Women, Ageing and Health : a Framework for Action : Focus on Gender

Women, Ageing and Health: A Framework for Action

Focus on Gender Women, Ageing and Health: A Framework for Action

Women, Ageing and Health: A Framework for Action

Focus on Gender

PAGE 57 WHO Library Cataloguing-in-Publication Data

Women, ageing and health : a framework for action : focus on gender.

1.Ageing. 2.Women's health. 3.Longevity. 4.Women. 5.Gender identity. I.World Health Organiza- tion. II.United Nations Population Fund.

ISBN 978 92 4 156352 9 (NLM classification: WA 309)

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PAGE 2 Women, Ageing and Health: A Framework for Action

Contents

1. Introduction 1 About this report 1 Key concepts and terms in this report 2 A global profile of ageing women 3 The knowledge gap 3 2. A framework for action 4 A life-course approach 4 Determinants-of-health approach 6 Three pillars for action 7 A gender- and age-responsive lens 7 3. The health status of older women 11 Key points 11 Implications for policy, practice and research 15 4. Health and social services 18 Key points 18 Implications for policy, practice and research 20 5. Personal determinants 23 Biology and genetics 23 Key points 23 Implications for policy, practice and research 24 Psychological and spiritual factors 26 6. Behavioural determinants 27 Key points 27 Implications for policy, practice and research 30 7. Economic determinants 32 Key Points 32 Implications for policy, practice and research 34 8. Social determinants 36 Key points 36 Implications for policy, practice and research 37 9. The physical environment 40 Key points 40 Implications for policy, practice and research 42 10. Moving ahead 44 Taking action 44 Active ageing pillar 1: health and health care 46 Active ageing pillar 2: participation 47 Active ageing pillar 3: security 47 Building a research agenda 47 References 50

PAGE i Acknowledgements

This report summarizes the evidence about women, ageing and health from a gender perspective and provides a framework for developing action plans to improve the health and well-being of ageing women.

This publication was developed by the Department of Ageing and Life Course (ALC) under the direction of Dr Alexandre Kalache and Irene Hoskins. ALC received support from Francois Farah and Ann Pawliczko from the Population and Development Branch of the United Nations Population Fund (UNFPA) and collaboration from Dr 'Peju Olukoya from the Department of Gender, Women and Health (GWH) of the World Health Organization (WHO).

The input and contribution of the following experts – who represented all WHO regions and provided background material – are gratefully acknowledged: Dr Isabella Aboderin (Nigeria), Prof. Nana Araba Apt (Ghana), Dr Narimah Awin (Malaysia), Dr Denise Eldemire-Shearer (Jamaica), Dr Randah R. Hamadeh (Bahrain) Dr Anita Liberalesso Neri (Brazil), Dr Indira Jai Prakash (India), Dr Mary Ann Tsao (Singapore), Dr Barbro Westerholm (Sweden) and Mahmoud Fathalla (Egypt). In addition, contribution from colleagues from international non-gov- ernmental organizations was gratefully received: Dr Jane Barratt (IFA), Dr Gloria Gutman (IAGG), Mark Gorman (HelpAge International)

The report was prepared based on a literature review available at: http://www. who.int/en/ageing/en compiled by Peggy Edwards, a health promotion consultant from Ottawa, Canada who, under the direction of the ALC Department, produced a draft of the report.

Taking action for older women and men

As they age, women and men share the basic needs and concerns related to the enjoyment of human rights such as shelter, food, access to health services, dignity, independence and freedom from abuse. The evidence shows however, that when judged in terms of the likelihood of being poor, vulnerable and lacking in access to affordable health care, older women merit special attention. While this publication focuses on the vulnerabilities and strengths of women at older ages, it is often difficult and sometimes undesirable to formulate recommendations that apply exclusively to women. Clearly many of the suggestions for action in this report apply to older men as well.

PAGE ii Women, Ageing and Health: A Framework for Action

1. Introduction

This report endeavors to provide informa- “Gender is a ‘lens’ through which to consider the appropriateness of various policy options tion on ageing women in both developing and how they will affect the well-being of and developed countries; however, data are both women and men.” often scant in many areas of the developing … Active Ageing: A Policy Framework1 world. Some implications and directions for World Health Organization, 2002 policy and practice based on the evidence and known best practices are included in This framework for action addresses the this report. These are intended to stimulate health status and factors that influence discussion and lead to specific recommenda- women’s health at midlife and older ages tions and action plans. The report provides with a focus on gender. It provides guid- an overall framework for taking action that ance on how policy-makers, practitioners, is useful in all settings (Chapter 2). Specific nongovernmental organizations and civil responses in policy, practice and research society can improve the health and well- is undoubtedly best left to policy-makers, being of ageing women by simultaneously experts and older people in individual coun- applying both a gender and an ageing lens tries and regions, since they best understand in their policies, programmes and prac- the political, economic and social context tices, as well as in research. A full review within which decisions must be made. of the evidence is available in a longer This publication and the complementary complementary document entitled Women, longer Review are designed to contribute Ageing and Health: A Review. Focus on to the global review of progress since the Gender. It will be available online shortly Fourth World Conference on Women at http://www.who.int/ageing/publications/ (Beijing, 1995),2 the Madrid International gender/en/index.html Plan of Action on Ageing (2002),3 and About this report the implementation of the Millennium Development Goals.4 While some progress The concepts and principles in this docu- has been made as a result of these United ment build on WHO’s active ageing policy Nations initiatives and new policy direc- framework, which calls on policy-makers, tions have been adopted at the country practitioners, nongovernmental organiza- level, the rights and contributions of older tions and civil society to optimize opportu- women remain largely invisible in most nities for health, participation and security in order to enhance quality of life for people as they age.1 This requires a comprehensive approach that takes into account the gendered nature of the life course.

PAGE 1 settings. This lack of visibility is especially are a normal part of the ageing process. At problematic for ageing women who face the same time, socioeconomic factors such multiple sources of disadvantage, including as living arrangements, income and access those who are poor, divorced or widowed; to health care greatly affect how individuals immigrants and refugees; and members of and populations experience ageing. ethnic minorities. Ageing may also constitute a continuum Key concepts and terms in this of independence, dependence and inter- report dependence that ranges from older women who are essentially independent and coping Sex and gender. Sex refers to biology where- well with daily life, to those who require as gender refers to the social and economic some assistance in their day-to-day lives, roles, responsibilities and opportunities to those who are dependent on others for that society and families assign to women support and care. These groups are hetero- and men. Both sex and gender influence geneous, reflecting diverse values, health health risks, health-seeking behaviour, and status, educational levels and socioeco- health outcomes for men and women, thus nomic status. influencing their access to health care systems and the response of those systems.5 The health of older men Older women refers to women age 50 and This report does not address men’s health older. Ageing women refers to the same issues. It recognizes, however, that ageing chronological group but emphasizes that men like ageing women have health ageing is a process that occurs at very – – concerns based on gender. For example, different rates among various individuals the gender-related concept of “masculin- and groups. Privileged women may remain ity” can exacerbate men’s risk-taking and free of the health concerns that often ac- health problems as well as limit men’s company ageing until well into their 70s access to health care. The report also and 80s. Others who endure a lifetime of acknowledges that men of all ages can poverty, malnutrition and heavy labour play a critical role in supporting the health may be chronologically young but function- of women throughout the life course. ally “old” at age 40. Decision-makers need Readers who want to learn more about to consider the contextual differences in male ageing and health are referred to the how the process of ageing is experienced in WHO document entitled Men, Ageing and their specific environment, when designing Health: Achieving Health Across the Life Span gender-responsive policies and programmes 2001 (WHO, 2001, available online at http:// for ageing women. whqlibdoc.who.int/hq/2001/WHO_NMH_ NPH_01.2.pdf). Ageing is also both a biological and social construct. Physiological changes such as a reduction in bone density and visual acuity

PAGE 2 Women, Ageing and Health: A Framework for Action

A global profile of ageing women Equity in health means addressing the For multiple reasons the feminization of disparities between and among differ- ageing has important policy implications ent groups of older women, as well as for all countries: those between women and men.

• Ageing women make up a significant proportion of the world's population The knowledge gap and their numbers are growing. The When it comes to research and knowl- number of women age 60 and over will edge development, older women face increase from about 336 million in 2000 double jeopardy — exclusion related to to just over 1 billion in 2050. Women both sexism and ageism. Current infor- outnumber men in older age groups mation concerning ways in which gender and this imbalance increases with age. and sex differences between women and Worldwide, there are some 123 women men influence health in older age is inad- 6 for every 100 men aged 60 and over. equate. While gender-inclusive guidelines have been implemented in some countries, • While the highest proportions of older there is still a tendency for clinical stud- women are in developed countries, the ies to focus on men and exclude women. majority live in developing countries, Surveillance data that include sex and where population ageing is occurring at age-disaggregated data are also limited. a rapid pace. For example, most international studies • The fastest growing group among ageing on health issues – such as violence and women is the oldest-old (age 80-plus). HIV/AIDS – fail to compile statistics for Worldwide, by age 80 and over, there people over the age of 50. Lastly, there is a are 189 women for every 100 men. By paucity of research on gender differences age 100 and over, the gap reaches 385 in the social determinants of health. A women for every 100 men.6 While most recent study mapping existing research and ageing women remain relatively healthy knowledge gaps concerning the situation and independent until late in life, the of older women in Europe found a lack of very old most often require chronic care research related to women aged 50 to 60 and help with day-to-day activities. in particular.7 While there were numerous longitudinal studies on ageing, these stud- • Older women are a highly diverse ies had little or no gender analysis of the group. Life at age 60 is obviously very different impacts of health conditions and different from life at age 85. Although the social determinants of health on ageing cohorts of older women may experience women and men. In this report, some key some common situations, such as a issues for research and information of and shared political environment, exposure are described in each chapter. to war and the arrival of new technologies, their longevity has given them more time to develop unique biogra- phies based on a lifetime of experiences.

PAGE 3 2. A framework for action

This chapter describes a gender- and age- This finding implies that individuals can -in responsive framework for action based on fluence how they age by practising healthier the following components: lifestyles and by adapting to age-associated changes. However, some life course factors • A life-course approach may not be modifiable at the individual • A determinants of health approach level. For instance, an individual may have little or no control over economic disad- • Three pillars for action vantages and environmental threats that directly affect the ageing process and often • A gender- and age-responsive lens predispose him or her to disease in later life. A life-course approach Growing evidence supports the concept of Ageing is a lifelong process, which begins critical periods of growth and development before we are born and continues through- in utero and during early infancy and child- out life. The functional capacity of our hood when environmental insults may have biological systems (e.g. muscular strength, lasting effects on disease risk in later life. cardiovascular performance, respiratory For example, evidence suggests that poor capacity) increases during the first years growth in utero leads to a variety of chronic of life, reaches its peak in early adulthood disorders such as cardiovascular disease, and naturally declines thereafter. The slope non-insulin dependent diabetes, and hy- of decline is largely determined by exter- pertension.9 Exposures in later life may still nal factors throughout the life course. The influence disease risk in a simple additive natural decline in cardiac or respiratory way but it is argued that fetal exposures function, for example, can be accelerated by permanently alter anatomical structures factors such as smoking and air pollution, and a variety of metabolic systems.10 This leaving an individual with lower functional means that girls who are born into societ- capacity than would normally be expected ies that favour boys and deprive girls are at a particular age. Health in older age is particularly likely to experience disease and therefore to the largest extent a reflection of life. the living circumstances and actions of an individual during the entire life span.8

PAGE 4 Women, Ageing and Health: A Framework for Action

Examples of life course events that increase women’s vulnerability to poor health in older age

• Gender discrimination against girls child leading to inequitable access to food and care by female and male infants and children. • Restrictions on education at all levels. • Childbirth without adequate health care and support. • Low incomes and inequitable access to decent work due to gender-discrimination in the labour force. • Caregiving responsibilities associated with mothering, grandmothering and looking after one’s spouse and older parents that prevent or restrict working for an income and access to an employee-based pension. • Domestic violence, which may begin in childhood, continue in marriage and is a common form of elder abuse. • Widowhood, which commonly leads to a loss of income and may lead to social isolation. • Cultural traditions and attitudes that limit access to health care in older age, for example older women are much less likely than older men to receive cataract surgery in many countries.

A life-course perspective calls on policy- careers interrupted because of childbear- makers and civil society to invest in the ing and caregiving make it very difficult various phases of life, especially at key for women to earn as much as men in their transition points when risks to well-being respective lifetimes. Thus, the prevention and windows of opportunity are greatest. and alleviation of poverty in older age calls These include critical periods for both bio- for a set of policies based on a new para- logical and social development, including in digm that provides social safety nets at key utero, the first six years of life, adolescence, times in the female life course, and particu- transition from school to the workforce, larly when women are unable to earn an motherhood, menopause, the onset of adequate wage in the open labour market. chronic illnesses and widowhood. Policies This includes policies and practices that: that reduce inequalities protect individuals • support reproductive health and safe at these critical times.11 motherhood programmes; Even with multiple changes in policies • support girls’ access to education with a related to education and labour-market special effort to enable their transition participation, gender-specified roles and from primary to secondary and to post- secondary schooling;

PAGE 5 • enable equitable entry to the labour mar- A determinants-of-health approach ket and to meaningful, protected work; There is now clear evidence that health care • provide incentives for 'family friendly' and biology are just two of the factors influ- policies in the workplace which support encing health. The social, political, cultural, pregnancy, breastfeeding, and caring for and physical conditions under which people children and older family members; live and grow older are equally important influences.12 • support caregivers of family members who are ill or frail, and ease the financial Active ageing depends on a variety of burden and employment opportunity “determinants” that surround individuals, costs of this essential role; families and nations. These factors directly or indirectly affect well-being, the onset • support changes in work practice that and progression of disease and how people enable older women to remain in both cope with illness and disability. The deter- the formal and informal labour markets; minants of active ageing are interconnected • support voluntary and gradual retire- in many ways and the interplay between ment as well as incentives to save for them is important. For example, women retirement and long-term care needs; who are poor (economic determinant) are more likely to be exposed to inadequate • ensure that equal rights to the inheri- housing (physical determinant), societal tance of property and resources upon the violence (social determinant) and to not eat death of a parent or spouse are upheld; nutritious foods (behavioural determinant).

• ensure the right to health and equal ac- Figure 1 shows the major determinants cess to health care; of active ageing. Gender and culture are cross-cutting factors that affect all the • ensure that all older women have an others. For example, gender- and culture- income that satisfies the basic necessities related customs mean that men and women of life, as well as equal access to required differ significantly when it comes to risk- health, social, and legal services; taking and health-care-seeking behaviours. • provide additional support to widows as Culturally driven expectations affect how required, to older women who live alone, women experience menopause in various to those who are poor or disabled, and to parts of the world. The gendered nature of those who require long-term care in or caregiving and employment means that outside of the family residence; and women are disadvantaged in the economic determinants of active ageing. • support compassionate end-of-life care and help with arrangements for a peace- ful death and appropriate burial required.

PAGE 6 Women, Ageing and Health: A Framework for Action

Figure 4. The determinants of Active Ageing

Gender

Health and Economic social services determinants

Behavioural Active determinants Social Ageing determinants

Personal determinants Physical environment

Culture

Source: Active Ageing: A Policy Framework, WHO, 2002 (http://www.who.int/ageing/publications/active/en/index.html)

Three pillars for action The priority areas for action described in Chapter 10 of this report are grouped under The ideas presented in this report build on the three pillars. the WHO active ageing framework, which calls on policy-makers, service providers, Active ageing is the process of optimizing nongovernmental organizations and civil opportunities for health, participation and society to take action in three areas or security in order to enhance quality of life as “pillars”: participation, health and secu- people age.1 rity (see Figure 2, next page). The policy framework for active ageing is guided by The gender- and age-responsive lens the United Nations Principles for Older Under the active ageing framework, the People: independence, participation, care, overall goal is to improve the health self-fulfilment and dignity. Decisions are and quality of life of ageing women by based upon an understanding of how the implementing gender-responsive policies, social, physical, personal and economic programmes and practices that address determinants of active ageing influence the the rights, strengths and needs of ageing way that individuals and populations age. women throughout the life course. These This framework aims to reduce inequities efforts need to take into account the special in health by understanding the gendered situations of older women with disabilities, nature of the life course. members of minority groups, those who live in rural areas, and those who have low socioeconomic status.

PAGE 7 Figure 2. The three pillars of a policy framework for active ageing

Active Ageing

Participation Health Security D g eter ein minants of Active Ag U e nit opl ed Na er Pe tions Principles for Old

Source: Active Ageing: A Policy Framework, WHO, 2002

Fulfilling this goal means that governments • enable the full and equal participa- at all levels, international organizations, tion of older women and men in the nongovernmental organizations and other development process and in all econom- leaders in civil society and the private sector ic, social, cultural and spiritual spheres need to: of community life;

• mainstream gender and age perspec- • adopt a life course perspective that tives in all policy considerations by tak- understands ageing and cumulative ing into account the impact of gender disadvantage as a process that spans the and age-based roles and cultural ex- entire lifespan and provides supportive pectations concerning ageing women’s policies and activities at key transition health, participation and security; points in a one’s life;

• systematically eliminate inequities • encourage intergenerational solidar- based on gender and age and their ity and respect between generations. interaction with other factors such as Gender analysis has become a common race, ethnicity, culture, religion, disabil- policy tool in many settings. This report ity, socioeconomic status and geograph- proposes that policy-makers apply a dual ic location; perspective to their decisions — a perspec- • acknowledge and address diversity tive that takes both gender and age into among older women and men; account (Figure 3).

PAGE 8 Women, Ageing and Health: A Framework for Action

Figure 3. Applying a gender- and age-responsive lens to decision-making

nder Len Ge s

Participation Health Security

Some questions to ask Outcomes 5. In what ways does the policy/programme Taking gender, age and equity into enhance the health/participation/secu- account rity of older women and older men? 1. Does the policy/programme address gender- and age-specific concerns? 6. How will the policy/programme affect women and men differently through- 2. Does the policy/programme take gen- out the life course, and particularly in der‑, age- and culturally-based tradi- older age? tions and roles into account? 7. Does the policy/programme acknowl- 3. Does the available evidence take gender edge the contribution and strengths of and age differences into account? older women and men and the heteroge- 4. Does the policy/programme support neity of the older population? equity and ensure equal access without 8. Does the policy/programme respect discrimination based upon age, gen- the United Nations Principles for Older der, class, race, ethnicity, health status, People: independence, participation, income and place of residence? care, self-fulfillment and dignity?

9. Does the policy/programme support intergenerational solidarity for both women and men and encourage a 'society for all ages'?

PAGE 9 Development and implementation An example of how to combine the 10. How have diverse groups of older wom- gender-sensitive/age-friendly lens with en and men contributed to the develop- the active ageing pillars and determi- ment of the policy or programme? nants is provided in the central pages of 11. How will the policy/programme be this document. It is focused on primary implemented, monitored and evaluated health care services and can be used as in an age- and gender-responsive way? a tool to facilitate the identification of issues/concerns; policy/action development; and formulation of research questions.

PAGE 10 Women, Ageing and Health: A Framework for Action

3. the health status of older women

This chapter provides an overview of the women’s life expectancy after reaching age health status of older women. Some dis- 60. For example, a 60-year-old woman in eases and conditions are highlighted in Sierra Leone can expect to live another 14 subsequent chapters, and it is therefore years while a woman of the same age in important to take all chapters into account Japan can expect to live another 27 years. when assessing the overall health and well- Mortality patterns also differ within coun- being of ageing women. tries; for example, in Australia, Canada and Mexico women in indigenous com- Key points munities have poorer health and signifi- With a few exceptions, women have longer cantly lower life expectancies than non- life expectancies than men in both devel- indigenous women.15-17 Life expectancy is oped and developing countries. The rea- closely related to income and social status sons relate to both female biology such as and can vary among neighbourhoods. For hormonal protective factors, and fatal risk example, female life expectancy between factors associated with male working con- women living in London varies from 84.7 ditions, lifestyles and higher risk of injury. years in Kensington/Chelsea to 79 years Worldwide, women are likely to continue in Newham. The latter neighbourhood is to maintain this advantage over men for situated in inner London and is character- the foreseeable future. However, the gender ized by poor housing conditions, low levels gap in life expectancy is decreasing in some of education and employment, high crime developed countries as a result of role and rates and a higher percentage of pensioners 18 lifestyle changes such as participation in living in poverty. the paid work force and increased rates of Noncommunicable diseases are the lead- 13,14 smoking by women. ing cause of death and disability among Global inequities in life expectancy among women in all global regions except Africa.19 women are immense — for example, a baby Approximately 80% of chronic disease girl born in France or Japan can expect to deaths occur in middle- and low-income live more than 40 years longer than a baby countries, where most of the world’s ageing girl born in a sub-Saharan African coun- women live. try. There are also dramatic differences in

PAGE 11 More older women than older men are blind, increase.23,24 Worldwide, older people have largely because they live longer but also be- a higher risk of completed suicide than any cause of restricted access to treatment. They other age group. The male:female ratio for are also at higher risk for trachoma because completed suicides among people over age they are more exposed to infection. Barriers 75 is 3:1 to 4:1.25 that prevent ageing women from receiving The onset of depression in the later years of eye care include: the cost of examinations, life may be related to psychosocial factors surgery, drops and eyeglasses; inability to (such as socioeconomic status) and stressful travel to a surgical facility or clinic; little life events (such as bereavement and car- family support for treatment; and a lack of ing for chronically ill family members and access to information about services due to friends).26,27 Depression may also be second- low literacy levels.20 ary to a medical disorder or to use of medi- Gender is a powerful determinant of mental cation use. Women are approximately twice health that interacts with such other factors as likely as men to experience a depressive as age, culture, social support, biology, and episode within their lifetimes.23 It is esti- violence. For example, studies have shown mated that by the year 2020, depression that the elevated risk for depression in will be the second most important cause of women is at least partly accounted for by disability burden in the world.28 negative attitudes towards them, lack of Although communicable diseases are not acknowledgement for their work, fewer op- among the most common causes of death portunities in education and employment, later in life, they account for high levels of and greater risk of domestic violence.21 The disability and morbidity — especially among risk of mental illness is also associated with older people in developing countries. The indicators of poverty, including low levels of impact of communicable diseases such as education and, in some studies, with poor malaria, tuberculosis and leprosy grows housing and low-income.22 increasingly severe with time and ageing. While women do not experience more For example, an individual who experi- mental illness than men, they are more enced pulmonary tuberculosis early in life prone to certain types of disorders, including may – even if successfully treated – sustain depression and anxiety.21 Women and men residual ventilatory incapacity which can are equally likely to develop Alzheimer’s be aggravated by the ageing process in later disease and other dementias in old age; years. In all countries, older people are at however, the prevalence is higher among high risk for contracting influenza and its women because they live longer.23 The complications, including death. emotional, social and financial costs of Alzheimer disease to families and societies are already massive and will continue to

PAGE 12 Women, Ageing and Health: A Framework for Action

Ageing women remain at risk for HIV/AIDS The HIV/AIDS epidemic has had devastating and other sexually transmitted infections economic, social, health and psychologi- (STIs). Like ageing men, women can remain cal impacts on older women especially in sexually active until the end of life, but they sub-Saharan Africa. Older women care for may have fewer opportunities because most those who are ill with HIV/AIDS and then outlive their partners. Many STIs are physi- for their orphaned children, and are them- cally transmitted more efficiently at all ages selves at risk of infection. Studies show that from males to females than from females older caregivers are under severe financial, to males. The risk is increased by customs physical and emotional stress — including such as older men engaging in extramarital arising from financial hardships leading relationships, widow cleansing, polygamy to inability to pay for food, clothing, es- and wife inheritance, as well as by older sential drugs and basic health care; a lack women’s roles as caregivers. Once infected, of information about self-protection while women face a disproportionate burden of providing care to their infected children sequelae from STIs, including AIDS result- and grandchildren; stigmatization of people ing from HIV infection and cervical cancer with the disease; negative attitudes of as a result of the transmission of the hu- health workers towards them as older per- man papilloma virus (HPV). sons, as well as towards people living with HIV/AIDS; and physical and emotional stress resulting from increasing levels of violence and abuse.29,30

PAGE 13 Older women and chronic diseases

Heart disease and stroke are significant causes of death and disability in women in both developed and developing countries19 and especially among women who are poor.31 Hormone replacement therapy, which was widely used in high-income countries has been shown not to prevent heart disease after menopause as was originally thought, but rather is associated with an increased risk of stroke and heart disease among some ageing women.32,33 Women with heart disease tend to present with different symptoms than men and are less likely to seek or to be provided with medical help and to be properly diagnosed until late in the disease process. While improvements have been made, women are less likely to have access to appropriate investigations and treatment, and are more likely to be underrepresented in research on heart disease.34 The lifetime risk for breast cancer among women in most developed countries is about one in ten. This risk increases with age – especially after age 50 – and only declines after the age of 80. Lower fertility rates, increasing age of pregnancy and a decrease in the number of years of breastfeeding all contribute to a predicted rise in breast cancer in developing countries.

Cervical cancer, which kills an estimated 239,000 women every year is – after cancers of the stomach and breast – the third most common cancer in women in developing countries. Providing girls with a new vaccine to prevent infection from the human papilloma virus (HPV), which causes cervical cancer, offers the possibility of eliminating the incidence of cervical cancer in the future. Meanwhile, it is critical to provide existing cohorts of ageing women with pap smear screening or other low-cost prevention and screening technologies.35 Use of these techniques can dramatically reduce mortality due to cervical cancer.

Osteoarthritis and osteoporosis are associated with chronic pain, limited quality of life and disability. Between the ages of 60 and 90 years, the incidence of osteoarthritis rises 20-fold in women as compared to 10-fold in men.36 Osteoporosis is three times more common in women than in men, partly because women have a lower peak bone mass and partly because of the hormonal changes that occur at menopause and the effect of pregnancy which can alter calcium composition in a woman’s body in the absence of appropriate diet and/or administration of calcium supplements. While these diseases and consequent fractures, spontaneous or caused by falls, place an enormous burden on the health care system and society, often they do not get the attention they deserve because they are incorrectly seen as an inevitable part of ageing or less serious than such conditions as heart disease or cancer.

NOTE: Lung cancer, diabetes and osteoporosis are discussed in subsequent chapters.

PAGE 14 Women, Ageing and Health: A Framework for Action

Implications for policy, practice and In light of the high burden of breast research cancer, and predictions that the incidence will increase worldwide, there remains an Life Expectancy. While life expectancy is urgent need for a better understanding of a crude measure of health, it does provide its root causes, increased availability of the ultimate yardstick. Efforts to overcome effective and affordable screening tools for dramatic inequities in life expectancies use with older women, the expansion of ef- among older women between countries, fective treatment regimes, and support for and among various socioeconomic popu- breast cancer survivors. lation sub-groups within a given country or region, must become an international Use of the new vaccine to prevent HPV priority. infection must be made widely available Preventing noncommunicable diseases. immediately in low-income countries where cervical cancer is a major cause While the progression from mortality of death. For older women, the use of pap caused by infectious diseases to that caused smears and other cost-effective prevention by chronic diseases is a positive sign of im- and treatment technologies must be made provements in public health, the increase in universally available. chronic diseases due to population ageing has substantial implications for human Health care priorities need to redress the suffering and health care costs. The ulti- imbalance in attention given to musculosk- mate goal is to prevent and manage chronic eletal disorders and joint diseases such as diseases, thus postponing disability and osteoporosis and arthritis. death and enabling ageing women and men to maintain their positive contributions to Another inequity that needs to be ad- society. If this achievement is to be shared dressed involves blindness. Local initia- equally by women and men, policies and tives and the political will to eliminate programmes must take both gender and gender inequities in eye care services are age into account. critical steps in achieving the goals of Vision 2020, a global initiative to combat Addressing inequities in diseases that affect avoidable blindness. older women. Tackling inequities in coronary heart disease requires the education and training of health professionals about sex and gender differences in the clinical manifestations and progress of the disease, the full inclusion of older women in cardiac studies, earlier and more aggressive control of risk factors, and appropriate access to diagnosis and treatment.34

PAGE 15 A gender-sensitive approach to improving HIV/AIDS and other STIs. It is essential to mental health. Understanding that mental dispel the myth that older women are not health and mental illness are the results sexually active. Sexual health care, educa- of complex interactions among biological, tion and knowledge about STIs and HIV/ psychological, and sociocultural factors AIDS are important not only for women is important for those considering ageing of reproductive age but also for girls and women. Such understanding places mental women in all stages of life. This concept health and illness within the social context needs to be considered when allocating of women’s life experiences and implies resources and planning future research and that equality and social justice are impor- programming. Programmes and preven- tant goals for improving mental well-being tion messages must be sex- and age-specific among women of all ages. Developing and should target not only individual gender-sensitive national policies, with behaviours but also the social and cultural budgets dedicated to mental health and context in which these behaviours occur. mental illness, needs to become a prior- The participation and representation of ity in all countries. Evidence suggests that older people – and older women in par- practices and programmes encouraging ticular – in HIV/AIDS programme plan- socialization and physical activity can help 37,38 ning at local, district and national levels ease depression, and that most mental will improve the response to HIV/AIDS. health problems in later life can be dealt This response will require support to older with in age-friendly primary health care people and their organizations. Health care services, and through community services staff should be appropriately trained to and interventions that support families and 39,40 support older people who are infected and caregivers. appropriate drugs should be made available Communicable diseases. Older women will as recommended by the WHO universal be major beneficiaries of efforts to control access approach. and eliminate infectious diseases in set- Dissemination of research and information. tings where communicable diseases are There are few controlled studies on depres- common. WHO urges all Member States sion in older women.28 Similarly, gender- to implement a national influenza vaccina- specific research into the causes and tion policy and to implement strategies to management of dementia becomes increas- increase vaccination coverage of all people ingly critical as life expectancies increase. at high risk, with the goal of attaining cov- Because of the stigma attached to suicide in erage of the older population of at least 50% many cultures, it is likely that the number by 2006 and 75% by 2010.41 of suicides among older men and women are undercounted. Many questions about suicide in later life remain unanswered.

PAGE 16 Women, Ageing and Health: A Framework for Action

Table 1. Life expectancy at birth and at age 60, women, selected countries, 2006 At At At At At At birth age 60 birth age 60 birth age 60

AFRO EURO SEARO

Mozambique 46 16 Bulgaria 76 20 India 63 18

Senegal 57 17 Russian 72 19 Indonesia 69 18 Federation Sierra Leone 40 14 Sri Lanka 77 21 Switzerland 83 26 AMRO WPRO EMRO Brazil 74 22 China 74 20 Bahrain 75 20 Canada 83 25 Japan 86 27 Egypt 70 18 Haiti 56 17 Papua New 61 14 Pakistan 63 17 Guinea Source: World Health Report, 2006.

Further studies are needed on the sex and There is a critical need for improved sur- gender-linked factors that contribute to veillance and for the collection of sex- and lung cancer, breast cancer, heart disease age-specific data after age 50. Also needed and obesity. are controlled trials on the epidemiology, pathogenesis, and therapeutic and clinical Currently, older people are largely invisible outcomes of older HIV-infected patients. in international data on HIV/AIDS infection rates because data collection does not routinely include the over-50 age group.

PAGE 17 4. Health and social services

In order to be comprehensive, health From a global perspective, the use of medi- systems should provide a continuum of cations can be a double-edged sword. In gender-responsive care from promotion and most countries, older women who have low prevention to acute and palliative care, as incomes and no access to benefits covering well as access to essential medications. the costs of medications either go without or spend a large part of their meager Key points incomes on drugs. In contrast, medications In many settings, ageing women do not are sometimes overprescribed to older have the same access to health care as do women who have insurance or the means to men or younger women. For example, in pay for medications. Older women may be many countries, older women are less likely more likely than men to experience adverse than men to receive cataract surgery and drug reactions because of smaller body size, eye care due to the cost of examinations, altered body metabolism and diminished eyeglasses, drops and surgery, as well as ability to compensate for drug-induced 47 gender- and age-discrimination, and a changes in normal homeostasis. lack of support for and information about The barriers to primary health care faced by 20 treatment. Men may gain quicker access older people are often worse for older wom- to selective operations42,43 and a life-saving en. These barriers include lack of trans- procedure following a heart attack.44,45, 46 portation, low literacy levels and a lack of These inequities may be a result of direct money to pay for services and medications. or indirect gender- and age-based dis- Invariably, gender and age interact with so- crimination, older women’s lower financial cioeconomic status, race and ethnicity. For status and limited access to health secu- example, older women who are homeless or rity schemes, and a focus on reproductive do not speak the dominant language may health that excludes older women. have even less access to health care and be more likely to encounter discrimination in treatment.

PAGE 18 Women, Ageing and Health: A Framework for Action

Personal expenses related to health care Palliative end-of-life care in the home or gradually take up a greater share of a wom- in small hospices will become increasingly an’s resources as she grows older, even in important to health systems as the number highly industrialized countries. For example, of very old women and men continues to studies in the United States of America increase. Services include pain relief, and (USA) show that health security is out medical, spiritual and psychological sup- of reach for many women over the age of port to the dying person and her family, as 50, and that out-of-pocket expenses for well as respite care for burdened caregivers. medications and long-term care are major Home caregivers (who are mostly middle- factors contributing to higher poverty rates aged and older women) of people who are ill among older women.48 Because women must be supported and nurtured to enable most often work at home or in the informal them to maximize the care they deliver, to sector or part-time, they have limited or no manage the considerable stress that can access to health insurance schemes that are accompany caregiving, and to be able to tied to employment. sustain a caregiving role over a long period Because women live longer than men and of time — often many years. Poor families are more likely to be alone in old age, policy- are in particularly precarious positions and makers and practitioners must pay special – as more and more women work outside attention to the gender implications of long- the home – a better balance in the shar- term care policies and programmes, whether ing of caregiving between women and men they be in the community or in residential becomes increasingly important.49 facilities. Most long-term care for older In both developed and developing coun- people who cannot live independently is tries, a range of health care reforms has had provided by informal support systems such a negative effect on women, particularly as family members and neighbours. But as in middle- and older age.50 User fees and the number of very old women continues to private provider schemes limit access to increase and the pool of available caregivers services for older women.51,52 The closing continues to decrease, families and policy of acute-care beds, and early release from makers will increasingly need to look for hospital without a corresponding increase other options. Part of the answer may lie in in support in the community, leaves age- increased home and community support ing women with an increased and unrec- services, but it is likely that the number of ognized burden of caring for partners and very old women who spend their last years other family members who are ill or frail. in institutional settings will also increase.

PAGE 19 Implications for policy, practice and of care. Caregivers also need a forum to research express their experiences and recommendations for system change and for sensitiz- Health professionals. Professionals need ing service providers. Most importantly, to understand and recognize sex and age caregivers need “respite”—time off from differences — especially when prescribing their caregiving role. medications, treating mental health problems such as depression, and dealing with Some of the options for financially support- health problems related to domestic abuse. ing caregivers include leave from work (paid A gender perspective means going beyond and unpaid), tax policies and payments for physical symptoms to explore the socio- caregiving services. In developing countries cultural as well as the biological factors it is especially important to foster intergen- underlying these problems. erational relationships and co-residency by providing subsidies for those who care for Medications. The goal is to ensure equity in older relatives, housing designs that enable the provision of essential, and high-quality multigenerational living, and community drugs among all age groups and between centres that can be used by older people as women and men. At the same time, physi- meeting places and clubs.53 cians and pharmacists need to take into account the risks of overprescribing medi- Health care reform. Cost-cutting measures cations based upon gender stereotyping, must not expect to transfer formal care to and of the adverse effects of multiple drug the unremunerated care provided by ageing use among older women. women without providing compensation for lost wages and community support ser- Supporting informal care. The needs of care- vices. Priority setting in health care servic- givers are confounded by culture, income, es should be based on evidence that is free living arrangements and the extent of from systematic gender- and age- biases. support from others. Caregivers of people who are ill or frail need information about Health security. The goal is to provide equal specific conditions, treatment, medications, access to essential health services and warning symptoms and necessary lifestyle medications, regardless of ability to pay. modifications. They need training in home Because older women have fewer financial health skills and how to work in partner- resources to pay for services and private ship with health care providers. Equally insurance premiums, taxes and social in- important are skills to help them identify surance schemes that are not based on time available resources, navigate the system and spent in formal employment provide the become effective advocates for recipients most equitable basis for health financing. Health insurance schemes should ensure that vulnerable and marginalized groups, including older women are adequately covered.

PAGE 20 Women, Ageing and Health: A Framework for Action

Mental health services. Policies and prac- Research and information dissemination. tices that benefit older women and men Priority areas for developing and sharing should: knowledge include:

• support and improve the care provided • ways to increase access to primary by their families (e.g. respite care, train- health-care and participation in health ing); promotion and disease prevention activities particularly among older women • incorporate mental health assessment in minority groups, who have low socio- and management of depression as well economic status and who live in rural as other mental health problems into and isolated areas; primary health care; • cost-effective ways to help older women • pay special attention to women who remain in their homes in the commu- have experienced elder abuse or other nity; forms of violence ; • gender perspectives, expectations and • help to remove the stigma associated experiences of long-term care options; with mental illness; and • effective policy options and legal guide- • include legislation to protect the human lines for providing dignified long-term rights of institutionalized people with and end-of-life care to older women and severe mental disorders. men;

Cataract surgical coverage • more detailed evidence on the differen- Cataract is the leading cause of visual tial use of medications by older women impairment in all regions of the world, and men and whether gender is system- except in the most developed countries.54 atically associated with inappropriate In many countries, older women with use; cataracts are much less likely to have • best practices related to receiving and surgery than men — a classic example giving care (i.e. filial, state and personal of how gender bias impacts on access to responsibilities); and health services.20 • the impact of health care reform on gender equity.

PAGE 21 Figure 4. Comparison of cataract surgery coverage between men and women in ve countries

Percentage Male Female 80

0 China* India* Nepal Saudi South Arabia Africa * Two sets of data displayed

Source: Lewallen S. and Courtright P. British Columbia Centre for Epidemiologic and International Ophthalmology. Gender and use of cataract surgical services in developing countries. Vancouver: University of British Columbia, 2000 (unpublished paper).

PAGE 22 Women, Ageing and Health: A Framework for Action

5. Personal determinants

Biology and genetics by socioeconomic conditions, and gender- based discrimination. For example, women Although biology and genetics are key de- may have had inadequate access to nutri- terminants of women’s health, the evidence tious food in early life. As another example, suggests that most of the time other factors in some cultures restrictions on movement related to gender-influenced roles and sta- outside the home are placed upon widows. tus are more important in determining the health and well-being of women at midlife Normal ageing includes some natural de- and older ages. However, as is the case with clines and physiological changes that lead all the determinants of active ageing, sex and to a loss of functional capacity and reserve. gender are likely to interact in synergistic These include reductions in hearing and ways. vision capacities, a decrease in taste, smell and thirst sensations, and declines in Key points basal metabolic rate and immunological It has been estimated that only 20-25% of response. There is also a significant reduc- variability in the age at death is explained by tion in bone density and muscle mass, both genetic factors.55 The influence of genetic of which are more pronounced in women factors on the development of chronic than in men.59,60 However, individuals may conditions varies significantly. For example, experience these declines at very differ- some women have a genetic predisposition ent rates. Physiological declines associated to breast and ovarian cancer; even when with ageing will likely be exaggerated for a this risk is known, however, it is not a fore- woman who has lived a life of poverty with gone conclusion that they will develop the poor nutrition and has had little, if any, ac- disease in their lifetime. cess to education and health care.

While women are more likely to survive into For ageing women, menopause is a signifi- older age, they have more disability than cant transition from both a biological and men in every age group after age 60, as well social perspective. Hormonal changes occur- as more co-morbidities.56-58 Biological fac- ring during the menopausal period are relat- tors may be a critical reason for this. For ed – either directly or indirectly – to adverse example, lower levels of muscle strength effects on quality of life, body composition and bone density in women increase the and cardiovascular risk. Women’s advantage likelihood of disabling conditions such as over men in terms of cardiovascular disease frailty and osteoporosis, and difficulty with gradually disappears with the significant tasks requiring optimal threshold levels declines in estrogen levels after menopause. of strength. However, the incidence and The loss of bone density at menopause is a prevalence of disability is also influenced significant reason why women have much higher rates of osteoporosis than men.61

PAGE 23 Menopause is directly associated with There are indications of intergenerational physical symptoms including increases in factors in obesity, such as parental obesity, vasomotor symptoms, vaginal dryness, maternal gestational diabetes, and maternal pain during sexual intercourse, and central birth weight. Interactions between early abdominal fat, as well as decreases in breast and later factors throughout the life course tenderness, bone mineral density and can be particularly harmful in later years. sexual functioning. Mood, self-rated condi- For example, low birth weight followed by tion of health, and life satisfaction are not adult obesity has been shown to result in a directly related to the menopause transi- significantly higher risk for cardiovascular tion. There is no evidence that memory loss disease.65 or dementia is linked to menopause.62 Reduced muscle mass (sarcopenia) in older Hormone replacement therapy (HRT) has age can have significant consequences for day- not been found to be effective in prevent- to-day living. For example, the Framingham ing heart disease but rather is associated study showed that 40% of women aged 55 with an increased risk of heart disease, to 64 and 65% of women aged 75 to 84 were stroke, and breast cancer. Generally, the use unable to lift 4.5 kilograms.66 of HRT is now only recommended in low Biological factors that relate to reproduction doses for short periods of time to deal with have traditionally been the major focus of severe symptoms such as vaginal atrophy policies and programmes related to women’s and hot flashes that prevent sleeping. This health. Research and health care practices therapy may be especially important for that focus almost exclusively on women’s women who undergo an early and dramatic reproductive biology fail to address chronic menopause due to surgical interventions.63 diseases and the broad social determinants Women’s experience of living through the of active ageing that lead to health or illness menopausal period is dramatically affected as women grow older. by sociocultural factors. The most relevant factors influencing a woman’s quality of life Implications for policy, practice and during the menopause transition appear research: biology and genetics to be her previous emotional and physical Health Services. While high-quality, acces- health, her social situation, her experience sible reproductive health services remain of stressful life events, and the beliefs about critical to women’s well-being, health menopause and female ageing in her cul- services need to expand beyond a focus on ture.64 For all women, leaving the reproduc- reproductive biology and adjust to today’s tive years marks both an important change realities of an ageing population. This must and a window for growth. Regardless of include age- and gender-sensitive services differences in how it is experienced, the geared to the prevention and management menopausal transition can provide an of chronic diseases such as heart disease, important focus, a time that can be used to diabetes, arthritis, and Alzheimer disease. reassess one’s health, lifestyle and goals.

PAGE 24 Women, Ageing and Health: A Framework for Action

Disability. A focus on healthy, active ageing Research and information dissemination. The and improved health services can lead to burden of disability in older women has the compression of morbidity and dis- wide-ranging and profound effects on older abilities until very late in life. At the same women themselves, their families, and the time, the dramatic increase in the number health care system. Gender-sensitive trials of older women in both developed and aimed at prevention of disability in older developing countries will inevitably lead to age should be considered a priority in the an overall increase in the number of older allocation of resources for health and social women with disabilities. To improve older care research. This work needs to take a women’s quality of life and to keep health life course perspective that underscores the care costs down, more attention needs to gender-related factors in the physical, social be paid to preventing and managing dis- and economic environments that are asso- abilities. ciated with women’s disabilities in later life.

Preventing problems associated with biologi- More cross-cultural knowledge about cal ageing. Regular physical activity, healthy menopause is needed. Other knowledge eating and not smoking can prevent and al- needs relate to the perimenopausal period leviate problems associated with age-related — especially among women who experi- loss of muscle strength and bone density ence severe symptoms during this time or and of increases in fat mass. Governments as a result of either an early but natural or and civil society need to overcome ageist surgery-induced menopause. Other priori- attitudes that suggest these healthy lifestyle ties include gathering evidence about al- behaviours are not important or appropri- ternative therapies and lifestyle changes to ate for older women. deal with the concerns of menopause, and the relationship between hormonal changes Dispelling misconceptions about menopause. after menopause and chronic diseases such Policies and programmes need to dispel as heart disease. misconceptions about the menopausal period and encourage ageing women to adopt healthy lifestyle behaviours (such as healthy eating and regular physical activity) that will help them cope with the physical symptoms of menopause.

PAGE 25 Psychological and spiritual factors prayer and faith as a way to cope with losses associated with ageing.69For many older Psychological capacities that are acquired people, spirituality and/or religion provides across the life course greatly influence the much of this meaning. way in which people age. Self-efficacy (the belief people have in their capacity to exert Besides offering hope in the face of death, control over their lives), optimism, and a faith can provide consolation and strength sense of coherence are linked to mental and during difficult times, and a guide for daily social well-being as one ages. Coping styles living. Being a valued member of a congre- determine how well people adapt to the gation of believers also is a source of social transitions (such as retirement) and nega- support and of self-esteem.70 Pastoral care tive life events associated with ageing (such and counseling may be particularly impor- 67 as bereavement and the onset of illness). tant to older women at the end of life who There is some evidence in developing coun- are alone and unable to leave their homes tries that ageing women are more resilient due to severe disabilities. than men when it comes to later life transitions and coping with crises.68 In addition to supporting an older woman in her search for spiritual answers, faith Active ageing also depends on a person’s institutions and religious groups can be an ability to maintain meaning in life despite important source of social support, valida- personal losses, physical decline and age- tion, hope and reassurance that her life and ism. While worldwide studies on gender death have meaning. However, negative differences are lacking, North American practices such as harmful mourning rites studies show that current cohorts of older for widows that are associated with reli- women, and particularly those in minor- gious rituals in some cultures are damaging ity races and ethnic groups rely heavily on to older women’s health.

PAGE 26 Women, Ageing and Health: A Framework for Action

6. Behavioural determinants

Much of the physical decline that occurs Increases in smoking among women, and with ageing is related to health behaviours gender-related roles in the household have including poor nutrition, physical inactiv- led to a fourfold increase in the incidence of ity, smoking, and a failure to use preventive lung cancer among women over the last 30 services. years. The increase in lung cancer in the USA and several other countries has led to Key points it overtaking breast cancer as the leading Young girls are now smoking at least as much cause of cancer death in women. Most of – if not more – than young boys.71 Moreover, this is due to increased smoking by women. while tobacco use has declined in some However, women’s risk for lung cancer is high-income countries, it is increasing in also elevated by gender-related roles and some low- and middle-income countries positions in the household. Many women — especially among young people and who do not smoke but live with husbands women. This trend is predicted to increase, who do are exposed to second-hand tobac- at least partly because of changing norms co smoke. In their role of preparing food, towards women’s roles combined with per- many women in poor countries are exposed vasive, gender-specific advertising by the to fumes and smoke from solid cooking tobacco industry.72 The tobacco industry fuels, which also exacerbate their vulner- 74-77 targets girls and young women using false ability to lung cancer. images of vitality, slimness, sophistication, Generally, as people age, their activity levels 71 sexual allure, and autonomy. tend to decrease; older women are less active While tobacco causes similar health problems than older men, at least in terms of deliber- for men and women, it poses some addition- ate exercise (they may be more active than 78,79 al threats in ageing women. These threats men in everyday chores). Barriers to include an increased risk of cardiovascular activity for ageing women include cost and disease and bone fractures due to reduced access, lack of time due to work and fam- bone mass.71 There is conclusive evidence ily responsibilities, disparities in income that the effects of smoking on women in- and education, cultural restrictions, a lack clude pre-cancerous changes of the cervix, of social support (including inadequate and cervical cancer, which is the lead- counselling by physicians) and low self- ing cause of cancer in women worldwide. efficacy (for example, feeling less physically 80 Some studies have shown that women who competent). smoke are more likely to experience certain menopausal symptoms such as hot flashes, night sweats and insomnia as well as early menopause.73

PAGE 27 Compelling evidence links physical activity developed countries, rates of obesity are with healthy ageing, such as improvements climbing quickly in developing countries as in physical and mental health, as well as the availability of foods that are affordable disease prevention and control, enhanced and high in fat and sugar increases world- emotional and social well-being, improved wide and people adopt more sedentary mobility and balance, and increased au- lifestyles. The number of older people who tonomy and independence. Older women are overweight (those whose body mass who are active are at lower risk of osteopo- index is 25 or above) and obese (body mass rosis, cardiovascular disease, obesity, back index above 30) has increased dramati- pain, and falls.78 Physical activity may also cally in recent years. For example, among be an antidote to the unpleasant side effects adults aged 60-69 in selected cities in of menopause experienced by some women Latin America and the Caribbean, 61% are and can help prevent or reduce the weight overweight and among these about half are gain and the increases in abdominal fat that obese.85 This trend is projected to continue often accompany middle-age.81 unless dramatic steps are taken. The largest increase is projected to be among women Healthy eating enhances resistance to dis- from upper middle-income countries.86 eases such as cancer, promotes optimal brain functioning, and helps prevent osteoporosis Among ageing women, obesity increases sus- and other chronic health problems. There ceptibility to a number of diseases and chron- is some evidence that the incidence rate of ic conditions such as endometrial cancer atherosclerotic disease is significantly less and gallbladder disease, and may encumber in women who eat 5-10 servings of fruit and mobility by exacerbating conditions such vegetables per day compared with those as osteoarthritis, which is more common in who eat 2-5 servings.82 Because of increased women than in men. Obesity puts women risk for low bone density after menopause, at greater risk of developing diabetes than older women need increased calcium in- men. Often, low socioeconomic status is take and regular weight-bearing activity.83 linked to a higher risk of obesity and to Vitamin D is also essential for both bone developing diabetes. and muscle strength. Serious deficiency of Type 2 diabetes, which is closely associated vitamin D is common among those who are with obesity, can be prevented by weight housebound or in nursing homes and long control and physical activity. Studies in stay wards, and has been identified as an China, Finland, and the USA have shown important public health problem.84 that even a moderate reduction in weight Once considered as solely as a problem for and only half an hour of walking each day reduced the incidence of diabetes by more than one half.87

PAGE 28 Women, Ageing and Health: A Framework for Action

Obesity and a lack of exercise are major Available evidence clearly indicates that contributors to urinary incontinence, which healthy lifestyle practices such as nutritious is two to three times higher among older eating, regular physical activity, not smoking women than among older men. In old age, and moderate or no alcohol use as proactive, incontinence is a predictor of the loss of non-prescription approaches are effective in independence and a key factor in institu- dealing with the symptoms of menopause. tionalization. Other causes of incontinence, Many women also use a variety of supple- especially in developing countries include ments and alternative medicines made from frequent childbirth, poor repair of birth plants, although the efficacy and safety of injuries, and untreated urinary tract infec- these are still inconclusive. tions. In these situations, improved reproductive health in younger women is the best way to prevent incontinence problems in old age.

Diabetes

Approximately 176 million people have diabetes mellitus worldwide and this number may well double by the year 2025.87 Differences in prevalence vary between women and men, and between countries and regions. For example, in Latin America and the Caribbean, the female prevalence of diabetes and obesity is approximately 15 to 20% higher than that for males.85 Overall in Canada, men have higher rates of diabetes than women, although the sub-population with the highest rates is Aboriginal women.88 Women who developed impaired glucose tolerance during pregnancy (gestational diabetes) are at greater risk of developing diabetes later in life if they become overweight. Diabetes greatly accelerates atherosclerosis, more in women than in men.89 In the early stages of Type 2 diabetes, the disease is mostly asymptomatic which is one reason why so many cases remain undiag- nosed. In later stages, it can lead to diabetic ulcers and gangrene requiring amputation and kidney failure.

PAGE 29 Implications for policy, practice and Making the healthy choices the easy choices. research Policies related to income, dental care, Increased attention to health promotion. education, housing and other social factors affect personal health behaviours. Age- and Women are never too old to benefit from gender-specific interventions that address health promotion and self-care initiatives underlying cultural values, practices and that encourage them to remain socially opportunities in the physical environment active, engage in regular physical activity, are needed to make the healthy choices the maintain a healthy weight, and refrain from easy choices. For example, older women behaviours that could have a detrimental who are confined by cultural traditions, or effect on their health, such as smoking, who are housebound looking after an ailing excessive drinking and overeating. Those spouse, have few or no opportunities to en- approaches that promote self-empower- gage in physical activity. Older women who ment and peer-leadership are most likely to do not readily have accessible transporta- be effective. tion may be unable to purchase fruits and While health promotion and prevention ef- vegetables and calcium-rich foods unless a forts should start early in life, programmes market or shop is nearby. should also be available to older women and men. Physicians, nurses and other health- Heading off the tobacco-related disease and social-service workers need to learn epidemic among ageing women. In most how to advise older people to quit smok- countries, some form of government action ing, drink alcohol in moderation or not at (including taxes and legislation) has been all, eat in a healthy way and stay physically enacted to control tobacco consumption active. Social marketing campaigns can and mitigate exposure to second-hand help dispel erroneous beliefs about eating, smoke. Countries that have adopted com- smoking, and exercising in older age. prehensive tobacco control strategies and Guidelines and education. Culturally ap- policies that address prevention, protection, propriate, and gender-responsive guidelines and cessation have seen considerable suc- 90 for healthy eating and physical activity, and cess. These efforts must address gender- which are specific to older people should and age-specific risks. be developed and taught in the community. These guidelines should include gender- specific needs such as increased calcium and vitamin D for women during and after menopause.

PAGE 30 Women, Ageing and Health: A Framework for Action

Research and information dissemination. controversy over optimal weights for older Policy and programme research is needed women and whether body mass index to determine how best to stop the spread of (BMI) measurements are appropriate for cigarette smoking to women in countries older adults given that weight is distributed where their smoking rates are still fairly differently (i.e. less muscle, more fat) as we low. Another important question is how age. This area requires further sex- and age- best to remove barriers, and to enable older specific exploration. women in all countries and varied cultures As this graph shows, the incidence of lung to become and stay more physically active. cancer mortality has increased in women Other priority areas for developing and over the past thirty years in most developed sharing knowledge include how to over- countries. At the same time, the death rate come cultural barriers to healthy living for men has declined in countries such as faced by older women, and the role of exer- Australia and the United Kingdom where cise, smoking cessation and healthy eating men took up smoking earlier than women (including alternative and complementary and have quit smoking in greater numbers supplements) in ameliorating hot flashes over the last 20 years. and other conditions associated with the menopausal period. There is significant

Figure 5. Percentage change in lung cancer mortality rates in selected countries 1968-1998

Percentage changes Male

300 Female 250 200 150 100 50 0 -50 Australia Canada Denmark France Hungary the United USA Kingdom

Source: Parkin D. M. et al. Globoscan (2000). Cancer incidence, mortality and prevalence worldwide. Version 1.01. 2001.

PAGE 31 7. Economic determinants

Key points Even in high-income countries, relative Ageing women make an important contribu- poverty and income inequities have a tion to the socioeconomic well-being of their detrimental effect on well-being, functioning and personal health behaviours.12 In families, communities and nations. Much some developed countries, recent increases of this is unpaid and unrecognized work in the gap between rich and poor have hit in caregiving, child-rearing, domestic and older women hard. In the United Kingdom volunteer occupations. A Swiss study cal- for example, the 2003 Labour Force Survey culated the economic value of family care showed that one in four single women pen- work to be between 10 and 12 billion Swiss sioners lived in poverty and twice as many francs, exceeding the cumulative spending women as men relied on means-tested on both home-care services and residential benefits in retirement.94 care homes.91 In Africa and other areas hard hit by the HIV/AIDS pandemic and Discrimination in wages, employment, the migration of men and young women in and pension policies hurts older women. a search of jobs, older women are increas- Those women, who make up a large pool ingly serving as the financial and emotional of workers in the informal economy (e.g. 92 heads of households. agriculture and petty trading), work until The greatest threat to ageing women’s health is very old age in precarious jobs that have no social security schemes or health care poverty. Poverty compromises older women’s benefits. Older women are increasingly access to food, shelter, health care, social employed in the formal workforce, mostly inclusion and dignity. Women of all ages in low paying and part-time jobs. All over make up 70% of the world’s 1.3 billion very the world, women have lower labour force poor — those who live on the equivalent of participation rates, higher unemployment less than US$1 per day93 and poverty is often and significant pay differences. Women worsened in old age. The vast majority live earn less than men, even when they have in the developing world where rapid ageing comparable education and training.93 Most has not been accompanied by the increase in significantly, women’s earning power is wealth experienced by industrialized coun- interrupted by pregnancy, childrearing tries. In all countries, some groups of women and (in mid- and later life) caregiving are especially vulnerable to poverty: older responsibilities. This means that even the women who are widowed or divorced, women small proportion of older women who are with disabilities, those who are looking after eligible for pensions because they were AIDS orphans, grandchildren and other fam- employed in the formal sector, receive ily members, refugees and immigrants, and lower benefits than men. women in visible minority and indigenous groups.

PAGE 32 Women, Ageing and Health: A Framework for Action

Undernutrition and older women

Undernutrition is closely related to household food security — the ability to produce or buy adequate, safe and good quality food to meet the dietary requirements of all family members at all times. While most undernutrition occurs in poor countries, it can also occur among older women in privileged societies, in pockets of poverty, social isolation or neglect. The loss of teeth and a lack of access to dental care exacerbates eating and nutrition problems among older people. Undernutrition can result in decreased muscular strength, lowered resistance to infection, and inadequate body weight for height, which in turn, can lead to reduced bone mass and fractures, reduced autonomy and higher mortality rates. Accumulating evidence also suggests an important relationship between the incidence of age-related cataracts and nutritional status.83

Older women are often excluded from Income security benefits and accessible, af- development programmes, including credit fordable health services are the bedrock of schemes, help for small businesses, farm- protecting the well-being of older people. It ing, and community development projects. has been demonstrated that it is feasible to This is unfortunate since studies show that provide older people with a small, universal collectives of ageing women can be highly old-age pension and that whole families successful in development projects and in benefit from this policy. For example, in repaying loans, and that older women rely Brazil and South Africa, the social pension upon a diverse range of activities to sustain programmes reach a large number of older themselves and their families.95 people at relatively low cost and attract a large measure of political and public sup- Women are more likely than men to be port. 98 Family support and access to health widowed. Widows invariably experience a care are also recognized as important reduction in income and are highly vul- pillars to old age security and improved nerable to poverty.96, 97 In some countries, health.99 inheritance laws still discriminate against women; in others, it is common practice for male relatives to take possession of a widow’s property and possessions, even when the laws demand otherwise. Ageing women who divorce may be even more vulnerable to poverty than widows.

PAGE 33 Implications for policy, practice and Governments, employers and civil soci- research ety must ensure that widows and divorced women are not left destitute and excluded Income and health security. Ultimately each by enacting and enforcing laws that pro- country must decide on the best mix of hibit gender discrimination in inheritance policies and practices in taxation, income practices, access to property, pensions and security, health care and social services that resources, and cultural practices that harm are needed to maintain the economic well- women whose husbands die or divorce them. being and health of older women. In very old age (80-plus) women far out- The most urgent need is to ensure that all older women have access to the basic neces- number men in the same age category. It is prudent therefore to encourage women to sities of life, including food, clean water, prepare financially for old age (and in many shelter, primary health care and social cases to live alone) and to promote a mix of support. Assisting older women who live public and private sources of income in old in poor rural areas and in urban slums will age. Financial aid and social support should help address some of the world’s poorest be provided for families who care for older people. women and men who are unable to live The second most important need is to independently. increase opportunities for older women to Support for the caregiving role. participate in development and anti-poverty By approach- programmes, and in productive, paid and ing caregiving through a gender lens across the life course, decision-makers, nongov- decent work when they are able and will- ernmental organizations, civil society and ing to do so. Providing credit, informa- the private sector can promote family- tion, services, training, social security and friendly solutions that address the dispro- health care benefits to older women would portionate financial burden that caregiving enhance their productivity and support imposes upon women.100 Childcare and their efforts to maintain themselves and eldercare require policies that protect care- their families. givers from losing their jobs or receiving re- Providing a basic old age pension that is not duced benefits, and provide employers with tied to work in the formal sector is one of incentives to support the care of dependent the best ways to improve older women’s family members. health and that of their families. Other A coordinated response to HIV/AIDS must policies that will reduce inequities include acknowledge and financially support the extending employer-provided pensions and caregiving roles and contributions of older benefits to part-time workers and facilitating people (and particularly grandmothers) in the access to health security and primary health fight against IH V/AIDS. Enabling the partici- care through health cooperatives for ageing pation and representation of older people, women who work in the informal sector. and older women in particular, in HIV/ AIDS programme planning at local, district

PAGE 34 Women, Ageing and Health: A Framework for Action

and national levels will help to improve the to credit and resources to buy food, medi- lives of all who are infected and affected by cine and other essentials for not only the HIV/AIDS. older person but also for his/her family. 98

Changing attitudes. Many societies view Research. A better economic analysis is older people and older women in particular needed to improve the visibility of work as a drain on society. In their efforts to re- involving in informal care and to assure duce poverty and improve the quality of life that this work is included in the national for older women, policy-makers and prac- and global picture of social and economic titioners need to envisage them not only as statistics. Other research and information recipients of protection and assistance, but dissemination priorities include identifying: also as agents of change and development • effective ways to reduce poverty and who can help identify solutions for the increase older women’s participation in problems affecting them. development activities; International solidarity. Despite the fact that • the long-term impact of informal care- poverty is usually greater in old age and giving in various settings, from both that gender is a cross-cutting issue in all the the perspective of the caregiver and the Millennium Development Goals, no specific care recipient — especially in relation to mention is made of older women and men in HIV/AIDS, dementia and adult children the prescribed goals, targets and indicators. with disabilities; This exclusion of older people may contribute to the failure to reach the Millennium • the best 'policy and programme mix' to Development Goals by 2015, unless reme- support older women caregivers; dial action is taken. For instance, the non- • contributory pension schemes that have effective ways to reduce the gender gap been adopted in Brazil and South Africa in wage earnings and to encourage age- indicate that households which comprise an ing women to work longer; and older person are less poor than those which • effective ways to provide income and do not. The pension received by the older health security to ageing women who person is often the only regular source of in- work in the informal sector, or without come for the entire family, providing access wages in the home.

Grandmothers looking after their dying children and AIDS orphans

Grandmothers comprise the majority of older caregivers who care for people with HIV/ AIDS and orphans with AIDS. Since they have depleted their resources on medicines and burials and because there are few or no younger adults left to help earn an income, most of these families of the 'young and old' face desperate poverty, accompanied by stigma and isolation. It is estimated that there are over 12 million AIDS orphans in Africa and that this number will more than double over the next decade.101,102 and yet the older caregivers who look after these orphans are rarely recognized or supported in current HIV/AIDS policies and interventions.

PAGE 35 8. Social determinants

This chapter deals with some of the most Social exclusion is often the result of discrimi- important social influences on active age- nation based upon gender, age, race, ethnic- ing: education and literacy, violence and ity, ability and socioeconomic status. Older, abuse, ageism and social exclusion, human minority women may face triple jeopardy rights, social support, and leadership and and suffer poor health as a result of social empowerment. Family support and living exclusion based on barriers to education, arrangements are covered in the section on work, citizenship and health care. Older the physical environment. women in transitional societies such as those in eastern and central Europe may Key points experience a deep sense of social isolation, People with a low level of education have in the face of massive political and social shorter lives and fewer years in good health upheaval and unemployment, in addition to than people with a higher level of education. the early deaths of their husbands.109 Some studies have shown that this inequal- Widows are particularly vulnerable to social ity in health expectancy is greater in women exclusion. In addition to the reduction in than men.103,104 income that invariably follows the death Worldwide, women age 60 and over have of one’s spouse, widows in some cultures extraordinarily high levels of illiteracy, and suffer social stigma, taboos, and restric- the gender gap between women and men tions that are detrimental to their mental is predicted to persist.105 Older indigenous and physical health. For example, the women bear the burden of the highest rates approximately 33 million widows in India of illiteracy, even in countries with high are expected to lead chaste, isolated and 110 literacy levels. This limits their ability to austere lives. be active citizens, workers and members of Older women are more likely than older men their society, and infringes on their access to engage in volunteer work in the com- to fundamental human rights.106 munity. In Australia, the value of unpaid Older women are vulnerable to loneliness due voluntary work outside the home by older to their greater longevity, and incur a high women is estimated to range from AU$670 111 likelihood of being widowed, living alone, to AU$975 per woman per year. and experiencing an increased number of years with declining health.107 At the same time, women are more likely than men to have a social support network centred on close relationships with family members and friends.108

PAGE 36 Women, Ageing and Health: A Framework for Action

Abuse and gender-based violence in the Ageism (negative attitudes and discrimination home and community affects older wom- based on age) is a concern for both women en.112 Many older women who are abused and men; however, it can be particularly or neglected were and sometimes still problematic for ageing women. The me- are caregivers to those who abuse them; dia and prevailing attitudes often portray parents who provide their adult children men as ageing with wisdom, while women and/or grandchildren with food, shelter, become 'invisible' in middle-age and are spending money and love; or partners who viewed as a burden in older age. This dis- are looking after spouses who have been advantage is, in part, due to a tendency to diagnosed with a chronic illness. In conflict equate women’s worth with beauty, youth, and situations where law has broken down, and reproduction. isolated older women are not excluded in the widespread incidences of rape and other Elder abuse human rights violations linked to gender- Elder abuse is “a single or repeated act, 113 based violence. or lack of appropriate action, occurring Older women, like other groups in soci- within any relationship where there is an expectation of trust, which causes harm ety, must have legal protection for the full or distress to an older person”. Older range of internationally accepted human women who are abused are more likely rights. Despite being signatories to the to suffer from depression, anxiety and UN Convention on the Elimination of all physical disabilities. The effects may also Forms of Discrimination Against Women be fatal as a result of homicide, severe (CEDAW), many countries still discrimi- injury, neglect, or suicide.112 nate against ageing women through unequal rights to marry, divorce, acquire Implications for policy, practice and nationality, inherit property, seek employ- research ment, be protected from abuse and obtain Education and literacy. Eliminating gender access to credit and health care.114 disparity in primary and secondary educa- Older women are under-represented in position (one of the Millennium Development tions of leadership and power at community, Goals) will help improve literacy levels in national, and international levels. This is generations to come. At the same time, it especially true for women in low-income is essential to address the literacy needs circumstances where the interaction be- of ageing cohorts now. Governments, tween poverty and social exclusion creates civil society, and employers need to make barriers to social, political, and economic special efforts to support the participation participation. of midlife and older women in literacy, skills and job training, and lifelong learning activities.

PAGE 37 Social support and social exclusion. Policies Cruel and violent practices against wid- and practices that encourage social support ows and older women who are branded as and discourage social exclusion include witches must be stopped. Policy-makers those that: and law enforcement officials need to be aware that violent acts such as rape and • involve older women in all levels of slavery in lawless situations affect older – as planning and remove the social barriers well as younger – women. Action must be to participation; taken to deal with and prevent atrocities • increase opportunities for older people committed against older women such as – especially those who live alone, are rape and sexual coercion, as well as street disabled or are members of minority crimes and financial abuse. groups – to interact; Ageism and human rights. Policies need to • foster intergenerational activities and adopt a rights-based approach that allo- relationships; cates older women their fair share of national and global resources, and is faithful • reach out to widows and members of to the United Nations Principles for Older indigenous populations; and People: independence, participation, care, self-fulfilment and dignity. • encourage and enable older women to make use of their productive potential Parents and teachers, business leaders, by volunteering for work. nongovernmental organizations and older women themselves all have key roles to play Elder abuse and societal violence. A com- in changing misconceptions and nega- prehensive approach to the prevention and tive attitudes towards ageing women. It is amelioration of violence against women of particularly important to encourage the all ages includes strengthening the capac- media to make ageing women more visible ity of law enforcement and justice officials through increased attention to their contri- to respond to complaints. This response butions, needs and rights. should include protecting the victims and punishing the perpetrators, establish- Leadership and empowerment. Supporting ing support services in the community the development of organizations for older and supporting collaborative efforts with people, networks, and self-help and advoca- nongovernmental organizations. Groups cy groups will help empower older women working in the areas of ageing and women’s and strengthen their capacity to represent rights need to advocate for these actions their own interests. Women’s groups need on behalf of older – as well as younger – to encourage older women to participate women. Grandfathers, fathers and male and take leadership roles, and to ensure leaders can assert the responsibility of men that advocacy and educational efforts for to condemn gender and age stereotyping and to commit to preventing crimes against women of all ages.

PAGE 38 Women, Ageing and Health: A Framework for Action

Figure 6. Male and female illiteracy rate at ages 60 or over and gender gap: 105 less Figure 6. Percentage of labour force participation by people 65 and older, by region developed countries, 1980-2010 Percentage Percentage changes 45 90 Male 40 80 35 1995 70 Female 30 2000 60 25 2010 50 Gender gap 20 40 15 30 10 20 5 10 0 0 Africa Asia LAmC NAm Oceania Europe 1980 2000 2010 LAmC: Latin America and the Caribbean NAm: North America Source: ILO, 2000

Source: World Population Ageing 1950-2050. United Nations, Department of Economic and Social Affairs, 2005 women’s health and rights include those • accurate reporting of the levels of elder of older women. International measures abuse, domestic violence and communi- of gender equity should be applied and ty violence experienced by older women expanded to document the ages of women and older men; leaders in business, politics and academia. • best practices to address elder abuse and Research and information dissemination. violence against older women and older Areas requiring further investigation in- men in all its forms; clude: • the treatment and coverage of older • how best to address inequities in lit- women by the media; eracy and education among current • infringements upon and policies and cohorts of older women and to ensure practices related to the human rights of that future cohorts have better access to older women (e.g. rights to inheritance, literacy and lifelong learning opportuni- property, marriage, health care); and ties; • participation of older women in politics • how to best address the social exclusion and leadership roles. of widows and the infringement on their human rights in some cultures;

PAGE 39 9. The physical environment

Key points who live with their families are neglected, abused or abandoned in the face of unem- Gender, sex and age interact to make older ployment, overcrowded housing, alcohol women particularly vulnerable to hazards abuse and gender discrimination exacer- in the physical environment. bated by age and frailty. Older women are particularly vulnerable to Older women have become increasingly likely illness and death related to indoor air pollu- to live alone in the last several decades. This tion. Indoor air pollution that results from trend has been most noticeable in indus- burning coal and solid fuels to meet basic trialized countries although it is beginning energy and cooking needs is a public health to happen in developing countries as well. tragedy, resulting in nearly 500 000 deaths Older women who live alone and tend to each year among women.115 be divorced or widowed are more likely to Extreme weather conditions strongly affect experience greater levels of poverty and to older people. In 2003, when record-high be institutionalized than those who live temperatures in Europe claimed an esti- with family members. They are also more mated 35,000 lives, most of the victims likely to feel isolated and depressed, and to were older citizens and people with chronic require services from the state in the form illnesses. In very cold climates, older wom- of home help — although family members en are particularly vulnerable to mortality (particularly daughters who live nearby) in winter116 and to broken bones resulting still provide the majority of care and sup- from falls on icy streets and sidewalks. port. 117-119

In developing countries most older women In developing countries, when men and live with family members. In situations of young women migrate in search of work, co-residency with family members, there older women often become heads of house- is most often an agreeable exchange of ser- holds. In these situations, distance and vices and support. Older women often sup- access to public transport become primary ply a significant amount of services (such as factors in terms of mutual support. When child care and domestic duties) that benefit adult children are unable to travel home younger people. But rapid social and eco- regularly, older people ultimately receive nomic changes combined with a reduced reduced social support and the little fi- pool of caregivers, have put enormous pres- nancial help that children had promised to sures on families and kin. Some families send home may not arrive.120 are unable to share their small homes with older relatives. In some cases, older women

PAGE 40 Women, Ageing and Health: A Framework for Action

Ensuring that older women have access to Accessible public transportation is critical for affordable, safe, and appropriate shelter is maintaining independence, and carrying out central to their well-being.121 Older women everyday tasks such as shopping, getting to who are widowed may find that they cannot appointments and socializing. This is espe- afford to repair or modify their house to cially important for older women because meet their age-related needs. Those who they usually carry out these duties and even live in dwellings in poor repair are at espe- in developed countries they are less likely cially high risk of falls. than men to have access to a car.

Women and girls in households without electricity or piped water are heavily burdened The cost of falls with the tasks of water and fuel collection. The consequences of falling are more This can lead to musculoskeletal pain and likely to be severe among women disability in later life. Some 1.7 billion peo- because of lower bone density and ple currently lack access to safe water and the higher incidence of osteoporosis. this number is expected to reach 2.3 billion Approximately 2 million hip fractures are by 2025.122 Surveys in Africa and Asia show estimated to occur worldwide in 2025, that more than half of households in rural the great majority among older women. Hip fracture almost always leads to areas are without electricity.123 hospitalization and often causes death. Older women are especially vulnerable in Convalescence is prolonged and many disaster situations because they lack infor- women never return to the same level 61 mation, mobility and resources. Those that of functioning. Efforts to prevent falls survive face desperate circumstances and can mean large savings to the health care system. For example, the Public barriers related to access to shelter and Health Agency of Canada estimates that food. At the same time, older women make a reduction in falls by 20% could result in an important contribution during emergen- an estimated 7,500 fewer hospitalizations cies (for example, as caregivers and birth and approximately $138 million annually attendants). These capacities are seldom could be saved nationally.126 acknowledged and older women are rarely included in decision-making and leadership roles related to disaster risk reduction, management and recovery.124, 125

PAGE 41 Figure 7. Estimates of the number of hip fractures by sex and region 1950-2025

HIP fractures (thousands) Rest of the world 2000 North America Europe Women Men 1500 Asia

1000

500

0 1950 1965 1980 1995 2010 2025 1950 1965 1980 1995 2010 2025

Source: Prevention and Management of Osteoporosis. Report of a WHO Scientific Group. World Health Organization, 2003

relatives, housing designs that enable multi- Implications for policy, practice and generational living and community centres research that can be used by older people as meeting places and clubs.127 Indoor air pollution. In the short term, deaths and disability caused by indoor air Ageing in place adapting to functional pollution from solid fuels can be reduced impairments without moving from “home” and prevented by better stoves and hous- is the choice of most people. Older women ing designs. In the longer term, the use of may require help with home repairs and cleaner fuels and electricity can eliminate other services. The use of new technologies this public health tragedy. to enable older people to remain independent in their homes has great potential. Housing and living arrangements. As the number of older women who live alone Age-friendly cities and communities will continues to increase around the world, address many of the factors in the physical policy-makers need to ensure that a vari- environment that help determine the state ety of living arrangements are available. of older women’s health, such as barrier- In situations where independent living is free interior and exterior spaces; public economically impossible or culturally inap- spaces that encourage active leisure and so- propriate, it is important to foster intergen- cialization; appropriate, accessible housing; erational relationships and co-residency by supporting families who care for older

PAGE 42 Women, Ageing and Health: A Framework for Action

hazard-free streets, sidewalks and build- • how best to support families who pro- ings; safe, accessible public transportation; vide a home to older women; and secure, supportive neighbourhoods. • innovative housing options, especially Local governments are uniquely positioned for older women who are poor and to support age-friendly built environments alone; by coordinating decision-making, promot- • effective strategies for preventing falls ing awareness and implementing commu- in a variety of settings; nity design plans, strategies and policies 128 that support age-friendly environments. • ways to reduce mortality and morbidity linked to pollution (outdoors and in- Disaster and emergencies. When formulat- doors) and extreme weather conditions; ing disaster relief and reduction measures, policy-makers and nongovernmental orga- • application of new technologies and nizations need to systematically assess gen- designs for assisted living in the com- der- and age-based vulnerabilities, needs munity; and and strengths. This assessment is needed to • ensure equal access for women and men of application and evaluation of age- all ages to services at all stages of a relief ef- friendly principles and interventions in fort, and to include older women in disaster urban and rural settings. risk reduction, environmental management and recovery activities. Cash transfers to The WHO Global Age-friendly Cities project older people are a vital lifeline in the re- In 2006 WHO initiated the Global Age- building process and will benefit both older friendly Cities project with partners in 125 people and their families. several countries. Partners first consult Research and information dissemination. with older persons, and then with community leaders and experts to identify Priority areas for increasing our under- the major physical and social barriers standing of how to make physical envi- to active ageing. Each partner uses this ronments more age-friendly and gender- knowledge to develop, implement and responsive, include: evaluate local action plans to make the • innovative and practical ways to make environment more age-friendly. To share the findings, WHO compiled the results transportation and buildings more into practical 'age-friendly city' guide- accessible for older people with disabili- lines that could be used by cities around ties; the world. 129 • pros and cons of living arrangement options for older women who live alone;

PAGE 43 10. Moving ahead

This report provides a comprehensive Taking action framework for taking action. Decision- Active ageing pillar 1: health and health makers will need to decide how best to ad- care dress – within their own settings – the key findings and implications described in this Numerous international agreements affirm report. This should be done in consultation the right of all people to the highest possi- with ageing women themselves, nongov- ble level of health and access to appropriate ernmental organizations and civil societies, health care services. However, older women academics, and professionals working in are often forgotten, ignored or invisible health care, economics, the labour market, in efforts to achieve health for all — even housing, transportation and other sectors. though they are often crucial to the real- In so doing, it is critical to recognize that ization of this goal. Decision-makers can improving health requires intersectoral redress these inequities through policies action in a variety of spheres and working that enable active ageing and address the collaboratively towards a common goal of key issues described in this report. Because improved public health for all. of the potential costs associated with living for many years with illness or disability, No single organization, group, or sector is and the important contributions that age- likely to have sufficient resources to tackle ing women make to informal health care, the complex issues related to the gendered investing in their health is both a humani- dimensions of ageing. This is all the more tarian and economic necessity. true because the solutions needed to ensure active ageing often fall outside the health Priority areas for action include: sector. Partnerships and collaboration • reducing the dramatic inequities in life among organizations and sectors is essential. expectancy among different groups of Nongovernmental organizations concerned women both within and among coun- with gender, as well as with those con- tries and regions; cerned with ageing issues, have a key role to • establishing or strengthening pro- play in advocating and enabling policy and grammes, policies, services and research practice changes at local, regional, national efforts that address the prevention and and international levels. Leaders in these management of chronic diseases and two areas must work together to ensure conditions that significantly affect age- that both age and gender lenses are simul- ing women. Particular attention needs taneously applied to policy and programme to be paid to disabling conditions such development. as arthritis, osteoporosis and dementia; eliminating inequalities in vision care

PAGE 44 Women, Ageing and Health: A Framework for Action

and in the management and treatment • informing ageing women about healthy of health problems (such as heart dis- sexuality, HIV/AIDS and other STIs, and ease) that have traditionally been con- providing high-quality services related to sidered 'male' diseases; and introduc- reproductive health throughout the life ing new technologies like a vaccine to course; prevent cervical cancer as well as widely • recognizing and supporting the essen- using established technologies e.g. pap tial role that grandmothers play as care- smear screening for older women in low givers for people with HIV/AIDS and and middle-income countries; subsequently as surrogate parents for • establishing or strengthening pro- grandchildren and other AIDS orphans; grammes, policies, services and re- • creating environments that enable and search efforts that promote mental encourage girls, young women and older health and manage mental illnesses that women to be physically active, to re- affect older people. For many women, frain from tobacco use, to eat nutritious it is especially important to increase foods and to maintain a healthy weight. awareness about and reduce the stigma This approach includes the adoption of associated with depression; to protect gender-responsive, comprehensive strate- the rights and dignity of older people gies in tobacco control, physical activity with Alzheimer disease and other forms and diet; of dementia; to reduce gender-based stereotyping related to menopause and the • building capacity among health and use of psychotropic drugs; and to sup- social service professionals who work port the mental health of older people with older people by providing training who have experienced elder abuse or concerning how gender and sex influ- other forms of violence at any stage of ence health; their lives; • recognizing and supporting the es- • improving ageing women’s access to a sential contribution that ageing women continuum of quality care that is both make as caregivers and major providers age- and gender-responsive, with an in- of informal health care; and creased emphasis on health promotion • for all age groups; reducing gender-related exposure to second-hand smoke and to indoor air • creating age-friendly, gender-responsive pollution from cooking fuels. primary health care services;

• providing gender-responsive options in long-term care and palliative care in both community and residential settings;

PAGE 45 Active ageing pillar 2: participation • improving opportunities for ageing women During the last 20-30 years, the world’s to engage in decent work when they want governments have affirmed their com- to or need to do so. This requires policies mitment to promote and protect the full that remove employment barriers and enjoyment of human rights and participa- age- and gender-based discrimination; tion by all women throughout their life recognize work in the informal sector of course. CEDAW (1979), the International the economy; and support employers who Conference on Population Development respond to the needs of ageing women (Cairo, 1994), the Fourth World Conference facing intensive long- or short-term care- on Women (Beijing, 1995) and the Second giving demands; World Assembly on Ageing ( Madrid, 2002) • supporting intergenerational efforts and were central to a major policy shift in cooperation to improve the economic, this direction. But progress has remained social and physical well-being of both the uneven and many challenges remain. One older and younger generations; of these challenges is the full inclusion of women in general, and older women in • recognizing, valuing and supporting the particular, who often face discrimination unpaid work that ageing women do in the based on both age and gender in many sec- home and community; tors of society. • addressing the literacy needs of ageing Ageing women make substantial economic women and redressing the large gender and social contributions to society. They gaps in literacy levels between women and also represent an important and growing men; political constituency in both developed and • providing equal access to primary, second- developing countries. Recognizing and sup- ary and tertiary education for girls and porting their full participation – regardless boys, and to lifelong learning and training of socioeconomic status and ethnicity – will opportunities for ageing women and men; benefit the health and well-being of individuals, families, communities and nations. • supporting the social inclusion of all ageing women and reaching out to isolated older Priority areas for action include: women by creating environments that en- • dispelling misconceptions, negative able their physical and social involvement attitudes and stereotypes about older in community life; women; • supporting organizations and groups that • empowering older women to take an are working to develop ageing women’s active role in economic growth and the empowerment and leadership capacities at development process; all levels; and

• involving older women in decision-making related to political, social, spiritual and economic issues at all levels.

PAGE 46 Women, Ageing and Health: A Framework for Action

Active ageing pillar 3: security • providing equal access to health secu- Poverty and poor health go hand-in-hand. rity and health services for older women Through the first Millennium Development and men; Goal, governments and international agen- • ensuring food security and safe, secure cies have committed to reducing and elimi- living arrangements for older women; nating poverty. All over the world women are poorer than men, and in most countries, • preventing, reducing and eliminating female poverty deepens with age. Despite elder abuse and violence against ageing this situation, and the fact that gender is a women in all its different forms; cross-cutting issue in all the Millennium • ensuring respect for widows' rights to Development Goals, no specific mention is property, dignity, freedom of movement made of older people in the prescribed goals, and self-fulfilment; and targets and indicators. Similarly, as awareness and action to confront violence and • ensuring that ageing women’s human abuse against younger women gain support rights are respected and protected — within the health sector and beyond, older particularly in times of emergency, women consistently remain outside the disaster, and conflict. scope of most advocacy campaigns, direct interventions and research. A lack of policies Building a research agenda and programmes that ensure the rights of This report highlights some of the research older women and enhance their economic and knowledge gaps that hamper our ability and physical security jeopardizes their to formulate policies and programmes that health and their ability to remain active reduce gender inequities and effectively contributors to their families, communities promote active ageing. This section sum- and nations. marizes some key priorities for knowledge Priority areas for action include: development and sharing under each of the three pillars of active ageing. Underlying • preventing and reducing poverty among each of these is the urgent need for in- older women, especially older women creased surveys, studies, and policy analy- who live alone and those in indigenous ses in developing countries. Developed and minority groups who suffer addi- countries can play a key role in improving tional discrimination; our understanding of the global picture of ageing women’s health by providing tech- • reducing income inequities between nical assistance and funding for research various groups of older women both efforts in less developed countries. within and among cities, countries and regions;

• providing equitable access to sustain- able social security options for older women — including non-contributory pensions;

PAGE 47 Health and health care – the long-term impact of informal Increase our understanding of health issues caregiving in various settings from related to ageing in women and the effec- both the perspective of the caregiver tiveness of various interventions, through and the care recipient — especially in the following measures: relation to HIV/AIDS, dementia and adult children with disabilities; • Include ageing women in all medical research and clinical trials on diseases and – gender perspectives, expectations and health conditions that affect them, both experiences of long-term care options; as subjects and in advisory functions. and

• Ensure that all data are age- and sex-dis- – more detailed evidence on the dif- aggregated and published in that format, ferential use of medications by older and extend all data gathering to include women and men and whether gender the oldest old (age 80-plus). is systematically associated with inappropriate use. • Priority areas for developing and sharing knowledge should be centred on Participation strengthening primary health care and Increase our understanding of issues and include: solutions related to the participation of older women in work, development, edu- – ageing women’s experience with abuse cation, training and literacy, community and violence, in terms of cumulative activities, and leadership roles through the exposure and in exposure specific to following measures: older age; • Include older women at each stage of the – ageing women’s experience with HIV research, and make use of both quanti- and AIDS; tative and qualitative methods. – the modern experience of midlife in • Make use of composite indices such as a variety of cultures and settings, in- the Gender Empowerment Measure cluding the physical and sociocultural (GEM) and the Gender Development changes related to menopause; Index (GDI) which measure women’s – the experience of widowhood in a empowerment at all stages of the life variety of settings and cultures; course. • – how the social determinants of health Clarify the unpaid contribution of age- differentially affect disease causality ing women caregivers to the economy and health status (both mental and and suggest practical ways to recognize physical) among women and men; and reward this contribution.

PAGE 48 Women, Ageing and Health: A Framework for Action

Security Final Remarks Increase our understanding of security is- Policies and practices that support health sues and solutions related to gender differ- and active ageing for all will benefit women ences and the experiences of ageing women. as well as men. However, it is also criti- Priorities for knowledge development and cal to understand and act on the gendered sharing include: dimensions of ageing. Many older women continue to face inequities related to health, • elder abuse and violence in the broader security and participation. Often, they face community and in times of conflict and stereotyping and misconceptions that por- disaster; tray them as a burden or as invisible. • the dynamic relationships between liv- On a daily basis and around the world, ing arrangements, intra-family transfers older women make life better for their and the health of older people, paying peers and succeeding generations, in both special attention to urban-rural and small and large ways. It is time to celebrate gender differences; and those contributions and to provide ageing • innovative health and social poli- women with full human rights; a positive cies that prevent and alleviate pov- quality of life, love, and care throughout the erty among women and their families life course; and an environment that sup- throughout the life course. ports active ageing.

PAGE 49 References

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