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Women, Ageing and Health: A Framework for Action

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)

         © World Health Organization 2007

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Women, Ageing and Health: A Framework for Action


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

          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 re-
          ceived support from Francois Farah and Ann Pawliczko from the Population and
          Development Branch of the United Nations Population Fund (UNFPA) and collabo-
          ration 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 publica-
          tion focuses on the vulnerabilities and strengths of women at older ages, it is
          often difficult and sometimes undesirable to formulate recommendations that ap-
          ply exclusively to women. Clearly many of the suggestions for action in this report
          apply to older men as well.

Women, Ageing and Health: A Framework for Action

1. Introduction

                                                     This report endeavors to provide informa-
 “Gender is a ‘lens’ through which to consider
                                                     tion on ageing women in both developing
 the appropriateness of various policy options
                                                     and developed countries; however, data are
 and how they will affect the well-being of
 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
                                                     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 secu-
rity in order to enhance quality of life for
people as they age.1 This requires a compre-
hensive 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 sys-
         tems and the response of those systems.5
                                                            The health of older men
         Older women refers to women age 50 and
         older. Ageing women refers to the same             This report does not address men’s health
         chronological group but emphasizes that            issues. It recognizes, however, that ageing
         ageing is a process that occurs at very            men – like ageing women – have health
         different rates among various individuals          concerns based on gender. For example,
         and groups. Privileged women may remain            the gender-related concept of “masculin-
                                                            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_
         Ageing is also both a biological and social
         construct. Physiological changes such as a
         reduction in bone density and visual acuity

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-
  for every 100 men aged 60 and over.6         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 technolo-
  gies, 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
         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

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 com-
   mon form of elder abuse.
 • Widowhood, which commonly leads to a loss of income and may lead to social isola-
 • Cultural traditions and attitudes that limit access to health care in older age, for ex-
   ample 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
         • 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 re-

Women, Ageing and Health: A Framework for Action

   Figure 4. The determinants of Active Ageing


                                                                 Health and
                                    Economic                    social services

                                                      Active                    determinants
                          Social                      Ageing



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
                                                            ermin                   eing
                                                                  ants of Active Ag
                                             Un i                                           le
                                                    ted N
                                                         a                           er Peop
                                                             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).

Women, Ageing and Health: A Framework for Action

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

                                            ender Lens

                          Participation          Health           Security

Some questions to ask                              Outcomes

Taking gender, age and equity into                 5. In what ways does the policy/programme
account                                               enhance the health/participation/secu-
                                                      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 devel-
                                                       opment; and formulation of research

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
lifestyle changes such as participation in       living in poverty.18
the paid work force and increased rates of
                                                 Noncommunicable diseases are the lead-
smoking by women.13,14
                                                 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 societ-
          ies are already massive and will continue to

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 coun-
           tries. 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 inci-
           dence 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

           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 condi-
           tions as heart disease or cancer.

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

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
                                                immediately in low-income countries
Preventing noncommunicable diseases.
                                                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 coro-
nary 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
                                                          ning at local, district and national levels
          ease depression, 37,38 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
                                                          support older people who are infected and
                                                          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.

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
 Sierra Leone      40        14                                       Sri Lanka      77        21
                                     Switzerland      83      26
 AMRO                                                                 WPRO
 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 infec-
tion 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 with-
                                                           out 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
          gender- and age-discrimination, and a            changes in normal homeostasis.47
          lack of support for and information about
                                                           The barriers to primary health care faced by
          treatment.20 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

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 recommen-
                                                         dations 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 prob-
          lems 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

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 ac-
                                                   tivities 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
  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.
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 five countries

              Percentage                                                                                      Male




                            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).

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
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