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Promoting the health of older people: Making it happen

Rhiannon Walters

European Commission

Background

Eurolink Age is a not-for profit network of organisations and individuals that promotes good policy and practice on ageing in the interests of older people in the European Union. In London in 1992 it held a meeting which launched Ageing Well Europe, a pan-European network of local health promotion projects. A meeting in Helsinki in 1996 considered how the countries of the European Union could address the personal, social and economic challenge of preventable illness among older people.

An expert report prepared for the Helsinki workshop (1) set out why health promotion for old age has become so important.

• The proportion of older people is rising - people over 65 constituted 9% of the European population in 1950, and will make up 18% in 2020, with the proportion aged over 80 quadrupling over this period.

• While for individuals the chances of a long healthy life are improving, there will be larger numbers of older people in need of health care and social support.

• Much of this poor health and dependency is preventable. The greatest scope lies in lifelong health promotion. However, action can be taken to promote the health of older people, and even of the 'oldest old' and those already in poor health. Many interventions are known to be effective.

• Health promotion actions include building healthy public policy, creating supportive environments, strengthening community action, developing personal skills and reorienting health services (2).

• Research can add to our knowledge.

The participants were broadly in favour of the draft action plan set out in the expert report. For two days, they discussed additions and shifted its priorities, assisted by the expert presentations.

As a result of that meeting the London Health Economics Consortium drafted an Action Plan to promote the health of the older people of Europe (3). The Plan calls for concerted action across all sectors and at all levels to promote the health of older people. It aims to influence policy and practice at all levels and in all sectors towards that which will promote the health of older people and uses the strong public policy approach to health promotion of the Ottawa Charter (4). Most effective actions to promote the health of older people lie outside the direct influence of professionals such as the Helsinki delegates, in the field of public policy. However, that group is best equipped to make the case for actions to be taken. The plan is necessarily general, lacking in detailed recommendations for action. The countries of the European Union vary in their demography, their culture, their history, their institutions and their health problems, and each nation needs to adapt the plan to its own circumstances.

An exception to this is the strong and specific call for the collection of a standard health and social data set to assist in the formulation and monitoring of public policy as an urgent priority. This could realistically be standard across the European Union, and proposals for a health data set are under consideration. Academic institutions and government bodies must expand the research base for policy formulation and evaluation, which is grossly inadequate, and such a data set would be a valuable support.

An expert group of around 30 health and welfare professionals will meet in Luxembourg in October 1997 to continue the work begun in Helsinki. They will consider what practical steps could be taken to increase the attention that decision makers give to these issues and urge them to take action. In particular the expert group will advise on how decision makers, particularly those in government, can be encouraged to respond to all of the points made in the Action Plan with commitments to specific effective actions. The Luxembourg meeting will advise on how alliances to promote the health of older people in each country can support and encourage policy makers to adapt the plan.

The aims of the meeting are:

1. to identify the critical success factors in getting societies at all levels to accept that older people's health is a valuable resource;

2. to identify the key issues in our Action Plan for decision makers at all levels and to refine the tools for successful implementation;

3. to identify the actions demanded by the special roles of health and welfare professionals and non-governmental organisations;

4. to identify and make a commitment to concerted action.

The moral basis of action to promote the health of older people

The proportion of people over 65 in the populations of the European Union member states is increasing. The demands on health and welfare services are growing while the proportion of the population of working age is diminishing. Undoubtedly, a fitter, healthier older generation would make fewer demands on health and welfare services, and might remain in the workforce in greater numbers. However a case made entirely on grounds of economic impact could lead in an unwelcome direction, since promoting the health of older people could increase costs.

• A fitter older generation might live longer and some older people are likely to make demands on the health service over a longer period. The cost might work out much the same or even greater.

• A desirable outcome of health promotion is that people are better equipped to take control over and improve their own health. Such an empowered generation might demand a higher standard of service, again increasing service costs.

Promoting the health of older people is worthwhile because older people are valuable. Older people themselves want good health and the independence that good health brings. If, by promoting the health of older people, societies also contain health service costs, so much the better.

What issues get on to the policy agenda?

Convincing decision makers of the value of older people's health will be a difficult task. Older people are a marginalised generation, and health promotion and disease prevention are neglected relative to curative health services for any age group. What is the nature of the policy-making process and what are the characteristics of issues which successfully engage the attention of decision makers? Kingdon (5) studied policy adoption in the United States and described a situation of great complexity. The identification of important problems, the development of policies and the political activity leading to policy adoption happened independently of each other in three 'streams' involving different groups of people. The progress of an issue from problem identification through policy development was most unlikely to be sequential. A 'policy window' opened if an acceptable solution was available for a problem at a time when it aroused widespread concern and when politicians and other key actors were committed to ensuring that the solution was implemented. Policy windows were rare. This description of a complicated and mainly haphazard process is probably applicable to most liberal democracies.

One element of a policy window exists for health promotion for older people in that demographic change, with its implications for pensions and health care costs, has made older people's health an issue which gains decision makers' attention.

Can this process be influenced? Kingdon suggests that the skills required are opportunism (the ability to spot the policy window) and entrepreneurial skills to broker solutions at a time when circumstances are receptive to them. Chapman, a media advocate for healthy public policies such as gun control and tobacco control in Australia, argues that:

"the processes whereby a public health issue comes to be defined as important by the public and key decision makers are amenable to both analysis and emulation." (6)

Walt describes the health policy environment as one where, although there are powerful interest groups,

"opportunities for participation in public policy . . . do exist, through overlapping policy communities that exchange ideas, and through a process of 'enlightenment', highlight issues for the policy agenda or options for implementation. Even 'outsider' groups can affect the trajectory of policy through direct action." (7)

A practical implication of all three writers' conclusions is that direct approaches to the formal political process are unlikely to be productive on their own. To bring about public policy which values the health of older people, we need to influence not only politicians but the social climate in which policies are considered. All actions which change this social climate, including local changes which affect only a few people directly, have a part to play in moving towards a society which values older people more.

Tools for action to promote the health of older people

A number of tools may be used to influence the adoption and implementation of the Action Plan, and the following are considered briefly:

• alliances;

• formal endorsement of statements, policies, plans and strategies such as the Action Plan to promote the health of the older people of Europe;

• setting targets;

• media advocacy;

• lobbying politicians and bureaucrats;

• action at local level.

Walt's observation on the contribution of research to policy adoption is relevant to most of these tools.

"Although considerable scepticism has been expressed about the extent to which research and evaluations have been used to inform policy - partly because critics used a linear model and looked for direct examples of research influencing policy - I argue that policy is affected by research. However, the process of influence must be seen not directly but as a process of enlightenment." (7)

Direct evidence of effectiveness in changing health policy is rare although persuasive but less conclusive evidence abounds, and it is likely that several approaches used simultaneously by strong committed alliances at every level create the greatest opportunities for change.

Alliances for older people's health

Practitioners and academics working in public bodies, health authorities, local authorities, the corporate sector working in partnership with these bodies and non-governmental organisations (NGOs) representing the interests of older people, and older people themselves, will take the lead in advising decision makers on promoting older people's health, and ensuring that this issue is constantly on their agenda. Policy advocacy by alliances benefits from the strengths of all partners - the 'insider' expert status of the professions (particularly the medical profession), the freedom of action of NGOs which can, where appropriate, campaign to achieve policy objectives and the conviction of the authentic experience of older people themselves. Alliance partners will sometimes have to begin, however, by gaining the support of their own colleagues within their organisations and professions.

Alliances need to take deliberate efforts to establish communication networks because they involve groups as different as university professors and community activists, who do not meet in their regular daily activity. Efforts to promote the health of the older people of Europe through concerted action will be strengthened by sharing experiences in international networks. Time invested in conferences, and newsletters could be crucial in consolidating alliances. Electronic channels such as web sites and news groups are rapid and effective. At present, while there is a Europe-focused web site on older people's health, intended mainly to serve the needs of academics, (8) web sites and news groups on health policy and community action or self-advocacy for older people have a strong North American focus.

Endorsement of the Action Plan

A first step could be for intergovernmental bodies, governments at every level, and other organisations, to endorse the Action Plan. This is a technique which has been used in high profile examples such as the WHO European Strategy for Health for All and the UN Convention on the Rights of the Child. While obtaining endorsement can have important symbolic value, it is only a beginning. Limits of endorsement are:

• it does not mean implementation, as the endorsement of the UN Convention on Human Rights by governments which continue to practice torture so distressingly illustrates;

• many such documents require an intermediate step - the preparation by national governments or other endorsing bodies of a programme which specifies action to be taken at national level. Our Action Plan and the WHO European Strategy for Health for All are examples. In the case of Health for All it is taking a very long time to get even this far;

• the endorsing bodies do not necessarily have the power to ensure implementation. Certainly intergovernmental bodies such as WHO and, in this respect, the European Commission do not. Even national and regional governments in liberal democracies have limited powers, depend on collaboration with local agencies, commercial bodies and citizens, and can be frustrated by economic and political forces.

Endorsement of the Action Plan by those with influence over its implementation is valuable, but it cannot deliver implementation on its own. Alliances of professionals, NGOs and older people themselves must also insist on the development of an operationalised version at every appropriate level and the implementation of each of its recommendations. Often policy makers will act without formal endorsement, and energy put into seeking endorsement could be more effectively directed, either at broader change in the climate of opinion or at seeking a specific action.

Targets

The versions of the Action Plan which are drawn up at national and sub-national governmental level may well include quantified and scheduled targets - for example to achieve a given standard of housing for a given proportion of the population aged over 75 years by a certain date. Targets like this can focus and motivate action, but may also divert resources away from other important problems where targets cannot be set for practical reasons. Important issues in target setting include:

• Comprehensive/selective target areas? targets should always address important problems, but should they only address those areas where effective interventions exist, and data are available to monitor progress? Important problems may be ignored if selection criteria are too strict. The existence of the target may in itself stimulate research and data collection, as in US Healthy People 2000 targets; (9)

• Outcome only, or process, proxy and intermediate targets? It is sensible to include targets for indicators of progress towards a health outcome, as well as targets for the health outcome itself. For example targets can be set for the availability of accessible, acceptable and affordable healthy food, as well as for heart disease mortality and morbidity. However, this greatly expands the task of forecasting, target setting and monitoring, and requires an adequate knowledge base including validated proxy measures of outcome;

• Specific (quantified and scheduled) or general? The US Healthy People 2000 targets, and the Health of the Nation targets for England (10) were quantified and scheduled in detail while the WHO European Region Health for All targets (11) were expressed as proportions of unspecified baselines. Power to focus and motivate is increased with specificity but precise modelling and forecasting techniques are expensive and may not be justified;

• Who sets them? If governments set targets they have more commitment to them than they would to targets promoted by another body distanced from government such as WHO or the US Healthy People 2000 consortium of experts. However, governments are more likely than these bodies to set targets which are less ambitious, less comprehensive, and less likely to cover process and intermediate measures.

Abel-Smith et al propose criteria for targets which address these issues and issues of feasibility and ethics (12). It is unlikely that targets which meet all these conditions can be set to address all the actions required to implement the Action Plan.

It is not clear how effective targets are in improving health. Progress towards targets sometimes follows target setting (13), but it is hard to establish what progress would have been made without the target. It is likely that targets work best as part of a strategy which includes other approaches. Professionals, NGOs and older people themselves can help to ensure that targets are scientific and realistic by providing advice through consultative processes which often precede target setting.

Media advocacy

The media can be used deliberately to change public consciousness and influence decisions about matters of social concern. Neglected social groups and their advocates are learning to use the print and broadcast media in a realistic way to advocate for action, accepting journalists' constraints and being opportunistic within them.

Some constraints are technical ones regarding deadlines and styles of presentation. More serious and limiting ones relate to subject and content.

• The media are interested in 'stories' and drama - by their nature relating to individuals. Wallack and colleagues observe that there is an inherent conflict between 'stories' and issues such as promoting the health of older people which concern large population groups and social determinants (14) although public health issues can sometimes legitimately be put from an individual perspective.

• Popular coverage of older people may be resistant to change in the presentation of older people. A journalist in the popular media may be happy to present an older person sympathetically as a victim of street crime, but if the story concerns poor health care facilities, may prefer the subject to be a child.

• A tedium threshold means that problems which continue over a long period need imaginative angles to maintain a degree of attention which reflects their importance.

• Even in liberal democracies the media cannot be assumed to be independent. Conflict with the interests of advertisers or of the owner's other commercial enterprises may influence what issues the media are prepared to cover and the line they take on them.

Media can be valuable, with skilful use, to influence the way in which issues are covered, to change the way problems are perceived and sometimes to influence major decisions. Journalists welcome experts who understand their constraints, provide reliable information in a format they can use, and present themselves well. Journalists will come back to these experts regularly. Professionals, NGOs and older people themselves need to learn skills in the use of the media and some useful books are available (6,14). Development of the knowledge base through more research and provision of regular accurate statistics will help experts to make an impact in the media.

Media advocacy, like any tool, needs to be used to achieve predetermined aims as part of a strategy which also uses other tools. Chapman emphasises the importance of the media in policy change:

"there are few instances in the recent history of public health where advocacy staged through the news media has not played a pivotal role in effecting the changes sought by public health workers." (6)

Lobbying politicians and bureaucrats

Although the social climate is a major determinant of policy adoption, it is still worth making direct approaches to elements of the formal political system, and taking trouble to do this well. We should approach the right individuals taking into account the formal and actual extent of their power. The power of individual elected representatives is often merely a rubber stamp for decisions taken elsewhere and bureaucrats, political parties, the executive and the media all exert influence which compromises the constitutional power of the elected legislature. The minister of health is usually expected to lead inter-departmental health policy initiatives, but often carries less weight than other ministers (7).

Bureaucrats have considerable influence on ministers. They provide continuity through a change of government. Their subject expertise means that they communicate easily with professionals and academics and draw them into the consultative process. Chapman and Lupton point out that bureaucrats are sometimes frustrated by their inability to ensure the implementation of policies which their expertise convinces them are sensible (6). In these circumstances they may be willing to assist advocates for health promotion discretely by providing useful inside information on the policy process.

Experts can help and influence bureaucrats and politicians by providing accurate information and statistics to support the case for health promotion action.

Kingdon is reassuring about the robustness of democracy despite the influence of bureaucrats:

"At least as far as agenda setting is concerned, elected officials and their appointees turn out to be more important than career civil servants of participants outside of government. To those who look for evidences of democracy at work, this is an encouraging result. These elected officials do not necessarily get their way in specifying alternatives or implementing decisions, but they do affect agendas rather substantially." (5)

The effectiveness of political lobbying is restricted by points made earlier about the importance of social climate in the policy process. As Chapman and Lupton assert:

"The task for public health advocacy is . . . fundamentally involved with efforts to shift public opinion towards their preferred position to the point where political action becomes compelling, and political inaction a political liability". (6)

Professionals, NGOs and older people themselves can learn how to make the greatest impact on the formal political system, but details of effective political lobbying will vary from country to country.

Acting at local level

Local community-led action to influence public policy decisions has the additional benefit of empowering individuals, groups and communities. The report of the third international conference on health promotion held in Sundsvall, Sweden in 1991 is a useful community action handbook (15). The projects under Ageing Well Europe provide examples of local initiatives for the health of older people across ten countries which have great potential for implementation of the Action Plan, and could be vital alliance partners.

Action at local level can also make a large contribution at every level to changing attitudes to the value of a healthier older generation. There may be a direct impact on national decision-makers. Formally strategic decisions may be taken at national level, leaving only details of implementation to be resolved at local level, but in practice this may not be the case. Policy makers know that acceptability to the agencies which implement policy is important to feasibility. They know they cannot push through policies in the face of the opposition of local agencies responsible for implementation. These agencies - health facilities, planning authorities and so on - are very responsive to the opinion of service users and local people.

Furthermore, with effective media coverage local action can raise awareness of issues at national level. The local story gives a more direct, personal, uncompromising and newsworthy flavour to what might be a dry policy issue.

Conclusions

• It is possible to raise the issue of promoting the health of older people on the public policy agenda, guided by the Action Plan, especially when the issue overlaps with existing concern over the fiscal consequences of a larger older generation. We need to identify the key issues in our Action Plan for decision makers at all levels and to refine the tools for successful implementation

• Decision makers change their position when the social climate moves, so raising issues on the political agenda means creating receptive climates for healthy public policy. We need to identify the critical success factors in this task

• We need to identify the actions demanded by the special roles of health and welfare professionals and non-governmental organisations. Some steps could be to:

• strengthen networks

• gather commitment

• gain advocacy skills

• assemble advice on prioritised action in each country of the European Union based on sound research on effectiveness, and regular collection of monitoring data

• develop a stronger European presence on the internet and the world wide web covering public policy initiatives to promote the health of older people

This is only an initial list, and the steps above need more specific definition.

Finally we must identify and make a commitment to concerted action.

References

(1)    Eurolink Age. Health promotion for old age. London: Eurolink Age 1996.

(2)    Ottawa Charter for Health Promotion. Health Promotion 1987; 1(4): i-v.

(3)    Eurolink Age. Adding life to years. A report of the Eurolink Age workshop , Helsinki 7-9 November 1996. London: Eurolink Age 1997. Available from Eurolink Age in English, French, Spanish, Italian, Finnish and Greek.

(4)    Ottawa Charter for Health Promotion. Health Promotion 1987; 1(4): i-v.

(5)    Kingdon JW. Agendas, alternatives and public policies. Boston, Mass: Little, Brown, 1984.

(6)    Chapman S, Lupton D. The fight for public health. Principles and practice of media advocacy. London: BMJ, 1994.

(7)    Walt G. Health policy. An introduction to process and power. London: Zed Books, 1994.

(8)    "Age Page Europe" run by the Biological Gerontology Group at the University of Manchester under the MOLGERON concerted action Programme of the European Biomed and the University of Manchester and University of Newcastle Joint Centre on Ageing. Address http://sg1.scs.man.ac.uk/APE/.

(9)    United States Department of Health and Human Services. Public Health Service. Healthy People 2000. Washington DC: US GPO, 1990

(10)  Secretary of State for Health. The health of the Nation. Cm 1986. London: HMSO, 1992.

(11)  World Health Organization. Regional Office for Europe. Targets for Health for All by the year 2000. Copenhagen:: WHO, 1985.

(12)  Abel Smith B, Figueras J, Holland W, McKee M, Mossialos E. Choices in Health Policy. Luxembourg: Office for Official Publications of the European Communities, 1985.

(13)  United States Public Health Service .Healthy people 2000 : midcourse review and 1995 revisions. Rockville, Md: US Dept. of Health and Human Services, Public Health Service, 1995.

(14)  Wallack L Dorfman L, Jernigan D, Themba M. Media advocacy and public health. Newbury Park Ca: Sage, 1993.

(15)  Haglund BJA, Petterson B, Finer D, Tillgren P. Creating supportive environments for health. Stories from the third international conference on Health Promotion Sundsvall, Sweden. Geneva: WHO, 1996.

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