prof hal kendig, anu research school of population health: social determinants of health;...

Social Determinants of Health Conference

Informa

Sydney, 11 December, 2013

Social Determinants of Health Inequalities over the Life Course

Hal Kendig

Professor of Ageing and Public Policy

Centre for Research in Ageing, Health, and Wellbeing (CRAHW) Research School of Population Health

Chief Investigator

ARC Centre of Excellence in Population Ageing Research (CEPAR)

Overview

1. Research informing change and new ways of thinking

a. Ageing perspectives on the WHO Closing the Gap

b. Ageing people and attitudes

c. Research funding priorities: what can we know?

2. Ageing Well Research: some Findings

a. Determinants of ageing well

b. Life Course Influences on ageing well

3. Actions on Ageing Well: Policies

4 Actions on Ageing Well: Service and Practice Innovations

5. Concluding Questions: How can all of us take ageing into account

Note: an earlier version of this paper was presented as ‘Ageing Well: Actions and Evidence’, Keynote Address, Australian

Association of Gerontology, Sydney, November, 2013. See www.cepar.edu.au for for more evidence

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Centre for Research on Ageing, Health and Wellbeing

ARC Centre of Excellence in Population Ageing Research

http://www.cepar.edu.au/

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1. Research informing change

and new ways of thinking

Kendig, H, and C. Browning (2010) A Social view on healthy ageing: Multi-disciplinary

perspectives and Australian Evidence. In D. Dannifer and C.Phillipson (eds), SAGE

Handbook of Social Gerontology. London, Sage Publications: 459-471

Centre for Research on Ageing, Health and Wellbeing; ARC Centre of Excellence in Population Ageing Research

1a WHO Closing the Gap (2008) and

Australian developments

Closing the gap in a generation: health equity through action on the social determinants of health. Final Report of the

Commission on Social determinants of Health, Geneva, World Health Organisation (CSDH, 2008) RECOMMENDS

1. Improve Daily Living Conditions Improve the well-being of girls and women and the circumstances in which

their children are born .. Early childhood development and education for boys and girls, improve living

conditions and working conditions and create social protection policy supportive of all, and create conditions

for a flourishing older life……

2. Tackle the Inequitable Distribution of Power, Money, and Resources…...

3. Measure and Understand the Problem and Assess the Impact of Action……

The Australian Senate Committee report 2013

Recommends (but no action has been taken):

1. Adopt the WHO Report

2. Adopt administrative practices that ensure consideration of the social determinants of health in all …. policy.

1. Responsibility within one agency with a mandate to address issues across portfolios.

2. The NHMRC gives greater priority to .. Public health and social determinants research.

3. Annual reports to Parliament……..

And important leadership from the Public Health Association Australia

4 Centre for Research on Ageing, Health and Wellbeing

ARC Centre of Excellence in Population Ageing Research

1b ‘Who it is for’ Older People and Life Goals (and boomers more so and much diversity)

Qualitative investigations with older people guiding our work from the beginning of the ‘health status’ research that led to the Ageing Well findings.

• Striving to ‘be oneself’ and self determining

• Fierce will for independence (not a burden)

• Imperative for Ageing in Place (and importance of the local environment)

• Goals: feel well, health as a resource, and quality of life

Clearly a life span approach is how people can and wish to be understood in all their diversity and commonalities ‘I am me and I have grown older’

(eg Davison, B., H. Kendig, F. Stephens and V. Merrill (1993). “It’s my place”, older people talk about their homes, Canberra: Australian Government Publishing Service.

Quine, S., H. Kendig, D. Touchard, and C. Russell (2004) Health promotion for socially disadvantaged groups: The case of homeless older men Health Promotion International, 19(2):157-165.

Experiences of public (dis)respect and social treatment being made to ‘feel old’, devalued, & powerless (ageism) versus ‘normal ageing’ [health professionals are the ‘worst’]

Minichiello, J. Browne, and H. Kendig (2000) Perceptions and consequences of ageism: Views from

older persons. Ageing and Society, 20:253-278.

5 Centre for Research on Ageing, Health and Wellbeing; ARC Centre of Excellence in Population Ageing Research


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1c Building Evidence Envisaging Ageing and

Informing Change (A Big Picture)

New ways of thinking about ageing in Australia - increasingly led by older people

and their advocates – potentially can generate whole of society innovations to

enhance the well-being of older people and sustainability for future generations.

Australia is different from Europe and North America: eg, we face workforce

shortages as the large baby boom cohort retires over the coming decades. Ageing

people can be part of the solutions to the challenges of an ageing Australia.

‘Intergenerational Reports’ (IGRs), Commissions of Audit, and ‘think tanks’ are

contesting policies, prompting change, and reinforcing negative images of ageing. Kendig, H. (2010) The Intergenerational Report 2010: A double-edged sword. AJA, 29(4): 145-146.

Research funding determines what is ‘know-able’

- 2003 National Research Priority goal on ‘Ageing Well, Ageing Productively’. -

- Prime Minister’s 2003 PMSEIC research agenda and a ‘vision’ for another ten

years of healthy and productive ageing by 2050’

- Ageing Well, Ageing Productively Research Programs (2005)

- ARC/NHMRC Research Network in Ageing Well (2005)

- NHMRC Health Priorities (diseases) and Dementia research initiatives (2013)

2. Ageing Well Research Findings

Examples from the

– Melbourne Longitudinal Studies of Ageing

(MELSHA) and

– The Life History and Health Survey

(Social Determinants of Health Disparities)

(presenting mainly recent work now being published)

Centre for Research on Ageing, Health and Wellbeing ARC

Centre of Excellence in Population Ageing Research

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2a. The Melbourne Longitudinal Studies of

Healthy Ageing (MELSHA) 1994-2010

Baseline Health Status of Older People Survey (N=1000)

- aged 65+ interviewed in private residences

- biennial follow-up: phone, home, mail or informant report

- 70 % response rate (some bias towards healthy people)

- Limited diversity – eg in terms of ethnicity and disadvantage

Funding Support

Victorian Health Promotion Foundation, National Health and Medical

Research Council, Australian Research Council, and our Universities (with thanks to the guidance of the VicHealth Health Status of Older People Working Group)

Browning, C. J. and H. Kendig (2010) Cohort profile: The Melbourne Longitudinal Studies

on Healthy Ageing Program. International Journal of Epidemiology, 39(5): e1-e7.

2b Melbourne Longitudinal Surveys of Healthy

Ageing (baseline findings)

Respondents say healthy ageing means

- being active physically and socially

- feeling well

- continuing to contribute

- as well as absence of disease

Value of a Health Action Approach

- what motivates, enables and constrains

Health as a resource for the ‘continuing self’ (identity)

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2c Defining Ageing Well (quantitatively)

Components of Ageing Well (all positive; at Baseline)

1. Positive Affect (mood) : Scores > 17 (83%); and

2. Living Independently: Can shop for food, prepare meals, do own

housework. (81%); and

3. Excellent/Very Good Self rated health (80%)

Ageing Well (all of above) (64% at baseline)

Note: This holistic definition aims to have a wider scope than ‘successful

ageing’, ‘healthy ageing’, or ‘positive ageing. It builds on a small literature

on ‘lay conceptions’ and builds on our qualitative research.

Multi-variate Cox regression: Best fit models for baseline characteristics on continuing to live in a state of ‘ageing well’? (article under review)

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2d Life Style Predictors & Outcomes to 2008

(significant potentially improvable actions)

Significant

Baseline

Predictors 1

Survival

Living in the

Community (not

in residential

care)

Ageing Well

Low Strain ✔

Physical Activity ✔

Healthy Nutrition ✔

BMI Acceptable ✔ ✔

Perceived Social

Support Adequacy

✔

Social Activity

Amount

✔ ✔

1 p < .01 (net of other health and socioeconomic predictors)

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2e Gender, Life Style, & Ageing Well

Significant Baseline

Predictors 1

Women only Men only Total sample

High Strain ✔

Physical Activity ✔ ✔

Healthy Nutrition ✔

BMI acceptable ✔ ✔

No Urinary

Incontinence

✔

Perceived Social

Activity Adequacy

✔

Perceived Social

Support Adequacy

✔

Social Activity Amount ✔

Ex-Smoker ✔

12 1 p < .01 (net of other health and socio-economic factors)

2f Ageing, Living Well, and Chronic Disease

(more MELSHA findings)

Preliminary findings from the paper ‘Ageing Well with Chronic Disease’

presented by Kendig, Browning, and Burns presented to the Invited

Symposium ‘Multiple Chronic Disease: Australian and Canadian Perspectives’,

Chair Andrew Wister, Discussant Marcia Ory, Gerontological Society of

America, New Orleans, November 2013



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2i Defining Chronic Disease

Chronic Disease Self reports (Prevalence at baseline)

(The definitions could be wider – we are exploring further …)

– Heart disease (11%)

– Stroke (6%)

– Cancer (14%)

– Diabetes (6%)

– Arthritis (56%)

– Pct with any (72%)

– Pct with two or more (17%)

The analyses count are based on counts of chronic disease.

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2j Ageing influences on not living

well and chronic disease (to 2008) • With increasing age there is an increased likelihood of

Not Living Well and also having a Chronic Disease.

• Ageing has a more significant impact on Not Living Well

than on Chronic Disease. Ageing well is complex that

involves multiple bio-psych-social factors.

• Especially at relatively younger ages most people having

a chronic disease are ageing well!

And the risk of both is increased among people who have

low socio-economic resources.



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2l Likelihood of Mortality

(ref Living Well/No Chronic Disease)

2.06

2.95

0.78

0

1

2

3

4

5

6

7

Not Living Well/NoChronic Disease

Not Living Well/HaveChronic Disease

Living Well/Have ChronicDisease

** p < .01

**

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2m MELSHA Key findings so far

• Healthy life styles in later life are related to longer term benefits

• Life Style directly influences quality of life outcomes

• Social determinants (eg income) are more underlying influences

• Older women and men face different vulnerabilities

Question: Can life style interventions yield the same benefits as ‘natural’ variation?

(based on articles under review and in progress by Kendig, Browning, and colleagues)

2n Socio-economic determinants of health

disparities over the life course

Investigators: Kendig, Byles, Nazroo, O’Loughlin, Mishra, and collaborators

• ARC Discovery Grant and ARC CEPAR

• 2010-2011 Life History and Health Survey of babyboomers (60-64 yrs) in NSW

as a substudy of 45 and Up

Paper presented yesterday (article under review) by Vanessa Loh showing that

Quality of life (e.g., “I feel that my life has meaning’) and Life satisfaction

are influenced by childhood health and socio-economic status

which relate to adult health and occupational attainment; and hence

health and socio-economic resources on entry to later life.

Comparisons to the English Longitudinal Survey on Ageing will enable us to investigate the influence

of Australian post war social, economic, and policy factors on individuals life course developments.

Implication: The value of a life course and human capital approach to ageing well from an early start

onwards. It is never too early (nor too late!)



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Part 3 Policy Directions


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The broad context of increasing health and longevity of ageing people notwithstanding

increases of people ageing with obesity and chronic disease. Health promoting activities are

increasing among babyboomers but less so for disadvantaged people

Humpel, N., K. O'Loughlin, Y. Wells and H. Kendig (2009) Ageing baby boomers in Australia: Evidence for

informing actions for better retirement. Australian Journal of Social Issues, 44(4): 399-415.

The centrality of mainstream employment, housing, and income as well as health programs

with the evidence suggesting that health gain is maximised with distribution to those with the

least resources. Various CEPAR and other investigations underway. www.cepar.edu.au

Whole of government and whole of society strategies, eg the NSW Ageing Strategy and the

Age Friendly Communities movements. Kendig, H., & Phillipson, C. (in press). Building age friendly cities: New approaches and evidence. In N. Denison & L. Newby

(Eds.), Health inequalities: Social determinants at a local level: British Academy Policy Centre.

The Government’s Advisory Panel on Positive Ageing (now disbanded) [submissions and targeted consultations]

The UN human rights approach to ageing under the leadership of the Age

Discrimination Commissioner. [mainly consultancies and complaints]

3a Positive Policy Directions [& evidence base]


http://www.cepar.edu.au/

3b The Living Longer Living Better Directions

The Government’s Living Longer, Living Better reforms (with bipartison

support) aim to radically refocus ‘aged care’ to support older people mainly

at home including new ‘consumer-directed’ approaches.

Leadership from the Council on the Ageing (Australia) Listening to Older

Australians and

Productivity Commission Report on Caring for Older People. [extensive review Trends in Aged Care, submissions, and secondary data analysis]

Kendig, H. (2011) Research and evaluation priorities: the Report of the Productivity

Commission on Care of Older People. Australasian Journal on Ageing, 30(2): 54-56.


3c Big-Picture Aims for Care Systems

• Provide for changes (trajectories and transitions) and

multiple needs (social, economic, care & health)

• The importance of ‘upstream’ action (keep healthy) not

only ‘downstream’ care, e.g. centrality of health

promotion and maintaining and regaining independence

• Client centred: consumer-led, continuity, improvability,

integration, & timeliness – what service systems must

and can deliver

• Whole of government integration with mainstream

health, housing, transport... At the community level

Based on a range of ageing well and services research


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3d LLB and PC: Enable Independence

• Older People in the mainstream of health promotion and community supports eg transport (difficult but essential)

• Health promotion and self care in aged care and primary care (including chronic disease)

• Enable and regain independence in community care as well as rehabilitation (Active Service Model in Vic)

• The Home Independence Program Gill Lewin in WA (more below)

[Our research shows that choice and a control are valuable in themselves]


3e Enhancing quality of life in older people

• Deliver what older people want rather than what we think they want

• Understand that there are individual differences in older people’s

wishes that need to be incorporated into service tailoring

• Explicitly include QOL measurement and concepts in service

evaluation and quality improvement

• Help older people avoid and manage chronic illness

• Promote meaningful social engagement

• Improve self perceptions of ageing by valuing and

promoting the contributions that older people make to Society

Professor Colette Browning FAPS and Professor Shane Thomas MAPS, ‘Enhancing

quality of life in older people’, InPsych | The bulletin of The Australian Psychological

Society Limited February 2013, pp 12-13


3f A few policy observations on

prevention and health promotion • In Australia there is a strong policy focus on

chronic disease yet little attention to ageing and

older people.

• For prevention, self management, and

amelioration it is important to ensure inclusion of

the middle and older age groups for whom

chronic disease is most salient.

• There is encouraging evidence on the efficacy of

prevention and interventions for ageing people.

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3g And the big picture on well being (or

can we only achieve what we measure) Flourishing refers to the experience of life going well. It is a combination of feeling good

and functioning effectively…high level of mental wellbeing,

Well-being matters for health outcomes

Burns,Byles, Mitchell and Anstey. Positive components of mental health provide significant protection

against likelihood of falling in older women over a 13-year period

International Psychogeriatrics (2012), 24:9, 1419–1428 C International Psychogeriatric Association

2012doi:10.1017/S1041610212000154

Can we monitor well-being along with other valued outcomes of ageing people Huppert, Marks,Clark, Siegrist, Stutzer, Vittersø and Wahrendorf

Measuring Well-being Across Europe: Description of the ESS Well-being Module and Preliminary Findings

Soc Indic Res (2009) 91:301–315 DOI 10.1007/s11205-008-9346-0



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Part 4 Service Innovations

and Practice: A few Examples

Notes:

- The potential of Consumer-Directed Care under the Living Longer,

Living Better reforms.

- Past failures of policies and services to adopt valuable, proven

community based inovations


4a. ACH Group ‘Good Lives for

Older People’ 2011 • Innovative community care agency … committed to shifting

• from client centred (organisation controlled ‘places’) - to consumer

directed (persons with entitlements)

• Language is important: - ‘customers’ (not clients/consumers) -

‘advisors’ (not coordinators)

• Redefine power relationships – so people can continue with - the

choice and the control they have had their whole lives - (not a

rationed system where other people decide for them)

• Restorative approaches, social participation & physical activity

(and Barnett with Dean 2012 for the evidence base)



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4b ACH Group Principles of a Good Life

1. Unique: “I am me!” ‘No life has been lived before and it won’t be lived

again… to be honoured, including my life experiences, strengths, culture,

and spirituality’

2. Being in Control: ‘I am in control of my life… I am my own boss’

3. Optimistic: ‘I have a sense of future and hope’ ‘I set goals for myself’

4. Belonging: ‘I love being with family and friends’ … a variety of relationships

in everyday life

5. Contributions and Engagement: ‘I want to do my bit’ … To give, take, and to

enjoy the fullness of life with interests and passions….

6. Healthy – ‘I want to stay fit!’ … I am as healthy as I can be

(based on Board Conversations with Older People and CDC customers’

comments)

And thanks to Jeff Fiebig, Mike Rungie, and colleagues



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4d Healthy Ageing and Inclusive Design

Healthy

Ageing

Agenda

Inclusive

Design

Agenda

Disability

Social

sustainability

Ageing continuum Kate Bridge UNSW

Eco sustainability

Maintain

activity levels

4e Evidence for Environmental

approaches Bridge, C. and H. Kendig. Environments, professionals, and positive ageing

(2005) In I. Coulsen and V. Minichiello (eds.) Contemporary issues in

gerontology: Promoting positive ageing. Sydney: Allen & Unwin,

• 144-166.

Plus additional Bridge publications available from the UNSW Cities Future

Program and the Australian Housing and Urban Research Institute (AHURI)



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5. Some Concluding Observations

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5a Implications for practise

Importance of the Clinical and Service Relationship

- Attitudes and advice for each person (listening)

Don’t make people ‘feel old’!

More than a clinical problem on a body

Positive: what can be done

what matters for you?

Recoverable and Improvable

Not disability and death denying

- Reinforcing who we are and who we can become

- Enabling and facilitating


5b Developing an ‘Age-sensitive’

perspective in Programs and Policies The centrality of a life span perspective:

The young will become old (human capital investments)

The old were once younger (and we can learn from them)

It is never to early nor to late (opportunities at all ages)

The main game is how ageing and older people fare in their

communities and mainstream services

Eg, the NSW Ageing Strategy (potential and difficulties)

The challenges:

Diversity across social groups and individuals

Entrenched disadvantage across family generations

Confronting Ageism



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Key Collaborators in Developing Ageing Well Research ANU Ageing and the Family Project ARC-NHMRC Research Network in Ageing Well (RNAW)

• Diane Gibson sociology - Kaarin Anstey psychology

• Jane Halton psychology - Helen Bartlett gerontology

• John McCallum sociology - Tony Broe geriatric medicine

• Don Rowland demography - Colette Browning psychology

- Julie Byles epidemiology and medicine

- Mathew Carroll psychology

- Judith Healy social policy

- Sue Richardson economics

- Barbara Squires social work

- Sue Richardson economics

La Trobe ARC Key Centre in Gerontology ANU Centre for Research in Ageing, Health, and Well-being (CRAHW

• Colette Browning psychology ARC Centre of Excellence in Population Ageing Research (CEPAR)

• Libby Brooke sociology - Kaarin Anstey psychology

• Barbara Davison occupational therapy - Richard Burns psychology

• David de Vaus sociology - Colette Browning psychology

• Victor Minichiello sociology - Julie Byles epidemiology and medicine

• Karen Teshuva public health - Cathy Gong economics

• Rhonda Nay nursing - Vanessa Loh psychology

• Yvonne Wells psychology - Kerry Sargent-Cox psychology

University of Sydney, Health Sciences and Centre for Education and Research on Ageing

• Kate Bridge, occupational therapy and architecture

• Lindy Clemson occupational therapy

• Bob Cumming geriatric medicine, epidemiology, and public health

• David Le Couteur geriatric medicine and biology

• Vanessa Loh psychology

• Jack Noone psychology

• Kate O’Loughlin sociology

• Susan Quine sociology and public health

Centre for Research on Ageing, Health and Wellbeing 35

Some References

• Browning, C. J. and H. Kendig (2010) Cohort profile: The Melbourne Longitudinal Studies on Healthy Ageing Program.

International Journal of Epidemiology, 39(5): e1-e7.

• Browning, C., Heine, C., & Thomas, S. (2012). Promoting ageing well: Psychological contributions. In L. Ricciardelli & M.

Caltabiano (Eds.), Applied Topics in Health Psychology (pp 57-71). Wiley-Blackwell.

• Browning, C., & Heine, C. (2012). Ageing and health: Biological, social and environmental perspectives. In P. Liamputtong,

R. Fanny & G. Verrinder (Eds.), Health, Illness and Well-being: Perspectives and social determinants (pp 92-106). Oxford

University Press.

• Browning, C. J., Chapman, A., Cowlishaw, S., LI, Z. X., Thomas, S. A., Yang, H. & Zhang, T. (2011). The Happy Life Club™

study protocol: A cluster randomised controlled trial of a type 2 diabetes health coach intervention. BMC Public Health, 11.

• Browning, C., Thomas, S., Yang, H., Chapman, A., Zhang, T., Li, Z. (2011). The Happy Life Club: Improving the quality of life

of patients with type 2 diabetes mellitus. Chinese General Practice,14, 5A, 1397-1401.

• Shariff, S., Browning, C. & Yasin, S. (2012). Promoting physical activity in sedentary elderly Malays with type 2 diabetes: A

protocol for randomised controlled trial. BMJ Open, BMJ Open, 6 (2), available on BMJ Open 2012;2:e002119

• Kendig, H. and C. Browning (2010) A social view on healthy ageing: Multi-disciplinary perspectives and Australian evidence.

In D. Dannefer and C. Phillipson (Eds.) The SAGE Handbook of Social Gerontology. London, Sage Publications: 459-471.

• Kendig, H. and C. Browning (2011). Ageing well in a healthy Australia. ASSA Dialogue, Academy of the Social Sciences in

Australia, Canberra, 31(2): 22-30.

• Kendig, H., Browning, C.J. and Young, A.E. (2000) 'Impacts of illness and disability on the well-being of older people',

Disability & Rehabilitation, 22:1, 15 – 22

• Kendig, H. L., R. I. Pedlow, C. J. Browning, Y. D. Wells and S. A. Thomas (2010) Health, social and lifestyle factors in entry

to residential aged care: an Australian longitudinal analysis. Age and Ageing, 39: 342-34.

Some related to broader policy

Gibson, D. M. & Academy of the Social Sciences in Australia. (2010). Beyond life

expectancy. Canberra : Academy of the Social Sciences in Australia,

http://www.assa.edu.au/publications/occasional_papers/2010_CS5.php Jorm, L., Walter, S. R., Lujic, S., Byles, J & Kendig, H. (2010). Home & community care services: a major opportunity for preventive health care, BMC Geriatrics, 10, 26. Kendig, H. (2010). The intergenerational report 2010: a double-edged sword, Australasian Journal on Ageing, 29 (4): 145-146. Kendig, H., Browning, C., Pedlow, R., Wells, Y., & Thomas, S. (2010). Health, social, and life style predictors of entry to residential aged care: An Australian longitudinal analysis, Age and Ageing, 39 (3): 342-9. Kendig, H. & Duckett, S. (2001). Australian directions in aged care: The generation of policies for generations of older people, Australian Health Policy Institute at the University of Sydney, Commissioned Paper Series 2001/5 (113 pp.). Lewin, G. & Vandermeulen, S. (2010). A non-randomised controlled trial of the Home Independence Program, an Australian restorative programme for older home care clients, Health and Social Care in the Community, 18(1): 91-96.


http://www.assa.edu.au/publications/occasional_papers/2010_CS5.php

prof hal kendig, anu research school of population health: social determinants of health;...

Health & Medicine

ageing people

ageing australia

ageing perspectives

healthy ageing

ageing well3

determinants of ageing

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