SOCIAL DETERMINANTS OF HEALTH

Understanding and addressing the various types of SDOH across the life course are important goals because experiences in early or young adult life can have long-term implications and determine whether people will age well or poorly and achieve their full potential. These determinants can arise at various points along the life course and may not be directly linked to health or to factors that can be influenced by a health system. The following are examples of SDOH that can affect health and equity (WHO, 2022b):

• “income and social protection;
• education;
• unemployment and job insecurity;
• working-life conditions;
• food insecurity;
• housing, basic amenities, and the environment;
• early-childhood development;
• social inclusion and nondiscrimination;
• structural conflict;
• access to affordable health services of decent quality”; and
• health, financial, and digital literacy.¹

Researchers estimate that 10–20 percent of health outcomes are influenced by clinical care (Magnan, 2017), while the remaining 80–90 percent are influenced by SDOH and other related factors, such as health behaviors and the environment. Accordingly, addressing these factors is of critical importance to increasing the potential for global healthy longevity.

This chapter addresses the key targets related to social infrastructure the commission believes are most integral to healthy longevity. Key targets include capitalizing on the prosocial strengths of older people, combating ageism, fostering social inclusion, ensuring financial security, and improving digital literacy. Other SDOH are discussed in Chapters 3, 5, and 6. It is beyond the scope of this report to analyze the effects of all SDOH, so the commissioners prioritized the inclusion of those that are most important to tackle in the near term.

Effects Across the Life Course

Healthy longevity can be achieved only by making changes across the life course. The commission emphasizes the numerous opportunities to improve healthy longevity among younger people, at a time when their actions, experiences, and environmental exposures have a significant influence on their health trajectory across the life course.

Although the key targets in this report are important for today's older people and, in most cases, all people, other interventions targeting younger people will also be needed to improve healthy longevity for older people of the future. For example, high-quality “early-childhood development and education are key determinants of future health and well-being” (Paris, 2018, p. 16). The advantageous lifelong effects of a supportive and safe childhood and the beneficial role of socioemotional competence in individual health and well-being influence future health. For example, a Jamaica-based study studied outcomes in children who were part of a program in which community health workers taught parenting skills and provided nutritional supplementation over a 2-year period (Gertler et al., 2014). The children who received the intervention realized 25 percent higher earnings 20 years later compared with the control group. Thus, early-childhood development sets the stage for lifelong thriving and is a cost-effective investment that countries can make to improve lifelong health and well-being. While it is beyond the scope of this report to discuss such interventions and their effects in detail, many reports, such as the WHO (2009) report Social Determinants of Health and Well-Being Among Young People, address the relationship between SDOH and younger people.

Poverty prevention, education, secure and safe housing, social support systems, and access to integrated health systems at all ages are also important for ensuring healthy longevity. Structural changes in social policies and practices can help to avoid negative impacts on health that stem from social and economic disadvantage. Public understanding that poor health outcomes and unhealthy aging are socially determined can empower people to demand change from their governments. Medicalizing these social determinants and needs and focusing on them at an individual level will improve health status only for those individuals at that particular point in time. To have a real effect on populations, investments must be made in the community, addressing social needs and risks at the system level, with downstream benefits for the entire community. For example, providing access to food for a patient who presents at a health clinic will help that person for a discrete period of time, whereas ensuring that there are markets in a neighborhood without access to food can help the entire community.

Making systemic investments is key to leveraging an unprecedented opportunity to improve health on a global scale through focused attention on the needs of disadvantaged populations. To represent the relationships between structural drivers and various SDOH and their combined impact on equity, the commission adapted Solar and Irwin's (2010) conceptual framework (see Figure 4-2).

FIGURE 4-2

Conceptual framework for structural and social determinants of health. SOURCE: Adapted from A conceptual framework for action on the social determinants of health, Solar and Irwin, 2010.

THE SOCIAL CAPITAL OF OLDER ADULTS

Beyond SDOH, social connections are important drivers of health and well-being. The importance of social engagement to healthy longevity at both the individual and societal levels cannot be overstated. Figure 1-4 in Chapter 1 outlines the key enablers and disruptors of healthy longevity, and illustrates how social engagement can work with other enablers to influence a person's health trajectory. People grow old within social networks of family members, friends, and others with a set of assumptions, expectations, and beliefs that shape their experience of aging. Societal perceptions of what it means to have a fulfilled, successful, or dignified life are diverse, and they change over time, but in all cultures, social contexts, and countries, community institutions have a role in providing meaningful opportunities in which older adults can participate.

Social capital has been defined as “the connections among individuals, social networks and the norms of reciprocity and trustworthiness that arise from them” (Putnam, 2000, p. 19). The more recent literature suggests a new definition of social cohesion as “the ongoing process of developing well-being, sense of belonging, and voluntary social participation of the members of society, while developing communities that tolerate and promote a multiplicity of values and cultures, and granting at the same time equal rights and opportunities in society” (Fonseca et al., 2019, p. 246). The absence or decline of social cohesion can also be thought of as social erosion, with fewer citizens believing they are part of a moral community and having trust in one another (Larsen, 2014).

While a strong fabric of social cohesion provides many benefits to a community, one positive consequence is increased capacity for collective efficacy, with such outcomes as less conflict and violence in the community and increased formation of self-help enterprises, and a virtuous cycle from these benefits to improved bridging and bonding social capital. Social capital in communities has been found to have a “buffering” effect that counters the more adverse factors. For example, one study found that Hispanics and foreign-born citizens in the United States have a longer life expectancy than native-born non-Hispanics, which the authors attribute to strong social connections despite lower income levels (Singer et al., 2017). Social capital has also been noted as a key factor in resilience to and recovery from disasters. Following the Nepal earthquake in 2015, for example, researchers found that “high levels of bonding and bridging capital among residents reduced barriers to collective action” and assisted in rescue and recovery efforts (Panday et al., 2021). In the context of aging populations, the development of these connections across generations can be described as intergenerational cohesion, which can also have numerous advantages for families and societies. The United Nations recognizes intergenerational cohesion as essential to healthy societies (Butts et al., 2012).

Older adults have the capability to play a significant role in improving social cohesion both within and across generations, as well as increasing social capital, although opportunities to benefit from this capability have thus far been largely untapped. In the commission's vision for healthy longevity (see Chapter 2), maintaining health into the second half of life will enable older people to remain engaged in their communities. With the right structures, older people could bring decades of accumulated knowledge and experience to the community and help younger people achieve success as they enter the workforce. Older people also provide care for grandchildren. The positive dimensions of aging and corresponding benefits to society can create social and human capital that can help address unmet needs and increase societal well-being (Fried, 2016). Social capital can be strategically and intentionally built, for example, by helping people who want to work at later ages remain in the workforce and creating volunteer opportunities, as described in Chapter 3.

KEY TARGET: PROSOCIAL STRENGTHS OF OLDER PEOPLE

Being embedded in a larger social group holds powerful evolutionary advantages because humans are social beings. However, the nature of social networks changes with age. Abundant evidence demonstrates positive developmental trends in social and emotional functioning as people age, including evidence that older people are more prosocial than younger people. Prosocial behaviors are actions that benefit others (Cutler et al., 2021).

Quality relationships with families, kinship and friendship networks, and community ties, as well as the impact of social ties on health, remain important to well-being throughout the life course (Umberson et al., 2010). Evidence suggests that social networks narrow as people age (Lang and Carstensen, 2002). However, longitudinal findings suggest that the narrowing of social networks begins long before old age, which means it is not attributable to causes specific to aging (English and Carstensen, 2014). On the contrary, networks narrow selectively, such that people retain emotionally close social partners while eliminating more peripheral ones.

The current literature on social and emotional aging documents numerous positive trends in socioemotional functioning that contrast with stereotypes. Older people are more emotionally stable than their younger counterparts and often enjoy more positive emotional functioning in daily life (Carstensen and Chi, 2021; Carstensen et al., 2011). Notably, these emotional advantages were evident even during the COVID-19 pandemic, and studies validating this advantage of age during the pandemic have been replicated in scores of countries (Sun and Sauter, 2021). While aging is often associated with declines in cognitive function, a recent study found that social cognitive abilities and prosocial learning were more pronounced in older adults compared to those under age 36 (Cutler et al., 2021). Lack of concern for others was also found to be lower among older adults. Compared with younger and middle-aged people, moreover, older people experience fewer negative emotions in everyday life (Carstensen et al., 2011). They also express more gratitude, which in turn has been positively associated with physical and mental health (Emmons et al., 2003; Kubzansky et al., 2018). This evidence should inspire those in power to aim beyond simply addressing problems of vulnerable older people to work to build systems that leverage the social capital that increasing numbers of older and healthier people will bring to society.

Prevalent stereotypes of older people as regularly frail, burdensome, and dependent limit society's ability to appreciate and capitalize on their potential human and social resources, which in turn undermines intergenerational cohesion and solidarity and threatens the achievement of inclusive, just societies (WHO, 2020). Efforts to foster social connections and build cohesion start in local communities, where informal caring for family members, neighbors, and acquaintances is the norm.

Finding 4-2: Advancing age is associated with increased motivation to contribute to other people, younger generations, society, and the greater good. In addition, older people's experience, knowledge, and emotional stability hold the potential to build the social and human capital needed to create and perpetuate healthy longevity.

Conclusion 4-2: Societies with healthy longevity can capitalize on the emotional stability and prosocial strengths of older people by enabling them in their existing roles and emerging new roles.

KEY TARGET: AGEISM AND AGE DISCRIMINATION

One of the most significant barriers to achieving healthy longevity is ageism. Ageism encompasses systemic stereotypes and prejudice, whether directed toward others or oneself—even many older people believe age-based stereotypes. Ageism can occur at the interpersonal level, between individuals; at the social level; or at the structural or institutional level (Marques et al., 2020). Because every person who lives to an advanced age will experience ageism, its scope and breadth are massive. In the European Social Survey, age discrimination was the most frequently reported form of discrimination for every age group. Among European countries, reports of unfair treatment of older people ranged from 17 percent (in Portugal and Cyprus) to 54 percent (in the Czech Republic), with an average of 35 percent (Ayalon, 2014). The COVID-19 pandemic has made ageist attitudes even more entrenched (see Appendix B). Structural ageism can also be found across sectors, including entertainment, marketing, social media, the workplace, and health care (Levy, 2022). Yet despite the scale of its negative impacts on older people and societies, “ageism remains a neglected global health issue” (Officer et al., 2020, p. 1).

Ageism is grounded in the belief that older people are fundamentally different from younger people. However, the old and the young actually have much in common; they work in the same jobs, maintain households, and participate in society. Media and advertising characterizations reinforce negative attitudes and biases toward older people. A 2019 AARP study found that adults over age 50 “represent only 15 percent of adults in online media images, and are seven times more likely to be portrayed negatively,” relative to younger adults (Dychtwald, 2021). Commonly held ageist attitudes are embodied in laws, policies, and institutions—particularly those related to health, social, and legal systems. When left unchecked, they can impede progress toward healthy longevity.

Older people experience the deleterious effects of ageism most directly. Once they are perceived as an “older adult,” they are exposed to external stereotyping and discrimination, as well as internalized ageist attitudes that are unconscious self-stereotypes. Worse health outcomes are seen among those exposed to ageism, including weaker and more negative social expectations of older generations, and internalization of ageist attitudes is “significantly associated with poorer physical and mental health in older adults” (Officer et al., 2020, p. 2). Accumulating evidence is also linking structural ageism to adverse health outcomes. According to a systematic review, 85 percent of 149 studies found that clinicians were less likely to offer treatments to older versus younger patients even if those treatments offered equal benefit regardless of age (Chang et al., 2020). At the same time, however, young people are not immune from discrimination. While more data are needed, attitudes toward younger people in Europe are more negative than attitudes toward older people (WHO, 2021a). Younger people are more likely than those in other age groups to report that they have been the victim of age-based discrimination. As evidence on cumulative exposures across the life course continues to demonstrate the importance of discrimination, it becomes clear that this is an area in need of greater attention.

In addition to its enormous burden in the area of health and well-being, ageism has substantial economic impact, costing countries billions of dollars annually (WHO, 2021a). One study found that negative age stereotypes, negative self-perceptions, and age discrimination in the United States led to estimated annual costs of USD63 billion for the top eight most expensive health conditions, and in Australia, estimates suggest the national economy would realize an additional AUD48 billion annually if 5 percent more people aged 55 or older were employed (WHO, 2021a). As discussed in Chapter 3, ageism is also a factor in decreased labor force participation among older people.

Compounded Discrimination

Ageism can interact with other forms of bias and exacerbate or compound the disadvantages they cause, greatly affecting an individual's health and well-being (WHO, 2021a). A growing number of studies have explored the intersections between ageism and different forms of discrimination, including racism, sexism, ableism,² heterosexism, classism, xenophobia, and others. Ageism and ableism, and ageism and sexism are two examples of multiple, compound, and intersectional discrimination that are especially pervasive.

Women constitute the majority of the older population around the world, but they often remain invisible to policy makers. Yet, they face unique ageism challenges that need to be accounted for in the global response to aging. In countries at all income levels, lifetimes of marginalization and discrimination, including unequal and inadequate access to education and jobs, compound the effects of ageism for women.

Women are more likely than men to engage in informal sectors of the economy and to perform unpaid work, such as caring for children and family members with disabilities and performing household work. Older African women, for example, contribute substantial amounts of unpaid domestic and care work, and often perform this type of work for longer relative to women in other regions/countries (He et al., 2020). In Latin America, for example,

[t]he overload of unpaid care work and the time-poverty that women face prevent equality of opportunity, rights, and outcome relative to men regarding participation in the labour market, but also social and political participation, and in the enjoyment of free time. Ultimately, the overload of this type of work on women limits their opportunities and stands in the way of their economic empowerment and also in the way of the possibility to enjoy their rights on an equal footing with men. (UN, 2020a, p. 7)

Although many older women contribute substantially to national economies, their lower rate of participation in the paid workforce across adulthood has cumulative negative consequences, including greater risk of poverty due to limited access to or low pensions (Bonnet et al., 2019). The caregiving burden often borne by women is exacerbated in such crisis situations as war, famine, forced migration, and epidemics or pandemics. Older women are negatively affected in these situations if they are not economically empowered because they rely heavily on the support of younger adults. To combat inequality, it will be essential to address the root causes and intersection of such prejudices as ageism and sexism. An example from Lebanon focuses on the engagement and empowerment of older women (see Box 4-1).

BOX 4-1

Providing a Platform for Older Women to Voice Concerns.

Interventions for Combating Ageism

A recent meta-analysis suggests that “relatively low-cost, feasible strategies involving education and intergenerational contact can serve as the basis of effective interventions to prevent ageism” and address the digital divide that keeps many older adults from using technology (Burnes et al., 2019, p. e1). In Australia, The Benevolent Society has conducted focus group discussions that have highlighted the importance of older people using their voice to combat ageism by participating in discussions regarding societal constructs of retirement ages and providing counter information and opportunities for other older people to reflect on their own internalized biases and ageism (Every Age Counts, 2017). In addition to educational campaigns, laws and policies can bring some needed strength to the importance of reducing and preventing age discrimination. As an example, the Organization of American States drafted the Inter-American Convention on the Protection of the Human Rights of Older Persons (OAS, 2017). It underscores that “older persons have the same human rights and freedoms as other persons,” which include the right not to be subjected to age-based discrimination or violence (OAS, 2017). Signatories agreed to accomplish this by adopting measures such as eradicating isolation, overcrowding, and food or medical treatment deprivation, and adopting or strengthening legislative or administrative measures to ensure adequate access to justice.

While some may assume that international frameworks such as the Universal Declaration of Human Rights (UN General Assembly, 1948) guarantee basic human rights to older people, ageism persists and is a violation of those rights. As is, the Declaration does not go far enough to address age discrimination against older people, and the rights of older people often remain invisible (Mokhiber, 2018). Even documents such as the Madrid Plan of Action are not legally binding and ask governments for commitments, so many are calling for a UN Convention on the Rights of Older People to combat ageism, clarify responsibilities, improve accountability, and guide policy making (UN, 2010).

Recognition of ageism as an SDOH could also help eliminate it (WHO, 2020). For example, WHO Africa and HelpAge International have organized a regional campaign to raise awareness of the magnitude and impact of ageism. The main objective is to strengthen the capacity of African countries by sharing resources and tools to establish a community of young advocates who work to change the narrative around aging (WHO Africa, 2021). Interventions that include both education and intergenerational contact demonstrate especially strong effects, especially for combating negative attitudes toward and perceptions of aging (see Box 4-2).

BOX 4-2

Strategies for Combating Ageism: Public Awareness Campaigns and Intergenerational Contact Interventions.

KEY TARGET: SOCIAL INCLUSION

Isolation is defined as the experience of being alone (a state of objective physical separation), while loneliness refers to perceived isolation and lack of satisfying emotional connections to others. Humans are not meant to survive alone. The perception of isolation and feelings of loneliness have negative consequences for socioemotional and physical health and are risk factors for disease and early death (NASEM, 2020). Loneliness is often associated with old age but has been increasing in people of all ages in recent decades. Research has found that loneliness levels actually peak before the age of 30, then diminish through middle adulthood into early stages of old age. After a person turns 80, reported loneliness begins to increase again, to levels comparable to those of younger people (Luhmann and Hawkley, 2016). Thus, while it is wrong to assume that older people as a group are lonely, a significant minority do report loneliness. The challenge is worldwide, with an estimated 20–34 percent of older adults in China, Europe, Latin America, and the United States identifying themselves as being lonely (WHO, 2021b).

Aside from emotional impacts, loneliness is associated with poor health outcomes including depression, dementia, heart disease, and other conditions (Singer, 2018). The combined neurobiological effects of loneliness on sleep, executive functioning, and mental and physical well-being contribute to higher rates of morbidity and mortality in older adults (Cacioppo and Hawkley, 2014). The costs of social isolation and loneliness are only beginning to be fully appreciated. In the United States, for example, social isolation adds an estimated USD6.7 billion to Medicare spending annually (Flowers et al., 2017). In many high-income countries experiencing historically low birth rates and longer lives, increasing numbers of older people are living alone without other family members, raising concern that loneliness may be more prevalent in the future.

Cultural and social factors across the life span can affect a person's ability to achieve healthy longevity. As discussed earlier in this chapter, social capital and social cohesion can be particularly influential toward building strong communities and keeping adults engaged as they age. But ongoing demographic changes will require greater attention to minimizing age segregation and ensuring ongoing social connection, which can help combat loneliness. Some potential mechanisms to this end include leveraging religious and spiritual connections, empowering older adults within communities, and creating opportunities for intergenerational connections and cohesion. Societies can support these and other intergenerational programs to promote healthy longevity.

Finding 4-5: Older people have lower rates of loneliness relative to younger people, but rates begin to rise again after age 80. When paired with the increasing prevalence of chronic conditions as people age, this rise in loneliness can contribute to several comorbidities affecting healthy longevity.

Empowering Communities and Engaging Older Voices

Fostering social inclusion in communities requires creativity when government resources are stretched and populations are aging rapidly. Overall, fostering community advocacy and seeking the voice of older people are valuable policy goals that could complement the more traditional roles of advocacy for prevention of abuse of older people (Field and Fenton, 2014). Biological age cutoffs are not useful markers for understanding the needs of older people, and having a more nuanced understanding of aging across the life course would provide additional insight. One approach to engaging older people is through participatory design, ideally to bring underrepresented groups and minorities into the decision-making process that directly affects them, which differs from the traditional top-down decision-making model. A study in New Zealand with the Maori community summarizes steps in that community's approach as “(1) understanding of place, (2) relationship building, (3) respectful facilitation, and (4) empowered participation” (Marques et al., 2018, p. 6). Using a collaborative approach in seeking feedback and informing the design of programs and policies can result in greater sustainability and social benefits because the results acknowledge that different people can experience different realities.

Without an opportunity for the voices of older adults to be heard and incorporated into community and urban development, it will be impossible to truly meet their needs and optimize the environment for healthy aging across the life course. Engaging people in their own community development is more important than ever today, given the rate of population aging and the availability of older adults as an underutilized resource (HelpAge International, 2016b). Community-level interventions are effective and can lead to improved earning, healthier residents, and more active participants in the community. In Taketoyo, Japan, for example, the implementation of community-based centers, or “salons,” where senior residents could gather showed a protective association against cognitive decline among those over 65 who participated (Hikichi et al., 2017).

Each region and country will have its own methods for incorporating the voices of older adults, but the Older People's Associations (OPAs) found throughout Asia are a good example. A four-country study conducted in 2017 found that OPAs can make a true difference in the lives of older people, and can be used to develop local structures to fill the gaps between families in need of assistance and governments with limited resources (Howse, 2017). Keys to success for an OPA include strong management, sustained funding, and active and engaged members (HelpAge International, 2016b). Box 4-3 highlights a pilot project in Vietnam that promotes healthy longevity through a variety of community-driven activities and interventions.

BOX 4-3

The Intergenerational Self-Help Club Development Model.

Intergenerational Cohesion

Globally, economic security, social norms, and cultural values form ties within communities composed of families, kinship groups, and nonfamilial groups. When these ties are robust, with opportunities for interaction among different subpopulations, such as intergenerational social networks, cohesion is strong, and loneliness is less likely. Intergenerational social networks differ among countries and regions, but the dominant norms emphasize the importance of intergenerational connections and the protection they can provide against social isolation and loneliness. Importantly, benefits are seen across generations, not just among older adults.

Intergenerational programs have been developed by the public and private sectors. Although their effectiveness and optimal parameters are still being refined, benefits are widely reported for such programs. Older adults in these programs become less isolated and feel less lonely, and experience improved health and well-being (Jayson, 2018). Older adults with dementia experience positive effects and increased engagement when interacting with children when compared to activities that do not mix generations. Benefits accrue to the children in these programs as well, including improved learning and social development and more positive perceptions of older adults (United for All Ages, 2018). To generate these benefits, some organizations have created intergenerational play programs or classrooms designed to bring disparate age groups together. In the United States, for example, the St. Ann Center in Wisconsin specializes in adult and child day care services that include an intergenerational activity or class twice a day that provides an opportunity for the groups to interact and learn from one another (St. Ann Center, 2021). A systematic review of intergenerational programs examining benefits for children and older adults found improvements in attitude, behavior, confidence, and competence for the children, along with “significant differences in mental and physical health and quality of life for the older adults” (Giraudeau and Bailly, 2019, p. 363). However, the design and implementation of these programs is key to their success, and benefits will not be automatic.

Another approach to building intergenerational connection is illustrated by the Cycling Without Age program, started in Denmark in 2012 (Cycling Without Age, 2021). Limited mobility was preventing older adults from riding bicycles, so the program obtained “trishaws” that seat two people in front and the cyclist (usually a younger person) behind. The program gives older people an opportunity to remain an active part of society and the local community while also creating new relationships between generations. Younger people volunteer to drive the older riders and have the opportunity to hear stories from them before those stories are forgotten. The program currently has 2,700 chapters in 52 countries.

Another mechanism for building or maintaining strong connections across generations, directly and indirectly, is through multigenerational households that pair either older and younger generations or families. An increasing number of innovative examples of such arrangements have emerged worldwide as housing has become a shrinking, desirable commodity and older adults strive to age in place. Critical evaluations of these arrangements are often lacking, and because of variability in cultures and contexts, what works in some places may not work in others. Nonetheless, drawing lessons from successful interventions involving multigenerational households can guide the future development of such programs. In the Netherlands, for example, experiments in which college students live with older people began in 2012. This quite successful housing scheme, often dubbed “free rent for companionship,” provides students free housing in exchange for 30 hours per month of their time spent with their older housemates (The Economist, 2019a). Similarly, a study in France found that intergenerational housing arrangements solved two pervasive problems in the city of Paris: caring for older adults and providing affordable housing (Holman, 2019). 61 percent of people aged 18–30 living in one of these arrangements said they would not have had access to traditional housing otherwise, and more than half of the older adults reported that having a young person living with them allowed them to delay moving into a retirement home.

Adults of all ages are at risk of social isolation and shrinking family ties as a result of global trends toward smaller families and employment-related migration (Cacioppo and Hawkley, 2003). While families have varying reasons for multigenerational living, they often go beyond a desire for connection, reflecting structural pressures and individual circumstances, such as affordability, divorce, or illness, that make these arrangements the most practical option (Burgess and Muir, 2020). Among rural dwellers in Myanmar, for example, close proximity or coresidence of older people and their adult children's families provides personal material support and services (Knodel and Teerawichitchainan, 2017). Multigenerational living offers other benefits aside from potential financial savings. In one study, healthy subjects in the United States who lived in two-generation housing had lower premature mortality than those who did not (Muennig et al., 2018). And researchers in China found that men and women who lived in an institution or moved to such a facility after living with family faced a greater risk of dying relative to those who continued living with family (Feng et al., 2017).

Living arrangements are highly variable depending on culture and region. In North America and Europe, one in five older adults live alone (UN, 2019a), while in Asia, Africa, and Latin America and the Caribbean, more than 75 percent of older people live with children or extended family (Kamiya and Hertog, 2020). Evidence suggests, however, that these numbers may be shifting. A recent study found that multigenerational living is on the rise in the United States: one in four Americans now live in a household with three or more generations, representing a four-fold increase in multigenerational households in the past decade (Generations United, 2021). Box 4-4 describes a variety of influences and factors that may be at work in shaping intergenerational households in different countries.

BOX 4-4

Explorations in Intergenerational Living.

KEY TARGET: FINANCIAL SECURITY IN RETIREMENT

Comprehensive financial security systems are critical to mitigating socioeconomic inequalities and providing opportunities for individuals and families to navigate their health, education, and work circumstances to contribute to society. Financial security is an ageless need. Regardless of work history, gender, disability, or position in society, all people require a reliable, adequate income over the life course. Financial security benefits everyone because people with a secure income can contribute to their communities, have good quality of life, and live with dignity. But the right systems, structures, and opportunities must be in place for population-wide financial security to become a reality. The collection of these systems, structures, and opportunities can look different across regions and countries, but includes at a minimum pensions and social protection against poverty, vulnerability, and social exclusion; work that provides a fair income, safe working conditions, and equal opportunities; and access to financial services without discrimination (HelpAge International, 2021).

In many parts of the world, national and local governments are responsible for delivering on positive outcomes for the social enablers of healthy aging since they have the infrastructure and capacity to make change within and across generations. While high-income countries have established financial security systems, many low- and middle-income countries do not yet have such old-age protection for all of their population. Most countries offer old-age pensions to formal-sector employees only, leaving those in the informal work sector exposed to financial insecurity. Even in high-income countries, however, social security systems were instituted before population aging became an issue. Consequently, existing financial security systems were often designed for shorter lives and so lack mechanisms for adjusting the retirement age to reflect demographic change. Adjusting the retirement age is politically contentious in most high-income countries, but failure to do so can result in financial crisis, delayed disbursement, and reduced social pensions, affecting the most vulnerable older people who depend on social security for a living. Globally, this challenge can be an opportunity for those nations with less well-developed systems to design a better system from the ground up and learn from past lessons of other countries that will need to redesign their financial security infrastructure to be a more appropriate fit for the future.

Financial security schemes are an example of equitable income access and transformation of opportunity structures within communities, supporting the most vulnerable people in society. As described previously, poverty can have a critical influence on life expectancy, and differences of just a few miles within a city can translate into several years added to or subtracted from a person's life. A few countries (e.g., Australia, Denmark, the Netherlands, Switzerland) have successfully implemented systems that include generous health-promoting social structures, usually, although not always, means-tested, to meet the objective of alleviating poverty. They also have mandatory private saving plans, sometimes called “prefunded” plans, to help achieve consumption smoothing—essentially, the tendency of individuals to alter their spending and saving habits throughout their life depending on available resources. These designs are much more sustainable than others, as indicated by a global pension index that routinely places the systems of these countries near the top of its rankings for their sustainability (Mercer, 2021). Still, striking differences are evident across regions and countries with regard to pension availability and the structural and sociocultural contexts in which they were created. For example, only 12 African countries have established national pension schemes, and only 5 of those are universal (He et al., 2020). Furthermore, it is estimated that worldwide, more than 95 percent of people above retirement age in Europe receive a pension, while this is the case for only 26 percent in Central and Southern Asia and 23 percent in sub-Saharan Africa (UN, 2018).

Finding 4-8: Regardless of their work history or social status, financial security into older age can allow people to live with dignity, contribute to their communities, and have good quality of life, especially when they are unable to work. Absent this security, lack of access to necessary resources can have a detrimental effect on people's health and life span.

Interventions to Ensure Financial Security

Many countries have tried various interventions to improve the financial security of their residents. These interventions range in breadth and depth depending on the country's needs and circumstances. In 2015, for example, Australia reformed its welfare system, which led to an investment approach that ensures that funds are invested in groups of people with the largest anticipated future lifetime costs and the capacity to transition to self-reliance. The approach was established as part of the country's 2015–2016 national budget, with funding totaling AUD66 million (Australian Government, 2015). A different approach was taken by Brazil at the turn of the 21st century, when it was facing high levels of hunger, poverty, and inequality in many of its densely populated cities. The government introduced the Programa Bolsa Família in 2003 to provide conditional cash transfers for low-income families to ensure that their children could attend school and receive childhood vaccinations. Years later, the program's results demonstrate that it has reduced the proportion of the country's population living below the international poverty line from 13 percent to 3 percent. Bolsa Família is also credited with 12–21 percent of the country's reduction in income inequality and is widely seen as a model for conditional cash transfer programs (Centre for Public Impact, 2019). While this program is focused on families and young children, the long-term effects of providing these levels of security for younger adults will be influential in their aging trajectory, improving their chances of healthy longevity.

Addressing the wealth of workers in the informal sector can present an added challenge for many low- and middle-income countries. The size of the informal economy as a share of GDP in Africa is the largest in the world (Guven et al., 2021). Understanding this group will be key to successfully expanding social protection schemes, which will likely include instruments such as safety nets, economic inclusion programs, and productivity-enhancing measures—as outlined in the World Bank's report Social Protection for the Informal Economy (Guven et al., 2021). In Togo, for example, more than 92 percent of the workforce is considered informal (WIEGO, 2022). After years of stalled progress in including these workers in social protection programs, a combination of a top-down and bottom-up approach bringing together international organizations such as ILO and civil society advocacy groups led to better understanding on the part of the government and greater awareness among informal workers. As additional case examples, Box 4-5 highlights the design and outcomes of three recent social protection programs in low- and middle-income countries that have seen success.

BOX 4-5

Case Examples of Social Protection Programs in Kenya, Bolivia, and Mexico.

KEY TARGET: DIGITAL LITERACY

Another contributor to the challenges of aging is the lack of digital literacy among older adults, whereby those who are unfamiliar with computers and new devices are increasingly being left behind as technology advances and becomes ubiquitous in daily life. This has led to the “digital divide.” Physical access to broadband technology, discussed in Chapter 5, is one key component of addressing the digital divide. This section focuses on the social aspects and root causes of the lack of digital literacy and how it can be used to achieve healthy longevity.

Older adults continue to be the least likely age cohort to have access to the internet because of both physical and psychological factors (Chu et al., 2021). According to a European Union report, one-third of older adults reported never using the internet (Anderson and Perrin, 2017). This issue has been percolating below the surface for years, but the onset of the COVID-19 pandemic has amplified its importance. In China, for example, news reports highlighted an older woman who wanted to pay for her medical insurance in cash but was refused because of contamination concerns. Because she did not have mobile payment capability, she was left without options. Similarly, an older man in China was refused bus access because he did not have the mobile app to show his health status code (Kidron and Yang, 2021).

Reasons for this lack of digital literacy are numerous. One study in South Korea examining people over age 55 found digital engagement to be significantly influenced by factors such as gender, academic background, usage motive, life satisfaction, and household type (Yim et al., 2020). Interestingly, in Singapore, poor health has been found to be a main cause of the digital divide among older people, as health problems can affect a person's online communication and social activities within their networks (Ang et al., 2021). In Latin America, many older people live in homes with internet access, but they do not use the internet, highlighting barriers such as lack of motivation or desire (Sunkel and Ullmann, 2019). Given that there is no single reason for the lower levels of computer and internet use among older adults, solutions for increasing digital engagement across this population will be multifaceted.

Recently, a Lancet and Financial Times Commission stated that weak governance of digital technologies contributes to inequities and compromises human rights (The Lancet and Financial Times Commission, 2021). While much of that commission's focus is on youth, especially in low- and middle-income countries, interventions beginning with young people and continuing across the life course can have important implications as people age. Those who are educated in and immersed in digital technologies from a young age will likely continue to use technology throughout their lives. The Lancet and Financial Times Commission argues that digital access is a determinant of health, and technology needs to become a positive driver for equity. Otherwise, existing inequities will be exacerbated by the widening digital divide.

A WHO report addresses “the potential interplay between ageism and AI [artificial intelligence] for health as it affects older people, including the conditions in which AI for health can exacerbate forms of ageism and whether use of AI for health introduces new forms (or risks) of ageism” (WHO, 2022a, p. 3). The report emphasizes that “[l]egal, nonlegal, and technical measures can be used to minimize the risk of ageism in AI and to maximize its use for older people as these technologies become more widespread” (WHO, 2022a, p. 2). As AI technologies revolutionize aspects of public health and medicine and can be especially important for older people who have several comorbidities or conditions to monitor, the technologies can lead to harm without careful and ethical oversight. Indeed, numerous studies have highlighted the potential for embedding biases in AI systems as they rapidly develop (Chu et al., 2021). A WHO policy brief on Ageism in Artificial Intelligence for Health notes that the datasets used to train AI models and improve machine learning often exclude older people. Additionally, it is rare for design teams building these models to include older people; instead, they overwhelmingly include young White men. This increases the likelihood that older people will be excluded from new AI technology and that technologies targeting them will be inappropriate. Remedies for this challenge include leveraging participatory design approaches for AI technologies to involve older people, and having age-inclusive data collection and age-diverse data science teams (WHO, 2022a).

CONCLUSION

Many aspects of healthy longevity are influenced by social determinants that cannot be addressed or resolved within the health system. Interventions geared toward building social cohesion and social capital within communities can contribute to the cultural change needed for older adults to be more engaged in their societies. But to achieve the goals set forth in Chapter 2 and at the beginning of this chapter, these interventions also need to be paired with policies that work to combat ageism, promote social inclusion, protect the financial security of older adults, and improve opportunities for developing competence in using technology. Additionally, all of these areas would benefit from greater understanding and insight, so it will be important to ensure that translational research is funded and conducted across an array of areas to inform governments and other stakeholders when designing policies and fostering cultures of inclusion. For the findings emerging from research to be most useful and generalizable, translating and testing them in real-world settings will be a valuable addition to knowledge generation.

Older people already have meaningful roles in society as they age, but the need for new opportunities will grow with the rapid aging of populations. Meaningful engagement can yield a multiplicity of benefits for both aging populations and society. In terms of healthy longevity, challenging expectations, particularly in terms of opportunity structures, is one of the most important elements of achieving Vision 2050. Integral to the discussion in this chapter is the cross-cutting theme that the intersection of family, community and social cohesion, and equity has a vital role in achieving healthier, longer lives. Addressing these diverse but interconnected determinants holds promise for helping to achieve healthy longevity for the greatest number of people around the world. The ability of social and behavioral enablers to feed into the opportunities for healthy longevity is limitless, providing building blocks for measuring success and progress toward the world the commission envisions for 2050.

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