THE BUILT ENVIRONMENTCOMHE 303 - Bernicia and Melinda

Anne McMunn, Elizabeth Breeze, Alissa Goodman, James Nazroo, and Zoe Oldfield

Chapter 13: Social Determinants of Health in Older Age

“Successful Aging” United States: A response to the

traditional stereotypes of ageing as associated with inevitable sickness and decline

Rowe and Kahn: the absence of disease of disability, the maintenance of cognitive and physical function, and engagement with life

United Kingdom: “The Third Age”, potentially a period of self-fulfillment in which individuals are freed from the responsibilities of paid work and child care to plan their lives and pursue those plans

Studies on Aging

Roos and Havens – found that neither occupation, education, nor income at baseline predicted successful aging

Honolulu Heart Program – both education and previous occupation were associated with successful aging

Europe and Canada – relationships between health outcomes other than physical functioning are also associated with educational attainment among older people

Swain – being in a manual class household carried a disadvantage in reporting poor health seven years later regardless of health at baseline

Taylor and Ford – did not find class differences in reported difficulties in functioning, self-esteem, or morale; gender and age accounted for class differences in reported chronic conditions, acute symptoms, and self reported poor health

Studies on Aging Cont.

Dahl and Birkelund – men aged 65 and over, whose main job was manual, were more likely than non-manual workers to have poor mental health; found no association between class or main occupation and mental health for women aged 65 and older

Whitehall – difference aspects of socioeconomic position are important for pre-retirement mortality than are post-retirement mortality; occupational grade strongly predicted functioning in older age

Arber and Ginn – current household income was inversely associated with both self-reported poor health and functioning after adjusting for other socioeconomic factors

North America – found household income to be positively associated with functioning in older respondents after adjusting for numerous factors

Life Course Perspective

Life Course Hypotheses – emphasize the accumulation of advantage and disadvantages across the entire life course

Barker, Marmot, and Wadsworth – describes a latency effect whereby exposures early in life have later effects on health

Marmot et all. – no direct effect on social circumstance from earlier life on health in later life, but determine the social and economic position that a person reaches in later life

Retirement as a Transitional Period

Labor market exit linked with subsequent health outcomes

Sweden – those who became unemployed are more likely to have an subsequent hospitalization and health at work

Whitehall – participants had better subsequent health of those who took voluntary redundancy or voluntary early retirement (pre-retirement)

Health Determinants

Education, occupation, and income Material circumstances, working conditions, social

status or prestige Sense of security and control over ones work and

life Inequalities in healthcare, lack of resources Social support Disability and mobility; physical and mental health Gender imbalances in caring responsibilities

Health Behavior

According to Rowe and Kahn, healthy behavior is the route to successful aging

Not genetically determined, but by lifestyle choices

Influence by social position, culture, and financial constraints

Associated with health outcomes

Policy in Relation to Health Inequalities

Wanless – Funding old age through increased health services, “full engagement” the public are active in securing improved health and quick to respond to healthcare intiatives

United Kingdom – Help the poorest older people including minimum income guaranteed

Camden’s Quality of Life Strategy – Improving involvement and independence of older people with outreach to isolated and the minority ethnic groups as priorities

Department of Social Security – government encourages private savings but will provide a “safety net” for those who cannot save for retirement

The New York Academy of Medicine

Toward an Age-friendly New York City: A Findings Report

New York City Elderly

By 2030, one-fifth of NYC’s population will be over the age of 60 older adults will soon outnumber school-aged

children Goals

Create a caring model for modern urban aging Focus on the needs of older adults, as defined by

older adults themselves Create a process for older adults to voice their

hopes and dreams for a friendlier city

Initiatives Age-friendly New York City – effort by the World Health

Organization (WHO) to respond to two significant demographic trends Urbanization and Population Aging

Global Age-friendly Cities – Involves 35 cities around the world in analyzing their communities and neighborhoods through the lens of the WHO Active Aging Framework WHO Active Aging Framework: shifts city planning away from a

“needs-based” approach toward a “rights-based” approach recognizes people should have equal opportunity and treat ment as

they grow older entails enhancing quality of life by optimizing opportuni ties for health,

participation, and security as people extend the years an individual can live independently and above the

“disability threshold”

Determinates of Aging

Age-friendly New York CityIn July 2007, partnership with the New York City Mayor’s “A City for All Ages” Initiative and the New York City Council The objective was to assess the city from

the perspective of older residents in order to identify potential areas for improvement.

Question: To what extent are the city’s services, settings, and structures inclusive of and accessible to older people with varying needs and capabilities?

Methodology A committee of local poli cymakers, service providers, community leaders, researchers, and older residents

Community forums Focus groups Interviews Constituent feedback forms Expert roundtables Data mapping Request for information Self-Assessment of City agencies Secondary research Website

Eight Domains of an Age Friendly City

The City’s Older Population

The majority of New Yorkers age 65 and above reside in the boroughs of Queens (30.2 percent) and Brooklyn (29.9 percent) Manhattan (20.7 percent), the Bronx (14.6

percent) Staten Island (5.5 percent)

10 several neighborhoods within the city have high concentrations of residents age 65 or older

The City’s Older Population In 2005, 43% of non-institutionalized New Yorkers

age 65+ reported experiencing some form of disabil ity

Nearly half of today’s older New Yorkers are members of racial and ethnic minority groups this diversity has significant implications for the

importance of culturally and linguistically appropriate materials and services for older adults.

In 2006, the poverty rate among older New Yorkers (age 65+) was nearly twice the national average 18.1 percent vs. 9.9 percent

The City’s Older Population “I think New York is the greatest place in

the world to be old” Health and social disparities among

older New Yorkers linked to issues beyond race and poverty

Where Do We Go From Here?

Commission for an Age-Friendly City will be seated Supported from the Office of the Mayor and

the City Council Guide and oversee the development of

implementation plans that synthesize commitments from the different sector

oversee progress on the implementation plans promote public policies to institutionalize effective

practices guide a process for evaluating the impact of

actions taken assure continued activity for future years

Charles E. Drum, Gloria Krahn, Carla Culley, and Laura Hammond

Recognizing and Responding to the Health Disparities of People with Disabilities

Health Status

An individuals health status impacts… Quality of Life Self-Sufficiency Participation in Society

Question: What does that mean for the 54 million Americans with disabilities?

Healthy People 2010

Objective:

Promote the health of people with disabilities

Prevent secondary conditions Eliminate disparities between people

with and without disabilities in the U.S. population.

Health and Wellness Defined as…

Physical, emotional, social, spiritual, and other factors that enable individuals to maximize their potential and fully participate in their community.

DisabilityU.S. Legislation has 67 definitions for disability.

Medical Model: Disease, trauma, health impairment, deficits located within the individual that can be cured or ameliorate through a particular treatment or intervention.

Functional Model: Individualistic, medical, physiological, or cognitive impairment; the inability to perform a number of functional activities regardless of etiology.

Social Model: The barriers people face when interacting with the environment, a consequence of social (dis)organization that creates or results in inaccessible environments.

American Disability Act: multiple dimensions of disability including A physical or mental impairment that substantially limits at least one “major life

activity” Has a record of such an impairment Regarded as having such an impairment

Social Security Act: Inability to engage in any substantial gainful activity by reason of any medically determinable physical or mental impairment which can be expected to result in death or which has lasted or can be expected to last for a continuous period of not less than 12 months

Public Health

Traditionally focuses on prevention of disabling conditions

Contemporary focus on disability surveillance and support for research in health promotion

Health Disparities High rates of oral disease and diabetes Difficulty finding, getting to, and paying for

healthcare Low rate of high school completion, social

activities, and high rate of unemployment High rate of obesity, alcohol and tobacco

consumption Little access to early prevention, transportation,

and comprehensive health information More likely to experience early death, chronic

conditions, and preventable secondary conditions Secondary conditions: increased risk that people with a

primary disability condition experience that may result in poorer health

Addressing Disparities Legal and Regulatory Reforms:

Broader definitions of medical necessity to address habilitation needs Simplification of regulations to make maneuvering the health care system easier Tax incentives that support persons with disabilities in purchasing equipment or making home

modifications to increase access to the community Increased physical accessibility of medical and fitness facilities and equipment (e.g., mammography

machines, athletic equipment) Health Plan Benefits:

Ensure access to needed specialty care, habilitative and rehabilitative services, care coordinated “defragmentation”, and coverage for prescription medications and durable medical equipment

Communication Enhancement: Interpreter services for non-English speakers, sign language interpreters Health information materials in alternative formats (e.g., large print, electronic copies for screen

readers) Adequate time for medical care appointments Use of “plain language” to promote comprehension by all, but particularly people with cognitive

disabilities Health Promotion Programs:

Access to generic health promotion programs (e.g., smoking cessation, weight management, drug and alcohol treatment)

Complementary and alternative medicine Accommodation of facilities and staff to allow equitable participation by people with disabilities

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