(November 2010) In many countries, the elderly now make up an unprecedented share of the population. This increase in the number of older people has implications for national budgets, labor force growth, and family support systems. How are elderly people faring and are there differences across countries in how well they fare? To help answer this question, the Stanford Center on Longevity and the Population Reference Bureau worked together to develop a comprehensive and robust measure of well-being for older populations using data from 11 European countries and the United States. During a PRB Discuss Online, Marlene Lee and Toshiko Kaneda, senior research associates at the Population Reference Bureau, answered questions from participants about what factors are important to the welfare of the elderly, how to make comparisons across countries, and the lessons learned from cross-national comparisons.


 Nov. 16, 2010 1 PM (EST)

Transcript of Questions and Answers

Dr. Uzodinma Adirieje: 1. What are the proven negative effects of Alzheimer's diseases on the vision performance/sight and their nutrition of older populations? 2. How can one access the "comprehensive and robust measure of well-being for older populations" developed by Marlene Lee and Toshiko Kaneda.
Toshiko Kaneda: While we do not include in our index any indicator that specifically gets at individuals with Alzheimer's disease, I believe they are likely captured in one of the indicators we include to measure physical well-being. We have five indicators for this domain, including percent of older adults with no disability (measured using ADLs) and percent of older adults with no limitations in physical function. While much has been written about the impact of Alzheimer's disease on vision, you might be interested in a review article that appeared in Optometry (the journal of the American Optometric Association) earlier this year called, "Alzheimer's disease: Visual system review" (www.optometryjaoa.com/article/S1529-1839(09)00494-1/abstract). I am less familiar with the nature of the link between Alzheimer's disease and nutrition, but Journal of American Medical Association (JAMA) published an article this summer titled, "Diet and Prevention of Alzheimer Disease" (http://jama.ama-assn.org/cgi/content/extract/303/24/2519) that you might find interesting. The final report that describes our index is scheduled to come out by the end of the year. It will be posted online when published. You can sign up at www.prb.org/Home/EmailSignup.aspx to receive email announcements for the publication of our report as well as all other PRB contents updated on our website. Finally, I'd like to point out that the index was not developed exclusively by us, but there is a team consisting of staff from the Global Aging Program at the Stanford Center on Longevity, the Population Reference Bureau, and our advisory committee that consists of experts on substantive areas we examined as well as on index methodology and datasets we used. It was truly a team effort.

Richard Cincotta: While social scientists never got very excited the fact that youthful populations over-taxed government services and fostered inequalities, the promise of a bulge among seniors seems to distress analysts. What evidence is there that turning back some of the support to the private sector and families is fostering greater inequality among seniors (in morbidity and mortality)?
Toshiko Kaneda: Let me be sure that I understand your question by paraphrasing: If government supplies fewer resources for seniors and instead relies on the private sector and families to meet their needs, does this increase inequality in health among older adults? If this is your question, I am unaware of evidence one way or another. We have not done any analyses that can address questions like this with our index yet. We hope to expand our index to sub-groups within countries so as to address this interesting issue that you raised. We may be able to provide some insight with the index as-is, albeit indirectly. Since we constructed the index for twelve countries, comparing the levels of physical well-being across countries with different policies and programs with respect to the provision of various types of old-age support can shed some light on your question. For example, if older adults in countries whose governments provided generous services consistently fared better than their counterparts in other countries (net of GDP and other confounders), there is the possibility that the lack of such governmental provision of support may be associated with larger inequality in the well-being of older populations.

Mary Kritz: Does your database allow you to compare the 12 countries in terms of the ethnic and/or nativity well-being of their older populations? If so, I would be interested in that dimension.
Toshiko Kaneda: Our work unfortunately does not provide ways to compare the well-being of older populations by ethnicity or nativity in the present state, but it is something our colleagues at the Stanford Center on Longevity and we hope to incorporate in the future. The datasets we used to create our index are the Health and Retirement Study (HRS) for the United States and the Survey of Health, Ageing and Retirement in Europe (SHARE) for the eleven European countries we examined. For the United States, the HRS allows you to look at fairly complex racial/ethnic categories. Some of the countries in SHARE allow you to look at languages spoken and this might be used to identify certain ethnic groups. These categories can be used to understand ethnic differences in the well-being of older populations within respective countries, but it is difficult to construct categories that can be used to compare racial/ethnic disparities across many countries. One simple designation might be minority vs. majority group, but more work needs to be done to understand the methodological problems in doing this. I believe all the datasets we used allow you to examine nativity/immigration status, which can be compared across countries.

Srinivas Goli: How far do growing economic inequalities effect the well-being of older population in developing countries (such as India)?
Toshiko Kaneda: In fact, we are currently in the midst of conducting a sensitivity analysis to assess how different levels of inequality in income across countries can affect their relative standing according to our index of well-being. The question of the impact of growing economic inequalities on the well-being is a tricky one. Growing economic inequality accompanied by income declines for everyone or for the less fortunate clearly reduces the well-being of older population. But economic inequalities can be growing in a country at the same time that the standard of living is improving for everyone including the less fortunate. So, it depends. Some research suggests that income inequality, or a sense of relative deprivation, does affect one's well-being. This would be reflected in physical well-being, social engagement, and emotional well-being. However, increases in income for everyone must improve well-being with respect to the material well-being component of our index regardless of inequality.

Usha Natampalli: According to studies in India, the well-being of elderly persons differs when they are with family members vs. in elderly care homes. Do the countries in your study present patterns of wellness among elderly persons across age, gender, and location of stay?
Toshiko Kaneda: We create the index of well-being separately for three age groups—50-64, 65-74, and 75 and older. We find that the level of well-being is lower for older age groups, though there is substantial variation in this across the countries we examined. The association between age and well-being also differed across the four domains of well-being: material well-being; physical well-being; social engagement; and emotional well-being. We have not yet examined differences by gender in the countries used to develop the index. Based on previous literature, however, we might predict some patterns. For example, women tend to have higher disability at any given age, tend to be less well-off financially, are more socially engaged, and generally have worse emotional health outcomes. There are unfortunately no data available on institutionalized elderly that are comparable across countries. As such, our index is based on survey datasets that focus on community-dwellers and not those living in institutional settings (e.g., nursing homes, assisted living facilities), though we do provide sensitivity analyses to show that bias due to exclusion of the institutionalized population likely does not affect the results. Even if data were available, comparing older adults living at home and those living in institutions is very difficult, as there is strong selection into nursing homes and other institutional settings. Health, finances, the availability of informal care providers, preferences of elderly and their families all affect the likelihood of institutionalization. Different cultural norms across countries (or even across groups within a country) also dictate what it means to live in nursing homes and who end up there. In some societies, one must be financially quite well-off to be able to afford living in nursing homes, thus, can be considered a sign of wealth, while it might be perceived as a sign of being deserted by family members in other countries. Despite these difficulties, this is an important issue to study.

Ghazy Mujahid: It is very timely to have this discussion as the world prepares for MIPAA+10, a review of a decade of implementation of the Madrid International Plan of Action on Ageing in 2012. As I understand from the introduction, it will focus on developed countries. However, the situation as it is emerging is going to be far more serious than or at least as serious as in the developed countries. Their populations are ageing more rapidly and as Go Harlem Brundtland summarised it at the Second World Assembly on Ageing in 2002: "We must be fully aware that while the developed countries became rich before they became old, the developing countries will become old before they become rich." How do you think the developing countries can learn from the experience of developed countries with respect to ageing given the fundamental economic, social and cultural differences? Also I would recommend a discussion when possible in the future, preferably sooner than later, on the ageing situation in the developing countries.
Toshiko Kaneda: Thanks for bringing up the situation in developing countries. You are absolutely right that, in many ways, developing countries face more pressing aging-related challenges than developed countries; their populations are aging at much faster rate than in developed countries and they have fewer resources to provide for their growing elderly populations. On the other hand, traditional sources of support in old age, such as children and other kin, may be more readily available, for example, as illustrated by the higher fertility for the current cohorts of elderly and the higher percentages of them residing in multigenerational households compared to their counterparts in developed countries. Rapid urbanization, socioeconomic changes, and changing norms, however, do tend to weigh down the capabilities as well as willingness of adult children to take on these roles. Population aging in developing countries indeed brings about critical issues that require attention and much debate. Despite the differences in contexts, there is a lot that developing countries can learn from the experiences of developed countries since what defines well-being in old age is pretty much universal. In our index, we define well-being along four dimensions: material well-being, physical well-being, social engagement, and emotional well-being. We find substantial differences in the levels of well-being across these domains in the countries we examined. Looking at the policies and programs of countries that score high on the elderly well-being index can suggest ways in which developing countries might improve the well-being of their older populations. While our index currently allows one to examine the well-being of older populations at a single point in time, we eventually want to track changes over time. Comparing the well-being of older adults in countries before and after they introduced some aging-related policies or programs can also provide some insight into effective policies for developing countries. In any case, extending our work to developing countries is among the list of things we hope to accomplish in our future work.

Robert Prentiss: What will be the consequences for the older population in the United States if the retirement age is raised to 69 years old as proposed by the Deficit Commission and benefits are reduced?
Toshiko Kaneda: As we mentioned earlier, we measure well-being in old age using four domains including material well-being and social engagement. The association between an increase in the retirement age, resulting in a reduction in benefits over a typical lifetime, and the well-being of older populations is a complicated one. On the one hand, some individuals may have to retire before age 69 even if they do not have a full pension. Thus, an increase in the retirement age would result in a reduction of their material well-being (and perhaps other dimensions of well-being too). On the other hand, research shows that an increase in retirement age is associated with longer labor force participation among older adults. For individuals that can continue to work, this might actually increase their material well-being. Most individuals have lower income after they retire, and if individuals earn more for longer, they might have greater assets upon retirement. Furthermore, while exact reasons individuals choose to work into old age differ (from intrinsic reward to financial need), employment is one important way for individuals to stay socially engaged in old age. The various benefits of social engagement on the well-being of older adults are well documented. In our index, we capture employment in old age with one of the indicators we use for the social engagement domain. As we continue to refine our index and use it in research, we hope to address some of the important issues that your question raises.

Patrick Mangochi: What impact will a bulging elderly population have on health services for the elderly in developing countries, where the bulk of health services delivery target the birth to midlife populations?
Marlene Lee: In developing countries, functional aging may occur earlier than in developed countries, so some services targeting midlife populations may actually be able to extend assistance to older adults. However, population aging is a good thing because it is the result of improving survival and health of birth and midlife populations, so there may be potential savings as programs targeting these populations are successful. Bloom, Canning, and Jamison discuss the economic virtues of improved health, noting that these diminish as population aging starts to occur—www.heart-intl.net/HEART/110105/Health,Wealth,and.pdf.  Such savings might be used in planning changes in health delivery to assist older populations. The challenge then is to adapt the health service delivery to the new population structure and to have a healthy older population. One step might be training of health workers in the diagnosis and care of conditions more common in older adults. The net impact of a bulging elderly population on health services in developing countries is hard to assess without taking into account the specific context of each country. The elderly are also resources, sometimes providing care for ill family members or orphaned children. To some extent having an able older population may actually alleviate some demands on the health service system (see work by John Knodel on HIV/AIDS www.psc.isr.umich.edu/people/profile/54, some of which is also discussed in PRB publications/webcasts (www.prb.org/Journalists/Webcasts/2009/hivaidsandolderpersons.aspx).

Charlie Teller: Hi Marleen and Toshiko, definitions of well-being and welfare differ from culture to culture, and to where the country is on the demographic transition. How do older populations self-identify well-being and how different is it from their middle-age children; and how does this differ from country to country?
Marlene Lee: Hi Charlie—thanks for this question. While I am aware of work using SHARE data to look at cultural differences in self-assessment of health across countries (www.share-project.org/t3/share/index.php?id=journalarticles), I don't believe anyone has actually done any cross-country comparison of differences in self-assessments made at middle age vs. at older ages. Laura Carstensen has done work showing a "positivity effect" as we age in the United States. Laura's answer to a question about the mental health of older people (http://longevity.stanford.edu/mymind/mythsandchallenges) discusses a "well-being paradox"—subjective well-being or life satisfaction among older adults is as high as among younger adults.The Gallup World Poll data (https://worldview.gallup.com) and recent journal articles using these data might also be helpful to further explore this question. We use the Gallup World Poll measure of life satisfaction as one indicator of emotional well-being in our study.

Dr. Anima Sharma, INDIA: Older population is a matter concern in every society, world over. They are one of the most vulnerable sections of the society....In the traditional societies where people live in close socio-cultural boundaries, are bound by network ties, which gives protection to each and every individual living within the premises, but in the modern societies, where due to the prevalence of nuclear families, older people either live alone or in the Old People Home, the problems are more and various. As an Anthropologist, I have (am) studied (studying) Urban/ Rural and Tribal population in different parts of India. During my field work I have come to know that most of the sufferings of the elderly people are due to health hazards and economic deprivation. At the Administrative level, Social Security Policies have been chalked out but due to various reasons most of the elderly people are ignorant about those, especially those living in the rural and remote areas. Sometimes the elderlies do not get their due to genuine reasons as they either do not have children, or the children are living separately due to their jobs, but in several cases I have found that children deliberately ignore their elderlies, which adds to latter's agony. My summation is that along with advocacy, policy making and providing economic, health and social security to the elderly, we should also try to instigate the feeling of socially responsible behaviour and better civic sense among the youths. May I know your views in this regards?
Marlene Lee: Thank you for the overview of your findings. There is no doubt that many factors influence the well-being of older adults. I cannot speak specifically to the situation in India. However, in both countries that rely heavily on well-established government services and those countries where traditional family exchanges play a greater role, engaging family members in the care of older people is not always simple or easy. At every stage of life, adults have multiple responsibilities—they may be saving to help their children, working outside the home, and caring for an elderly relative. As my colleague Toshiko Kaneda noted in an earlier answer, social changes such as urbanization and the demands of modern work pose new challenges. I believe the best path is to raise awareness of options for handling these responsibilities. As you mentioned, advocacy may raise awareness of the programs available to the elderly. Targeting some of this information to young people can also be useful in educating them about the role that families have in the care of older people—even as traditional family assistance may be more difficult to offer as family members migrate for work.

Ghazy Mujahid: "Ageing in place", that is, for the elderly to stay at home is receiving increasing emphasis. In China, Shanghai (the most "aged" area) has come up with plans for a "90-7-3 initiative," that is, 90 percent to age at home, 7 percent in community-care and 3 percent in institutions. Beijing is reportedly following with a corresponding "90-6-4 initiative." This reflects the growing realisation of the importance of "ageing in place." Like mothers-in law are the best baby-sitters, daughters-in-law and daughters should be the best care-givers in old age. I remember that about 5-6 years ago, Chinese officials dealing with ageing went to Australia for a study tour. When asked why they went to a country so culturally different, the answer was that they wanted to see the working of elderly homes (institutional living). They learnt that, with the benefit of hindsight, the Australians themselves were not enthusiastic about institutional living for the elderly. I would like to know if this issue has drawn attention in North America and Europe? A study to compare the overall welfare (not just material) of the elderly by varying modes of living arrangements should be undertaken. If any such study has been done please provide references and, if possible, in brief the main findings.
Marlene Lee: In 2005, the UN Population Division published a report on the living arrangements of older people around the world. This might be a useful place to start www.un.org/esa/population/publications/livingarrangement/report.htm. One pertinent finding is "There is a widespread trend towards independent forms of living arrangements among older persons. The trend towards living alone or with spouse only is in accordance with a general preference for independent living in economically developed countries, and there is a growing preference for separate residence in some developing countries as well." Another is: "the exercise of the preference for independent forms of living arrangements appears to be strongly constrained by factors that affect autonomy, such as having difficulty in performing either activities of daily living (ADL) or instrumental activities of daily living (IADL)." The lack of good quality data on institutionalized individuals is a strong barrier to any study of well-being that compares the institutionalized vs. the non-institutionalized. Also, the more objective measures of well-being—the physical and mental functioning—are generally worse in the institutionalized population and can be barriers to obtaining subjective (self-reported) measures of well-being.

Pushpanjali Swain: Medical intervention no doubt improved the life expectancy of older persons, however, quality of life of older people are at stake. Majority of older especially those living single and widows in especially in India are lonely and keep fighting morbidity. Studies show that functional disability increases with age. Caregivers role is important to take care of disabled elderly. What should be government strategies to take care of elderly for disability free healthy ageing?
Marlene Lee: I am not familiar with studies of aging in India, but in the United States, good health in early childhood and higher education have been found to be associated with having good in midlife and old age. Government efforts to improve early childhood health and higher education pay off at older ages.

Bethany Brown: The conspicuous absence of published national demographic data on older persons is a formidable barrier to advocacy for their well-being from the perspective of their health, quality of life, economic security, and human rights. How might you suggest encouraging or incentivizing disaggregated data collection for populations over retirement age around the world?
Marlene Lee: Some national data might not be available in the detail needed because of small sample size which can create issues of data quality or the risk of violating the confidentiality of the person who gave the information. Other data may not be available because of the additional resources required to collect the data or to publish disaggregated data. One approach to encouraging useful data collection on older populations around the world is to demonstrate how these data may be used. This is one reason for developing the SCL/PRB index of well-being for older populations with a limited number of countries. A methodology that might be usefully applied to other countries and possibilities for using the index in analysis will, we hope, encourage continued efforts to collect data needed to assess the well-being of older adults.

Margaret Gaines: I am concerned about the well-being of women in the older population. They will live longer and most likely have few economic resources to support themselves, than men. What issues would you consider important in a comparative study of older women? Also, do you believe that your comparative study could include developing countries? Why or why not?
Toshiko Kaneda: In addition to living longer with fewer economic resources, women also have higher rates of disability than men. They also tend to fare worse than men in various emotional health outcomes. The four dimensions we examined in our index as mentioned earlier—the material well-being, physical well-being, social engagement, and emotional well-being—thus are all important in a comparative study of older women. In addition, the issue of domestic violence is more pertinent among women than men and should be examined. Ideally, developing countries should be included in comparative work, but there are challenges. One basic challenge is the lack of the comparative datasets. Some developing countries, however, have either started or are starting data collection on older populations. We hope to take advantage of new studies as they become available and extend our work to include developing countries.

Sara: Do you believe the identified indicators and tool for measuring the well-being of older adult populations, developed by PRB and Stanford Center on Longevity, can be used as a template by localities to test the age readiness of their communities?
Marlene Lee: Without similar surveys done at the local level, it would be difficult to replicate the SCL/PRB index for a locality. However, we did not investigate data sources for localities, so I would not completely rule out the existence of viable data sources for larger localities. Where the sample size is large enough some of the data that we used might lend itself to being used for regions within a country.

Mahesh Nath Singh: As the mostly older people face the problems in urban setup, more and more among them are from rich families, so the upcoming National Urban Health Mission (NUHM) will focus on well-being of older population in India.
Toshiko Kaneda: Thanks for sharing this interesting information. It will be good if there was a similar mission available to address the well-being of older population living in rural areas. As you indicated, the rural elderly in developing countries generally have less resources while having worse health conditions.

Amy Ford: What can employers expect with this increase in older populations? Also, how can they support their older workers who may be choosing not to retire, as well as dependents who are caring for their aging parents? Does this differ by country?
Marlene Lee: Amy, we did not look specifically at this question, but the SCL/PRB index looks at different dimensions of well-being, physical functioning, social connections, emotional-well-being. Looking at the results for these European countries and the United States, employers generally have a pool of healthy workers among older adults, but in some countries emotional well-being and social connections varies by country and by age. Income also declines with age. I think that continued integration into the workplace and a supportive environment where workers know that their contribution is valued would help older workers as well as those workers who are caring for aging parents.

Dr. Constance Bowes: How are the sexual rights and desires of older populations (over 50) being researched today?
Marlene Lee: In the United States, some research has been done on this at the University of Chicago. See the link to publications at this site (www.norc.org/nshap).

Adebayo Oladayo Abayomi: What effects does international migration has on the well-being of older population?
Toshiko Kaneda: Most immigrants are working-age and, therefore, immigration may mediate the financial pressure on public programs for the aged, such as pension system, by increasing those who can contribute to tax base. In other words, "dependency ratios" might be improved slightly by immigration. Migration of health care workers from developing countries to the developed countries have also improved the health care staffing needs of caring for older population in these countries, thus, improving the well-being of older population.

Karin Ringheim: As income inequality has grown more pronounced in the U.S. and other western countries over the last several decades, have you looked at the impact of this growing inequality on older populations? And since the U.S. has the distinction of being the most unequal among these, are you able to compare the impact of growing income inequality on the elderly in the U.S. relative to its impact on the elderly in Europe?
Marlene Lee: An earlier answer to Srinivas Goli outlines how increasing inequality may be accompanied by increased material well-being even for those at the lower end of the income spectrum. We are looking at the possible effect of inequality but have not yet looked at more than one point in time.

Meskerem Bekele, Ethiopia: Is there any reason that your research focused in European countries and United States only? When you are making your research could you get the old age difference between countries to countries? And what are the reasons for that? In most developing countries older people retired for once and for the last. And they are going be to discourage for doing anything but I think that in some cases older people is better for countries development—could you see that from your research?
Marlene Lee: Our research is focused on European countries and the United States because of the availability of comparable data and the broad similarities in stage of development and culture. These consistencies have helped in the development of the index. However, similar data is available for more countries, including Mexico and Korea. Data collection that might yield comparable information is also ongoing in other countries. Our hope is to apply the methodology to other countries as more comparable data becomes available.