The role of indicators in supporting policy initiatives and actions

This chapter addresses, broadly, how the indicators on active and healthy ageing are used by policymakers. This question is addressed by an overview of policies adopted in five Nordic municipalities and by a roundtable discussion with key informants from these municipalities. Results show that municipalities lack tools to measure and compare the status of active and healthy ageing in their areas of work.

Indicators by themselves can have great utility for creating knowledge on the topic of active and healthy ageing, but they are also needed to inform policymaking. In addition, it is necessary to uncover the advantages and challenges of the existing indicators in order to improve their usage by all policymakers. Therefore, in this section we address our second research question, namely:

How are these indicators used for supporting and following up on policy initiatives and what are the main advantages and challenges?

First, we briefly review some of the current strategies for active and healthy ageing, welfare technology, and age-friendly cities and communities in some Nordic municipalities. Second, we provide an account of how these municipalities work with available statistical indicators.

Methodology

To collect the necessary data to answer our second research question on how the indicators previously described, or other relevant indicators, are being used in policymaking across the Nordic region, we conducted desk research, a roundtable discussion, and two individual interviews. The desk research consisted of reviewing policy and strategic documents in the selected municipalities that participated in the roundtable. To carry out the desk research, we examined material that the municipalities have made publicly available such as their webpages and policy documents. To supplement and provide context to this material, regional and/or national resources were also examined when necessary.

In addition, we conducted a roundtable discussion with representatives of five Nordic countries working on the issue of active and healthy ageing and welfare technology. Invitations were sent to three or four municipalities in each of the Nordic countries based on a list of relevant contacts related to active and healthy ageing provided by the Nordic Welfare Centre. Overall, the five Nordic countries were represented, and this allowed us to get a glimpse of different strategies and current situations. The roundtable lasted around an hour, and it was structured around three aspects and guided by twelve questions. The first of these aspects was the current state of municipal strategies across the two topics of interest for us in this study: active and healthy ageing and welfare technology. Second, we were interested in knowing if municipalities use statistical indicators in relation to their strategies and, if so, which indicators these are and how they are used. Third, we will focus on an assessment from the municipal representatives on the indicators as to explore their advantages and challenges.

In addition, and to supplement the material on active and healthy ageing and welfare technology, we also approached two representatives from Gothenburg and Uppsala who are responsible for coordinating the work on enhancing age-friendliness in their respective cities. This topic is closely linked to active and healthy ageing and welfare technology and, as such, it is highly relevant to provide material in this regard. Therefore, we conducted a short interview with the representative from Uppsala and we obtained input from the representative of Gothenburg through email. Our topic was mainly focused on which indicators municipalities use to follow-up the work they are carrying out on age-friendly cities.

Current examples of municipal strategies

The roundtable discussion around this topic showed the different strategies adopted in Nordic municipalities to address active and healthy ageing and welfare technology. One common aspect that emerged in the roundtable was the view that users of health and welfare technology could, and should, become more independent from the municipal healthcare services.

Aarhus municipality (Denmark), for example, has adopted a short 5 clues (ledetråde in Danish) strategy with the goal to make citizens more independent in health-related matters (Aarhus kommune, 2021). These five clues focus on:

Using welfare technology to keep citizens self-sufficient
Adapting health services to citizens’ needs to empower them
Collaborating with local communities to help them enjoy life
Giving freedom to health workers to improve their job satisfaction
Improving leadership to bring these clues to life

In addition, the municipality is developing a 10-year plan to improve welfare technology. However, as their representatives mentioned, their approach is that welfare technology is not a goal in itself but instead something that must be used to increase citizens’ independency by supplementing other human-based efforts.

This perspective was shared by Eskilstuna municipality (Sweden). Their strategy The future healthcare 2035 (Framtidens vård och omsorg 2035, in Swedish) aims to support the prolonged empowerment and independency for users of healthcare (Eskisltuna kommun, 2021). In addition, from a multidimensional understanding of health and ageing, they state that rather than a reactive provision of care, their focus is to become more proactive in order to focus on engagement, participation, digital inclusion, safety, and security.

Reykjavík (Iceland) also shares the perspective of providing more independence to their citizens when they have to deal with health matters. Their current strategy for senior citizens (Stefna Reykjavíkurborgar í málefnum eldri borgara 2018−2022, in Icelandic) is structured around three mottos that aim at making Reykjavík an age-friendly and health-promoting city (Velferðarsvið Reykjavíkurborgar, 2018):

Respect: for knowledge, experience, opinions, the right to self-determination, and the different access needs of Reykjavík residents.
Activity: everyone can be active in society regardless of age or social status, origin, sexual orientation, gender, and economic status.
Friendships: senior citizens have the opportunity to cultivate family and friendship relationships, to enjoy the company of others, and to participate in social activities.

Besides this, Reykjavík also has a welfare technology strategy in place (Stefna Reykjavíkurborgar á sviði velferðartækni 2018-2022, in Icelandic) that focuses on using welfare technology to make it easier for people to live in their own homes with a better quality of life despite aging, disability, or illness and at the same time enable them to be more active participants in society (Velferðarsvið Reykjavíkurborgar, 2021). Nonetheless, there might be some issues in the implementation of welfare technology. For instance, they point to the fact that senior citizens are not accustomed to using many of the digital devices that the municipality is testing on them because it is a novel technology that they are not that familiar with. In addition, it is also challenging to develop and build up a system for people who will not be their core users in the long run.

Similarly, Kristiansand municipality (Norway) established a regional coordination group for e-health and welfare technology (regional koordineringsgruppe e-helse og velferdsteknologi, in Norwegian) that focuses on (Kristiansand kommune, 2020):

Giving users greater confidence, quality of life, and control over their own lives
Giving relatives greater security and mastery over their life situations
Giving employees more opportunity to use their professional expertise
Better utilising resources in the municipal health services

In addition, regarding welfare technology, the municipality has created a network of healthcare personnel with the aim to supervise the implementation of welfare technology as well as to upskill healthcare personnel in the use of welfare technology.

Kristiansand is also taking part in the project Common Telemedicine solution Agder or TELMA (Felles Telemedisinsk løsning Agder) that aims to a) test and evaluate a common telemedicine solution for distance monitoring of patients with chronic disorders and comorbidity, b) establish a common telemedicine solution for all 30 municipalities in the Agder region, and c) provide good health services with less use of health staff resources (TELMA, 2021).

At the regional level, Agder collaborates with the Norwegian municipalities’ association (KS, Kommunenes Sentralforbund), the Norwegian Directorate of e-Health (Direktoratet for e-helse) and the Norwegian Directorate of Health (Helsedirektoratet) in the national Welfare Technology Programme (NVP, Nasjonalt Velferdsteknologiprogram).

In Finland, the Association of Finnish Municipalities (Kuntaliitto) is part of a cross-administrative group for the programme on ageing (Ministry of Social Affairs and Health, 2020a). The programme establishes the following six key policies to be addressed by 2030:

To improve the functional capacity of older working-aged people and longer duration careers
To enable older people to retain their functional capacity for a longer time
To establish voluntary work in society
To increase wellbeing through digitalisation and new technologies
To implement services in a socially and economically sustainable manner
To make housing and living environments age-friendly

Although Finnish “municipalities will continue to be responsible for promoting health and wellbeing, the self-governing regions extending beyond municipalities will be responsible for organising social welfare and health care services” (Ministry of Social Affairs and Health, 2020a, p. 25). Nonetheless, municipalities will still play a relevant role in some of the aforementioned policies. For example, regarding the first of the six priorities, they “shall be obliged to draft a plan on their measures to support the well-being, good health and functional capacity of the elderly population and their ability to cope independently, and for organising and developing services and informal care required by elderly people” (Ministry of Social Affairs and Health, 2020b, p. 23). For the last of the policies, municipalities are expected to include the housing needs for elderly people in the municipal plan for supporting the elderly population with the aim of anticipating those needs (Ministry of Social Affairs and Health, 2020b).

The examples showed here point towards an increased use of technology-based tools to be implemented in healthcare with the goal of giving more autonomy and independence to the final user. However, digital exclusion is still an important matter to acknowledge. For instance, a Swedish study from 2021, by Internetstiftelsen (The Internet Foundation), shows that internet use is 83 per cent among those born in the 1940s and 57 per cent among those born in the 1930s (Andersson, Blomdahl, & Bäck, 2021) id est two groups that represent the target group of welfare technology. Furthermore, e-health services are used by 81per cent of those born in the 1960s, 76 per cent of those born in the 1950s, 61 per cent of those born in the 1940s, and only 34 per cent of those born in the 1920s and 1930s (Andersson, Blomdahl, & Bäck, 2021). These data suggest, therefore, that welfare technology needs to take into consideration the users’ perspective insofar as they might not be comfortable with technology tools that they are not familiar with.

Use of statistical indicators

Active and healthy ageing and welfare technology

One conclusion from both the desk research and the roundtable is that the municipalities examined here do not to a large extent use existing indicators in support of their work. This is due to several factors. First, as highlighted in the review of indicators in the second chapter, there are not many useful indicators at the local level. Most of them are produced by national or supranational institutions and thus they rarely cover subnational country divisions. In addition, beyond territorial coverage it is also important to highlight that indicator for active and healthy ageing need to focus on the individual level, id est, disaggregation by socio-demographic markers such as age and gender is necessary.

This, of course, is a costly process because it often requires conducting surveys in order to grasp issues that go beyond medical or tax records. In Sweden, for instance, the Swedish Association for Local Authorities and Municipalities (SKR, Sveriges Kommuner och Regioner) provides data to municipalities on the number of users of health and social services, but this falls short of informing about the situation of the senior populations. Also, rather than using existing indicators municipalities themselves produce indicators based on their needs. This is the case in Aarhus and Reykjavík, for example. In Aarhus, they have developed their own statistical records (faktacenter) where they compile various data from the health care services, for instance. In Reykjavík, they also collect their own statistics, and, in addition, they run a survey about seniors’ wellbeing every three years.

These approaches, however, have some limitations. For instance, because collecting and processing statistical data is an expensive endeavour, those municipalities that lack the resources, both financial and technical, might not have the same opportunities to develop such indicators. Furthermore, municipalities might be able to collect data for themselves, but if there is no structured and systematised way to publish them, these data might not become public and, thus may be of no use for other stakeholders. Another limitation could be that municipalities focus too much on financial aspects of active and healthy ageing and welfare technology. A third reason for municipalities not using indicators to draft their strategies might be due to miscoordination within municipalities themselves.

As it was pointed out during the roundtable, municipalities might not have the incentives to work proactively towards monitoring purely active and healthy ageing issues. It can be the case that healthcare services within municipalities are organised as differentiated silos, e.g., local services and hospitals working on their own instead of working together. This comes down to how resources are distributed and who takes the responsibility of producing knowledge.

Municipalities, though, find that having the right indicators could be of use for developing better strategies and policies. One concern raised by municipalities was that more subjective indicators focusing on self-assessment are necessary in order to have a better grasp of active and healthy ageing among their populations. In this regard, some good examples could be those indicators produced by the ESS or Eurostat. For instance, in the ESS there are indicators related to subjective happiness, feelings about household income, and feelings of subjective general health. Eurostat also provides a range of self-perceived indicators on various health issues including mental health.

Municipalities argue in this aspect that quality of life is a central concept for active and healthy ageing, but this is difficult to grasp from objective statistical indicators such as time spent on physical activity or educational level. Therefore, including the individual’s perceptions, ideas, or feelings in the indicators can be useful for acquiring a better understanding of the individual’s quality of life in the municipality. In addition, as Nordic populations become more diverse, having subjective indicators could be useful to accommodate other cultural habits that might not be grasped from objective indicators. Nonetheless, subjective indicators have the limitation of not being a useful tool for comparing individuals. While comparing objective indicators such as tobacco use gives a concrete measure, comparing subjective general health is more complex because individuals might not perceive, and measure, their health in the same way.

Concerns about developing useful indicators comprised different aspects such as the quality of indicators, the definitions and concepts measured, and the political will to provide municipalities with tools to keep track of active and healthy ageing. As previously mentioned, the development of statistical indicators requires many resources that not all municipalities have available. For this reason, some of the municipalities mentioned that political will needs to be directed towards providing these resources to municipalities themselves. As municipalities see it, the allocation of resources is too focused on the monitoring and evaluation of municipal models for addressing active and healthy ageing instead of focusing on the actual needs and demands of local communities.

These needs and demands, furthermore, are subject to change along with the needs of a more diverse older population. For example, one participant in the roundtable noted the need to consider cultural diversity when drafting strategies because not all population groups share the same values. Regarding healthcare provision, for instance, independence might be valued more strongly by Nordic cultural standards, but this may not be the case by other cultural standards where the family takes a more important role in the delivery of healthcare. Therefore, when implementing policies and strategies on welfare technology, for instance, municipalities need to take these issues into consideration, and this calls for good tools to know the target groups to which policies are directed.

Age-friendly cities and communities

Regarding the topic of age-friendly cities and communities, the experiences of Gothenburg and Uppsala paint a different picture. In terms of evaluating the work of the age-friendly cities and communities’ programme, Gothenburg has appointed an older people ombudsman (äldreombudsman) to follow up on the work across the city. In addition, the parties with shared responsibility (administration and companies) shall cooperate with the city management office in the follow-up and evaluation. These activities will be followed-up in 2022, and the indicators measuring the impact on the target groups at the societal level will be followed-up in 2024. These indicators are taken from Statistics Sweden’s citizen survey and from the Swedish Public Health Agency’s health survey, but there are no indicators specifically focusing on age-friendly cities. From January 2022, a baseline for 2021 will be completed and it will touch upon the topics of mobility, housing, social inclusion, urban development, community support and services, and information and communication.

In Uppsala, it was decided to focus on the already existing local indicators. However, those indicators do not grasp the entirety of the municipality’s work and thus they require revision. In relation to this, from January 2022 the municipality will strengthen the cooperation between the statistics and age-friendly departments to develop more suitable indicators. These indicators will focus on the older population and will also be developed with the aim of facilitating comparisons across the Nordic countries. So far, the social compass (sociala kompassen) has been used to map social characteristics and social issues and has been helpful for measuring living conditions of the older population and relating to the age-friendly cities programme. The biggest opportunity that Uppsala has is the chance to create a dynamic and flexible set of indicators that can help the municipality to better evaluate their own work within the age-friendly cities programme.

Advantages and challenges of indicators for addressing active and healthy ageing

Up to this point we have shown what indicators are available in the Nordic region and discussed how they are used by policymakers at different levels. This is an advantage for those who work with active and healthy ageing in the Nordic region as it shows the existing wide range of indicators from the municipal to the international level. Nonetheless, this can also raise some challenges, which have already partially been discussed in this report. In this subsection we address the advantages and challenges of using these indicators.

It is worth addressing the conceptualisations of active and healthy ageing and how these conceptualisations influence the production of indicators. We have shown how UNECE and WHO work with active and healthy ageing as well as with the concept of age-friendly cities. These frameworks, while highly relevant as lighthouses for other stakeholders, might fall short in addressing local needs, even at national levels. Some participants in the roundtable, for instance, mentioned the need to deal with more culturally diverse populations in their municipalities. This requires a local perspective to grasp all social nuances, not only at municipal or regional levels, but also at the national level. Therefore, it is clearly not easy to synthesise all these indicators into a working conceptualisation spanning all of the target population’s needs.

For example, health-related indicators play a big role in measuring the health aspects of active and healthy ageing. However, as we have seen, there exist many domains of health that go beyond the health status of individuals, and entire populations, and that contribute to a healthy ageing society. Aspects such as public resources, welfare technology, or age-friendly cities are some of these relevant domains in measuring and contributing to active and healthy ageing. Nonetheless, these stem from frameworks that do not always consider the necessities of local policymaking. Therefore, if local actors (municipalities, regions, or countries) do not possess the tools to address active and healthy ageing due to the already made conceptualisations it might be hard for them to make a good diagnosis of their situations.

Therefore, it is a great advantage for the Nordic region to be relatively well covered by international indicators, but as it has been shown these indicators need to be treated carefully so as not to draw wrong conclusions on the status of active and healthy ageing. This is even more important if we consider that international indicators do not reach the more local levels of governance in the Nordics. This is a challenge because municipalities in the Nordics have, to a large extent, the responsibility of providing healthcare and wellbeing to their populations.