This chapter outlines key concepts related to active and healthy ageing as posited by the WHO in recent decades. It also provides a brief overview of how Nordic health policies targets active and healthy ageing and how intersectionality can enhance heterogenous understandings in both policy and research practice.
Active and healthy ageing: WHO frameworks and related concepts
Why is active and healthy ageing important to address in a Nordic context? Data indicate that living longer does not necessarily mean living a healthier and more active and independent life (Eurostat, 2020). Policies on active and healthy ageing are a response to the challenges that ageing Nordic societies share when it comes to the sustainable provision of goods and services, moving towards age-inclusive societies, and strengthening equality in health. In addition to the commitments to the Madrid International Plan of Action on Ageing, much of the work on active and healthy ageing in the Nordic countries gained momentum in 2012 when the EU announced the European Year for Active Ageing and Solidarity Between Generations as a platform.
The focus in the following is on the key concepts addressed in this study, namely active ageing, healthy ageing, age-friendliness, and welfare technology.
Active ageing, according to the WHO (2002) definition, is the process of optimising the opportunities for health, participation, and security in order to enhance quality of life in older age. In the WHO framework for active ageing, “active” is related to the ambition that people remain active in social, economic, cultural, spiritual and civic affairs as they age. It has also been emphasised that ageing policies should embrace a life course perspective and acknowledge that earlier life experiences influence how individuals age (Holman et. al., 2021). According to the WHO Active Ageing Policy Framework (WHO, 2002), there are six key determinants of active ageing: economic, behavioural, personal, social, health and social services, and the physical environment (Figure 1).
Figure 1. The main determinants of Active Ageing (adapted from WHO, 2002).
In the framework, economic determinants refer to factors such as income and employment; behavioural determinants include physical activity and healthy eating; and personal determinants include factors such as biology and genetics. Determinants of the social environment include features such as education, social support, violence, and abuse, while determinants related to health and social service systems include health promotion and mental health services. Finally, determinants connected to the physical environment include aspects such as safe housing, clean water and air, and fall prevention (WHO, 2002).
There are additionally two cross-cutting determinants that influence active ageing, namely culture and gender. First, culture determines how society views older people and ageing. There is high cultural diversity among and within countries and regions, but there are also certain universal values that transcend culture, such as ethics and human rights. Second, gender differences also have an effect, where in many societies women have lower social status and less access to education. Men on the other hand are more likely to suffer from injuries or death due to violence, occupational hazards, and suicide and are also more likely to smoke, consume alcohol, and use drugs.
Healthy ageing refers to maintaining and improving the functional ability that enables well-being in older age (WHO, 2019). Health and well-being in older age is influenced by a multitude of factors such as socio-economic status, ethnic background, physical activity and dietary habits, family situation and housing arrangements (WHO, 2002). Fundamental to both of these concepts, and for this report, is the idea that the older population is a highly heterogeneous group with diverse needs.
Another concept closely linked to active and healthy ageing is age-friendliness. The term is central in the context of age-friendly cities and communities, which can be defined as places that promote active and healthy ageing (WHO, 2015). At the core of the idea of planning for an age-friendly community is adopting an integrated and holistic approach where different policy and planning domains are considered in unison (WHO, 2007). The WHO has developed the Global Age-friendly Cities Guide that proposed eight interconnected domains that can help to identify and address barriers to the well-being and participation of older people (Figure 2). The domains have been adapted to the Age-Friendly Cities Networks
of which several Nordic cities are members.
Figure 2. Eight domains of age-friendliness, adapted from the WHO (2007).
The concept of welfare technology is also central in supporting active and healthy ageing activities and frameworks. This has a prominent agenda reflected in the European Innovation Partnership in Active and Healthy Ageing, an initiative started in 2011 that aims to foster innovative use of digitalisation for active and healthy ageing. Welfare technology consists of all technology that contributes to improving the lives of users, and it is often needed, for instance, for maintaining and increasing security and for promoting the activity, participation, and independence of seniors and people with disabilities (Nordic Welfare Centre, no date).
The WHO framework acknowledges a diverse approach, but it also encompasses additional aspects beyond active and healthy ageing. Overall, these aspects underline that an active and healthy lifestyle in older age is determined by a wide range of determinants that also intersect (WHO, 2002). Since the framework was developed, the research, demographic trends, and policy approach reflect how important it is to understand how, why, and for whom these determinants intersect, as made ever more clear by the Covid-19 pandemic.
Nordic policies targeting active and healthy ageing
In the Nordic countries, governments have in recent years launched various initiatives dealing with active and healthy ageing that are being implemented at various levels of governance. These initiatives form the backdrop of this study and the broader policy landscape in which this report is embedded. Next, some of the key policy initiatives launched in each of the Nordic countries are briefly outlined.
In Denmark, government measures have targeted the expected labour market effects of population ageing. When it comes to active and healthy ageing, Sundhedsstyrelsen published the report, Gode ældreliv med trivsel og sundhed in 2019, which was followed by an action plan and 14 recommendations to support the overall objectives for healthy ageing (Sundhedsstyrelsen, 2019). In 2021, the Sund aldring report further examined what constitutes healthy ageing in the Danish context (Sundhedsstyrelsen, 2021). Significantly, the report includes the selection of 45 indicators across 8 key domains that were considered relevant health benchmarks based on the available data. The National Digital Health Strategy 2018–2022 promotes digitalisation as way to boost health and the health-care system for the older population (Sundhedsdatastyrelsen, 2018).
In Sweden, Socialstyrelsen has recently mapped the development of elderly care for people older than 65 years (Socialstyrelsen, 2020), and the topic of eHealth for the ageing population is a well-anchored policy topic. However, it primarily targets social and medical care improvement and not healthy aging in society as such. One example is led by the Swedish Government and the Swedish Association of Local Authorities and Regions, which have endorsed a common vision for eHealth up to 2025 (SKR, 2016). The Public Health Agency in Sweden also addresses healthy ageing by targeting the population in their third age who have left the workforce and who are dependent on the help of others (Folkhälsomyndigheten, 2020). Other ministries responsible for issues related to the active and healthy ageing of older adults include the Ministry of Health and Social affairs, the Ministry of Employment, the Ministry of Education and Research, and the Ministry of Infrastructure.
In Norway, the government launched a broad and cross-sectorial strategy for an age-friendly society in 2016 called More Years – More Opportunities (Ministry of Health and Care Services, 2016). This was followed by a reform called A Full Life - All Your Life (Ministry of Health and Care Services, 2018), to address the following four key areas of population ageing: an age-friendly Norway, activity and community, food and meals, and health care. A fifth area looks at connecting the four priorities (Ibid, 2018). The reform emphasises the role of municipal networks for knowledge and experience sharing, and it relies greatly on cross-sectoral work and co-creation, pointing to the increased proportion of seniors in rural areas and the development of welfare technology in the healthcare sector, among other aspects. In 2021 an implementation roadmap was published for the municipalities to support age-friendly mainstreaming (KS, 2020). The emphasis in this work is that active and healthy ageing should be equated with the functionality needed to be part of society well into life despite ageing and that age-friendliness should be promoted in order to better harness the participation, contribution, and resources offered by older adults. The implementation of the national age-friendly strategy continues, and at the beginning of 2021 the Centre for Age-Friendly Norway
was established in Ålesund.
In Finland, the National Programme for Ageing 2030 aims to develop preventive health-related measures and to improve the functional ability of older adults and people in risk groups (Ministry of Social Affairs and Health, 2020). It also seeks to create a more age-friendly Finland, providing quality recommendations for improving the quality of life of older adults aimed at decision-makers and managers in municipalities. Moreover, promoting active and healthy ageing is a central aspect in several national initiatives, including the ongoing Finnish social welfare and health care reform (Ministry of Social Affairs and Health, 2011). Finland is witnessing the most significant population ageing not just in the Nordics, but also in a European context, where the country stands out with one of the oldest populations in the region (ESPON, 2020).
In Iceland, one of the national policies dealing with population ageing is the Policy for Iceland’s health services (Ministry of Health, 2019). There is also the Act on the Affairs of the Elderly and increasing access for pensioners to the labour market has been prominent on the political agenda in recent years. Like Finland, the country publishes comprehensive health reports where issues of active and healthy ageing are addressed. The National eHealth Strategy 2016–2020 seeks to establish an integrated and interconnected health information system to support the continuity of health-care delivery (Directorate of Health, 2016).
The work on active and healthy ageing is cross-sectoral, and responsibilities are, broadly speaking, allocated to all levels of governance and to a wide range of stakeholders in all of the Nordic countries (Bodin et. al. 2020). Common for the Nordic countries is that senior health policies are increasingly recognising the need for enhancing health promotion and disease prevention that takes a multifaceted view linked to wellbeing, and not solely focusing on biomedical health and disease prevention (Evans et al., 2018 cited in Stjernberg et al. 2021). In implementing national-level strategies, many regions and municipalities have taken actions to adapt to the challenges and opportunities arising from demographic change. As seen across the Nordics, adapted frameworks at the local level include activities that are enhancing participation and increasing volunteer work, widening opportunities for prolonging the careers of older adults, and integrating cross-generational housing, public spaces, and age-friendly living environments. Other initiatives address loneliness and social isolation by aiming for more effective coordination and financial sustainability, facilitating physical activity and healthy eating, building digital competences, and strengthening approaches to digital solutions within healthcare, with many regions being at the forefront of implementing innovative welfare technologies.
Ageing policies are increasingly based on the notion that older adults are highly diverse and heterogeneous. Intersectionality in this context has yet to emerge as an explicit framework for tackling health inequalities within the field, suggesting the complexity of the theoretical nature of a concept-to-practice approach. Nevertheless, an overview of some key national initiatives, visions, and strategies has been provided, for instance, in the Nordic Welfare Center’s report Att åldras i Norden (Bodin et. al.,2020).
Based on current national-level strategies and frameworks, efforts to meet objectives to improve quality of life in older age and to promote active and healthy ageing require combined efforts from stakeholders across all areas of public policymaking. Cross-cutting efforts also reflect the importance of addressing the complexities of heterogenous populating ageing in Nordic policies and research so that all groups of older adults can age with dignity and equality in a healthy environment.
Adopting intersectional and diverse perspectives
The WHO framework for active ageing acknowledges a diverse approach to understanding that an active and healthy lifestyle in older age is determined by a wide range of determinants (WHO, 2002). An intersectional perspective involves looking at an individual from different perspectives and noting, for example, the power relations in society that affect individuals' opportunities to actively participate in society on equal terms.
The concept of intersectionality was coined by Crenshaw (1989) to describe the combination of various sources of inequality among individuals. Applications of the concept across numerous fields of research and policymaking point to how the interactions and multiplying effects of these inequalities can together result in a qualitatively different form of discrimination than what would commonly be considered. Intersectionality places an emphasis on social justice and equality, which in the context of health inequality could help counteract aspects of ageism, while promoting a positive view of older adults and seeing them as a valuable resource in society.
Intersectionality highlights the significant differences of power, such as those among younger versus older persons, and how their position in society changes over time as they age (Holman & Walker, 2021). For instance, among some sub-groups of older adults, those who are socio-economically disadvantaged are most vulnerable and face a higher risk of ill health and disabilities. In some cases, belonging to an ethnic minority and having a migrant background is also correlated with socio-economic deprivation or poorer health conditions. There are also noticeable gender differences where, for example, older women in all Nordic countries are generally at greater risk of poverty and have lower pensions than older men, usually due to having had shorter working careers and lower wages than men (OECD, 2019). However, the intersectional lens means looking not only at gender equity, but also at the impacts of the intersections of multiple positions of privilege and oppression. To this end, household structure also plays a role, as older adults who live alone generally have lower health status than those who live with someone else.
Additionally, one’s sexual orientation is also something that may influence how one can participate in society and community life, meaning that LGBT aspects are also important to consider. This area is topical in the Nordic context and is addressed in a dedicated project on the conditions for older LGBTQ adults carried out by the Nordic Information on Gender. The project will produce a knowledge review upon which concrete measures will be proposed to enhance older LGBTQ adults' living conditions and quality of life in the Nordic countries, especially when it comes to public health and care services.
Regional differences are also highly relevant, and there are noticeable variations in health and well-being between different regions and areas. There may be important urban-rural differences to consider along with differences between neighbourhoods within the same city where the preconditions for active and healthy ageing may differ quite significantly. By understanding the intersecting processes of these aspects, we can better determine how power and inequity are produced or reproduced when it comes to enabling conditions for active and healthy ageing and for reducing inequalities in health.
In a literature review on ageism, the studies showed that ageism appears to be an overlooked category in intersectionality studies (Lindqvist, 2013). The review stated that the conditions for offering senior care worsen with age compared to the wider population aged between 18 and 64 years, and more generally, age stereotypes restrict older adults’ space to act. Other studies on active and healthy ageing often focus on the life-course cycle rather than intersectionality, although a combination of both methods would be key to informing policy analysis (Holman & Walker, 2021). However, intersectionality has over the past decade received an increasing amount of attention in health inequality research (Ibid, 2021). These findings suggest that treating social characteristics such as age, gender, civil status, ethnicity, sexual identity, and ability, as well as socio-economic status and geography, such as urban or rural residency, separately fails to match the reality that people simultaneously embody multiple characteristics and can therefore be subject to multiple forms of discrimination (Ibid, 2021). While mainstreaming this type of approach in practice is still at an early stage, consideration of intersectionality in the Nordic countries’ ongoing response to Covid-19, and more generally in policies beyond the pandemic, will be important.
As a policy framework, Holman et. al. (2021) citing Hankivsky et al. (2018) argue that intersectionality “encourages critical reflection to move beyond singular categories, foregrounds issues of equity, and is innovative in highlighting processes of stigmatization and the operation of power in policy-making, offering various applied examples of intersectionality in practice” (Holman et. al., 2021: 2). Other studies also show that large gaps still separate different age groups. Maintaining these gaps may result in the sustained exclusion of sub-groups of the Nordic senior population.
Adopting an intersectional perspective in the context of policy mainstreaming may expand practitioners’ understandings of what typically constitutes evidence-based decision-making in health by recognising a diversity of knowledge, paradigms, and theoretical perspectives that can be included in policy analysis and practice. An intersectional and diverse approach to active and healthy ageing in the Nordic region can therefore bring to light the structural barriers to be addressed. Inequities in health will continue to exist where differences in outcomes of active and healthy ageing among the Nordic senior population are inaccessible and unjust.