and opening up as the gap between different generations grows. As societies become increasingly reliant on ICT and the internet in particular, as a medium for retail, media, public service delivery and social interaction, this digital divide represents a growing risk for the exclusion of older people from the community and the labour market. Therefore eliminating the digital divide represents a major priority for public policy, and future ageing research will have a crucial role in identifying how this can best be achieved.

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To support this goal, more research is needed to reveal new ICT utilisation patterns and discover differences between current and new generations of older users. This field includes the analysis of changing social interactions with regard to virtual networks and their impact on traditional (also intergenerational) relationships, as well as of new services and social/health care available through more user-friendly ICT solutions.

15.2.3.5 Accessibility and Mobility Physical accessibility is a key component of inclusion and participation, as a pre-requisite to many daily activities, such as maintaining relationships with family and friends, leisure activities, work, access to public services and health care or carrying out everyday tasks such as shopping for food. Promoting inclusion and enabling participation through accessibility can be tackled in two ways: by maintaining and promoting physical mobility as people age, and by developing accessible environments in the community to become inclusive of the widest possible range of physical accessibility needs. Both these approaches have limitations, since not all existing infrastructure can be adapted to the highest standards of accessibility. Many people, especially among the very old, experience significant frailty and disability resulting in limited mobility despite advances in health care. In spite of these limitations, it is still possible to push the boundaries in both domains and, moreover, collaborative multi-disciplinary research offers a powerful opportunity to combine the focus on the person and on the environment to achieve optimal gains for participation and inclusion through accessibility and mobility. For example the Age Friendly Cities Programme promoted by the WHO. Future research projects in this area can be identified in experimental trials involving the re-design of city transport systems in order to meet the changing needs of the ageing population and to increase their accessibility to people with reduced mobility (e.g. by starting new lines to ease transportation to community health or recreational centres, or by granting special discount

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schemes and other incentives based on universal-design principles). Appropriate followup assessments would ensure a scientific evaluation of the intervention, in terms of health and economic outcomes. In this respect, the role of assistive technologies will be crucial in contributing to delay dependency as people age. A more coordinated contribution from ergonomics and engineering can improve the performance of everyday life activities and facilitate mobility. Housing adaptation and domotics should also be considered.

15.2.3.6 Volunteering Volunteering is one of the possible ways for people to remain active as they age and, at the same time, to contribute to society as well as to profit from the opportunities offered by it. Although awareness about this phenomenon is widespread, in some countries only a minority of the population is involved in this form of activity. This reflects, on the one hand, a different role of volunteering within each society and national welfare system; on the on other hand, it also derives from the fact that, since there is no common definition of volunteering across countries, what is considered volunteering in one country is not necessarily considered as such in another. What is clear, however, is that the involvement of older people is becoming increasingly crucial for the vitality of the whole voluntary sector. It is therefore important to identify appropriate strategies to promote voluntary work at all ages, since especially senior citizens represent to a large extent a still untapped human resource, whose involvement in voluntary organisations should receive more attention if we really want to properly tackle the challenges of our ageing societies. At an individual level, the probability to work as volunteer in older age is positively associated with both educational and income level, good health and ‘civic’ motivations and values, while being employed and/or providing informal care to a dependent relative often represent a crucial barrier to voluntary engagement. At an organisational level, the recruitment and retention of ageing volunteers depends upon the ability to

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meet their individual needs and aspirations, by levering on organisation’s characteristics such as structure, membership composition and atmosphere. Other relevant factors are represented by the awareness and appraisal of older volunteers’ experience, social skills and reliability, and by the ability to capitalise these capacities through appropriate training and by fostering intergenerational relationships between volunteers of different age groups. At the institutional level, evidence shows that appropriate campaigns to promote volunteering in younger age are often able to ensure positive results in older age groups, since young volunteers are likely to play this role also later in their life course. A major role in encouraging older people to become volunteers and to look at it as a vital component to promote their active ageing might also be played by general practitioners and other health and social care professionals, who are relevant reference persons for the older population. We urgently need more comparable information in form of common definitions and reliable statistical data in this area, which in many countries is still very poorly covered. Only this will allow us to really know how useful volunteering can be both to promote individuals’ active ageing and to contribute to the welfare of societies.

15.2.3.7 Employment The existing evidence base confirms that the current under-representation and exclusion of older people in paid employment is partly associated with age discrimination. Research is needed to identify and quantify the different types of direct and indirect age discrimination at play in the labour market. Regional level research offers the scale and the resources necessary to compare differences across countries, across employment sectors, job types and age groups. It should also investigate the interactions between age discrimination and other known grounds for discrimination such as ethnicity, gender or disability. Furthermore we need a greater understanding of which areas within the labour market people are most likely to experience age discrimination: whether in recruitment, remuneration or access

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to training for example. This mapping exercise is necessary to support the development of successful interventions to alter ageist perceptions, attitudes and practices within the context of paid employment and the labour market. In addition, it is also crucial to develop research into the impact of older people’s participation in the labour market in order to understand the potential benefits of increased participation. This research will serve to build a deeper understanding of discrimination and exclusion in the labour market and labour market dynamics, but must also go beyond the individual micro level, and seek to understand the wider social and economic impact at a macro level. For example, such research might seek to investigate any relationships between reduced/increased employment among older people, older people’s health and well-being and consequent demands on national healthcare systems.

15.2.3.8 Extending Working Lives This topic is high on the policy agenda in many developed countries. New and innovative structures and approaches in the labour market will be needed to enable older people to continue working as long as they choose. Since the working age population is shrinking, it will be also important to study solutions that motivate people to work longer. For example, preserving older people’s skills through mentoring schemes could encourage older workers to keep on participating in the labour market as workers or volunteers. It will also be a way to promote age-friendly workplaces and fight ageism. Research is needed to ensure that policy making is informed by a proper understanding of the advantages and disadvantages of the different regulations on pensions and labour laws that can support those who wish to work longer. This will be a practical resource to support new thinking and the design of better policymaking processes. Moreover, research should provide guidance to policymakers and employers in the use of incentives to retain and hire older workers, by paying special attention to women, migrants, ethnic minorities and people with disabilities.

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Research should also help employers adjust to their ageing workforces, by promoting age diversity in employment and continuous training. In order to maintain older people’s employability, further measures should also be studied to prevent illness and disability, as well as to compensate for physical decline, in particular for those with physically arduous jobs involving manual labour and night shift workers.

15.2.3.9 Reconciling Formal and Informal Work In the context of an ageing population, the oldestold face increasing care needs and dependency not only in institutional, but also in home-based care. This phenomenon represents a big challenge for informal carers of working age, who need to reconcile work with their family duties. In particular, there is a clear and direct link between difficulties in combining family life, private life and professional life, on the one hand, and poverty and social exclusion, on the other hand. Where the need to care for a dependant family member cannot be reconciled with the demands of work through care leave or part-time employment, many people, mostly women, are forced to stop work temporarily or altogether. Having no adequate monthly income and no adequate social security coverage in case of divorce, separation or death of the partner, such people are left vulnerable to poverty and social exclusion. Therefore, ensuring care/employment reconciliation is a key factor to fight poverty and social exclusion. Beyond family responsibilities, the possibility of combining private life and professional life is an important component of wellbeing as well as of inclusion and participation in society, including through volunteering activities during free time. More focussed research is therefore needed to identify the measures in terms of policies and services that are relevant to combining work and care duties, allowing informal carers to remain in the labour market, and preventing the risk of poverty and social exclusion, with proper regard to gender equality. These measures should also promote equal opportunities and men’s role in caring.

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Research should furthermore provide rigorous empirical evidence, which can be helpful to companies and policy-makers to find the most effective working time arrangements and leave schemes to support employees with caring responsibilities, and ensure an adequate income for them. Appropriate measures should also be studied to support persons who wish to return to the labour market after a long break spent caring. Raising awareness on these issues among the general public at both a national and a global level is an important task, in which research can and should play a relevant role.

15.2.4

Unequal Ageing and Age-Related Inequalities

While life expectancy has risen steadily over recent decades, the gradient in life expectancy between more or less deprived populations and those with greater access to social and environmental resources continues to persist and, in some cases, widen. Inequalities in life expectancy are systematically generated and grounded in social and economic factors. Globally there is uneven distribution of life expectancy and healthy life expectancy between countries and between population groups within them. Health follows socioeconomic gradients so that, put simply, the poorest experience the shortest lives and also live a greater proportion of those lives in the worst health. Life course trajectories are socially embedded and strongly influenced by the accumulation of opportunities and risks. Some of these risks are ‘structural’ and relate to the ‘social environment’ and the way society is organised. Individuals exert little if any control over these factors, which de facto restrict the potentiality of individual human agency. Family lineages, in the first instance, set the background conditions of individuals’ early life and through them inequalities are transmitted between the generations. Along the life course, the ageing of individuals differs as a consequence of the unequal impact of life events: childhood, puberty,

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reproduction, and senescence. Inequalities are influenced by biological, social, psychological, economic and ecological processes. Inequalities are par excellence a multidimensional concept which may refer to the financial, social, functional, spiritual, and cognitive sphere. Much attention has been paid so far to the social inequalities (and inequities, the normative concept applied to inequalities which are judged to be unfair and unjust) in health: social differences are well reflected in the health domain, with many of the common age-related health conditions being distributed unequally across socio-economic gradients so those with limited access to socio-economic resources also tend to experience the worst health.

15.2.4.1 Monitoring Inequality Monitoring and resolving inequalities in healthy ageing demands not only that there is a concerted collection of measures that are truly harmonised but also that they are appropriate at a country or regional level. Not only does this include the key concepts of healthy ageing and frailty, addressed above, but also the major drivers of health inequalities: for example socio-economic status, multi-morbidity, social engagement. Newly harmonised measures must also reflect current social priorities and concerns. Data collection methods including survey design and sampling must also be harmonised. Consideration should be given to the collection and banking of biological data (BioBanking), which could provide unprecedented opportunities to expose biological mechanisms by which inequalities in healthy ageing might be addressed (for example by the development of new clinical or pharmacological targets for intervention). Monitoring any indicator across all countries immediately poses tensions between maintaining individual countries’ needs with those of the collective whole, but the gains are great in terms of potentially quantifying the impact of health systems, social and health reforms and wider social policies.

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15.2.4.2 Retirement/Pensions Ages While many countries are delaying the age at which state pensions are provided we have little understanding of how health in later life and healthy ageing are affected by changes in the pension system or the current economic crisis and unemployment, how these changes are affecting social gradients in health and whether we can increase (healthy) working life. This research area requires explanation of the trends in the health (physical and mental) of the young-old and understanding of the relationship with the different exits from the labour market, pensions, socioeconomic status, social engagement, family structures, informal caregiving and cultural expectations surrounding work and caring. With the growth in the numbers of the very old, decisions to retire or not may be influenced not only by the individual’s family circumstances and whether they are required to provide care to an aged parent but also the cultural expectations of elder care and the health and social support systems within a society. Enhanced support within the workplace will also be vital to ensure longer working lives, hence the need for research involving public and private sector organisations assessing the scope for work-based health promotion to older employees. This topic area requires harmonisation of measures and is therefore potentially risky and long-term. Longitudinal studies will be required but these should be conducted in comparative countries to cover the variation in pensions and social policy. We should also utilise existing datasets such as those established by the Finnish Institute of Occupational Health across a 30-year long period, together with those established by surveys such as The Irish LongituDinal Study on Ageing (TILDA), and the English Longitudinal Study on Ageing (ELSA). 15.2.4.3 Ageism Discrimination within the health field can happen in a variety of ways and levels. It can manifest itself as sub-standard or inappropriate treatment of older people by individual healthcare practitioners or it can take a more structural

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form, limiting older patients’ access to healthcare or appropriate medication. There is a need for multi-disciplinary research including health professionals, carers, gerontologists, geriatricians, demographers and involving older patients to map different areas where discrimination on the grounds of age (but also combined with other grounds like ethnic origin, gender or disability) have an impact on the health treatment or health condition of an older person. This comparative work would pinpoint problematic areas and provide policy recommendations. Research is required to understand the prevailing norms within the health and care sectors that potentially contribute to negative attitudes such as ‘why bother creating a drug which is efficient for the over 85 years old?’ or ‘prevention of a disease after the age of 50 is not possible as people have already acquired habits that they cannot change in order to get results’. This is knowledge that is required in order to contribute to the development of effective interventions against common failings of healthcare systems, such as a failure to treat co-morbidities. It is anticipated that ‘changing perceptions’, and ultimately behaviours, within the health field will require specific knowledge and skills and therefore will require a specific focus in addition to a general focus on ‘changing perceptions’ throughout society. At a macro level, more research is needed on age discrimination in access to health care, including the financing of treatment and hospitalisation. As the burden of paying for health care increasingly shifts to the private sphere and because of the increasing uncertainty on the future of pension rights for older people, insurance companies need to provide affordable solutions to older patients. A future project could focus on gathering examples of current practices, analysing them and providing recommendations for sustaining health care systems taking into account financial capacity and risk factors for older people. An understanding of ageism, equality and rights provides a useful framework for this research to help identify why and how access to healthcare needs to be and can be improved for older people.

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15.2.4.4 Migration Migration also contributes to increase the range of inequalities both in positive and negative terms. Migrants’ different backgrounds and life course experiences are often reflected in remarkable differences, within the general population, in crucial dimensions such as health and socioeconomic status. Inequalities and discrimination based on ethnic and/or racial diversity represent indeed a relevant issue for many—migrants and non-migrants—but are particularly salient among the subsets of migrants featuring physical, linguistic, religious or cultural differences compared to the majority population of their destination country. Especially—but not only—with regard to these groups of migrants it is therefore important that future ageing research focuses on existing and perceived migration-related socio-economic inequalities, conflicts and integration difficulties, in order to identify the most appropriate interventions and policy strategies to tackle and prevent them. More research is for instance needed to explore how to improve the access of ethnic minority elders to health and care services, through a better understanding of the intersection between age, ethnicity, gender and disability. Future investigations should try to capture both migration-related multiple and intersectional discrimination as well as forms of direct (e.g. refusal to treat a patient and so on) and indirect discrimination (e.g. absence of linguistic support which hinders chances of access to care). Comparative policy analyses of provisions relating to inequalities and discrimination experienced by minority ethnic elders will also be crucial in this regard, as will comparative studies addressing research questions concerning needs, expectations and perceptions of minority ethnic elders and health professionals on how to improve and manage culturally sensitive services.

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15.2.5

Biogerontology: From Mechanisms to Interventions

While the research themes and priorities discussed so far invariably reflect a multidisciplinary perspective the challenges that arise from population ageing need, at the most fundamental level, to be understood in terms of the biological mechanisms that sustain life and of the gradual compromise of these mechanisms which results in age related morbidity, disability and death. Individuals have many dimensions of being— social, cultural, economic, medical, and others— each of which is important for well-being. Underpinning each of these dimensions is the current state of the individual body as a biological organism. In parallel with the change in demography, there has occurred significant progress in one of the newest areas of biomedical research—the biological study of ageing, or biogerontology. From a biological perspective ageing is one of the most demanding objects of study. The ageing process affects the functions of the body at all levels, from the smallest changes affecting individual molecules, through impacts on cellular integrity and function, to changes that influence the operation of whole organs and organ-systems. The ageing process is influenced by genes, with some tendency for longevity to run in families, but overall the genetic contribution is modest (around 20 of the whole complex of factors influencing longevity) and there is an overwhelming consensus among biogerontologists that ageing is not itself programmed by direct gene actions. Instead, ageing is caused by the accumulation through life of a wide variety of faults in molecules and cells. Indeed, gene actions are for the most part concerned with survival, regulating the numerous maintenance and repair systems that allow humans to survive as long as they do. Key questions in biogerontology: • The nature of the mechanisms that cause the age-associated accumulation of damage • How genetic and non-genetic factors, including lifestyle factors such as exercise and nutrition, influence the trajectory of health across the life course

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• The deep connections between intrinsic biological ageing and the many diseases for which age is the dominant risk factor • How medicine can develop new, biologicallyinformed ways to target age-related frailty • How interventions might be developed to improve health span faster than the growth in average longevity, and • How the biological age of individuals can be monitored to provide a rapid feedback of data that can inform about the success of intervention strategies. There is not space here to discuss the detailed research priorities arising from this biogerontological perspective—which include the urgent need for more biomarkers; the exact mechanisms by which telomere erosion, DNA damage and mitochondrial dysfunction contribute to cellular ageing; the role of oxidative stress in protein damage; the role of inflammation in age-related pathology; how metabolic factors modulate the ageing process; more research on skin ageing; and the prevalence, causes and functional consequences of sarcopenia—a full analysis can be found in the European Road Map (Futurage 2011, pp. 73–83).

15.3

Conclusion

This chapter has set out the bare bones of a research agenda designed to support the twin goals of active ageing and improved quality of life in old age. Implicit within this agenda is the assumption that a comprehensive approach to active ageing, which engages all levels of society (macro, meso and micro), would of itself result in radical improvements in the quality of later life in all societies. This is because a life course focus would aim to prevent ill-health and the onset of chronic conditions at every age and stage of life: from cradle to grave. This would mean, on the one hand, the promotion of physical and mental well-being before, including long before, old age but also, on the other, their maintenance during later life, including advanced old age. Research on quality of life among older people regularly places good health and social participation high

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on their priorities (Gabriel and Bowling 2004; Bowling 2018). In this sense active ageing may be regarded as a key driver of quality of life in old age. While this chapter has endeavoured to be comprehensive it has not been possible to include every topic of relevance to the promotion of active ageing and there have had to be notable omissions, such as research on the role of social protection systems in supporting or inhibiting it. The coverage in the Futurage (2011) Road Map is more comprehensive. Despite that lacuna there is sufficient detail above to convey the huge scope and need for research in this field. Also demonstrated is the great potential for this research to inform policy makers and myriad practitioners so that a direct beneficial impact may be made on ageing across the life course. It is a research agenda aimed at enhancing the quality of people’s lives as they age. It is one thing to propose such a research agenda but quite another to see it implemented. This rests fundamentally on infrastructure, including funding. Globally the US stands out in this respect because its National Institute of Aging (NIA) has coordinated, prioritised and encouraged research in this field for four decades. Canada also has an ageing institute doing similar exemplary work. Some Member States of the European Union (EU) have such national institutes too but Europe as a whole does not. So, if a major regional bloc such as the EU is not able to coordinate its ageing research resources there is little hope that less developed countries will have the means to do so. China and India are partial exceptions and both of them have invested in longitudinal studies (with NIA help). In the absence of national resources in the majority of the global south it falls to the richer parts of the world to assist in building their research infrastructures and databases. Without these there will be little scope for either comparative research or benchmarking. A final key element of infrastructure development is capacity building. Ageing research capacity building is an urgent necessity everywhere but, especially so in the less developed parts of the world. The common

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goal of active ageing should be the catalyst for an open global exchange of knowledge, experience and research know-how. Acknowledgments This chapter draws on the Road Map for European Ageing Research and I want to acknowledge gratefully the multiple contributors to the Road Map and thank them for their permission to use it in this form.

References Biggs, S., & Lowenstein, A. (2011). Generational intelligence – A critical approach to age relations. London and New York: Routledge. Bowling, A. (2018). Measuring the quality of later life. In A. Walker (Ed.), The new dynamics of ageing (Vol. 1, pp. 81–102). Bristol: Policy Press. Bronfenbrenner, U. (1979). The ecology of human development. Experiments by nature and design. Cambridge: Harvard University Press. Deeg, D., Boertje, M., & Galenkamp, H. (2019). Healthy life years and social engagement. In A. Walker (Ed.), The future of ageing in Europe (pp. 143–176). Singapore: Palgrave. Futurage. (2011) A road map for European ageing research. Retrieved from www.futurage.group.shef. ac.uk Gabriel, Z., & Bowling, A. (2004). Quality of life in old age from the perspective of older people. In A. Walker & C. Hagan Hennessy (Eds.), Growing older: Quality of life in old age (pp. 14–34). Maidenhead: McGrawHill. Geoghegan-Quinn, M. (2010, April 15). Healthy ageing – A European priority. European Parliament. Jagger, C., Gillies, C., Moscone, F., Cambois, E., Van Oyen, H., Nusselder, W., et al. (2008). Inequalities in healthy life years in 25 countries of the European Union in 2005: A cross-national meta-regression analysis. Lancet, 372, 2124–2131. Riley, M. W. (1994). Cohort perspectives. In E. Borgatta & M. Borgatta (Eds.), The encyclopedia of sociology (pp. 52–65). New York: Macmillan. United Nations. (2002). Report of the second world assembly on ageing. New York: United Nations. Walker, A. (2009). The emergence and application of active ageing in Europe. Journal of Aging and Social Policy, 21, 75–93. Walker, A. (Ed.). (2015). The new science of ageing. Bristol: Policy Press. Walker, A. (2018). Why the UK needs a social policy on ageing. Journal of Social Policy, 47, 252–275. https:// doi.org/10.1017/S0047279417000320. World Health Organisation. (2002). Active ageing: A policy framework. Geneva: World Health Organisation.

Part III Methods, Measurement Instruments-Scales, Evaluations

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Measures, Instruments, and Applications Carmen Rodríguez-Blázquez and Maria João Forjaz

16.1

Introduction

The increase in ageing population has attracted great attention in developing studies, policies and interventions that promote health and quality of life (QoL) in this group. The relevance of QoL in older people is highlighted in the concept of active ageing: “the process of optimizing opportunities for health, participation, lifelong learning and security in order to enhance quality of life as people age” (International Longevity Centre Brazil (ILC-BR) 2015). QoL has numerous definitions, but it can be understood as “an individual’s perception of his or her position in life in the context of the culture and value system where they live, and in relation to their goals, expectations, standards and concerns” (The World Health Organization Quality of Life assessment (WHOQOL 1995). It is a broad and multidimensional concept: as people age, their QoL is largely determined by having good health, an adequate degree of autonomy and independence, the availability of a social network and of social support, the ability of engageing in meaningful activities, having a good financial situation C. Rodríguez-Blázquez (*) National Centre of Epidemiology and CIBERNED, Carlos III Institute of Health, Madrid, Spain e-mail: [email protected] M. J. Forjaz National Centre of Epidemiology and REDISSEC, Carlos III Institute of Health, Madrid, Spain e-mail: [email protected]

and living in an accessible and friendly environment (Boggatz 2016). In this context, measuring QoL in older adults is of vital importance for achieving a better understanding of factors that influence it. Models of QoL in old age agree in the multidimensional composition of the construct, with components related to physical, psychological and social domains (Netuveli and Blane 2008). QoL should be differentiated from other related-constructs such as life satisfaction—the individual’s overall feeling or global evaluation about one’s life as a whole. On the other hand, happiness refers to an immediate experience, triggered by events, activities or cognitive processes. Due to its relevance, QoL in old age has gained importance over the years since it was first used in a scientific publication in 1972 (Elwood 1972), and measures of QoL are nowadays applied in most scientific studies, clinical trials and interventions in older people. A wide range of QoL instruments and questionnaires are available. Some of them have been designed and validated to be used in general population, such as the Personal Wellbeing Index (PWI) (Cummins et al. 2003; International Wellbeing Group 2006) and the Schedule for the Evaluation of Individual Quality of Life (SEIQoL) (O’Boyle et al. 1993), for global quality of life, and the EQ-5D (EuroQol Group 1990) and the SF-36 (Ware and Sherbourne 1992) for health-related quality of life (HRQoL). Generic QoL or HRQoL rating scales are widely used in studies on ageing and have demonstrated its usefulness in

# Springer Nature Switzerland AG 2021 F. Rojo-Pérez, G. Fernández-Mayoralas (eds.), Handbook of Active Ageing and Quality of Life, International Handbooks of Quality-of-Life, https://doi.org/10.1007/978-3-030-58031-5_16

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older population, allowing for comparisons with younger people (Cummins et al. 2003; Ratcliffe et al. 2017). Older people have specific characteristics and needs that may be not covered by generic QoL rating scales. Many older people can suffer from limitations or decline in physical and mental health as a result of chronic or degenerative diseases (World Health Organization 2015). Older people must also deal with adverse vital events, such as retiring from job, loss of relatives or friends, loneliness, and changes in familial and societal roles. The format and type of administration of generic rating scales can also imply difficulties for older people with vision, hearing or cognitive impairments or lower education level. The use of QoL rating scales specifically designed for this population is thus recommended. The version for older people of the World Health Organization QoL questionnaire (WHOQOL-OLD) (Power et al. 2005), the Older People’s QoL questionnaire (OPQOL) (Bowling 2009), and the Control, Autonomy, Self-realisation and Pleasure Scale (CASP-19) (Hyde et al. 2003) are the main specific QoL instruments for older people, and have demonstrated their psychometric properties. In this chapter, we will review the characteristics of the generic and specific QoL rating scales, with focus on their applications and usefulness as outcome measures in studies related to active ageing.

16.2

Methodology

Authors performed a non-systematic search in two bibliographic databases (PubMed and Web of Science) using the following terms: active ageing/aging, quality of life/QoL. The search was not restricted to any year, but it was limited to full text articles written in English, Spanish and Portuguese. Fifty nine papers were retrieved and reviewed, looking for the QoL rating scales applied in the studies. Additional searches, combining the name of the QoL scale with the term “active ageing/ aging”, were then performed. The different rating

scales were classified as generic or specific and their main characteristics were explored.

16.3

Generic Rating Scales

The most used generic QoL measures in older people are displayed in Table 16.1, with a description of their characteristics. There are some other generic rating scales, such as the Nottingham Health Profile or the Sickness Impact Profile, but they have been less applied in this population.

16.3.1

Personal Wellbeing Index (PWI)

The PWI (Cummins et al. 2003; International Wellbeing Group 2006) represents the first level deconstruction of the concept “satisfaction with life as a whole”. It is composed by seven items, measuring satisfaction with standard of living, health, achieving in life, relationships, safety, community-connectedness and future security. In 2006, a new item about spirituality/religion was added (International Wellbeing Group 2006), although the 7-item version is the most applied. Items are scored on an 11-point Likerttype scale, ranging from 0 (completely dissatisfied) to 10 (completely satisfied), with the score 5 as a neutral point. Total score is calculated by the mean value of its items transformed into a percentage of the maximum possible score. The PWI has been translated and validated in several languages (Lau et al. 2005). In the original study, PWI score showed differences between younger and older people, with the latter group presenting higher satisfaction than young people in all domains except in health (Cummins et al. 2003). Authors explain these differences through the theory of subjective wellbeing homeostasis, which propose that subjective wellbeing is stable within a narrow range for each individual, regardless of the threats to wellbeing that the person has to face (Tiliouine et al. 2006). Following this theory, older people can maintain a positive view of life despite health concerns, limitations and adverse life events. The

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Table 16.1 Generic quality of life rating scales used in older population Rating scale Personal Wellbing Index (PWI)

Schedule for the Evaluation of Individual Quality of Life (SEIQoL) EQ-5D

Author/s Cummins et al. (2003) International Wellbeing Group (2006) O’Boyle et al. (1993) EuroQol Group (1990)

Main areas, items and domains Satisfaction with standard of living, health, achieving in life, relationships, safety, community-connectedness and future security. Additional item on spirituality/religion (optional) 5 most important areas of life for the individual’s QoL, level of satisfaction and weighting of each area. 5 dimensions (mobility, self-care, usual activities, pain/discomfort and anxiety/ depression) and a visual analogue scale (VAS)

PWI has adequate psychometric properties in older population, with good acceptability, reliability and validity in several countries (Forjaz et al. 2012; Lau et al. 2005; Rodriguez-Blazquez et al. 2011).

16.3.2

Schedule for the Evaluation of Individual Quality of Life (SEIQoL)

The SEIQoL is a semi-structured interview designed to measure three elements of QoL: those aspects of life considered by the individual to be crucial to his/her QoL; the individual’s current functioning/satisfaction with each aspect; and the relative weight of each aspect in judging overall QoL (O’Boyle et al. 1993). The interview has three parts: the interviewer first elicits the five areas of life considered most important by the individual in determining their QoL. The level of satisfaction/functioning in each area is next recorded, in a scale from 0 to 100, followed by a judgement on the relative importance of each QoL area. The SEIQoL has a Direct Weighting version (SEIQoL-DW), in which the respondent indicates the weight for each QoL area manipulating the movable segments of a disk graduated from 0 to 100 (Joyce et al. 2003). A SEIQoL index can be calculated with the sum of the products of each weight and rating. The SEIQoL-DW has been found to be timeconsuming when used in routine medical

Scoring system 11-point Likert-type scale: 0 (completely dissatisfied) to 10 (completely satisfied)

Level of satisfaction and weighting: 0 to 100 For dimensions: 1 to 3 (EQ-5D-3L) or 1 to 5 (EQ-5D-5L). VAS: 0 to 100.

practice, but it is acceptable, reliable and valid when used in studies on ageing population (Mountain et al. 2004; Wettergren et al. 2009). The highest rate of missing data appeared in frail older people living in nursing homes, which were unable to answer due to poor physical condition or confusion (McKee et al. 2002). The correlation of SEIQoL-DW with health status and other QoL measures is weak to moderate (Mountain et al. 2004; Wettergren et al. 2009). The most important QoL domains in this population are health, independence, family, activities and leisure, social network and relationships, and finances, although the rank of domains differed by countries and samples (Hall et al. 2011; Robleda and Pachana 2019; RojoPerez et al. 2009; Seymour et al. 2008).

16.3.3

EQ-5D

The EQ-5D is a standardized measure of health status and HRQoL (EuroQol Group 1990). It is composed by a descriptive system and a visual analogue scale (EQ-VAS). The descriptive system has five dimensions: mobility, self-care, usual activities, pain/discomfort and anxiety/ depression, scored in 3 or 5 severity levels (EQ-5D-3L and EQ-5D-5L, respectively) (Herdman et al. 2011). The patient’s answers to each dimensions are then converted in a descriptive profile that describes the patient’s health state. Applying a formula, each health state can be transformed into an index (EQ-index), ranging

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from 0 (bad health) to 1 (perfect health). The EQ-VAS records the patient’s self-rated health on a vertical bar scored from 0 (worst imaginable health state) to 100 (best imaginable health state). Country-specific population norms by age and gender are available for EQ-5D-3L (Szende and Williams 2004). The EQ-5D allows for calculation of quality-adjusted life-year (QALY), a measure of disease burden (Brazier et al. 2019), and is one of the most commonly used HRQoL measures in cost-effectiveness analysis and in clinical trials. It has been translated and validated in numerous languages and has different modes of administration (self-complete, proxy, interview and online versions). A proxy version for older people with dementia has been also tested (DiazRedondo et al. 2013). The EQ-5D has been widely used in geriatric population, demonstrating its psychometric properties (Lutomski et al. 2017), although it may have poor discriminative ability due to ceiling effects and may not adequately capture the effects of anxiety and depression on QoL of older people (Lutomski et al. 2017; Sexton et al. 2017). In older people, lower EQ-index scores are associated with increased risk for depression, increased use of medication, increased number of chronic diseases and more problems with IADL (Andersson et al. 2014). The EQ-5D is one of the QoL measures proposed by the European Innovation Partnership on Active and Healthy Ageing (EIP-AHA) (Bousquet et al. 2015).

16.4

Specific Rating Scales

QoL rating scales specifically designed for a target population, in this case older adults, allow capturing unique aspects to this life stage. Some commonly used QoL scale in older adults are the Older People’s Quality of Life Questionnaire (OPQOL), CASP in its 12- or 19-item version, and WHOQOL-OLD (Bowling and Stenner 2011) (Table 16.2). These questionnaires may be considered global QoL scales since they include items that value both the health and social

domains, considered as equally important by older adults (Milte et al. 2014). There are two other specific QoL questionnaires for older adults, although less frequently used. The Elderly Quality of Life Index (EQOLI) was developed in a Brazilian sample (Paschoal et al. 2007). The EQOLI includes 46 items in 8 dimensions: physical health, functional capacity/autonomy, psychological, social/ family, economic, habits/life style, spirituality/ transcendence and environment. There is another 28-item questionnaire, developed in a sample from two Swiss regions, which assesses the importance that older adults give to feeling of safety, health and mobility, autonomy, close entourage, material resources, esteem and recognition, and social and cultural life (Henchoz et al. 2015). Although promising, these questionnaires have not yet been used by other authors.

16.4.1

Older People’s Quality of Life Questionnaire (OPQOL)

The OPQOL was developed based on the views of older people, using a representative sample of community-dwelling older adults in Britain with ethnic diversity (Bowling 2009). It is formed by 35 items, rated in a 5-point Likert-type scale, although some studies use a 32 or 33-item version (Bowling 2009). Items represent the following QoL dimensions: life overall, health, social relationships and participation, independence, control over life, freedom, home and neighbourhood, psychological and emotional well-being, and financial circumstances. Higher scores indicate better QoL. In the initial validation study, the OPQOL psychometric characteristics, including acceptability, reliability (Cronbach’s alpha was 0.75–0.90 for the total score) and construct validity, were good (Bowling 2009). Comparing to the CASP-19 and WHOQOL-OLD, the OPQOL seems to perform better in ethnically diverse samples (Bowling 2009). The OPQOL was originally developed in English and it has been validated in Chinese (Chen et al. 2014), Czech (Mares et al. 2016), Iranian (Nikkhah

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Table 16.2 Specific quality of life rating scales used in older population Rating scale Older People’s Quality of Life Questionnaire (OPQOL)

Author/s Bowling (2009)

CASP-12 and CASP-19

Hyde et al. (2003) Power et al. (2005)

WHOQOL-OLD

Main areas, items and domains 35 items, grouped in 9 dimensions: life overall, health, social relationships and participation, independence, control over life, freedom, home and neighbourhood, psychological and emotional wellbeing, and financial circumstances. There is also a 13-item version. 12 or 19 items in 4 domains: control, autonomy, selfrealization and pleasure. 24 items, divided into 6 facets: sensory abilities; autonomy; past present and future activities; social participation; death and dying; and intimacy.

et al. 2018), Italian (Bilotta et al. 2011) and Turkish (OPQOL-brief) (Caliskan et al. 2019). There is a short version, the OPQOL-brief, with 13 items, which is also reliable and valid (Bowling et al. 2013). Its internal consistency (Cronbach’s alpha) in a Turkish validation was 0.88 (Caliskan et al. 2019).

16.4.2

Scoring system 5-point Likert-type scale

4-point Likert-type scale, from 0 (often) to 3 (never) 5-point Likert-type scale.

Jürges 2005), with three items for each domain. Items are scored from 1–4 with higher scores representing better QoL. Internal consistency (Cronbach’s alpha) ranged from 0.74 to 0.79 for the domains and was 0.82 for the total score (Wahrendorf and Siegrist 2010). Confirmatory factor analysis showed a three factor structure: pleasure, self-realization; and autonomy and control (Pérez-Rojo et al. 2018).

CASP-12 and CASP-19

The name of this questionnaire comes from its main domains, Control, Autonomy, Selfrealization and Pleasure, derived from the theory on human needs of satisfaction (Hyde et al. 2003), by asking if these psychological needs are satisfied. This questionnaire, developed in a sample of people aged 65–75 years, is also used as a measure of well-being. The 19-item version comprises three domains with 5 items each, and the fourth domain, Control, with 4 items. Items are answer in a 4-point Likert-type scale, from often (0) to never (3). Higher scores indicate higher satisfaction and QoL in all four domains. The CASP-19 has been validated in many countries, including Brazil (Neri et al. 2018); Lithuania (Černovas et al. 2018); Czech Republic, Poland and Russia (Kim et al. 2015). Overall, it has been used in over 20 countries (Hyde et al. 2015). A study supports that a 15-item version of the CASP is unidimensional and unbiased by gender (Oluboyede and Smith 2013). CASP-12 is a shorter version, developed for use in the SHARE project (Börsch-Supan and

16.4.3

WHOQOL-OLD

The WHOQOL-OLD is an add-on module of the WHOQOL for use in older adults (Power et al. 2005). It was developed simultaneously in 22 centres around the world (20 countries, UK and China contributed with two centres each), with a total sample of over 7401 people aged 60 years or more. It comprises 24 items, equally divided into 6 facets: sensory abilities; autonomy; past present and future activities; social participation; death and dying; and intimacy. Items are scored in a 5-point Likert-type response scale. The total score ranges from 24 (lowest QoL) to 120 (highest QoL). Three short versions were proposed, using with one item from each facet (Fang et al. 2012; Urzúa and Navarrete 2013; Van Biljon et al. 2015). It has been validated in several counties, such as Brazil (Fleck et al. 2006), France (Leplège et al. 2013), Holland (Gobbens and van Assen 2016), Norway (Halvorsrud et al. 2008), Portugal (Vilar et al. 2016), South Africa (Van Biljon et al. 2015), Spain (Lucas-Carrasco

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et al. 2011), Turkey (Eser et al. 2010), showing adequate validity and reliability cross-nationally. The WHOQOL-OLD has been extensively used in many studies with older adults (Bottan et al. 2014; R. J. J. Gobbens and van Assen 2016; Margis et al. 2010; Punta et al. 2019; Urzúa et al. 2011).

16.5

Use of QoL Rating Scales in Active Ageing Studies

The relationship between active ageing and QoL is probably bi-directional, and thus difficult to analyse in cross-sectional studies. A crosssectional study with 2052 older adults in Brazil identified QoL and group participation as significant determinants of active ageing in both genders (Campos et al. 2015). It is surprising the lack of research about QoL and the active ageing construct. Nevertheless, some studies have analysed the relationship between specific active ageing indicators and QoL ageing The main determinants of subjective wellbeing as assessed by PWI are depression, health status, loneliness and social support, and some environmental attributes (Gao et al. 2017; MartinezMartin et al. 2012; Rodriguez-Blazquez et al. 2012). In studies in community-dwelling older people using the EQ-5D, depression was the main determinant of QoL, followed by the existence of chronic diseases, disability and perceived social support (Davis et al. 2015; Kwon et al. 2017; Martinez-Martin et al. 2012; Pino et al. 2014). Work status and leisure activities were also associated with EQ-5D (Pino-Domínguez et al. 2016). Higher QoL measured with the OPQOL is associated with better health and functioning, as well as increased active ageing (Bowling 2009) and lower frailty status (Bilotta et al. 2010; Kojima et al. 2016). In addition, it has a good predictive value of adverse health outcomes such as risk for falls, nursing home placement and death (Bilotta et al. 2011). Better QoL as measured by the CASP-12 was associated with: productive activities such as

volunteering or caring for a person (Wahrendorf and Siegrist 2010); greater social capital (Litwin and Stoeckel 2014) and emotional closeness with confidents (Litwin and Stoeckel 2014); worse health behaviours such as binge drinking, especially in women from Southern European counties (Fuentes et al. 2017). In addition, at a country level, better QoL was also associated with socioeconomic indicators (Conde-Sala et al. 2017) and availability of non-heath care services (Richardson et al. 2018). Improvement in QoL over time was observed in a study using a 15-item version of the CASP (Oluboyede and Smith 2013). One study specifically analysed determinants of QoL measured by the WHOQOL-OLD, in a sample of older adults in Brazil attending a psychosocial care centre (Bottan et al. 2014). Results indicate that higher QoL was associated with lower depression and number of comorbidities, better functional capacity and more frequent visits to the centre. Other significant determinants associated with lower QoL as measure by the WHOQOL-OLD are: depression (Margis et al. 2009), disease severity (Margis et al. 2009) and duration (Punta et al. 2019), sociodemographic characteristics such as being a women and older age (Gobbens and Remmen 2019); lower general health (Punta et al. 2019; Urzúa et al. 2011). In summary, research supports the hypothesis that there is a significant relationship between QoL and usual active ageing indicators. In addition, other variables, acting as a mediators or moderators, probably play an important role in the relationship between QoL and active ageing. Further research is needed to determine a causal model, using longitudinal designs and complex statistical models such as Structural Equation Modeling.

16.6

Conclusions

QoL is an important outcome of interventions to improve and maintain active ageing. In this chapter, the main characteristics and applications of QoL measures in older people have been described. While not specifically designed for

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measuring QoL in active ageing, they can help to identify and assess the relevant dimensions of active ageing for the individual. The choice of one instrument over the other should be guided by the research goals, and the psychometric properties of the scale and its content, taking into consideration practical issues such as the administration burden, especially important in the very old population. In this case, the use of proxies is advised, although results of subjective domains should be interpreted with caution. Though the description the main psychometric properties that a rating scale should have is not the scope of this chapter, there are several useful guidelines that can help the reader to understand validation studies and to select the most adequate QoL rating scale (Mokkink et al. 2010; Valderas et al. 2008). QoL instruments offer a key tool to measure changes in interventions. Although valid and reliable, there is a lack of studies about the sensitivity to change of the QoL measures. More research on the impact of active ageing on QoL, using validated QoL questionnaires, is needed. The use of generic QoL questionnaires supports the life course perspective, especially in large longitudinal, population-based studies. Generic QoL tools may be complemented with others specifically designed for older adults. This is the case of the WHOQOL-OLD, which was initially developed to be used a complementary module of the WHOQOL (Power et al. 2005). Nevertheless, the WHOQOL-OLD is frequently applied as an independent measure. Another direction of future research is the use of several methods to measure QoL in older age, including qualitative approach, as well as objective and subjective and indicators. In conclusion, there are a several generic and specific QoL instruments that can help to understand, measure and identify the impact of the main dimensions of active ageing in QoL. Further studies are needed in order to characterize the relationship between QoL and active ageing construct, as well as its indicators.

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282 psychometric study of the CASP-19 scale in adult and elderly Brazilians. Cadernos De Saude Publica, 34 (10), e00181417. https://doi.org/10.1590/0102311X00181417. Netuveli, G., & Blane, D. (2008). Quality of life in older ages. British Medical Bulletin, 85, 113–126. https:// doi.org/10.1093/bmb/ldn003. Nikkhah, M., Heravi-Karimooi, M., Montazeri, A., Rejeh, N., & Sharif Nia, H. (2018). Psychometric properties the Iranian version of Older People’s Quality Of Life questionnaire (OPQOL). Health and Quality of Life Outcomes, 16(1), 174. https://doi.org/10.1186/ s12955-018-1002-z. O’Boyle, C., McGee, H., Hickey, A., Joyce, C. R. B., Browne, J., O’Malley, K., & Hiltbrunner, B. (1993). The schedule for the evaluation of individual quality of life (SEIQoL). Administration manual. Dublin: Royal College of Surgeons in Ireland. https://epubs.rcsi.ie/ psycholrep/39. Oluboyede, Y., & Smith, A. B. (2013). Evidence for a unidimensional 15-item version of the CASP-19 using a Rasch model approach. Quality of Life Research, 22 (9), 2429–2433. https://doi.org/10.1007/s11136-0130367-z. Paschoal, S. M. P., Filho, W. J., & Litvoc, J. (2007). Development of elderly quality of life index— EQOLI: Theoretical-conceptual framework, chosen methodology, and relevant items generation. Clinics (Sao Paulo, Brazil), 62(3), 279–288. Pérez-Rojo, G., Martín, N., Noriega, C., & López, J. (2018). Psychometric properties of the CASP-12 in a Spanish older community dwelling sample. Aging & Mental Health, 22(5), 700–708. https://doi.org/10. 1080/13607863.2017.1292208. Pino, L., González-Vélez, A. E., Prieto-Flores, M.-E., Ayala, A., Fernandez-Mayoralas, G., Rojo-Perez, F., et al. (2014). Self-perceived health and quality of life by activity status in community-dwelling older adults. Geriatrics & Gerontology International, 14(2), 464–473. https://doi.org/10.1111/ggi.12119. Pino-Domínguez, L., Navarro-Gil, P., González-Vélez, A. E., Prieto-Flores, M.-E., Ayala, A., Rojo-Pérez, F., et al. (2016). Self-perceived health status, gender, and work status. Journal of Women & Aging, 28(5), 386–394. https://doi.org/10.1080/08952841.2015. 1018030. Power, M., Quinn, K., Schmidt, S., & WHOQOL-OLD Group. (2005). Development of the WHOQOL-old module. Quality of Life Research, 14(10), https://doi.org/10.1007/s11136-0052197–2214. 7380-9. Punta, P., Somrongthong, R., & Kumar, R. (2019). Factors influencing quality of life (QOL) amongst elderly caregivers of people living with HIV/AIDS in Phayao province, Thailand: A cross-sectional study. F1000Research, 8, 39. https://doi.org/10.12688/ f1000research.16892.1. Ratcliffe, J., Lancsar, E., Flint, T., Kaambwa, B., Walker, R., Lewin, G., et al. (2017). Does one size fit all?

C. Rodríguez-Blázquez and M. J. Forjaz Assessing the preferences of older and younger people for attributes of quality of life. Quality of Life Research, 26(2), 299–309. https://doi.org/10.1007/ s11136-016-1391-6. Richardson, S., Carr, E., Netuveli, G., & Sacker, A. (2018). Country-level welfare-state measures and change in wellbeing following work exit in early old age: Evidence from 16 European countries. International Journal of Epidemiology, 48, 389–401. https:// doi.org/10.1093/ije/dyy205. Robleda, S., & Pachana, N. A. (2019). Quality of life in Australian adults aged 50 years and over: Data using the schedule for the evaluation of individual quality of life (SEIQOL-DW). Clinical Gerontologist, 42(1), https://doi.org/10.1080/07317115.2017. 101–113. 1397829. Rodriguez-Blazquez, C., Forjaz, M. J., Prieto-Flores, M. E., Rojo-Perez, F., Fernandez-Mayoralas, G., & Martinez-Martin, P. (2012). Health status and wellbeing of older adults living in the community and in residential care settings: Are differences influenced by age? Aging and Mental Health, 16(7), 884–891. Rodriguez-Blazquez, C., Frades-Payo, B., Forjaz, M. J., Ayala, A., Martinez-Martin, P., Fernandez-Mayoralas, G., & Rojo-Perez, F. (2011). Psychometric properties of the International Wellbeing Index in communitydwelling older adults. International psychogeriatrics, 23(1), 161–169. https://doi.org/10.1017/ S104161021000092X. Rojo-Perez, F., Delgado-Sanz, M., Fernandez-Mayoralas, G., Forjaz, M. J., Ahmed-Mohamed, K., MartinezMartin, P., et al. (2009). Informal support according to level of competence related to health and functioning in quality of later life. In W. Ostasiewicz (Ed.), Quality of life improvement through social cohesion (pp. 64–85). Wroclaw: The Publishing House of Wrocław University of Economics. Sexton, E., Bennett, K., Fahey, T., & Cahir, C. (2017). Does the EQ-5D capture the effects of physical and mental health status on life satisfaction among older people? A path analysis approach. Quality of Life Research, 26(5), 1177–1186. https://doi.org/10.1007/ s11136-016-1459-3. Seymour, D. G., Starr, J. M., Fox, H. C., Lemmon, H. A., Deary, I. J., Prescott, G. J., & Whalley, L. J. (2008). Quality of life and its correlates in octogenarians. Use of the SEIQoL-DW in Wave 5 of the Aberdeen Birth Cohort 1921 Study (ABC1921). Quality of Life Research, 17(1), 11–20. https://doi.org/10.1007/ s11136-007-9291-4. Szende, A., & Williams, A. (2004). Measuring selfreported population health: An international perspective based on EQ-5D. Budapest, Hungary: SpringMed Publishing. The World Health Organization Quality of Life assessment (WHOQOL): Position paper from the World Health Organization. (1995). Social Science & Medicine, 41(10), 1403–1409.

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Measuring the Impact of Active and Assisted Living (AAL) Solutions

17

An Analysis of Research Practices Birgit Aigner-Walder, Albert Luger, and Julia Himmelsbach

17.1

Introduction

Measured in the percentage of population aged 60 years or more, Europe is currently the world region with the oldest population. In 2017, the mentioned age cohort accounted for 24.7% of Europe’s total population, compared to 21.7% in Northern America and 12.7% as the world average. On a country level, 22 out of the 25 “oldest” countries in the world are located within the European Union (United Nations 2017). According to recent population projections of Eurostat, by 2030, 30.7% of the population within the European Union will be aged 60 or more, by 2050, 34.5%, respectively (Eurostat 2019a). The population projections put pressure on the budgets of the EU-28 countries. The long-term budgetary projections show an expected increase in public expenditure of 1.8 percentage points in GDP from 2016 to 2040 due to age-related spending. This is particularly caused by higher costs for pensions, long-term care, and health care spending. In this context, Germany (+3.2pp) and Austria (+2.1pp) are two of the countries with

B. Aigner-Walder (*) · A. Luger Carinthia University of Applied Sciences, Institute for Applied Research on Ageing, Villach, Austria e-mail: [email protected]; [email protected] J. Himmelsbach AIT Austrian Institute for Technology GmbH, Center for Technology Experience, Vienna, Austria e-mail: [email protected]

an above-average expected impact of age-related expenditure (European Commission 2018). In Germany as well as in Austria approximately 30% of the GDP (2016) is spent on public social and health care benefits and services (Eurostat 2019b), being an indicator for the importance of public social security. In this context, 44% of social benefits and services in Austria are related to old age (e.g., pensions), while a quarter of the expenditures are associated with health care, including health and care benefits and services (Federal Ministry of Labour, Social Affairs, Health and Consumer Protection 2018). Besides structural reforms in the social security system, technological innovations could lead to a reduction in costs. Especially active and assisted living (AAL) technologies, such as smart home systems, tele-care systems or telehealth systems, should contribute to a prolonged autonomous life of older adults as well as guarantee the implementation of successful strategies for an optimal management of aging processes. In this connection, potential support of AAL technologies is likely in the following fields of application: health and care, living and buildings, security and protection, mobility and transport, work and training, vitality and abilities, leisure and culture as well as information and communication (SYNYO et al. 2015). Technical innovations can play several roles with regard to social security. In a simple Internet-based setting, information and

# Springer Nature Switzerland AG 2021 F. Rojo-Pérez, G. Fernández-Mayoralas (eds.), Handbook of Active Ageing and Quality of Life, International Handbooks of Quality-of-Life, https://doi.org/10.1007/978-3-030-58031-5_17

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communication technologies (ICT) can enable people to change their health behaviour. Smart home solutions as well as tele-health or tele-care solutions can lead to more comfort and security at home (e.g., through fall detectors or vital data analysis), and service robots can support the elderly in their daily activities (Siegel and Dorner 2017). However, regarding AAL solutions, there are still open questions, namely: Are these technologies really leading to a cost reduction? Who pays for the development and use of these technologies? Can AAL solutions contribute to a higher quality of living of older adults? Can data security be guaranteed? What are the economic effects of such solutions? Finally, how can we measure the overall impact of AAL solutions? This paper aims to give an overview of existing practices to measure the effects of AAL solutions. Section 17.2 focuses on the specifics of innovations in the social security sector. In this context, the characteristics of the social framework are described based on the examples of Germany and Austria to get a better overview of the stakeholders involved and their perspectives as well as its effects on innovations within the sector. Section 17.3 describes the method used to analyse key objectives that are pursued with AAL solutions, keeping in mind the various perspectives of the AAL environment, and gives indicators that have been used so far to measure the impact of AAL solutions. Section 17.4 presents the results of the analysis, followed by a discussion of the results in Sect. 17.5. The paper ends with a conclusion (Sect. 17.6), summing up the main results of the paper.

17.2

Specifics of Innovations and Relevant Stakeholders in the Social Security Sector

According to Joseph A. Schumpeter (1883–1950), innovations are new combinations of factors of production. He distinguishes between innovations and inventions. While inventions are the discovery and development of new goods, processes, or methods innovations are

the commercial use of them in enterprises. Finally, as a third step, imitation and diffusion take place (Baßeler et al. 2010). The Organisation for Economic Co-operation and Development (OECD) and Eurostat (2018, p. 19) define an innovation as “a new or improved product or process (or a combination thereof) that differs significantly from the unit’s previous products or processes and that has been made available to potential users (product) or brought into use by the unit (process).” Innovations, and in particular technical innovations, are seen as the main source of longterm economic growth. While product innovations lead to new products (e.g., tablet, smartwatch) or products with improved quality, process innovations allow more cost-efficient methods of production (in the sense of a higher output with a constant input of the factors of production or the same output with a lower input). An increase in growth is associated with a higher standard of living of the population (Baßeler et al. 2010; Blanchard 2006). Innovations in the social security sector can be seen positively from another point of view: Investments in human resources in the sense of education or health of the working population increase the potential of production of an economy and are consequently a relevant economic location factor (Mayrhuber et al. 2018). Without a healthy and well-educated labour force, production, as well as research and development, might be hindered extensively. Thus, in general, technological progress is assessed positively from an economic point of view. But, in the field of social security, the main drivers for the development and application of new ideas are rather social than economic concerns, leading to the term social innovation. “Social innovation can be broadly described as the development of new concepts, strategies and tools that support groups in achieving the objective of improved well-being.”(Dawson and Daniel 2010, p. 9) Existing or new technologies and knowledge are used in a new manner to improve social conditions (Dawson and Daniel 2010). Nevertheless, technical innovations applied in areas of social protection and financed by public

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Measuring the Impact of Active and Assisted Living (AAL) Solutions

authorities are often also evaluated critically. The main reason for this is the expected increase in costs. Besides demographic structure, morbidity, income, and institutional settings, technological progress is seen as a major cost-driving factor in public health care expenditure. In particular, medical innovations that complement existing treating conditions often come with a rise in expenditure (European Commission 2018). In addition, costs in the medical sector increase if people live longer due to (technical) innovations but are mainly ill during these years (Bräuninger et al. 2007). However, technological progress in the health sector often leads to a reduction of the biological age, increasing at the same time the active life period of people. Thus, working life, productivity, and labour force participation rates can increase. Consequently, medical progress could finance itself. With projections and modelling calculations, Bräuninger et al. (2007) analysed for Germany how this effect could compensate for the additional costs of aging. The calculations are based on a steady health status compared to a scenario of improved health (increased life expectancy of seven years from 2007 to 2017). The results show a potential reduction of costs in the health sector of 12.5% through innovations. Reimers (2009) points out that technological innovations in the medical sector have to be distinguished from innovations in other sectors. Cost-intensive product innovations are more likely than process innovations, which decrease the input factors of production, and they are often used in addition to existing technologies. Moreover, technological innovations are distributed more quickly, as insured persons have an economic incentive to consume as many services as possible and care providers want to use all technological possibilities to be appreciated professionally and to minimize liability risks through medical malpractice. However, innovations in this sector underlie strict regulations—from patent rights via admission to market through to health technology assessments (see Reimers 2009 for a comprehensive overview of the situation in Germany). The mentioned differences concerning innovations in the health sector are of relevance

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in countries with insurance-based care systems, as it is the case in Germany and Austria. On the contrary, health care can also be directly tax-funded, as it is the case in the UK and the Nordic countries (Saltman et al. 2004). Within insurance markets, there are various groups of players with different interests and influences on innovation activities. Roughly speaking, there are the main stakeholder groups of service providers, public and private insurance institutions, and insured people. These main actors meet on the following markets: the market for health services, where service providers as suppliers meet insured persons as consumers; the market for insurances consisting of insurance institutions and insured persons; and the market for utility supply contracts, where insurance institutions and service providers meet (Reimers 2009). Service providers in the health sector are, for example, doctors, pharmacists, other healthcare professionals, and ambulatory and stationary care institutions. Insured persons are in practice often represented by their relatives. In general, they pay (if at all) only a part of the services privately, while private or public insurance institutions (and if financed via public budgets, in the end, the state) carry the main costs. Moreover, there are other public and private stakeholder groups: public institutions including legislation, administration, and jurisdiction; public research and development institutes as well as educational institutions; and industrial organizations as suppliers of technical equipment, information and communication technologies, services, etc. Therefore, in contrast to “normal” markets, where suppliers and consumers meet directly, there are many more actors in an insurance market, leading to complex processes of negotiation (Henke et al. 2011). Based on the perspectives of the stakeholder groups described above, different interests are pursued with regard to innovations (Bührlen and Kickbusch 2009; Henke et al. 2011): • For insurance institutions or the state as financiers of the services, economic utility (cost-utility relation), mobility, mortality, quality of life, satisfaction, and securing the

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mandate of supply are relevant aspects that can be influenced by innovations. Insurance institutions profit from innovations if their market position is strengthened—for example, through lower expenses, an improved service for their clients, or a better image. • For service providers, the positive effects of innovations on health, including potential risks, are an important dimension. Moreover, the influence of innovations on the short- and long-term expenses and the profit of the service providers are in focus. However, to use innovations in practice, information, incentives, and knowledge on the innovation need to be available for the service providers. • For public research and development institutions, innovations should contribute to social needs as well as open new research areas and methods. In addition, in order to be able to focus on relevant topics, the question of how to finance research and development (from a long-term perspective) is of high significance. A high innovation capacity enhances the visibility and attractiveness of research and development institutions, with positive effects for future financing, the hiring of qualified employees, and possibilities of cooperation. With regard to the competitive position of such institutions, publications and patents are pursued. • Industrial organizations as private producers of equipment or technology also seek to increase their competitive position by innovations, through a unique selling point, a better price-performance ratio, increased total revenues, an improved image, or long-term relations with costumers. To sum up, innovations are of relevance with regard to a sustainable turnover and the profitability of the company. Too much regulation by the state is seen critically, as it hinders an open market and competition. For this stakeholder group, a high innovation rate also leads to a better reputation and attractiveness of the company—for qualified employees and cooperation with the private or public sector.

B. Aigner-Walder et al.

• According to Henke et al. (2011), the benefits of innovations for political actors are much harder to identify, as the genuine interest itself, e.g., health care provision, is often in conflict with general political interests (e.g., economic growth). Moreover, it has to be considered that the decision-making authority is often distributed between various political institutions. • Finally, for the citizens as consumers of the innovations, questions of how to finance innovative applications, their availability for all citizens as well as a voluntary use, and information about potential risks are of relevance. In general, citizens benefit from innovations if new or improved services are available on the market, leading to an improved quality of life (Baßeler et al. 2010). The Ambient Assisted Living Association (2013) categorizes stakeholders into primary users (older adults that use an AAL solution), secondary users (which access or use AAL solutions for the benefit of primary end-users, e.g., family, care organizations), and tertiary users (that play a role in providing, financing, or enabling AAL solutions), whereby the categorization depends on the respective AAL solution. For instance, doctors could also be primary users if they are connected with seniors through a software. The described actors in the social security sector in Germany and Austria and their partly conflicting interests regarding innovations such as new active and assisted living technologies lead to numerous key objectives and indicators that are used in practice to measure the effects of active and assisted living technologies. Within the following section, the methodology for the specification of key objectives and indicators to measure the effects of AAL solutions in practice is presented. So far, a holistic analysis and representation of objectives of AAL solutions as well as of suggested and used indicators to measure their impact is lacking in research practice. Existing literature regarding the objectives of innovations in the field of AAL

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Measuring the Impact of Active and Assisted Living (AAL) Solutions

focuses mainly on the domain of quality of life (e.g., Siegel and Dorner 2017). Moreover, existing studies and reviews focus on the perspective of older users, for example, to gain insights into expected benefits and perceived usefulness as a factor of technology acceptance (e.g., Peek et al. 2014). Also regarding indicators, within existing papers solely a fraction of potential indicators, often with a specific purpose, is presented. For example, in Kumpf et al. (2014), indicators to measure the efficiency of AAL systems are presented. Technopolis Group (2014) focuses on the innovation impact, whereas Abadie et al. (2014) are discussing potential indicators in the context of active and healthy ageing. Hence, to get a comprehensive overview of the topic, taking into account all stakeholder perspectives involved, the following analysis was carried out.

17.3

Methodology

So far, there is no systematic overview of the objectives of AAL solutions and the indicators to assess their effects. Asking about impact measurements must inevitably also imply the question of what impacts should be aimed for and, thus, measured. Hence, we first analysed the aspired objectives of AAL solutions, followed by identifying applied and suggested indicators. In detail, we investigated the following research questions: What are the objectives and intended impacts of AAL solutions? Which indicators are already in use or have been suggested to investigate the effects of AAL solutions?

This section outlines the methodology of the study. First, we present the methodological approach and the procedure of identifying AAL objectives. Next, we briefly discuss the often inconsistently used term indicator and then outline the procedure of identifying indicators.

17.3.1

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Identifying Key Objectives of AAL Solutions

The methodological approach to investigate the objectives of AAL solutions was based on Mayring’s (2014) content analysis for summarizing and reducing the material to its core. As a first step, we built the material corpus. We argue that AAL innovations are closely interwoven with the scientific (funding) landscape, since, on the one hand, it is decisively involved in the, often costly, developments and, on the other hand, scientific findings form the basis for innovations and new AAL solutions are primarily created in scientifically accompanied innovation and development processes. Thus, all call for proposal texts published within the framework of the “AAL— Active and Assisted Living Programme” of the AAL Association (AALA) as well as “IKT der Zukunft: benefit—Demografischer Wandel als Chance [ICT of the future: benefit—demographic change as an opportunity]” of the Austrian Research Promotion Agency FFG were analysed. Both programs started in 2008; the material corpus includes all texts starting with the first call for proposals. All AAL Programme call for proposal texts published annually were included until 2016, FFG texts until 2015. Thus, in sum, 20 texts were analysed: nine AAL Programme calls for proposals and eleven FFG calls for proposals. Next, the material was prepared. For this purpose, we recorded the following formalities and context information: (1) consecutive numbering of the texts, (2) link to the document (if available), (3) author or responsible person (if specified), (4) institution, (5) title and subtitles, (6) date of publication, (7) scope of application. Concerning the scope of application, the first level of the TAALXONOMY (SYNYO et al. 2015) was considered. In order to code the objectives, the call texts were read line by line and then section by section. We defined propositions as the unit of analysis. An objective was coded if a proposition referred to effects and goals on a subjective, institutional, or social level of the solutions to be developed.

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Implicit goals were also taken into account, for instance, if current situations were problematized or potential wishes of the user groups were cited. Each identified objective was entered only once per text in order to keep the material corpus organized. The assigned codes are formulated as close as possible to the original wording. In detail, the following information on the identified goals were collected: (8) identified proposition, (9) code of the objective, (10) target group and context information, (11) degree of abstraction (1 ¼ low, 2 ¼ moderate, 3 ¼ high). In total, 1,035 relevant propositions were identified. The next step was the formal cleansing, restructuring, and ordering. The 323 assigned codes were then summarized and clustered thematically. Based on the available data, we inductively formed the main categories. In this way, a total of 22 objectives could be identified and assigned to four objective groups.

17.3.2

Identifying Indicators for the Assessment of AAL Solutions

This section gives an overview of indicators suggested and used so far to measure the effects of AAL solutions. As indicated in the previous sections, the existing stakeholder groups pursue different objectives by implementing AAL solutions. This leads to various indicators for the evaluation of different solutions based on ICT that support an active, healthy, and independent living of older adults. For the analysis at hand, the various indicators were catalogued and clustered. Similar to the analysis of the objectives of AAL solutions, freely available reports and deliverables of 37 projects, which have been supported by the “AAL—Active and Assisted Living Programme” of the AAL Association, were checked for potential indicators. Additionally, another 13 projects of the programme “IKT der Zukunft: benefit—Demografischer Wandel als Chance [ICT of the future: benefit—demographic change as an opportunity]” were examined. Other relevant project reports and initiatives, for instance, the “Monitoring and

Assessment Framework for the European Innovation Partnership on Active and Healthy Ageing (MAFEIP)” (Abadie et al. 2014), were also taken into account. The analysis carried out suggests that the definition of the term “indicator” is difficult for several reasons. It is derived from the Latin word “indicare,” which means, amongst other things, to announce, point out, expose, reveal, or indicate. The OECD has defined an indicator as “a parameter, or a value derived from parameters, which points to, provides information about, the state of a phenomenon/environment/area, with a significance extending beyond that directly associated with a parameter value” (OECD 2003). There are several types of indicators, such as simple indicators, relative measures, or composite indicators. Simple indicators may be discrete or continuous variables measuring one specific issue. The user-friendliness of certain devices or a software is a possible simple indicator for the evaluation of AAL solutions that can be measured by conducting a quantitative survey or a qualitative interview. Relative measures are measuring something compared to at least one other thing or estimating things proportionally to one another, for instance, human gender ratio or the gross domestic product per capita. While simple indicators and relative measures are specific indicators, there are also composite indicators (Meyer 2004). These condense a wide range of information on different (but related) phenomena into a single measure or index. Quality of Life (QoL) is a composite indicator, which combines information on various domains in life. For instance, the Short-Form (36) Health Survey measures eight sections of health status: vitality, physical functioning, bodily pain, general health perceptions, physical role functioning, emotional role functioning, social role functioning and mental health (Ware and Sherbourne 1992). Moreover, multiple scientific perspectives and, therefore, different theoretical and conceptual frameworks have to be taken into account when developing indicators for the evaluation of and applying them to socio-technical services and products like AAL solutions (Salvi et al. 2015; Maggino and Zumbo 2012). Consequently, there

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are ambiguities when cataloguing indicators used in AAL research projects. For this reason, we identified, as a first step, those measures as “indicators” which were expressly designated as such in relevant research reports and documents. Because the terms “value,” “quantity,” “variable,” “parameter,” and “indicator” are often used interchangeably in research, in a second step, these were also considered. Furthermore, the indicator analysis also focused on specific measuring instruments like the EuroQoL Five Dimensions Questionnaire (EQ-5D), a standardized instrument for measuring the generic health status developed by the EuroQol Group (Herdman et al. 2011). In general, for the indicator analysis, the following formal aspects were documented: (1) consecutive numbering of the texts, (2) link to the document (if available), (3) author or responsible person (if specified), (4) institution, (5) title and subtitles, (6) date of publication. Within the content analysis, the following components were analysed: (7) (assumed) indicator (original wording/translation), (8) encoding of the contents, (9) level of indicator abstraction (very concrete/ concrete/vague; subjective assessment), (10) method of measurement (qualitative/quantitative/no indication), (11) similar indicators in other project reports and deliverables, (12) any comments by the authors regarding constraints and limitations in the application of the specific indicator (e.g., short- or long-term application, micro- or macro-level). In a next step, the collection of indicators was summarized by content aspects and clustered. For the clustering process, it was also considered if the indicator/indicator category is relevant for the subjective, institutional, or social level. The following paragraphs give an overview of the results.

17.4

Results

In this section, we first present the results of the analysis of the objectives, followed by the identified indicators.

17.4.1

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Objectives of AAL Solutions

The objectives of AAL solutions relate to four main areas: vitality and care objectives, social objectives, design and technology objectives, and economic and scientific objectives. Table 17.1 shows the objectives of the different areas. Vitality and care objectives include goals that affect the well-being of the subjects concerned, including biopsychosocial and age-specific factors as well as health and care aspects. In sum, four goals were identified. In general, AAL solutions should contribute to the quality of life and well-being of the users. In detail, impact dimensions include physical, psychological, social, and spiritual well-being, and technology might contribute to autonomy, personal safety, self-confidence, or—in general—a satisfactory and dignified standard of living. In addition, AAL systems should support the health management of the users in terms of general health, prevention, medications, or offering teleassistance as well as the employability of older adults aiming for longer periods of employment (career, voluntary work) and increased coping with work requirements as well as work-life balance and occupational health. For these purposes, AAL solutions aim at contributing to maintaining independence in activities, namely activities of daily living (ADL), such as walking or bathing, instrumental activities of daily living (IADL), such as shopping or housework, perceived meaningful activities as well as supporting mobility, and to maintaining skills and competencies, such as cognitive and physical skills, by offering learning and further education opportunities as well as by supporting stress and time management. Social objectives are those that relate to the social coexistence of people in a society. Thus, objectives whose meaning refers to other persons and their behaviour are targeted. Related to AAL, three objectives are of main interest. First, the inclusion and participation of older adults should be achieved. On the one hand, social inclusion includes both the prevention of loneliness and

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Table 17.1 Overview of the objectives of AAL solutions Objective group Vitality and care objectives Social objectives Design and technology objectives Economic and scientific objectives

Objectives Quality of life and well-being, health management, employability of older adults, independence in activities, skills and competencies Inclusion and participation, social networks, fair socioeconomics User-centred innovations, data protection, technology acceptance, interoperability, aspects of building services European competitiveness, market growth and diffusion, market stimulation, financing and business models, innovation capacity, exchange between science and industry, scientific progress

Own illustration

opportunities for participation at the individual level but also a positive social role at an older age at the societal level. Furthermore, the diversity of older adults should be taken into account. On the other hand, digital inclusion or inclusion in the digital society should be fostered. Second, social networks should be strengthened, including intergenerational and cross-border communication. Third, AAL technologies should contribute to fair socioeconomics. In addition to ethical considerations, a positive social impact should be achieved. Design and technology objectives directly concern the characteristics of the AAL technology itself. Developers aim at user-centred innovations. Thus, user involvement and a clear definition of user groups or user segmentation are crucial. Research and development should follow a social, institutional, and individual needs-driven approach. Personalization and—especially relevant in terms of aging and changing needs— adaption are parts of user-centred objectives. By that, a positive user experience, including usability, accessibility, and hedonic aspects, should be enabled. As a further objective, data protection is named. In detail, solutions have to ensure confidentiality and anonymity. Data should only be gathered and processed if users give informed consent and personal data are necessary for the services. In line with this, AAL aims for technology acceptance and trust, not only regarding a specific solution but regarding assistive technologies in general. User-centeredness, data protection, and technology acceptance are closely related and mutually dependent. However, on a technical level, also interoperability, including

the integration of existing services and robustness, should be achieved and optionally include aspects of building services, such as lighting, acoustics, heating, and ventilation. In terms of sustainability, solutions have to contribute to energy efficiency. AAL systems also have to contribute to economic and scientific objectives. This includes all objectives relating to the national and European business and research location. Both business and economic goals as well as goals related to applied and market-oriented research are covered. In detail, AAL should strengthen European competitiveness. Thus, transnational European collaborations should be fostered, and technology development should be market-centred in addition to user-centred. Furthermore, the effects of demographic changes on the economy should be minimized. In line with this, market growth and diffusion should be achieved. Thus, commercialization and scalability are central. Nevertheless, growth must be sustainable. Market growth especially targets the expansion of the service sector. In addition, market stimulation should lead to the exploitation and launch of new solutions and, especially, the development of neglected and new markets. For these purposes, it is necessary to develop financing and business models. The models have to take affordability and economic feasibility into account and explore new value chains and cost sharing between the public and the private sector. Modularity and service integration are named as promising options. Economic and scientific objectives also include the expectation that AAL technologies might contribute to increased innovation capacity

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and an innovative and productive society. AAL research and development should, therefore, also define innovation processes and work towards social as well as business innovations. The achievement of these objectives is strongly related to the scientific community. Therefore, the exchange between science and industry has to be promoted. Transdisciplinary work and strong networks between research institutions and companies are in demand, and applied research should focus on market-oriented product development. However, scientific progress must not be ignored either. Based on the state of research, a scientific and technical impact should also be achieved. To this end, young researchers must be trained and the qualification of researchers supported.

17.4.2

Indicators for Measuring the Effects of AAL Solutions

More than 500 potential indicators that could be used for the assessment of AAL solutions were identified. As described above, the indicators were categorized according to their relevance for the subjective, institutional, or social level. The subjective level includes indicators relevant for persons who are directly or indirectly using an AAL product or service (primary end-users). These persons should exemplarily be the beneficiaries of an increased quality of life caused by AAL solutions. Hence, quality of life, life satisfaction, or the perceived value of the AAL product or service are some relevant indicators to mention in this context. The institutional level includes the perspective of persons, organizations, companies, etc. being directly in contact with primary end-users, such as care organizations or companies developing or distributing AAL solutions (secondary end-users). This group should also benefit directly from AAL products or services, for instance, by increased sales and/or revenues. Hence, managerial indicators are of high relevance in this context. The perspective of institutions, private or public organizations that are not directly in contact

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with AAL products and services but that contribute somehow in organizing, paying, or enabling them (e.g., the public sector, service organizers, social security systems, or insurance companies; tertiary end-users), is represented by the social level. Their potential benefit from AAL technologies is increased efficiency and effectiveness with the consequence of reduced expenses. Consequently, the costs of the health care system or positive economic effects caused by the AAL solutions are in focus concerning relevant indicators on this level. While the indicators for the subjective and institutional level are primarily focusing on a micro perspective, the social level includes a macro perspective. Some indicators could be assigned to all three perspectives. For example, increased quality of life is not only of relevance on the subjective level but also for institutions and society. Hence, the level regarded as the most relevant one was chosen for the categorization. Most of the indicators/indicator categories focus on the subjective level, followed by the social level and the institutional level. Table 17.2 shows the main categories and their allocation to the relevant level as well as a few specific indicators. In total, the indicators for the evaluation of AAL products and services are categorized into five subjective, two institutional, and four social main categories. At the subjective level, the indicators focus on health-related quality of life, social well-being, acceptance, family environment as well as financial impacts for private households. The main category health-related quality of life contains possible indicators like the level of activity, measuring the change of the physical condition, whereas social well-being concentrates on the state of mind (e.g., life satisfaction). Product design, usability, and the perceived value of a solution are of special importance concerning the acceptance. AAL devices have an effect on the family environment to the extent that the burden of informal caregivers or the quantity of unpaid work might be reduced if they are implemented. Moreover, financial impacts for private households (acquisition costs, direct costs) are of special relevance, although it is not

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Table 17.2 Overview of indicators for the evaluation of AAL solutions Perspective Subjective level

Main categories Health-related quality of life Social well-being Acceptance Family environment Financial impacts for private households

Institutional level

Technical aspects Business aspects

Social level

Health care system Public households Ecological aspects Economic growth

Sample indicators Blood glucose level, activity level, falls, quality-adjusted life year (QUALY), mortality Social participation, autonomy, life satisfaction, voluntary work, security Product design, usability, privacy, perceived value, frequency of use Burden of informal caregiver, unpaid work, social participation, security, usage fees Acquisition costs, direct costs, operating and maintenance costs, costsharing, cost savings Patents, frequency of use, intellectual property rights (IPRs), error data, adherence to ethical guidelines Turnover, usage fees, market potential, return on investment, customer relations Hospital bed days, nursing home admissions, patient transports, length of hospital stays, ambulance admissions Health care expenditure, cost savings, nursing costs, cost-sharing, work days Energy efficiency in usage, share of recyclable materials Spin-offs, start-ups, market potential, intellectual property rights (IPRs)

Own illustration

entirely clear who is going to pay for AAL solutions. Because of the uncertainty in terms of systems financing, there is a large overlap of indicators between this main category and the category public households (see social level below). Technical aspects (e.g., frequency of use, patents) and business aspects (e.g., turnover, usage fees) are the main categories expected to be the most important on the institutional level. Finally, at the social level, the main categories health care system (e.g., hospital bed days, nursing home admissions), public households (e.g., health care expenditure), ecological aspects (e.g., energy efficiency of usage), and economic growth (e.g., spin-offs, start-ups) are relevant. In general, the indicator analysis has shown that the majority of the indicators focus on the subjective level, for example, health-related quality of life, social well-being as well as acceptance. Then follows the institutional level and there, in particular, the technical aspects, while the business aspects tend to play a minor role. The fewest indicators were observed on the social level.

17.5

Discussion

The analysis at hand shows that the objectives pursued with and the indicators to measure the effects of AAL solutions are manifold. On the one hand, this can be traced back to the fact that there are various stakeholders involved if AAL solutions are considered, as already pointed out in Sect. 17.2. Moreover, the fact that AAL includes quite different forms of technical solutions with the aim to contribute to a prolonged autonomous life of older adults (see Sect. 17.1) leads to different aims as well as indicators, depending on the specific solution and field of application. With our analysis, we are able to give an overview of the objectives pursued with AAL solutions. The objectives not only specify what is to be made measurable by means of indicators but also what AAL systems are supposed to achieve in general. Obviously, there are differences depending on which perspective is taken. In the literature, there are various stakeholder groups or perspectives systematized (see Sect. 17.2). Considering the identified objectives against the background of the literature on stakeholders and their interests (especially Bührlen and Kickbusch 2009 and Henke et al.

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2011), it is noticeable that although vitality and care as well as social objectives are at the core of the characterization of AAL technologies, they are not the main focus of interest of all stakeholders (e.g., private producers of equipment or technology). Other objectives (e.g., economic concerns) might be relevant for all stakeholders but with differing emphasizes (e.g., economic utility for insurance institutions vs. reputation for research institutions vs. financing of applications for users). In addition, technology and design objectives might be seen more as a means to an end for almost all stakeholders. Thus, the objectives are interwoven and mutually dependent. This circumstance increases the complexity if the effectiveness of AAL systems is to be demonstrated but also indicates that a systematic meta-perspective that considers all objectives is useful. Indicators are necessary instruments to quantitatively evaluate and compare the results of research projects. As our results show, there is a wide range of indicators suggested or used so far in the context of AAL that are suitable to check different objectives in different ways. While some indicators seem already much specified and comparably easy to measure (e.g., hospital bed days, patents), others are still quite vague and require more specification (e.g., health care expenditure, quality of life). Moreover, some indicators can be measured directly (e.g., acquisition costs), while other effects will only be visible in the long run (e.g., spin-offs). In addition, some of the indicators might reflect differing perspectives and objectives of the groups of stakeholders. While a reduction in hospital bed days might be aimed by the state as the financier, the objectives of the patients or service providers could differ substantially. The indicator analysis has shown that the majority of the indicators focus on the subjective level. This observation might be explained by the fact that many AAL products and services are still at a very early stage of development (invention; see Sect. 17.2), where the relationship between researchers and developers with users and their needs is of particular importance. For this reason,

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technical and quality-of-life factors are in focus. Business, social, and economic aspects might gain interest, as the commercial use of the solutions gets closer. Considering the various stakeholder perspectives, the identified objectives, and the large number of potential indicators, it seems still difficult to measure the effects of AAL solutions and, especially, to compare different AAL products or services. The high variation in the fields of application complicates the situation even more, as not all indicators are of relevance for all AAL solutions. The results suggest to further elaborate appropriate constructs to measure the effects of AAL solutions. In more detail, it seems of special interest to specify which indicators are of relevance and feasible depending on the field of application of the AAL solution. In this context a unified definition of terms as well as an instruction on how to measure the indicators should be given. Moreover, it can be thought of the development of appropriate measurement tools with a special focus on the target group of AAL solutions, being older adults. The interest in AAL solutions is high—in particular, due to the increasing (financial) pressure induced by the aging of the population (see Sect. 17.1). However, the use and corresponding effects of AAL solutions in practice seem insufficiently verified, except for pilot projects. Such a set of defined indicators could lead to a proper measurement of the effects of AAL solutions, in the sense of a holistic approach, and guarantee the comparability of results.

17.6

Conclusions

The paper at hand pursued the aim to give an overview of existing practices to measure the effects of innovations in the field of active and assisted living solutions. Especially due to the aging of the population and its advanced development in Europe, AAL solutions are gaining importance, with the expectation of supporting a prolonged autonomous life of older adults and reducing costs for the social security system.

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Nevertheless, there are challenges when it comes to the question of how to measure the overall effects of the implementation of AAL solutions in practice. Technological progress within the social security sector is seen controversially, as it is, besides all positive effects, also a main cost-driving factor for public expenditure. Moreover, the social security sector in Germany and Austria is traditionally an insurance market. The consequence are various stakeholder groups that pursue different and partly conflicting interests regarding innovations. In this connection, service providers, insurance institutions, insured persons, public research and development institutions, public authorities, and industrial organizations are the main actors. The different perspectives lead to a high number of objectives and indicators for AAL solutions. The overview of the objectives and intended impacts of AAL solutions based on an analysis of research programs and projects led to the identification of 22 objectives, which were assigned to four main objective groups: vitality and care objectives, social objectives, design and technology objectives, and economic and scientific objectives. The majority of identified aims fall into the category of economic and scientific objectives, followed by vitality and care objectives, social objectives and design and technology objectives. Regarding the measurement of the effects of AAL solutions, there exists a large number of indicators. Based on the perspective of the indicator (subjective, institutional, or social level), they have been categorized into eleven main categories. On the subjective level, these include the categories health-related quality of life, social well-being, acceptance, family environment, and financial impacts for private households. On the institutional level, the indicators focus on technical and business aspects, while the main categories on the social level are the health care system, public households, ecological aspects, and economic growth. The analysis shows a great variation in the indicators concerning their level of detail, specification, and time horizon. Thus, there are still many open questions regarding the measurement

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of the effects of AAL solutions: Which indicators should be taken into account? How does the choice of indicators depend on the field of application of the AAL solution to be evaluated? What should be measured in detail? How do we proceed with indicators that concentrate on long-term effects? Finally, how can we guarantee the comparability of the results of different evaluations? Future research should address these questions to enable sound evaluations of AAL systems including all relevant perspectives. Acknowledgments The research presented in this paper was conducted as part of the project EvAALuation funded by the Federal Ministry of Transport, Innovation and Technology (BMVIT) as part of the programme “benefit” carried out by the Austrian Research Promotion Agency (FFG).

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Quality of Later Life in Europe

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An Econometric Analysis Noelia Somarriba Arechavala, Pilar Zarzosa Espina, and Patricia Gómez-Costilla

18.1

Introduction

Europe faces a number of major challenges, with one of the most important being aging and, therefore, the quality of life of its elders. The declining birth rate coupled with the increase in life expectancy is transforming the structure of the European population. According to Eurostat data from 2017, the proportion of elderly people was 19.4% of the total population, with the presence of this particular population group having risen by 2.4 percentage points compared to ten years earlier in the European Union. In addition, there is progressive aging of the elderly themselves, with the percentage of people aged 80 and over within the European Union expected to rise from 5.5% in 2017 to 12.7% in 2080, according to data from Eurostat’s population projections. This trend towards aging will also drastically affect the dependency rate of older people, which is forecast to increase from 29.9% to 52.3% (EUROSTAT n.d.). In this scenario of aging, the cultural, environmental and socioeconomic diversity of countries N. Somarriba Arechavala (*) · P. Zarzosa Espina Applied Economics Department, Valladolid University, Valladolid, Spain e-mail: [email protected]; [email protected] P. Gómez-Costilla Economic Analysis Department, Valladolid University, Valladolid, Spain e-mail: [email protected]

makes it difficult to analyse what impact their different policies have on the quality of life of their citizens and, above all, on the elderly. This population group suffers major inequalities in Europe as a whole. For example, gender gaps in life expectancy at birth in 2016 favoured women by over eight years in some countries, especially in certain Baltic and Eastern European countries (Lithuania, Latvia, Estonia, and Poland) (Eurostat 2017). There is no doubt that the country we live in is one of the determining factors when it comes to aging. The climate, culture, economy, as well as social policies affect how we age and our quality of life. Some authors have suggested that levels of quality of life (QoL) depend not only on individual factors, but also on the welfare provision of the country in which the person lives (MotelKlingebiel and Gordo Romeu 2009). In addition to the importance of socioeconomic inequalities, eastern European and Mediterranean countries are characterized in this respect by more limited social welfare and by greater socioeconomic inequalities, and consequently a lower QoL than is the case in countries in northern and central Europe (Knesebeck et al. 2005). In this scenario, it may be interesting to compare whether there are spatial patterns in elderly people’s quality of life levels. Such information would provide key insights into the way in which state activity, through different policies and strategies, triggers different quality of life outcomes.

# Springer Nature Switzerland AG 2021 F. Rojo-Pérez, G. Fernández-Mayoralas (eds.), Handbook of Active Ageing and Quality of Life, International Handbooks of Quality-of-Life, https://doi.org/10.1007/978-3-030-58031-5_18

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The aim of this chapter is to explore the determinants of the quality of life of people aged 60 and over in 26 European countries from a double perspective: individual and spatial. We draw on the latest data available from the Survey on Health, Ageing and Retirement in Europe (SHARE) (7th wave). To achieve our purpose, a synthetic indicator of quality of life is first estimated, as an alternative to the CASP12 scale that provides said survey. Economic models are then estimated to explore which factors prove most decisive when explaining quality of life in older European adults. Estimating econometric models as a tool for measuring the quality of life and well-being has been used in different works to determine which factors prove key to individuals and societies’ quality of life. In this sense, different specifications have been used depending on which variable is considered as dependent and on the measurement context. A series of extremely interesting works have recently been published estimating different econometric models using the CASP12 scale provided as a dependent variable in the SHARE survey, for different populations, depending on age, different countries, and using a range of methods. For example, Conde-Sala et al. (2017) analyse the clinical, sociodemographic and socioeconomic factors that influence perceived quality of life in a sample of people aged 65+ and examine the relation with social welfare models in Europe. These authors find that perceived quality of life scores are consistent with participants’ sociodemographic and clinical characteristics as well as with the socioeconomic indicators and social welfare models of the countries in which they live. Other authors, such as Cantarero-Prieto et al. (2018) estimate the effect of aging on quality of life of elderly people, analysing the effects of different factors on the quality of life among the elderly for southern European countries. Their findings show that the determinants which are correlated with quality of life include predisposing, health, geographic area, and social isolation factors. Ateca-Amestoy and Ugidos (2013) use the data for Spain to model the determinants of the quality of life for the elderly,

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focusing particular attention on their intergenerational relations. Hamren et al. (2015) evaluate the measurement and predictors of QoL amongst older Ethiopians. The relationships between social support, religiosity/spirituality and sociodemographic factors on QoL were tested using linear regression analyses. Other studies which used SHARE in their investigation include Wahrendorf et al. (2006), who determine the positive effects of social productivity on the wellbeing of the elderly. These findings underline the need to improve the quality of social activities as a means of encouraging older people to participate in social life. Knesebeck et al. (2007) examine the association between the quality of life of elderly European people and an array of socioeconomic status indicators for different European countries. Their aim is to determine whether the relative importance of socioeconomic status changes with age. These papers are only a small sample of the many existing works. The present work is structured as follows. Firstly, the DP2 distance measure is applied to obtain a modified version of the CASP12 in accordance with its four components: Control, Autonomy, Self-realization, and Pleasure, and which we call the CASPm. A brief study of the main results to emerge from this new synthetic indicator (CASP12m) in comparison with CASP12 is then provided from a spatial perspective. Different models are then estimated by ordinary least squares and multilevel regressions in order to assess the effects of spatial, socioeconomic and health factors on quality of life among the elderly in Europe. The results may alert us to differences and may point to where public policies aimed at improving citizens’ lives need to focus on.

18.2 18.2.1

Sample, Measurements and Methods Sample

The sample is made up of participants who responded to the latest cross-section of the 7th

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wave of the Survey of Health, Ageing and Retirement in Europe (SHARE), the questionnaire for which was fielded in 2017. The total sample in our study compromised 55,319 adults aged 60+ with complete CASP12 data from 26 European countries, not including Israel.

18.2.2

Measurement Instruments

18.2.2.1 CASP12 and Quality of Life The CASP12 self-report QoL instrument comprises twelve items. Each item is scored on a 4-point Likert type scale, with descriptive anchors provided for each response option: 1 ¼ Often, 2 ¼ Sometimes, 3 ¼ Not often, and 4 ¼ Never. Higher CASP12 total scores are interpreted as better QoL, with a possible range of 12–48. Six items are reverse scored. In our case, we propose a modification of this measurement based on its four components (Control, Autonomy, Self-Realization, and Pleasure) such that each component has a range of 4–12, in line with two-factor models. The first letter of the name of each of the four components gave rise to our scale; CASP. Table 18.9 of the Annex shows the description of the variables (Mehrbrodt et al. 2019). The scale originally consisted of 19 items (same components) (Knesebeck et al. 2005) although Wiggins et al. (2008) proposed a shortened version, comprising 12 items (CASP12). For these authors, the CASP index has a solid theoretical basis and respects the property that any measure of quality of life must be clearly different from the factors that determine the quality of life itself. In any case, several studies have examined the validity of the scale from a psychosocial perspective, globally, or for different countries. Confirmatory Factor Analysis (CFA) was used in most of the works to test the properties of the

scale, as for example in the case of CASP12 works such as Borrat-Besson et al. (2015) and Pérez-Rojo et al. (2018), amongst others. A wide variety of works have also been used and evaluated by CASP19 (Bowling 2010; Bowling and Stenner 2011; Kim et al. 2015; Lima et al. 2014; Wu et al. 2013). As pointed out by Borrat-Besson et al. (2015), one of the problems evident in this scale is the assumption of the across-cultural invariant. It is one of the limitations we are faced with in this work and, indeed, in others which aim to explore concepts such as quality of life from an international perspective using a wide-ranging group of countries which display major cultural and economic difference. As Hyde et al. quite rightly point out (2015, p. 573): “However, even though the scale has proven itself to be a valid and reliable measure it is not without its limitations”. For the case of our sample, the following Table 18.1 shows the average values for the different components and the CASP12 scale itself: The component adopting the highest average value is Pleasure, with the average for the rest of the components being quite similar.

18.2.2.2 Other Variables The variables and instruments used for the present study in the second part of the chapter are the following (Table 18.2). The data include variables related to individual characteristics such as age and gender, variables related to health (self-assessed health status, limitations regarding daily activities), economic variables (household income, difficulty making ends meet), social variables (education, recreational and social activities), and labour status. We also incorporated variables related to the location where individuals lived (rural and cluster country).

Table 18.1 CASP12 average values and its components Mean Std. deviation

Control 8.32 2.40

Source: own elaboration. SHARE

Autonomy 8.97 1.96

Self-realization 8.92 2.33

Pleasure 10.29 1.86

CASP12 36.5 6.97

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Table 18.2 List of variables and description Variable Individual characteristics Age Female Partnership

Description

Age of respondent (years) Gender of respondent: 1 female; 0 male Marital status (Married or with a registered partner 1, not married or without a registered partner 0) Secondary education Highest level of studies you have completed: secondary (1) Tertiary education Highest level of studies you have completed: tertiary (1) Health Self-assessed health (1: excellent, very good or good, 0: otherwise) Limitations ADL Respondent has some limitation regarding activities of daily living Socioeconomic characteristics Unemployed Respondent is unemployed (yes 1, 0 no) Homemaker Respondent is looking after the home or family (yes 1, 0 no) Disabled Respondent is permanently sick or disabled (yes 1, 0 no) Household income Respondent’s household income (tens of thousands) Difficulties making ends Respondent has difficulty making ends meet (yes 1, 0 no) meet Recreational and social Respondent has done voluntary work or word/number games, played cards, attended an educational or training course, gone to a sports/social club, taken part in a political or activities community-related organization or has read books, magazines or newspapers Spatial characteristics Rural Respondent lives in a rural area or village (yes 1, 0 no) Nordic Respondent lives in Sweden, Finland or Denmark (yes 1, 0 no) Continental Respondent lives in Austria, Germany, France, Switzerland, Belgium or Luxembourg (yes 1, 0 no) Mediterranean Respondent lives in Spain, Greece, Italy, Portugal, Malta or Cyprus (yes 1, 0 no) Eastern Respondent lives in the Czech Republic, Poland, Hungary, Slovenia, Croatia or Slovakia (yes 1, 0 no) Baltic Respondent lives in Estonia, Lithuania or Latvia (yes 1, 0 no) Source: own elaboration

Countries are grouped according to the regional cluster defined in Eurofound (2014), which develops a country typology to analyse quality of life in Europe, as can be seen in Table 18.3. In our analysis, we have no data in the sample for the cluster of countries known as the Western Islands (Ireland, United Kingdom). As a result, it is not listed in the above table. Another way to group countries is to use the approach employed in Eurofound (2013a, b). In this work, the authors use the typology of welfare regimes proposed by Whelan and Maître (2010). This typology divides countries into seven groups according to the type of welfare state in each. This classification completes the original typology of Esping-Andersen (1990) and adds a residual group that includes the poorest member states:

Bulgaria and Romania. The two classifications are closely related. In our country classification, we considered the following country groups: • Nordic countries (social democratic regime) are characterized by their emphasis on universality. This category includes: Denmark, Finland, and Sweden. • The continental group places less emphasis on redistribution. This group includes Germany, Austria, Belgium, France, Switzerland, and Luxembourg. • Mediterranean countries consider states distinguished by the key role played by family support systems. Labour market policies are underdeveloped and selective. This group

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Table 18.3 Country classification Nordic Sweden Finland Denmark

Continental Austria Germany France Switzerland Belgium Luxembourg

Mediterranean Spain Greece Italy Portugal Malta Cyprus

Eastern Czech Rep. Poland Hungary Slovenia, Croatia Slovakia

Baltic Estonia Lithuania Latvia

Balkan Bulgaria Romania

Source: Eurofound (2014)

contains Cyprus, Spain, Greece, Italy, Malta, and Portugal. • In the Eastern group, there are societies where spending on social protection is low. This group is made up of the Czech Republic, Slovakia, Slovenia, Hungary, Poland, and Croatia. • The Baltic group comprises the Baltic states (Estonia, Latvia, and Lithuania), which are characterized by a more flexible labour market. • Balkan countries have much higher levels of material deprivation than the other countries. This group is made up of Bulgaria and Romania.

organization, playing cards or games such as chess. 12.8% of respondents live in a household which has great difficulty making ends meet, with the annual average household income being 22,424.91 Euros (€). As regards spatial characteristics, 41% of the sample live in rural areas. By country groups, those that have more weight within the sample are continental, Mediterranean and eastern European, with 25.9%, 21.4% and 24.8%, respectively. Nordic and Baltic countries represent 11.6% and 11.1% of the sample, respectively. Finally, Balkan countries represent 5.2% of the sample.

The principal statistics of the explanatory variables are described in Table 18.4. Our sample has an average age of 71.53 years, and 56% are women. As regards marital status, 68% of our database are married or have a registered partner. Most respondents (57.5%) have studied secondary education, and 20.5% of them have completed a higher education degree. More than half (55.7%) self-report excellent, very good or good health, and 12.1% report a difficulty doing at least one of six daily living activities (ADL). As regards current employment status, 11.4% of respondents aged over 60 years are working, while the rest are outside the job market: retirees (76.7%), homemakers (7.1%), disabled (2.1%), and unemployed (1.2%). Although most of the sample does not form the economically active population, they do engage in many activities. Over three quarters of the sample perform social activities, such as doing voluntary or charity work, attending an educational or training course, taking part in a political or community-related

18.2.3

Methods

We first propose a modification of the CASP12 by means of the DP2 methodology. We then use two distinct estimation models: an ordinary least square model and a multilevel model to study the principal determinants of the quality of life for the elderly population. We now comment briefly on the DP2 method and the principal results of the CASP12m. To estimate the reformulation of the CASP12, CASP12m, we used the P2 distance method. This method has been used in numerous works when devising synthetic indicators of quality of life at the regional and country level (García et al. 2010; Ray 2014; Rodriguez Martin and Salinas Fernandez 2012; Somarriba et al. 2015; Somarriba and Pena 2008; Somarriba and Zarzosa 2016, Zarzosa and Somarriba 2013) and more recently at the individual level (PinillosFranco and Somarriba 2018a; Somarriba and Zarzosa 2018) This technique is suitable for the

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Table 18.4 Descriptive statistics Variable Individual characteristics Age Female Partnership No education or primary education Secondary education Tertiary education Good health Limitations ADL Socio-economic characteristics Employed Retired Unemployed Homemaker Disabled Household incomea Difficulties making ends meet Recreational and social activities Spatial characteristics Rural Nordic Continental Mediterranean Eastern Baltic Balkan

Mean;%

SD

71.53 56 68.4 22 57.5 20.5 55.7 12.1

8.010 0.496 0.465 0.414 0.494 0.404 0.497 0.326

11.4 76.7 1.2 7.1 2.1 2.2425 12.8 78.7

0.317 0.423 0.111 0.258 0.143 2.5726 0.335 0.419

41 11.6 25.9 21.4 24.8 11.1 5.2

0.492 0.320 0.438 0.410 0.432 0.315 0.222

Source: own elaboration a [Median ¼ 1.4945 IQR ¼ 2.0508]

aim of this paper as it allows inter-spatial comparisons to be made and different information to be included regardless of its heterogeneity. We also calculated the discriminant coefficient (DC) of each partial indicator to test its degree of dispersion among the individuals. Readers interested in the methodology can consult the method used in detail in the book chapter of this same collection prepared by Somarriba and Zarzosa (2016). When the CASP12 scale is modified using this method, the main aim is to study the strength of an alternative measurement, with the hierarchy reflecting the relative importance of its four components [Control, Autonomy, Selfrealization, and Pleasure]. SHARE proposes that those four domains should be treated equally (without hierarchies). We test whether this assumption is valid by designing our indicator.

It was initially suspected that the structure of four equally weighted components for obtaining the CASP might entail limitations. As a result, in order to test this hypothesis, the four-component scale was modified by designing a synthetic indicator that admits different weights for the components and removes redundant information. We then comment on the main results of the indicator and later on those of the econometric models.

18.3 18.3.1

Results CASP12. An Alternative Design

The statistical technique used in the present research allows us to explore the impact which each component (Control, Autonomy, Self-

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Table 18.5 Structure of CASP12m Component Self-realization Control Pleasure Autonomy

|r| 0.863 0.759 0.735 0.704

DC 0.231 0.328 0.191 0.247

(1 – R2) 1 0.715 0.616 0.753

Source: own elaboration

realization, and Pleasure) has on determining the quality of life of the elderly. This section analyses the relative importance of each component, as well as each simple indicator, in constructing the synthetic indicator [CASP12m] and in the results obtained, applying three statistical criteria: absolute linear correlation |r| with the resulting synthetic indicator, the correction factor (1 – R2) and the discrimination coefficient (DC). We now interpret the results corresponding to the three previously mentioned measures, for the CASP12m synthetic indicator (Table 18.5): The components of the CASPm are listed in the order they are ranked according to their degree of absolute correlation with the resulting synthetic indicator. In other words, the first simple indicator evidences the highest linear correlation, in absolute value terms, with the final indicator, with the last simple indicator evidencing the lowest absolute correlation. All of the components present high correlation coefficient values. The correction factors shown in Table 18.5 evidence a good selection of dimensions. The correction factor, (1- R2i.i – 1,. . ., 1), indicates the amount of fresh information attributable to each simple indicator. Self-realization is the first indicator that accesses the indicator synthetic, incorporating 100% of its information. Control is the second partial indicator, and adds 71.5% of its information, since the remaining 28.5% is redundant with regard to the information already contained in the preceding indicator. Pleasure is third and incorporates 61% of its information. Autonomy is in last position, adding 75% of its information. In addition, the non-redundant information provided by each dimension is considerably high. Likewise, all the components display a low capacity to discriminate. The discrimination coefficient (DC) ranges between 0 and 2 (Zarzosa

(1994), p. 180). If a variable takes the same value for all individuals, DC equals zero, indicating that this variable holds zero discriminant power. By contrast, if a variable only has a value other than zero for one individual, DC is equal to two and the variable has full discriminant power. The value of DC also depends on the number of individuals such that, ceteris paribus, as this increases, the discriminant power of a variable diminishes. As a result, given that the present research is working with a very high number of observations, it is only natural that all the components should have low DC values. Nevertheless, results indicate that the component which most discriminates between the elderly is the one related to control, and the one which discriminates least is the component of pleasure. The structure of the indicator supports the consistency of the CASP12 scale, in the sense that its composition must admit equal weights. Nevertheless, the study has been carried out for a European group as a whole, we also considered the spatial factor (countries, groups of countries) in the two econometric techniques applied, in the following section. However, although there are no significant differences in the distribution between CASP12 and CASP12m, while CASP12 assumes absolute homogeneity among individuals whose scores on the scale lead to the same overall value, the CASP12m differentiates between the different situations with respect to the components, leading to the same overall situation. As a result of being different, the CASP12m is retained in the analysis. In this sense, while the CASP12 variable adopts a total of 36 different values, the CASP12m adopts 5083 different ones. This idea can be seen in the following scatter plot (Fig. 18.1):

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Fig. 18.1 CASP12 and CASP12m scatter plot. (Source: own elaboration)

In other studies, in which the DP2 has been used to design synthetic indicators, greater sensitivity of the indicator has been obtained when measuring the differences between population subgroups (Pinillos-Franco and Somarriba 2018a, b). The CASPm scale offers greater advantages from the standpoint of the properties which ensure its estimation process, since whilst CASP12 assumes absolute homogeneity amongst individuals in the scores, CASP12m lets us distinguish individuals’ situations in greater detail by allowing the components to have different weights. It also removes duplicity of information in dimensions. This is a key advantage when carrying out the study at an individual level. The results to emerge from our study hold firm over the two different scenarios which involve linking the same weighting to the components (the case of CASP12) and linking a different weighting (the case of CASP12m). As a result, the conclusions from the analysis about the distribution of the CASP12m in European countries and individuals are robust, which is of interest due to the enormous importance that the system of weighting tends to have in this kind of research. For theses reasons, the results of the

two measures (CASP12 and CASP12m), will be presented in a comparative form.

18.3.2

Distribution of the CASP12m in European Countries and Individuals

Figure 18.2 illustrates the overall behaviour of the CASP12 and CASPm for individuals in the study. The graphs show the distributions of the indicators through a frequency histogram reflecting the values of the quality of life on the x axis, grouped into intervals of equal size. Table 18.6 shows the main descriptive statistics of certain features of the distributions. As can be seen in the histograms, the degrees of kurtosis are similar to that of a normal distribution (with the same mean and variance), although the distributions display asymmetry to the left due to the noticeable presence of unusually low quality of life levels. As a result, the Jarque and Bera test (1987) rejects the null hypothesis of normality of perturbations in both distributions for any level of significance. However, the statistical inference is asymptotically justified, such that in the present research the contrasts of usual

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5,000

Series: CASP_M Sample 155319 Observations 55319

4,000 3,000 2,000 1,000 0 0

2

4

6

8

10

Mean Median Maximum Minimum Std. Dev. Skewness Kurtosis

8.833626 9.038290 12.98160 0.000000 2.390419 -0.434376 2.661215

Jarque-Bera Probability

2004.173 0.000000

12

3,200

Series: CASP Sample 155319 Observations 55319

2,800 2,400 2,000 1,600 1,200 800 400 0

Mean Median Maximum Minimum Std. Dev. Skewness Kurtosis

36.49789 37.00000 48.00000 12.00000 6.597358 -0.435889 2.672574

Jarque-Bera Probability

1998.869 0.000000

12 14 16 18 20 22 24 26 28 30 32 34 36 38 40 42 44 46 48

Fig. 18.2 CASP12 and CASP12m histograms. (Source: own elaboration. SHARE)

Table 18.6 Results by country clusters. Averages and standard deviation Nordic Continental Mediterranean Eastern Baltic Balkan Source: own elaboration

Mean Std. Dev. Mean Std. Dev. Mean Std. Dev. Mean Std. Dev. Mean Std. Dev. Mean Std. Dev.

CASP12 39.55 5.18 39.07 5.71 34.52 6.63 36.14 6.39 34.02 6.64 32.02 6.44

CASP12m 9.97 1.88 9.78 2.06 8.11 2.39 8.69 2.31 7.92 2.4 7.24 2.34

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Figs. 18.3 and 18.4 Maps of quality of life. (Source: own elaboration)

hypotheses will be performed to evaluate and interpret econometric models. The CASP12m ranges from 0 to 13, with half of the European population emerging above 9. There is significant dispersion in the quality of life synthetic indicator values around the mean in relative terms (the variation coefficient is 27%). This reveals that, according to the results of this research, there is a significant degree of disparity between elderly Europeans with regard to quality of life. Figure 18.1 also illustrates the histogram of the original CASP12 from the survey, and evidences a similar distribution with regard to the kurtosis and asymmetry, although the variable ranges from 12 to 48. The following maps (Figs. 18.3 and 18.4) reflect the spatial distribution of the mean values by countries for the CASP12m and the CASP12 scales. A higher intensity colour reflects a better quality of life for the population in the study. Countries that do not participate in the study are shown in white.

northern and central European countries. Enlarging the sample in this seventh wave of the survey with more countries allows us to investigate the situation of the Baltic countries and the Balkan area, whose countries achieve the worst positions in relation to the average levels of QOL: These spatial patterns can be observed more clearly in Table 18.6 in which the averages for the previously defined country clusters have been calculated. The group of countries that make up the Balkan cluster with the Baltic countries obtain the worst results in both scales. In the middle is the cluster of eastern countries together with Mediterranean countries, with the eastern countries obtaining better results than those in the Mediterranean basin. Nordic and continental countries evidence higher values, with their means being almost identical. Detailed results by country can be seen in the Annex Table (Table 18.10).

The distribution of the two indicators shows similar results. In any case, as established by Knesebeck et al. (2005), it can be seen that there are several geographical patterns such as the North-Central versus South-East gradient. There are significant differences between the low levels evident in Mediterranean and eastern countries and the higher levels recorded for

18.3.3

Econometric Analysis of the Determinants of Quality of Life of the Elderly in Europe

This section examines the determinants of older Europeans’ quality of life using econometric techniques. Initially, we considered a wider set of factors which might determine quality of life,

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before subsequently applying a filter that finally left the variables shown in Table 18.2. We selected these variables taking into account sociological theory, the recommendations of the Eurostat report (2017) as well as statistical criteria such as data availability, homogeneity of data for making comparisons between countries, reliability and comprehensiveness of the information contained in said data together with conclusions drawn from the econometric models. Simultaneously applying all of these criteria has meant that in the part related to the econometric models it was not possible to use all of the observations employed in the previous part. This is because in order to perform the estimations, the same (individual) observations must be available for all the observable variables in the model, including all the explanatory variables which appear in this second part of the research. The chosen dimensions may be classified into three groups: those measuring personal features, such as gender and age; other socioeconomic and health characteristics, such as mean income and educational attainment; and spatial characteristics linked to the type of environment, whether rural or urban, and to the welfare regime where the individual lives. This choice aims to complement certain features which might determine quality of life at an individual level, with other features relating to the social, political and economic environment of the countries of residence, thereby creating a tandem between the individual and the spatial perspective. To measure the quality of life of the elderly, in this research we estimate several econometric models. The main results of the analysis will be shown later. First, as a dependent variable of the models, we use the synthetic indicator of the quality of life for elderly European people constructed in this research, namely the modified CASP12, or CASPm as we call it. Secondly, we compare the results with those obtained using the dependent variable CASP12. As explained above, the modified CASP12 indicator admits heterogeneity among individuals which the CASP12 indicator treats as homogeneous, since it weighs all of the components exactly. Indeed, this is where the

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interest in working with both dependent variables lies. We apply two different estimation methods for the models: ordinary least squares (OLS) that is robust to heteroscedasticity, and mixed-effects multilevel regression. The equations in Tables 18.7 and 18.8 show the econometric models finally selected, specification of which was obtained after applying the appropriate econometric procedures, carrying out the necessary tests. The quality of life of elderly Europeans was seen to display a different variability when compared to the mean quality of life. However, there are no signs of autocorrelation, even though countries in the same region of the world were observed. As a result, the OLS model was estimated robustly with regard to heteroscedasticity, following the method proposed by White (1980). The multilevel model takes into account, in the procedure itself, the existence of two levels in the sample: individuals (level 1) nested within 26 countries (level 2). We fit a multilevel with random intercept and constant slope across countries. In order to finally estimate these models, every effort was made to address the problem of multicollinearity present in other previous models analysed and to correctly select the relevant explanatory variables. In this sense, several decisions were taken vis-à-vis the variables. For example, age squared was excluded for two reasons: firstly, this research focuses on the final years of life. Secondly, it was found that the linear form is correct while a quadratic form led to problems of individual non-significance due to multicollinearity. Moreover, employment status in the first step was classified into four groups, although we observed that there are only significant differences between the unemployed, the homemaker, and the disabled, as well as individuals who receive income from work or retirement, this last category constitute the group of reference. In order to complete the economic analysis, we include household income and whether the respondent has had difficulty making ends meet. Additionally, one of the variables measuring the individual’s limitations was selected, namely those related to daily living

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Table 18.7 Parameter estimates: QoL and factors. OLS regression estimates Dependent variable Independent variables Individual characteristics Age Female Partnership Secondary Education Tertiary Education Health Limitations_ADL Socio-economic characteristics Unemployed Homemaker Disabled Household_income Difficulties_ends_meet Recreational and social activities Rural Spatial characteristics Nordic Continental Mediterranean Eastern Baltic Intercept R-squared Adjusted R-squared F-statistic

CASP12m Coef.

p value

CASP12 Coef.

p value

–0.025 –0.192 0.161 0.187 0.394 1.310 –1.073