WOMEN'S HEALTH SEAlES volume 2 Women's Experiences of Aging in the Western Pacific Region: A Diversity of Challenges and Opportunities WHO 'WP/!() LIBRilD "'lI.'lI,iJ/.a pa,~ '~ir~t ~ ~~~~..,.~7J::;: World Health Organization Regional Office for the Western Pacific Manila 1995 Copyright © World Health Organization 1995 This document is issued by the World Health Organization - Regional Office for the Western Pacific (WHOIWPRO) for general distribution. All rights are reserved. Subject to due acknowledgement to WHOIWPRO, this document may, however, be freely reviewed, abstracted, reproduced or translated, in part or in whole, provided that such is not done for or in conjunction with commercial purposes and provided that, if it is intended to translate or reproduce the entire work, or substantial portions thereof, prior application is made to the Maternal and Child Health Unit, WHOIWPRO, Manila, Philippines. The views expressed in this document are those by the principal contributor and do not necessarily reflect the policies of the World Health Organization. .. Map of the WHO Western Pacific Region NORTHERN . MARIANA ISLANDS GUAM, MARSHALL FEDERATED STATES OF '. ISLANDS M.ICRONiOSlA :.KIRIBATI NAURU .. !OKELAU SAMOA ." 'AMERICAN SAMOA \ Fur .. • VANUATU NI!,JE FRENCH " TONGA NEW COOK' POLYNESIA CALEDONIA ISLANDS j, ~ NEW ZEAlAND Contents Foreword v Acknowledgements vii l. Introduction 2. Background 3 2.1 Initiatives 3 Global 3 Regional 4 2.2 Regional diversify 5 2.3 Defining the older woman 6 3. Key issues 9 3.1 Changing demographics and the need 9 to plan for the future lhe demographic shift is female 12 3.2 Influences on health - the life course approach 13 Political history in the lifetime of older women 13 Economic history in the lifetime of older women 15 Education and Health 17 Religion and health 18 3.3 Lack of adequate research and data 19 Why women's health? 19 Indicators of health status 22 Health indicators in the Western Pacific Region 23 Social indicators 24 llL 3.4 Morbidily and mortalily 26 Morbidity 26 Mortality 28 3.5 Qualily of life 31 Indicators for qualily of life 31 Disabilily Adjusted Life Years (DAL Ys) 32 and Qualily Adjusted Life Years (QALYs) 3.6 Caring and health provisions 38 Older women as providers of health care 39 Older women as consumers of health care 40 3.7 Agism and sexism 42 Death and dying 45 4. Country initiatives 47 Issue No. 1 - Changing demographics 47 Issue No.2 - Influences on health - life course approach - ff) the context of older women's health Issue No. 3 - Lack of data 52 Issue No.4 - Mortalily and morbidily 55 Issue No. 5 - Qualily of life 61 Issue No. 6 - Communily care 63 Issue NO.7 - Agism and sexism 75 5. Conclusions and recommendations 79 Conclusions 79 Recommendations 80 Bibliography 89 Foreword The objective of the monograph is to give voice to the diversity of health needs of current and future generations of older women in the Region. It thus aims to put into practice the key recommendations of forums addressing women's health concerns which have emerged over the past two decades since International Women's Year in 1975. The Western Pacific Region currently has one-third of the world's population over the age of 65. More than half are women. With dramatic changes in the demographic structure of both developed and developing countries in the Region the proportion of older women in the Western Pacific is likely to double by the year 2020. Significant forward planning needs to be undertaken to answer the needs of this expanding group in the 21st century. Two key issues need to be addressed in the development of policies to promote the health of older women: the rich cultural diversity of women's experiences of aging in the Western Pacific and the quality of life of older women. This monograph aims to reflect the diversity of women's experiences of aging from backgrounds rendered different by cultural practices, levels of economic development and life expectancy. It also emphasizes the importance of adding life to years rather than just years to life. It represents a synthesis of two fundamental aspects of health in the next century: the health of the aged and the health of women. Women's life expectancy varies in the countries of the Western Pacific from 47.5 years to 81.8 years. Cot;lOOCluentJy, any definition of 'older women' remains problematic. Using menopause as the cut-off point is also difficult since it locates women's health experiences solely within the reproductive realm. Women are more than an amalgam of reproductive organs: their social, economic and political location as women within society determine all aspects of their minds, their bodies and their health and'well­ being experiences. In the preparation of this report we have dealt with these difficulties of definition by allowing countries to adopt their own definition of' older women'. Thus we do not exclude the experiences of the oldest women in societies where life expectancy for women is less than 50 years. For convenience, and acknowledging the limitations of adopting any cut-off point, the monograph has adopted the epidemiological convention of referring to the stages of aging. The life course approach recognizes that experiences and choices at every stage of life influence outcomes in old age. -:-L The fourth United Nations World Conference on Women to be held in Beijing in September 1995 has started a flurry of activity on research on women. In the health field the World Health Organization has established the Global Commission on Women's Health: this has been complemented with preparatory activities at the regional and local levels. In WPRO, a series of documents, of which this is volume two, is being prepared to reflect the most recent research addressing key themes for action identified by the Commission. Readers might ask: Why after two decades of special attention to women's health (which started with the UN Decade for Women in 1975) do we need to launch yet another campaign to promote the health and well-being of a group of people dermed by gender? After all, if we use the least ambiguous measure of health status, mortality rates, in all countries of the WPR women outlive men by an average of five years. However, epidemiological data suggest, without exception, that in terms of reported morbidity, women are in the worse position. This is especially the case for women who outlive their male counterparts and suffer from the "compression" of morbidity into the last ten years of their lives. In relation to existing indicators of economic status, political power, leadership and social standing, women consistently score worse than men. This is exacerbated for older women in societies where women are valued largely for their reproductive capacity. However, it is in subjective reports of quality of life that gender differences become most apparent. Living longer is not necessarily seen as an advantage for women who have a poor quality of life. This monograph ideritifies some of the social, political, economic and cultural factors which circumscribe older women's health experiences and quality of life. However, the report acknowledges that older women are not just victims of their environment, but that they can be actively involved in bettering their environment. The monograph concludes by identifying new initiatives being undertaken by countries in the Region to help secure a better quality of life for older women, and making recommendations for healthy aging. f)4~ S.T. Han, MD, Ph.D. Regional Director Acknowledgements We would like to thank Dr Elizabeth Eckennann, principal contributor to this monograph. This report was based on information collected from around the Region including country reports and discussions with participants at the Regional Workshop on Community Care for the Elderly in Manila in March 1995. The contributions of the following individuals and organizations are greatly appreciated: Dr Kongsap Akkhavong, Chief of Intemational Clinic and Geriatrics, Mahosot Hospital, Lao People's Democratic Republic; Professor Gary Andrews, Centre for Aging Studies, Flinders University of South Australia; Heather Birch, Executive Office, Aged and Community Care Branch, Commonwealth Department of Human Services and Health, Melbourne, Australia, Dr Tak-kwong Au. Department of Health, Hong Kong; Dr Ruth Bonita, School of Medicine, the University of Auckland; Warwick Bruen, Assistant Secretary, Community Care Branch, Department of Human Services and Health; Carol D' Audney, Ministry of Health, New Zealand; Gilda Estipona, Department of Health, Philippines; Susan Feldman, Director, Alma Unit for Women and Ageing, Key Centre for Women's Health in Society, The University of Melbourne; Anna Howe, La Trobe University; Dr Sunia Foliaki, Ministry of Health, Tonga; Dr Salesi Katoanga, UNFP A, Fiji; Lee Cheong-Ja, Director, Resource Development Department, Korean Women's Development Unit; Diane Morris, Ministry of Women's Affairs, New Zealand; Mesepi Mulitalo, Health Department, Apia, Samoa; Lillian Nakamura, Office of the Ministry of Social Services, State Unit Agency in Aging, Republic of Palau; National Health Planning Unit, Ministry of Health, Republic of Vanuatu; Dr Nor Aini Bt. Mohd. Noor, Ministry of Health, Malaysia; Janette Padasian, Sabah Tourism Promotion Corporation; Anne Riggs, Research Fellow, Centre for the Body and Society, Deakin University; Hong-kwon Shin, Ministry of Health and Welfare, Republic of Korea; Dr Yoichi Takigawa, Ministry of Health and Welfare, Japan; Dr Tingika Tere, Medical Officer, Ministry of Health, Cook Islands; Professor Tran Duc Tho, National Institute of Gerontology, Vietnam; Heleena Togakilo, Women, Youth and Sports Officer, Department of Community Affairs, Government of Niue; Sister Mereani Tukana, Divisional Health Sister, Ministry of Health and Social Welfare, Fiji; Dr Gim Hong Yap, Tao Payoh Senior Citizens' Health Care Centre, Singapore; Dr Nhonh Bun Yay, Deputy Director, Ministry of Health, Cambodia; and Dr Zhu Han Min, Deputy Director, Hua Dong Hospital, Shanghai Geriatric Institute.