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Women, Ageing and Health: A Framework for Action
Women, Ageing and Health:
A Framework for Action
Focus on GenderWomen, Ageing and Health: A Framework for Action
Women, Ageing and Health:
A Framework for Action
Focus on Gender
PAGE 57WHO Library Cataloguing-in-Publication Data
Women, ageing and health : a framework for action : focus on gender.
1.Ageing. 2.Women's health. 3.Longevity. 4.Women. 5.Gender identity. I.World Health Organiza-
tion. II.United Nations Population Fund.
ISBN 978 92 4 156352 9 (NLM classification: WA 309)
© World Health Organization 2007
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PAGE 2Women, Ageing and Health: A Framework for Action
Contents
1. Introduction 1
About this report 1
Key concepts and terms in this report 2
A global profile of ageing women 3
The knowledge gap 3
2. A framework for action 4
A life-course approach 4
Determinants-of-health approach 6
Three pillars for action 7
A gender- and age-responsive lens 7
3. The health status of older women 11
Key points 11
Implications for policy, practice and research 15
4. Health and social services 18
Key points 18
Implications for policy, practice and research 20
5. Personal determinants 23
Biology and genetics 23
Key points 23
Implications for policy, practice and research 24
Psychological and spiritual factors 26
6. Behavioural determinants 27
Key points 27
Implications for policy, practice and research 30
7. Economic determinants 32
Key Points 32
Implications for policy, practice and research 34
8. Social determinants 36
Key points 36
Implications for policy, practice and research 37
9. The physical environment 40
Key points 40
Implications for policy, practice and research 42
10. Moving ahead 44
Taking action 44
Active ageing pillar 1: health and health care 46
Active ageing pillar 2: participation 47
Active ageing pillar 3: security 47
Building a research agenda 47
References 50
PAGE iAcknowledgements
This report summarizes the evidence about women, ageing and health from a
gender perspective and provides a framework for developing action plans to
improve the health and well-being of ageing women.
This publication was developed by the Department of Ageing and Life Course
(ALC) under the direction of Dr Alexandre Kalache and Irene Hoskins. ALC re-
ceived support from Francois Farah and Ann Pawliczko from the Population and
Development Branch of the United Nations Population Fund (UNFPA) and collabo-
ration from Dr 'Peju Olukoya from the Department of Gender, Women and Health
(GWH) of the World Health Organization (WHO).
The input and contribution of the following experts – who represented all WHO
regions and provided background material – are gratefully acknowledged: Dr
Isabella Aboderin (Nigeria), Prof. Nana Araba Apt (Ghana), Dr Narimah Awin
(Malaysia), Dr Denise Eldemire-Shearer (Jamaica), Dr Randah R. Hamadeh
(Bahrain) Dr Anita Liberalesso Neri (Brazil), Dr Indira Jai Prakash (India), Dr Mary
Ann Tsao (Singapore), Dr Barbro Westerholm (Sweden) and Mahmoud Fathalla
(Egypt). In addition, contribution from colleagues from international non-gov-
ernmental organizations was gratefully received: Dr Jane Barratt (IFA), Dr Gloria
Gutman (IAGG), Mark Gorman (HelpAge International)
The report was prepared based on a literature review available at: http://www.
who.int/en/ageing/en compiled by Peggy Edwards, a health promotion consultant
from Ottawa, Canada who, under the direction of the ALC Department, produced
a draft of the report.
Taking action for older women and men
As they age, women and men share the basic needs and concerns related to the
enjoyment of human rights such as shelter, food, access to health services, dignity,
independence and freedom from abuse. The evidence shows however, that when
judged in terms of the likelihood of being poor, vulnerable and lacking in access
to affordable health care, older women merit special attention. While this publica-
tion focuses on the vulnerabilities and strengths of women at older ages, it is
often difficult and sometimes undesirable to formulate recommendations that ap-
ply exclusively to women. Clearly many of the suggestions for action in this report
apply to older men as well.
PAGE iiWomen, Ageing and Health: A Framework for Action
1. Introduction
This report endeavors to provide informa-
“Gender is a ‘lens’ through which to consider
tion on ageing women in both developing
the appropriateness of various policy options
and developed countries; however, data are
and how they will affect the well-being of
both women and men.” often scant in many areas of the developing
… Active Ageing: A Policy Framework1 world. Some implications and directions for
World Health Organization, 2002 policy and practice based on the evidence
and known best practices are included in
This framework for action addresses the this report. These are intended to stimulate
health status and factors that influence discussion and lead to specific recommenda-
women’s health at midlife and older ages tions and action plans. The report provides
with a focus on gender. It provides guid- an overall framework for taking action that
ance on how policy-makers, practitioners, is useful in all settings (Chapter 2). Specific
nongovernmental organizations and civil responses in policy, practice and research
society can improve the health and well- is undoubtedly best left to policy-makers,
being of ageing women by simultaneously experts and older people in individual coun-
applying both a gender and an ageing lens tries and regions, since they best understand
in their policies, programmes and prac- the political, economic and social context
tices, as well as in research. A full review within which decisions must be made.
of the evidence is available in a longer
This publication and the complementary
complementary document entitled Women,
longer Review are designed to contribute
Ageing and Health: A Review. Focus on
to the global review of progress since the
Gender. It will be available online shortly
Fourth World Conference on Women
at http://www.who.int/ageing/publications/
(Beijing, 1995),2 the Madrid International
gender/en/index.html
Plan of Action on Ageing (2002), 3 and
About this report the implementation of the Millennium
Development Goals.4 While some progress
The concepts and principles in this docu-
has been made as a result of these United
ment build on WHO’s active ageing policy
Nations initiatives and new policy direc-
framework, which calls on policy-makers,
tions have been adopted at the country
practitioners, nongovernmental organiza-
level, the rights and contributions of older
tions and civil society to optimize opportu-
women remain largely invisible in most
nities for health, participation and secu-
rity in order to enhance quality of life for
people as they age.1 This requires a compre-
hensive approach that takes into account
the gendered nature of the life course.
PAGE 1settings. This lack of visibility is especially are a normal part of the ageing process. At
problematic for ageing women who face the same time, socioeconomic factors such
multiple sources of disadvantage, including as living arrangements, income and access
those who are poor, divorced or widowed; to health care greatly affect how individuals
immigrants and refugees; and members of and populations experience ageing.
ethnic minorities.
Ageing may also constitute a continuum
Key concepts and terms in this of independence, dependence and inter-
report dependence that ranges from older women
who are essentially independent and coping
Sex and gender. Sex refers to biology where-
well with daily life, to those who require
as gender refers to the social and economic
some assistance in their day-to-day lives,
roles, responsibilities and opportunities
to those who are dependent on others for
that society and families assign to women
support and care. These groups are hetero-
and men. Both sex and gender influence
geneous, reflecting diverse values, health
health risks, health-seeking behaviour, and
status, educational levels and socioeco-
health outcomes for men and women, thus
nomic status.
influencing their access to health care sys-
tems and the response of those systems.5
The health of older men
Older women refers to women age 50 and
older. Ageing women refers to the same This report does not address men’s health
chronological group but emphasizes that issues. It recognizes, however, that ageing
ageing is a process that occurs at very men – like ageing women – have health
different rates among various individuals concerns based on gender. For example,
and groups. Privileged women may remain the gender-related concept of “masculin-
ity” can exacerbate men’s risk-taking and
free of the health concerns that often ac-
health problems as well as limit men’s
company ageing until well into their 70s
access to health care. The report also
and 80s. Others who endure a lifetime of
acknowledges that men of all ages can
poverty, malnutrition and heavy labour play a critical role in supporting the health
may be chronologically young but function- of women throughout the life course.
ally “old” at age 40. Decision-makers need Readers who want to learn more about
to consider the contextual differences in male ageing and health are referred to the
how the process of ageing is experienced in WHO document entitled Men, Ageing and
their specific environment, when designing Health: Achieving Health Across the Life Span
gender-responsive policies and programmes 2001 (WHO, 2001, available online at http://
for ageing women. whqlibdoc.who.int/hq/2001/WHO_NMH_
NPH_01.2.pdf).
Ageing is also both a biological and social
construct. Physiological changes such as a
reduction in bone density and visual acuity
PAGE 2Women, Ageing and Health: A Framework for Action
A global profile of ageing women
Equity in health means addressing the
For multiple reasons the feminization of disparities between and among differ-
ageing has important policy implications ent groups of older women, as well as
for all countries: those between women and men.
• Ageing women make up a significant
proportion of the world's population
The knowledge gap
and their numbers are growing. The When it comes to research and knowl-
number of women age 60 and over will edge development, older women face
increase from about 336 million in 2000 double jeopardy — exclusion related to
to just over 1 billion in 2050. Women both sexism and ageism. Current infor-
outnumber men in older age groups mation concerning ways in which gender
and this imbalance increases with age. and sex differences between women and
Worldwide, there are some 123 women men influence health in older age is inad-
for every 100 men aged 60 and over.6 equate. While gender-inclusive guidelines
have been implemented in some countries,
• While the highest proportions of older
there is still a tendency for clinical stud-
women are in developed countries, the
ies to focus on men and exclude women.
majority live in developing countries,
Surveillance data that include sex and
where population ageing is occurring at
age-disaggregated data are also limited.
a rapid pace.
For example, most international studies
• The fastest growing group among ageing on health issues – such as violence and
women is the oldest-old (age 80-plus). HIV/AIDS – fail to compile statistics for
Worldwide, by age 80 and over, there people over the age of 50. Lastly, there is a
are 189 women for every 100 men. By paucity of research on gender differences
age 100 and over, the gap reaches 385 in the social determinants of health. A
women for every 100 men.6 While most recent study mapping existing research and
ageing women remain relatively healthy knowledge gaps concerning the situation
and independent until late in life, the of older women in Europe found a lack of
very old most often require chronic care research related to women aged 50 to 60
and help with day-to-day activities. in particular.7 While there were numerous
longitudinal studies on ageing, these stud-
• Older women are a highly diverse
ies had little or no gender analysis of the
group. Life at age 60 is obviously very
different impacts of health conditions and
different from life at age 85. Although
the social determinants of health on ageing
cohorts of older women may experience
women and men. In this report, some key
some common situations, such as a
issues for research and information of and
shared political environment, exposure
are described in each chapter.
to war and the arrival of new technolo-
gies, their longevity has given them
more time to develop unique biogra-
phies based on a lifetime of experiences.
PAGE 32. A framework for action
This chapter describes a gender- and age- This finding implies that individuals can in-
responsive framework for action based on fluence how they age by practising healthier
the following components: lifestyles and by adapting to age-associated
changes. However, some life course factors
• A life-course approach
may not be modifiable at the individual
• A determinants of health approach level. For instance, an individual may have
little or no control over economic disad-
• Three pillars for action vantages and environmental threats that
directly affect the ageing process and often
• A gender- and age-responsive lens
predispose him or her to disease in later
life.
A life-course approach
Growing evidence supports the concept of
Ageing is a lifelong process, which begins critical periods of growth and development
before we are born and continues through- in utero and during early infancy and child-
out life. The functional capacity of our hood when environmental insults may have
biological systems (e.g. muscular strength, lasting effects on disease risk in later life.
cardiovascular performance, respiratory For example, evidence suggests that poor
capacity) increases during the first years growth in utero leads to a variety of chronic
of life, reaches its peak in early adulthood disorders such as cardiovascular disease,
and naturally declines thereafter. The slope non-insulin dependent diabetes, and hy-
of decline is largely determined by exter- pertension.9 Exposures in later life may still
nal factors throughout the life course. The influence disease risk in a simple additive
natural decline in cardiac or respiratory way but it is argued that fetal exposures
function, for example, can be accelerated by permanently alter anatomical structures
factors such as smoking and air pollution, and a variety of metabolic systems.10 This
leaving an individual with lower functional means that girls who are born into societ-
capacity than would normally be expected ies that favour boys and deprive girls are
at a particular age. Health in older age is particularly likely to experience disease and
therefore to the largest extent a reflection of life.
the living circumstances and actions of an
individual during the entire life span.8
PAGE 4Women, Ageing and Health: A Framework for Action
Examples of life course events that increase women’s vulnerability to poor health in older age
• Gender discrimination against girls child leading to inequitable access to food and care
by female and male infants and children.
• Restrictions on education at all levels.
• Childbirth without adequate health care and support.
• Low incomes and inequitable access to decent work due to gender-discrimination in the
labour force.
• Caregiving responsibilities associated with mothering, grandmothering and looking
after one’s spouse and older parents that prevent or restrict working for an income and
access to an employee-based pension.
• Domestic violence, which may begin in childhood, continue in marriage and is a com-
mon form of elder abuse.
• Widowhood, which commonly leads to a loss of income and may lead to social isola-
tion.
• Cultural traditions and attitudes that limit access to health care in older age, for ex-
ample older women are much less likely than older men to receive cataract surgery in
many countries.
A life-course perspective calls on policy- careers interrupted because of childbear-
makers and civil society to invest in the ing and caregiving make it very difficult
various phases of life, especially at key for women to earn as much as men in their
transition points when risks to well-being respective lifetimes. Thus, the prevention
and windows of opportunity are greatest. and alleviation of poverty in older age calls
These include critical periods for both bio- for a set of policies based on a new para-
logical and social development, including in digm that provides social safety nets at key
utero, the first six years of life, adolescence, times in the female life course, and particu-
transition from school to the workforce, larly when women are unable to earn an
motherhood, menopause, the onset of adequate wage in the open labour market.
chronic illnesses and widowhood. Policies This includes policies and practices that:
that reduce inequalities protect individuals
• support reproductive health and safe
at these critical times.11
motherhood programmes;
Even with multiple changes in policies
• support girls’ access to education with a
related to education and labour-market
special effort to enable their transition
participation, gender-specified roles and
from primary to secondary and to post-
secondary schooling;
PAGE 5• enable equitable entry to the labour mar- A determinants-of-health approach
ket and to meaningful, protected work;
There is now clear evidence that health care
• provide incentives for 'family friendly' and biology are just two of the factors influ-
policies in the workplace which support encing health. The social, political, cultural,
pregnancy, breastfeeding, and caring for and physical conditions under which people
children and older family members; live and grow older are equally important
influences.12
• support caregivers of family members
who are ill or frail, and ease the financial Active ageing depends on a variety of
burden and employment opportunity “determinants” that surround individuals,
costs of this essential role; families and nations. These factors directly
or indirectly affect well-being, the onset
• support changes in work practice that and progression of disease and how people
enable older women to remain in both cope with illness and disability. The deter-
the formal and informal labour markets; minants of active ageing are interconnected
• support voluntary and gradual retire- in many ways and the interplay between
ment as well as incentives to save for them is important. For example, women
retirement and long-term care needs; who are poor (economic determinant) are
more likely to be exposed to inadequate
• ensure that equal rights to the inheri- housing (physical determinant), societal
tance of property and resources upon the violence (social determinant) and to not eat
death of a parent or spouse are upheld; nutritious foods (behavioural determinant).
• ensure the right to health and equal ac- Figure 1 shows the major determinants
cess to health care; of active ageing. Gender and culture are
cross-cutting factors that affect all the
• ensure that all older women have an
others. For example, gender- and culture-
income that satisfies the basic necessities
related customs mean that men and women
of life, as well as equal access to required
differ significantly when it comes to risk-
health, social, and legal services;
taking and health-care-seeking behaviours.
• provide additional support to widows as Culturally driven expectations affect how
required, to older women who live alone, women experience menopause in various
to those who are poor or disabled, and to parts of the world. The gendered nature of
those who require long-term care in or caregiving and employment means that
outside of the family residence; and women are disadvantaged in the economic
determinants of active ageing.
• support compassionate end-of-life care
and help with arrangements for a peace-
ful death and appropriate burial re-
quired.
PAGE 6Women, Ageing and Health: A Framework for Action
Figure 4. The determinants of Active Ageing
Gender
Health and
Economic social services
determinants
Behavioural
Active determinants
Social Ageing
determinants
Personal
determinants
Physical
environment
Culture
Source: Active Ageing: A Policy Framework, WHO, 2002 (http://www.who.int/ageing/publications/active/en/index.html)
Three pillars for action The priority areas for action described in
Chapter 10 of this report are grouped under
The ideas presented in this report build on
the three pillars.
the WHO active ageing framework, which
calls on policy-makers, service providers, Active ageing is the process of optimizing
nongovernmental organizations and civil opportunities for health, participation and
society to take action in three areas or security in order to enhance quality of life as
“pillars”: participation, health and secu- people age.1
rity (see Figure 2, next page). The policy
framework for active ageing is guided by The gender- and age-responsive lens
the United Nations Principles for Older Under the active ageing framework, the
People: independence, participation, care, overall goal is to improve the health
self-fulfilment and dignity. Decisions are and quality of life of ageing women by
based upon an understanding of how the implementing gender-responsive policies,
social, physical, personal and economic programmes and practices that address
determinants of active ageing influence the the rights, strengths and needs of ageing
way that individuals and populations age. women throughout the life course. These
This framework aims to reduce inequities efforts need to take into account the special
in health by understanding the gendered situations of older women with disabilities,
nature of the life course. members of minority groups, those who
live in rural areas, and those who have low
socioeconomic status.
PAGE 7Figure 2. The three pillars of a policy framework for active ageing
Active Ageing
Participation Health Security
Det
ermin eing
ants of Active Ag
Un i le
ted N
a er Peop
tions Principles for Old
Source: Active Ageing: A Policy Framework, WHO, 2002
Fulfilling this goal means that governments • enable the full and equal participa-
at all levels, international organizations, tion of older women and men in the
nongovernmental organizations and other development process and in all econom-
leaders in civil society and the private sector ic, social, cultural and spiritual spheres
need to: of community life;
• mainstream gender and age perspec- • adopt a life course perspective that
tives in all policy considerations by tak- understands ageing and cumulative
ing into account the impact of gender disadvantage as a process that spans the
and age-based roles and cultural ex- entire lifespan and provides supportive
pectations concerning ageing women’s policies and activities at key transition
health, participation and security; points in a one’s life;
• systematically eliminate inequities • encourage intergenerational solidar-
based on gender and age and their ity and respect between generations.
interaction with other factors such as
Gender analysis has become a common
race, ethnicity, culture, religion, disabil-
policy tool in many settings. This report
ity, socioeconomic status and geograph-
proposes that policy-makers apply a dual
ic location;
perspective to their decisions — a perspec-
• acknowledge and address diversity tive that takes both gender and age into
among older women and men; account (Figure 3).
PAGE 8Women, Ageing and Health: A Framework for Action
Figure 3. Applying a gender- and age-responsive lens to decision-making
ender Lens
G
Participation Health Security
Some questions to ask Outcomes
Taking gender, age and equity into 5. In what ways does the policy/programme
account enhance the health/participation/secu-
rity of older women and older men?
1. Does the policy/programme address
gender- and age-specific concerns? 6. How will the policy/programme affect
women and men differently through-
2. Does the policy/programme take gen-
out the life course, and particularly in
der‑, age- and culturally-based tradi-
older age?
tions and roles into account?
7. Does the policy/programme acknowl-
3. Does the available evidence take gender
edge the contribution and strengths of
and age differences into account?
older women and men and the heteroge-
4. Does the policy/programme support neity of the older population?
equity and ensure equal access without
8. Does the policy/programme respect
discrimination based upon age, gen-
the United Nations Principles for Older
der, class, race, ethnicity, health status,
People: independence, participation,
income and place of residence?
care, self-fulfillment and dignity?
9. Does the policy/programme support
intergenerational solidarity for both
women and men and encourage a 'society
for all ages'?
PAGE 9Development and implementation
An example of how to combine the
10. How have diverse groups of older wom-
gender-sensitive/age-friendly lens with
en and men contributed to the develop-
the active ageing pillars and determi-
ment of the policy or programme?
nants is provided in the central pages of
11. How will the policy/programme be this document. It is focused on primary
implemented, monitored and evaluated health care services and can be used as
in an age- and gender-responsive way? a tool to facilitate the identification of
issues/concerns; policy/action devel-
opment; and formulation of research
questions.
PAGE 10Women, Ageing and Health: A Framework for Action
3. The health status of older women
This chapter provides an overview of the women’s life expectancy after reaching age
health status of older women. Some dis- 60. For example, a 60-year-old woman in
eases and conditions are highlighted in Sierra Leone can expect to live another 14
subsequent chapters, and it is therefore years while a woman of the same age in
important to take all chapters into account Japan can expect to live another 27 years.
when assessing the overall health and well- Mortality patterns also differ within coun-
being of ageing women. tries; for example, in Australia, Canada
and Mexico women in indigenous com-
Key points munities have poorer health and signifi-
With a few exceptions, women have longer cantly lower life expectancies than non-
life expectancies than men in both devel- indigenous women.15-17 Life expectancy is
oped and developing countries. The rea- closely related to income and social status
sons relate to both female biology such as and can vary among neighbourhoods. For
hormonal protective factors, and fatal risk example, female life expectancy between
factors associated with male working con- women living in London varies from 84.7
ditions, lifestyles and higher risk of injury. years in Kensington/Chelsea to 79 years
Worldwide, women are likely to continue in Newham. The latter neighbourhood is
to maintain this advantage over men for situated in inner London and is character-
the foreseeable future. However, the gender ized by poor housing conditions, low levels
gap in life expectancy is decreasing in some of education and employment, high crime
developed countries as a result of role and rates and a higher percentage of pensioners
lifestyle changes such as participation in living in poverty.18
the paid work force and increased rates of
Noncommunicable diseases are the lead-
smoking by women.13,14
ing cause of death and disability among
Global inequities in life expectancy among women in all global regions except Africa.19
women are immense — for example, a baby Approximately 80% of chronic disease
girl born in France or Japan can expect to deaths occur in middle- and low-income
live more than 40 years longer than a baby countries, where most of the world’s ageing
girl born in a sub-Saharan African coun- women live.
try. There are also dramatic differences in
PAGE 11More older women than older men are blind, increase.23,24 Worldwide, older people have
largely because they live longer but also be- a higher risk of completed suicide than any
cause of restricted access to treatment. They other age group. The male:female ratio for
are also at higher risk for trachoma because completed suicides among people over age
they are more exposed to infection. Barriers 75 is 3:1 to 4:1.25
that prevent ageing women from receiving
The onset of depression in the later years of
eye care include: the cost of examinations,
life may be related to psychosocial factors
surgery, drops and eyeglasses; inability to
(such as socioeconomic status) and stressful
travel to a surgical facility or clinic; little
life events (such as bereavement and car-
family support for treatment; and a lack of
ing for chronically ill family members and
access to information about services due to
friends).26,27 Depression may also be second-
low literacy levels.20
ary to a medical disorder or to use of medi-
Gender is a powerful determinant of mental cation use. Women are approximately twice
health that interacts with such other factors as likely as men to experience a depressive
as age, culture, social support, biology, and episode within their lifetimes.23 It is esti-
violence. For example, studies have shown mated that by the year 2020, depression
that the elevated risk for depression in will be the second most important cause of
women is at least partly accounted for by disability burden in the world.28
negative attitudes towards them, lack of
Although communicable diseases are not
acknowledgement for their work, fewer op-
among the most common causes of death
portunities in education and employment,
later in life, they account for high levels of
and greater risk of domestic violence.21 The
disability and morbidity — especially among
risk of mental illness is also associated with
older people in developing countries. The
indicators of poverty, including low levels of
impact of communicable diseases such as
education and, in some studies, with poor
malaria, tuberculosis and leprosy grows
housing and low-income.22
increasingly severe with time and ageing.
While women do not experience more For example, an individual who experi-
mental illness than men, they are more enced pulmonary tuberculosis early in life
prone to certain types of disorders, including may – even if successfully treated – sustain
depression and anxiety.21 Women and men residual ventilatory incapacity which can
are equally likely to develop Alzheimer’s be aggravated by the ageing process in later
disease and other dementias in old age; years. In all countries, older people are at
however, the prevalence is higher among high risk for contracting influenza and its
women because they live longer.23 The complications, including death.
emotional, social and financial costs of
Alzheimer disease to families and societ-
ies are already massive and will continue to
PAGE 12Women, Ageing and Health: A Framework for Action
Ageing women remain at risk for HIV/AIDS The HIV/AIDS epidemic has had devastating
and other sexually transmitted infections economic, social, health and psychologi-
(STIs). Like ageing men, women can remain cal impacts on older women especially in
sexually active until the end of life, but they sub-Saharan Africa. Older women care for
may have fewer opportunities because most those who are ill with HIV/AIDS and then
outlive their partners. Many STIs are physi- for their orphaned children, and are them-
cally transmitted more efficiently at all ages selves at risk of infection. Studies show that
from males to females than from females older caregivers are under severe financial,
to males. The risk is increased by customs physical and emotional stress — including
such as older men engaging in extramarital arising from financial hardships leading
relationships, widow cleansing, polygamy to inability to pay for food, clothing, es-
and wife inheritance, as well as by older sential drugs and basic health care; a lack
women’s roles as caregivers. Once infected, of information about self-protection while
women face a disproportionate burden of providing care to their infected children
sequelae from STIs, including AIDS result- and grandchildren; stigmatization of people
ing from HIV infection and cervical cancer with the disease; negative attitudes of
as a result of the transmission of the hu- health workers towards them as older per-
man papilloma virus (HPV). sons, as well as towards people living with
HIV/AIDS; and physical and emotional
stress resulting from increasing levels of
violence and abuse.29,30
PAGE 13Older women and chronic diseases
Heart disease and stroke are significant causes of death and disability in women in both
developed and developing countries19 and especially among women who are poor.31
Hormone replacement therapy, which was widely used in high-income countries has
been shown not to prevent heart disease after menopause as was originally thought, but
rather is associated with an increased risk of stroke and heart disease among some ageing
women.32,33 Women with heart disease tend to present with different symptoms than
men and are less likely to seek or to be provided with medical help and to be properly
diagnosed until late in the disease process. While improvements have been made, women
are less likely to have access to appropriate investigations and treatment, and are more
likely to be underrepresented in research on heart disease.34
The lifetime risk for breast cancer among women in most developed countries is about
one in ten. This risk increases with age – especially after age 50 – and only declines after
the age of 80. Lower fertility rates, increasing age of pregnancy and a decrease in the
number of years of breastfeeding all contribute to a predicted rise in breast cancer in
developing countries.
Cervical cancer, which kills an estimated 239,000 women every year is – after cancers of
the stomach and breast – the third most common cancer in women in developing coun-
tries. Providing girls with a new vaccine to prevent infection from the human papilloma
virus (HPV), which causes cervical cancer, offers the possibility of eliminating the inci-
dence of cervical cancer in the future. Meanwhile, it is critical to provide existing cohorts
of ageing women with pap smear screening or other low-cost prevention and screening
technologies.35 Use of these techniques can dramatically reduce mortality due to cervical
cancer.
Osteoarthritis and osteoporosis are associated with chronic pain, limited quality of life
and disability. Between the ages of 60 and 90 years, the incidence of osteoarthritis rises
20-fold in women as compared to 10-fold in men.36 Osteoporosis is three times more
common in women than in men, partly because women have a lower peak bone mass
and partly because of the hormonal changes that occur at menopause and the effect
of pregnancy which can alter calcium composition in a woman’s body in the absence of
appropriate diet and/or administration of calcium supplements. While these diseases and
consequent fractures, spontaneous or caused by falls, place an enormous burden on the
health care system and society, often they do not get the attention they deserve because
they are incorrectly seen as an inevitable part of ageing or less serious than such condi-
tions as heart disease or cancer.
NOTE: Lung cancer, diabetes and osteoporosis are discussed in subsequent chapters.
PAGE 14Women, Ageing and Health: A Framework for Action
Implications for policy, practice and In light of the high burden of breast
research cancer, and predictions that the incidence
will increase worldwide, there remains an
Life Expectancy. While life expectancy is
urgent need for a better understanding of
a crude measure of health, it does provide
its root causes, increased availability of
the ultimate yardstick. Efforts to overcome
effective and affordable screening tools for
dramatic inequities in life expectancies
use with older women, the expansion of ef-
among older women between countries,
fective treatment regimes, and support for
and among various socioeconomic popu-
breast cancer survivors.
lation sub-groups within a given country
or region, must become an international Use of the new vaccine to prevent HPV
priority. infection must be made widely available
immediately in low-income countries
Preventing noncommunicable diseases.
where cervical cancer is a major cause
While the progression from mortality
of death. For older women, the use of pap
caused by infectious diseases to that caused
smears and other cost-effective prevention
by chronic diseases is a positive sign of im-
and treatment technologies must be made
provements in public health, the increase in
universally available.
chronic diseases due to population ageing
has substantial implications for human Health care priorities need to redress the
suffering and health care costs. The ulti- imbalance in attention given to musculosk-
mate goal is to prevent and manage chronic eletal disorders and joint diseases such as
diseases, thus postponing disability and osteoporosis and arthritis.
death and enabling ageing women and men
to maintain their positive contributions to Another inequity that needs to be ad-
society. If this achievement is to be shared dressed involves blindness. Local initia-
equally by women and men, policies and tives and the political will to eliminate
programmes must take both gender and gender inequities in eye care services are
age into account. critical steps in achieving the goals of
Vision 2020, a global initiative to combat
Addressing inequities in diseases that affect avoidable blindness.
older women. Tackling inequities in coro-
nary heart disease requires the education
and training of health professionals about
sex and gender differences in the clinical
manifestations and progress of the disease,
the full inclusion of older women in cardiac
studies, earlier and more aggressive control
of risk factors, and appropriate access to
diagnosis and treatment.34
PAGE 15A gender-sensitive approach to improving HIV/AIDS and other STIs. It is essential to
mental health. Understanding that mental dispel the myth that older women are not
health and mental illness are the results sexually active. Sexual health care, educa-
of complex interactions among biological, tion and knowledge about STIs and HIV/
psychological, and sociocultural factors AIDS are important not only for women
is important for those considering ageing of reproductive age but also for girls and
women. Such understanding places mental women in all stages of life. This concept
health and illness within the social context needs to be considered when allocating
of women’s life experiences and implies resources and planning future research and
that equality and social justice are impor- programming. Programmes and preven-
tant goals for improving mental well-being tion messages must be sex- and age-specific
among women of all ages. Developing and should target not only individual
gender-sensitive national policies, with behaviours but also the social and cultural
budgets dedicated to mental health and context in which these behaviours occur.
mental illness, needs to become a prior-
The participation and representation of
ity in all countries. Evidence suggests that
older people – and older women in par-
practices and programmes encouraging
ticular – in HIV/AIDS programme plan-
socialization and physical activity can help
ning at local, district and national levels
ease depression, 37,38 and that most mental
will improve the response to HIV/AIDS.
health problems in later life can be dealt
This response will require support to older
with in age-friendly primary health care
people and their organizations. Health care
services, and through community services
staff should be appropriately trained to
and interventions that support families and
support older people who are infected and
caregivers.39,40
appropriate drugs should be made available
Communicable diseases. Older women will as recommended by the WHO universal
be major beneficiaries of efforts to control access approach.
and eliminate infectious diseases in set-
Dissemination of research and information.
tings where communicable diseases are
There are few controlled studies on depres-
common. WHO urges all Member States
sion in older women.28 Similarly, gender-
to implement a national influenza vaccina-
specific research into the causes and
tion policy and to implement strategies to
management of dementia becomes increas-
increase vaccination coverage of all people
ingly critical as life expectancies increase.
at high risk, with the goal of attaining cov-
Because of the stigma attached to suicide in
erage of the older population of at least 50%
many cultures, it is likely that the number
by 2006 and 75% by 2010.41
of suicides among older men and women
are undercounted. Many questions about
suicide in later life remain unanswered.
PAGE 16Women, Ageing and Health: A Framework for Action
Table 1. Life expectancy at birth and at age 60, women, selected countries, 2006
At At At At At At
birth age 60 birth age 60 birth age 60
AFRO EURO SEARO
Mozambique 46 16 Bulgaria 76 20 India 63 18
Senegal 57 17 Russian 72 19 Indonesia 69 18
Federation
Sierra Leone 40 14 Sri Lanka 77 21
Switzerland 83 26
AMRO WPRO
EMRO
Brazil 74 22 China 74 20
Bahrain 75 20
Canada 83 25 Japan 86 27
Egypt 70 18
Haiti 56 17 Papua New 61 14
Pakistan 63 17 Guinea
Source: World Health Report, 2006.
Further studies are needed on the sex and There is a critical need for improved sur-
gender-linked factors that contribute to veillance and for the collection of sex- and
lung cancer, breast cancer, heart disease age-specific data after age 50. Also needed
and obesity. are controlled trials on the epidemiology,
pathogenesis, and therapeutic and clinical
Currently, older people are largely invisible
outcomes of older HIV-infected patients.
in international data on HIV/AIDS infec-
tion rates because data collection does not
routinely include the over-50 age group.
PAGE 174. Health and social services
In order to be comprehensive, health From a global perspective, the use of medi-
systems should provide a continuum of cations can be a double-edged sword. In
gender-responsive care from promotion and most countries, older women who have low
prevention to acute and palliative care, as incomes and no access to benefits covering
well as access to essential medications. the costs of medications either go with-
out or spend a large part of their meager
Key points incomes on drugs. In contrast, medications
In many settings, ageing women do not are sometimes overprescribed to older
have the same access to health care as do women who have insurance or the means to
men or younger women. For example, in pay for medications. Older women may be
many countries, older women are less likely more likely than men to experience adverse
than men to receive cataract surgery and drug reactions because of smaller body size,
eye care due to the cost of examinations, altered body metabolism and diminished
eyeglasses, drops and surgery, as well as ability to compensate for drug-induced
gender- and age-discrimination, and a changes in normal homeostasis.47
lack of support for and information about
The barriers to primary health care faced by
treatment.20 Men may gain quicker access
older people are often worse for older wom-
to selective operations42,43 and a life-saving
en. These barriers include lack of trans-
procedure following a heart attack.44,45, 46
portation, low literacy levels and a lack of
These inequities may be a result of direct
money to pay for services and medications.
or indirect gender- and age-based dis-
Invariably, gender and age interact with so-
crimination, older women’s lower financial
cioeconomic status, race and ethnicity. For
status and limited access to health secu-
example, older women who are homeless or
rity schemes, and a focus on reproductive
do not speak the dominant language may
health that excludes older women.
have even less access to health care and be
more likely to encounter discrimination in
treatment.
PAGE 18Women, Ageing and Health: A Framework for Action
Personal expenses related to health care Palliative end-of-life care in the home or
gradually take up a greater share of a wom- in small hospices will become increasingly
an’s resources as she grows older, even in important to health systems as the number
highly industrialized countries. For example, of very old women and men continues to
studies in the United States of America increase. Services include pain relief, and
(USA) show that health security is out medical, spiritual and psychological sup-
of reach for many women over the age of port to the dying person and her family, as
50, and that out-of-pocket expenses for well as respite care for burdened caregivers.
medications and long-term care are major
Home caregivers (who are mostly middle-
factors contributing to higher poverty rates
aged and older women) of people who are ill
among older women.48 Because women
must be supported and nurtured to enable
most often work at home or in the informal
them to maximize the care they deliver, to
sector or part-time, they have limited or no
manage the considerable stress that can
access to health insurance schemes that are
accompany caregiving, and to be able to
tied to employment.
sustain a caregiving role over a long period
Because women live longer than men and of time — often many years. Poor families
are more likely to be alone in old age, policy- are in particularly precarious positions and
makers and practitioners must pay special – as more and more women work outside
attention to the gender implications of long- the home – a better balance in the shar-
term care policies and programmes, whether ing of caregiving between women and men
they be in the community or in residential becomes increasingly important.49
facilities. Most long-term care for older
In both developed and developing coun-
people who cannot live independently is
tries, a range of health care reforms has had
provided by informal support systems such
a negative effect on women, particularly
as family members and neighbours. But as
in middle- and older age.50 User fees and
the number of very old women continues to
private provider schemes limit access to
increase and the pool of available caregivers
services for older women.51,52 The closing
continues to decrease, families and policy
of acute-care beds, and early release from
makers will increasingly need to look for
hospital without a corresponding increase
other options. Part of the answer may lie in
in support in the community, leaves age-
increased home and community support
ing women with an increased and unrec-
services, but it is likely that the number of
ognized burden of caring for partners and
very old women who spend their last years
other family members who are ill or frail.
in institutional settings will also increase.
PAGE 19Implications for policy, practice and of care. Caregivers also need a forum to
research express their experiences and recommen-
dations for system change and for sensitiz-
Health professionals. Professionals need
ing service providers. Most importantly,
to understand and recognize sex and age
caregivers need “respite”—time off from
differences — especially when prescribing
their caregiving role.
medications, treating mental health prob-
lems such as depression, and dealing with Some of the options for financially support-
health problems related to domestic abuse. ing caregivers include leave from work (paid
A gender perspective means going beyond and unpaid), tax policies and payments for
physical symptoms to explore the socio- caregiving services. In developing countries
cultural as well as the biological factors it is especially important to foster intergen-
underlying these problems. erational relationships and co-residency by
providing subsidies for those who care for
Medications. The goal is to ensure equity in
older relatives, housing designs that enable
the provision of essential, and high-quality
multigenerational living, and community
drugs among all age groups and between
centres that can be used by older people as
women and men. At the same time, physi-
meeting places and clubs.53
cians and pharmacists need to take into
account the risks of overprescribing medi- Health care reform. Cost-cutting measures
cations based upon gender stereotyping, must not expect to transfer formal care to
and of the adverse effects of multiple drug the unremunerated care provided by ageing
use among older women. women without providing compensation
for lost wages and community support ser-
Supporting informal care. The needs of care-
vices. Priority setting in health care servic-
givers are confounded by culture, income,
es should be based on evidence that is free
living arrangements and the extent of
from systematic gender- and age- biases.
support from others. Caregivers of people
who are ill or frail need information about Health security. The goal is to provide equal
specific conditions, treatment, medications, access to essential health services and
warning symptoms and necessary lifestyle medications, regardless of ability to pay.
modifications. They need training in home Because older women have fewer financial
health skills and how to work in partner- resources to pay for services and private
ship with health care providers. Equally insurance premiums, taxes and social in-
important are skills to help them identify surance schemes that are not based on time
available resources, navigate the system and spent in formal employment provide the
become effective advocates for recipients most equitable basis for health financing.
Health insurance schemes should ensure
that vulnerable and marginalized groups,
including older women are adequately
covered.
PAGE 20Women, Ageing and Health: A Framework for Action
Mental health services. Policies and prac- Research and information dissemination.
tices that benefit older women and men Priority areas for developing and sharing
should: knowledge include:
• support and improve the care provided • ways to increase access to primary
by their families (e.g. respite care, train- health-care and participation in health
ing); promotion and disease prevention ac-
tivities particularly among older women
• incorporate mental health assessment
in minority groups, who have low socio-
and management of depression as well
economic status and who live in rural
as other mental health problems into
and isolated areas;
primary health care;
• cost-effective ways to help older women
• pay special attention to women who
remain in their homes in the commu-
have experienced elder abuse or other
nity;
forms of violence ;
• gender perspectives, expectations and
• help to remove the stigma associated
experiences of long-term care options;
with mental illness; and
• effective policy options and legal guide-
• include legislation to protect the human
lines for providing dignified long-term
rights of institutionalized people with
and end-of-life care to older women and
severe mental disorders.
men;
Cataract surgical coverage • more detailed evidence on the differen-
Cataract is the leading cause of visual tial use of medications by older women
impairment in all regions of the world, and men and whether gender is system-
except in the most developed countries.54 atically associated with inappropriate
In many countries, older women with use;
cataracts are much less likely to have • best practices related to receiving and
surgery than men — a classic example giving care (i.e. filial, state and personal
of how gender bias impacts on access to responsibilities); and
health services.20
• the impact of health care reform on
gender equity.
PAGE 21Figure 4. Comparison of cataract surgery coverage between men and women
in five countries
Percentage Male
Female
80
60
40
20
0
China* India* Nepal Saudi South
Arabia Africa
*Two sets of data displayed
Source: Lewallen S. and Courtright P. British Columbia Centre for Epidemiologic and International
Ophthalmology. Gender and use of cataract surgical services in developing countries. Vancouver: University of
British Columbia, 2000 (unpublished paper).
PAGE 22Women, Ageing and Health: A Framework for Action
5. Personal determinants
Biology and genetics by socioeconomic conditions, and gender-
based discrimination. For example, women
Although biology and genetics are key de-
may have had inadequate access to nutri-
terminants of women’s health, the evidence
tious food in early life. As another example,
suggests that most of the time other factors
in some cultures restrictions on movement
related to gender-influenced roles and sta-
outside the home are placed upon widows.
tus are more important in determining the
health and well-being of women at midlife Normal ageing includes some natural de-
and older ages. However, as is the case with clines and physiological changes that lead
all the determinants of active ageing, sex and to a loss of functional capacity and reserve.
gender are likely to interact in synergistic These include reductions in hearing and
ways. vision capacities, a decrease in taste, smell
and thirst sensations, and declines in
Key points basal metabolic rate and immunological
It has been estimated that only 20-25% of response. There is also a significant reduc-
variability in the age at death is explained by tion in bone density and muscle mass, both
genetic factors.55 The influence of genetic of which are more pronounced in women
factors on the development of chronic than in men.59,60 However, individuals may
conditions varies significantly. For example, experience these declines at very differ-
some women have a genetic predisposition ent rates. Physiological declines associated
to breast and ovarian cancer; even when with ageing will likely be exaggerated for a
this risk is known, however, it is not a fore- woman who has lived a life of poverty with
gone conclusion that they will develop the poor nutrition and has had little, if any, ac-
disease in their lifetime. cess to education and health care.
While women are more likely to survive into For ageing women, menopause is a signifi-
older age, they have more disability than cant transition from both a biological and
men in every age group after age 60, as well social perspective. Hormonal changes occur-
as more co-morbidities.56-58 Biological fac- ring during the menopausal period are relat-
tors may be a critical reason for this. For ed – either directly or indirectly – to adverse
example, lower levels of muscle strength effects on quality of life, body composition
and bone density in women increase the and cardiovascular risk. Women’s advantage
likelihood of disabling conditions such as over men in terms of cardiovascular disease
frailty and osteoporosis, and difficulty with gradually disappears with the significant
tasks requiring optimal threshold levels declines in estrogen levels after menopause.
of strength. However, the incidence and The loss of bone density at menopause is a
prevalence of disability is also influenced significant reason why women have much
higher rates of osteoporosis than men.61
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