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Healthy and Positive Ageing Initiative Literature ReviewIntroductionIn recent years, there has been a shift in the perception of ageing from a negative to a positive perspective. Instead of a period of decline and ‘retirement’ from life, later life is increasingly seen as a period in which older people can continue to develop and to contribute their experience and knowledge to their communities. This view has informed the approach towards policy development in many countries and is central to the vision set out in the Irish National Positive Ageing Strategy (NPAS), published in 2013 (Government of Ireland, 2013). The Strategy arose from a commitment in the Programme for Government in early 2011 to complete and implement the NPAS so that ‘older people are recognised, supported and enabled to live independent full lives’ (pg. 56). In essence, the Government committed to enhancing and protecting people’s wellbeing and quality of life as they age.The theoretical background for the NPAS is consistent with international developments in relation to ageing, and in particular the World Health Organisation’s (WHO) Active Ageing – A Policy Framework (World Health Organisation, 2002). This framework provides a roadmap for designing multi-sectoral active ageing policies. It encourages policy makers to recognise and address factors or ‘determinants’ that affect how people and populations age, to adopt a life-course perspective, and to promote intergenerational solidarity in developing policies to respond to population ageing. The WHO Active Ageing Framework calls for action on three fronts, by defining active ageing as a process of optimising opportunities for participation, health and security. The implementation of the NPAS requires a ‘whole of government’ response, and must be framed within the implementation of Healthy Ireland - the national framework for action to improve the health and wellbeing of the population (Department of Health, 2013). Implementation of the NPAS is an essential part of the vision for creating a society in which “every individual and sector of society can play their part in achieving a healthy Ireland” (Healthy Ireland goal 4).These two interlinked Government strategies have each committed to the development of indicators to monitor and evaluate progress in implementation. Indicators have been developed in many different policy areas and are regarded as playing a vital role in policy making. Indicators facilitate the identification of problems and trends, while contributing to the process of priority setting, policy formulation, and the evaluation and monitoring of progress (Nardo et al., 2008). Developing indicators to measure progress will be central to the successful implementation of the NPAS. Development of an indicator set is a core aim of the Healthy and Positive Ageing Initiative (HaPAI). The indicator set will be primarily based around the goals and objectives of the NPAS, but also takes into account the use of indicators at international level. These indicators will be used to assess the level of progress being made through the implementation of the Strategy to improve the lives of older people over time, ideally benchmarked against other countries. A preliminary report has been published detailing an initial long-list of indicators for each of the NPAS goals and objectives, drawing on currently available national and international data sources (Department of Health, 2015). The purpose of this review is to outline in more detail the background theory and evidence under-pinning the indicator development process. The first section of this review will focus on definitions of ‘positive ageing’, health and wellbeing. It will also include a brief discussion of the life course approach, and what is meant by an indicator. The next section will examine current evidence for the relevance of various life domains for positive ageing, drawing on current research evidence and theory. The third section will discuss the international experience in relation to the development of indicators to measure wellbeing, particularly in the older population. In summary this literature review aims toOutline what is meant by Positive Ageing and define key relevant terms: Ageing, Healthy, Wellbeing and Quality of Life, Life course and IndicatorIdentify key life domains related to healthy and positive ageing and outline current evidence for the contribution of each domain to positive ageing Review existing international indicator sets which measure positive ageing Conceptual Framework: definition of termsA range of terms have been used in the literature to refer to positive outcomes in later life: “Positive Ageing” (Gergen & Gergen, 2001); “Ageing well” (Fries, 1989); “Healthy Ageing” (SNIPH, 2007), “Successful Ageing” (M. Baltes & Carstensen, 1996; Rowe & Kahn, 1997), “Productive Ageing” (Butler, 1996; Kaye, Butler, & Webster, 2003) and “Active Ageing” (World Health Organisation, 2002). Initially, the emphasis was on the physical and mental health of older adults, with ‘Healthy’ ageing identified as an aim by the WHO as early as 1980. In the 1990s the emphasis shifted towards ‘active and productive’ ageing, accompanied by an increasing focus on the economic implications of population ageing (Bass, Caro, & Chen, 1993). ‘Productive ageing’ views older people as a resource and emphasises the importance of their economic participation in society (OECD, 1998). The concept of ‘Active ageing’, was proposed by the United Nations in 1999, and argues that the old stereotype of older people as frail and dependent will change as active older people became more visible and better integrated into society.Concepts of ‘successful’ and ‘positive’ ageing emphasise a broad range of factors that contribute to wellbeing - physical, intellectual, emotional and spiritual - and suggest that psychological adjustment and autonomy are central to the achievement of good quality of life. Physical health is only one aspect of positive ageing, and a high level of physical function may not be necessary for a person to consider themselves “successfully aged” (Depp & Jeste, 2006). For example, one study of adults aged 60 and over in the US found that 92% of the sample considered themselves "successfully aged", despite the fact that 85% had chronic conditions, and 78% had at least some functional impairment (Montross et al., 2006).The NPAS uses a definition of positive ageing put forward by the Office of an Ageing Australia as “an individual, community, public and private sector approach to ageing that aims to maintain and improve the physical, emotional and mental wellbeing of older people. It extends beyond the health and community service sectors, as the wellbeing of older people is affected by many different factors including socio-economic status, family and broader social interactions, employment, housing and transport. Social attitudes and perceptions of ageing can also strongly influence the wellbeing of older people, whether through direct discrimination or through negative attitudes and images”. This definition acknowledges that positive outcomes in later life cannot be reduced to physical health and function, or to productivity. The positive ageing approach involves recognition that a broad range of supportive societal and external environmental factors play a role in improving general wellbeing and quality of life. Some of the key terms related to positive ageing – ageing, health, wellbeing and quality of life, are defined below. Ageing occurs throughout the life course and although there are commonly used definitions of old age, there is no general agreement on the age at which a person becomes old. Based on the most common age of retirement or qualification for a pension benefit, the World Health Organisation states that most developed world countries have accepted the age of 65 years as a definition of an 'elderly' or older person. The United Nations generally uses the cut-off of 60+ years to refer to the older population. However, when examining positive ageing it is also useful to include research with the population aged 50-64, as this is the time of life leading up to retirement, and is also when many people experience the initial onset of chronic conditions. Large-scale ageing surveys, such as the Irish Longitudinal Study of Ageing (TILDA) and the Survey of Health, Ageing and Retirement in Europe (SHARE) collect data from adults aged 50 and over. Health is described in Healthy Ireland as meaning “…everyone achieving his or her potential to enjoy complete physical, mental and social wellbeing”. As per the WHO definition, the concept is broadly defined as being “more than an absence of disease or disability” (Department of Health 2013. p.9).Wellbeing is also defined broadly in the Healthy Ireland strategy, as “quality of life and the various factors which can influence it over the course of a person’s life” (Department of Health 2013. p.9). A second definition is also used, which is “positive mental health, in which a person can realise his or her own abilities, cope with the normal stresses of life, work productively and fruitfully, and be able to make a contribution to his or her community” (p. 9). In the research literature, the term wellbeing is most commonly used in the context of “subjective wellbeing”, defined as “an umbrella term for different valuations that people make regarding their lives, the events happening to them, their bodies and minds and the circumstances in which they live” (Diener, 2006)(p. 156). Subjective wellbeing is most frequently measured as life satisfaction, and the presence of positive and negative mood or affect (Diener, Suh, Lucas, & Smith, 1999). In recent years, a broader definition of subjective wellbeing has been proposed, which includes concepts related to meaning and purpose in life, including personal growth, autonomy and self-acceptance (Dolan, 2014; Ryan & Deci, 2001; Ryff & Singer, 2008). However, consistent with the definition in Healthy Ireland, the term wellbeing can also be used to refer to the range of life domains that influence individual subjective assessments of wellbeing. Stiglitz, Sen & Fitoussi argue for multi-dimensional concept of wellbeing, which encompasses both subjective and objective measures of a broad range of life domains – economic circumstances, social participation, mental and physical health and environmental conditions (Stiglitz, Sen, & Fitoussi, 2009). Quality of life is another term used throughout this report. The WHO established a working party on quality of life using the following definition: “Quality of life is defined as the individual's perception of their position in life in the context of the culture and value systems in which they live and in relation to their goals, expectations, standards and concerns. It is a broad ranging concept affected in a complex way by a person's physical health, psychological state, level of independence and their relationships to salient features of their environment” (WHOQOL Group, 1997) This definition is very similar to the definition of subjective wellbeing used above, and the strong parallels between the two concepts have been highlighted (Camfield & Skevington, 2008). Research on wellbeing and quality of life have tended to exist in parallel silos with the wellbeing literature more focussed on measuring life satisfaction, and quality of life research more focussed on subjective assessments of health status. In recent years, however, definitions of quality of life and wellbeing have converged so that they are broadly interchangeable conceptually. As both terms continue to be used in the literature, both will be used in this review. Similar to wellbeing, the concept of quality of life can encompass both individual subjective assessments of life quality, but also the objective and subjective life conditions and circumstances which influence a person’s quality of life (Brown, Bowling, & Flynn, 2004; Lawton, Winter, Kleban, & Ruckdeschel, 1999). Amartya Sen has emphasised the importance of assessing whether a person has the necessary capabilities or opportunities to lead the kind of life they value, particularly compared to others (Sen 1985a, b; Sen, 1999). These capabilities include being well-nourished, well-clothed, mobile, taking part in the life of the community. Wellbeing is thus not just about the achievement of specific positive outcomes, but whether the person has the freedom or opportunity to achieve those outcomes. It is clear that definitions of wellbeing and quality of life are complex. Components include an individual’s assessment of their wellbeing and quality of life, including their overall satisfaction with life, happiness, autonomy and purpose in life. It also includes factors which contribute to those assessments of wellbeing, such as physical health, social relationships, financial security, and the quality of the home and neighbourhood. In measuring wellbeing, it is therefore important to include both people’s evaluations of their overall wellbeing or quality of life, and key life domains that both influence and are part of wellbeing. In considering positive ageing, it is also important to take a life course approach. The life course has been defined as a sequence of age-related transitions that are embedded in social institutions and history (Bengston et al., 2012) and as such, lives are institutionally structured (Mortimer and Shanahan, 2003). Institutional contexts include the family, school, work and labour markets, church and government and these institutions define the normative pathways we take, the social roles we take on and the timing of key life transitions. These contexts also influence the psychological, behavioural and health related trajectories of individuals and groups as they age and move through them. According to Bengston et al. (2012) there are five principles of the life course which are relevant to understanding health, wellbeing and positive ageing. The first is the principle of ‘linked lives’ whereby lives are embedded in relationships with people and are influenced by them. For example the plans of grandparents for retirement can change during times of economic hardship when adult children return home and need their support. The second principle relates to historical time and place. Historical events such as the Second World War, the Great Depression and the economic crises of the 1980s and 2008 create opportunities and constraints and ultimately influence the choices, behaviours and lives of individuals who live through them (Bengston et al. 2012). The third principle is the link between transitions, their timing and social contexts (Bengston and Allen, 1993; Elder, 1995). Historical events have influenced people’s lives in different ways depending on the age and stage they were at when the event occurred. This can lead to differences between cohorts in terms of demographic behaviour such as delaying marriage, occupational outcomes such as reduced job security and psychological wellbeing (Putney and Bengston, 2003). The fourth principle is agency; individuals are active agents in the construction of their lives who make choices within the context of their family background, stage in the life course, structural arrangements and historical conditions (Bengston et al., 2012). The fifth principle concerns the idea that ageing and human development are life-long processes and that relationships, events and behaviours of earlier stages have consequences for later life relationships, statuses and wellbeing (Roberts and Bengstons, 1996). The concept of an indicator is also critical for monitoring positive ageing. Many definitions of indicators exist in the literature and are in use internationally, varying slightly depending on their intended use. In a policy context, an indicator provides a measure of the relative position in a specific area (e.g. health) of a given population sub-group, geographical area or time-point (Nardo et al., 2008). It thus allows identification of trends over time, and of problem areas that require improvement. This in turn informs priority setting and performance monitoring. The purpose of indicators therefore, is to help us to analyse and understand a system or outcome, compare it and improve it (Association of Public Health Observatories, 2008). For the purposes of the HaPAI project the following definition of an indicator is used, adapted from the WHO: “A variable with characteristics of quality, quantity and time used to measure, directly or indirectly, changes in a situation…to appreciate the progress made in addressing it…and to assess the extent to which the objectives and targets of a programme are being attained” (World Health Organisation Centre for Health Development, 2004, p. 78). Domains of Positive AgeingPositive ageing is a multi-faceted concept. As outlined in the previous section, it includes a broad range of factors related to the person and their social and environmental context, both contemporaneously and throughout the life course. In recent years, there had been considerable research carried out to identify evidence for the factors that are important for positive ageing. In the UK, the ‘Growing Older’ research programme asked older people what they felt contributed to quality of life (Bowling & Gabriel, 2007; Bowling, 2006; Bowling et al., 2003; Gabriel & Bowling, 2004). These factors fall into a number of key life domains: individual issues such as health, income and ability; environmental issues about accommodation and mobility; and psychological and social issues such as social networks and support. In particular, older people highlighted seven areas of importance: Keeping active and healthy; Comfortable and secure homes; Having enough money to meet basic needs, to participate in society, to enjoy life and to retain one’s independence and control over life; Safe neighbourhoods; Getting out and about; Friendships and the opportunity for learning and leisure; and Access to good, relevant information. These factors were important not just in themselves, but because of what they provided: freedom, autonomy, enjoyment in life, social attachment and relationships, social roles and security. These identified areas correspond with the areas identified by an extensive consultation process carried out as part of the WHO Global Age-Friendly Cities project. The eight areas covered by the project are: respect and social inclusion, civic participation and employment, housing, community support and health services, communication and information, outdoor spaces and buildings, transportation and social participation.Recent research from The Irish Longitudinal Study of Ageing (TILDA) confirmed that older adults’ subjective quality of life is determined by multiple factors related to social participation, physical health and function, mental health and socioeconomic status (Layte, Sexton, & Savva, 2013). Mental health indicators appeared to be the strongest predictor of quality of life, followed by social participation, physical function, with socioeconomic status emerging as the least important predictor. The individual indicators that had the greatest independent effect on quality of life included: depression, anxiety, worry, stress, self-rated physical health, chronic pain, physical activity, loneliness, social activity, marital status and relationship quality with partner, relatives and friends.It can be difficult to distinguish factors that are part of wellbeing, and factors that influence it. For example, good physical health and social relationships are both part of wellbeing, but also have an influence on a person’s happiness and satisfaction with life. In fact, there are likely to be influences in both directions, as happiness also leads to improved physical health and social relationships. Similarly, better physical health may help a person to achieve a higher income, and vice versa. For this reason, when measuring positive ageing, it is essential to include multiple measures of life domains, all of which are likely to influence each other in complex ways. The following section will review the current evidence for the importance of a number of key life domains for healthy and positive ageing: Social and community relations, Employment and education, Disease and disability, Health behaviours, End-of-life care, Income and Financial Security, Home, Age-Friendly Environments, Safety, Ageism and Attitudes to Ageing and Subjective Wellbeing. It is important to note that these domains are not exhaustive, and there are many factors not dealt with here that are important for wellbeing. The purpose of this section is to provide a broad overview of the evidence linking various domains of participation, health and security to important wellbeing outcomes. The complexity of positive ageing outcomes can make it difficult to precisely identify how policy can impact of influence positive ageing. Each section therefore concludes with a small number of examples of how policy can impact outcomes in the specific life domain. Participation: Social and Community RelationsThe positive impacts of social connections and social networks are well known. Older adults with more active social networks tend to have fewer depressive symptoms, are more satisfied with their lives, and report better quality of life (Layte et al., 2013; Pinquart & Sorensen, 2000). There is extensive evidence to suggest that it is the quality of relationships that improve wellbeing, rather than presence or quantity of relationships e.g. (Antonucci, Lansford, & Akiyama, 2001). This may be particularly true for older people, as they choose to reduce the size of their social networks and focus on a smaller number of high quality relationships (Fung & Carstensen, 2004). Good quality social relationships can improve self-esteem, sense of belonging or companionship, and improve a person’s sense of purpose or “mattering” (Thoits, 2011). High quality social networks and relationships can also "get under the skin", and have a positive effect on self-rated health, disability, and mortality (Bath & Deeg, 2005; Cornwell & Waite, 2009; Leon, Gold, Glass, Kaplan, & George, 2001). It is thought that social relationships improve people’s physical health by making them happier and more satisfied with their lives, but also by increasing motivation and support for healthier lifestyles (Thoits, 2011). In addition to social relationships and networks, engaging in social leisure activities is also beneficial for quality of life among older people (Bowling, Banister, Sutton, Evans, & Windsor, 2002; Huxhold, Miche, & Schüz, 2014). There is also a growing literature on the positive effect on quality of life of productive social activities such as volunteering and providing support to others, particularly when the activities are characterised by a high degree of control or engagement (Matz-Costa, Besen, Boone James, & Pitt-Catsouphes, 2014; McMunn, Nazroo, Wahrendorf, & Zaninotto, 2009; Wahrendorf, von dem Knesebeck, & Siegrist, 2006).Engaging in creative activity also has benefits for psychological well-being among older people, at least partly through an increase in social interaction (Wikstrom, 2002). Evidence of the value of participation in the arts was found in a study carried out by Matarasso (1997) which identified the effects of participation such as increases in people’s confidence and sense of self-worth, increased involvement in social activity/reduced isolation, encouraging self-reliance, facilitating health education and building social capital.Examples of policies to improve social participation and engagementA high quality and inclusive built environment and transport system is critical to supporting active social participation in older people (see section on Age-Friendly Environments on page 16). Community-based programmes and interventions that promote active social activity, for example day centres or volunteering programmes, increase social participation and decrease loneliness and depression (Hagan, Manktelow, Taylor, & Mallett, 2014). Occupational therapy can support older adults with disability or functional impairments to maintain or improve their social participation (Berger, McAteer, Schreier, & Kaldenberg, 2010).Participation: Employment and EducationThe United Nations (UN) (2003) has stated that older people should be enabled to continue with income-generating work for as long as they want and for as long as they are able to do so productively. Among adults who do not have access to a full pension, employment has clear benefits, particularly in relation to financial security. However, even among adults who are past retirement age, continued access to paid employment may have some benefits. On one hand, retirement can be associated with increased mental wellbeing and social participation, as people are freer to spend their time as they choose (Mein, Martikainen, Hemingway, Stansfeld, & Marmot, 2003; Van Den Bogaard, Henkens, & Kalmijn, 2013). On the other hand, it can be associated with a loss of purpose and identity, as well as risks of social marginalization and impoverishment, particularly for those already on a low income before retirement. The benefits of retirement compared with working longer are therefore likely to vary depending on the circumstances. In particular, the type of job is important. Older adults with physically or psychologically challenging jobs may benefit from retirement, while those who are satisfied with their jobs benefit from continuing to work (Calvo, 2006). Similarly, individuals who feel that they have control over the decision to retire, rather than feeling that it was enforced, tend to experience more positive outcomes (Calvo, Haverstick, & Sass, 2009; De Vaus, Wells, Kendig, & Quine, 2007). This implies that giving people more control over the decision to retire, and providing people with options in relation to employment and retirement in later life – including continued working, gradual retirement and part-time working – is likely to contribute to positive ageing. A substantial body of literature highlights the potential contribution of older people within the workforce, as the advantage of greater knowledge acquired across the lifecourse overcomes the disadvantage of less effective novel processing. Indeed, “Because job experience and age are often inextricably intertwined, the midlife worker will be more skilled than the younger worker … thus any loss in Gf abilities will be compensated for by higher levels of job knowledge (Gc). ((Kanfer & Ackerman, 2004, p.450). Opportunities for employment in later life, as well as outcomes across life domains, are heavily influenced by educational attainment throughout the life course, and access to opportunities for learning in later life. In particular, a basic level of literacy and numeracy is essential for even minimal engagement in society as a citizen, consumer, parent or employee (OECD, 2013). In Ireland, there is a substantial number of adults with poor literacy and numeracy skills, and these poor skills are associated with negative social and economic outcomes including lower wages and a higher probability of unemployment both short and long term (Kelly et al. 2012a; Kelly et al., 2012b; Morrisroe, 2014). This highlights the need for older adults to have access to continuing education at all levels. Finally, it is important to highlight the role that employment and education can play in reducing the risk of cognitive decline and dementia. Older adults with higher lifetime educational attainment and with higher skill occupations appear to be less likely to experience age-related cognitive decline. In addition, it appears that increased or continuing engagement in leisure and social activities that are cognitively stimulating in later life, such as a hobby or learning a new skill, can protect against cognitive decline (Stern, 2012; Valenzuela & Sachdev, 2006). Examples of policies to improve employment options and educationThe European Observatory of Working Life (EurWORK) has highlighted that national active ageing policies must support ongoing skills development and validation of existing competencies on the basis that lifelong learning and ongoing skills development are key to supporting sustainable employability for older workers and the workforce at large (Farrelly, 2013). Flexible working options for older people, such as gradual retirement or part-time work, can be encouraged by ensuring that such work is incentivized and not penalized by relevant tax and pension rules. However, it is also important that such policies increase rather than reduce older adults control over their retirement transitions. It is also important that flexible work practices are accompanied by basic employment rights, to ensure that they are not associated with increased mental distress or risk of poverty (Platman, 2004).Healthy Ageing: Disease and disabilityAlmost all approaches to conceptualising successful or positive ageing place considerable emphasis on the importance of health, and the research literature broadly supports this emphasis. In particular, worse functional health and worse self-rated health, have been consistently found to be associated with lower life satisfaction or quality of life (Bowling, Farquhar, & Grundy, 1996; Diener et al., 1999; George, 2010; Pinquart & Sorensen, 2000; J. Smith, Borchelt, Maier, & Jopp, 2002). In addition, disability is predictive of greater depressive symptoms (Ormel & Rijsdijk, 2002; Stegenga et al., 2012).However, findings in relation to chronic disease are less consistent (Gwozdz & Sousa-Poza, 2009), particularly for the oldest-old (Berg, Hassing, McClearn, & Johansson, 2006). It has been argued that diagnoses may not be a good predictor of wellbeing because of the heterogeneity of health status even across individuals with the same condition (Berg, Hassing, Thorvaldsson, & Johansson, 2011). This was supported by recent evidence from TILDA that suggests that chronic conditions only have a negative effect on emotional wellbeing and quality of life if they are associated with impaired body function (e.g. weaker muscle strength) or activity limitations (e.g. reduced ability to carry out basic activities of daily living) (Sexton, King-Kallimanis, Layte, & Hickey, 2014). This highlights the importance of measuring functional deficits and perceived health as indicators of health, in addition to specific diseases or diagnoses.In recent years, there has been increasing research interest in the concept of frailty. Frailty is a state of increased vulnerability to stressors, which is brought on by age-related decline across physiological systems (Clegg, Young, Iliffe, Rikkert, & Rockwood, 2013). Frail older adults are more likely to suffer major health effects as a result of a relatively minor health problem, such as a minor infection. Current evidence suggests that approximately one in 10 adults aged 65 and over are physically frail (Collard, Boter, Schoevers, & Oude Voshaar, 2012) , and that these adults are at a higher risk for falls, disability, hospitalisation, nursing home admission and death (Clegg et al., 2013). Cognitive decline is strongly associated with increasing age, and maintaining cognitive function is also considered a critical part of healthy ageing. Cognitive function and dementia have been identified as key risk factors for the onset of disability and reduced physical function in later life (Spiers et al., 2005). However, evidence for the association between cognitive function and wellbeing outcomes is mixed. A number of studies found that cognitive decline was not associated with lower life satisfaction or higher risk of depression (Gerstorf, L?vdén, R?cke, Smith, & Lindenberger, 2007; Gow et al., 2005). However, there is some evidence that cognitive decline, particularly in the area of executive function, has a negative effect on dimensions of wellbeing related to purpose and personal growth (Allerhand, Gale, & Deary, 2014; Wilson et al., 2013). There is also evidence that older adults can adapt to disability, maintaining their subjective wellbeing as physical health declines. Oswald & Powdthavee (2008) found evidence that people adapt to disability, with the negative impact of the disability on life satisfaction reducing over time. However, life satisfaction did not fully recover to the same level as before disability onset (Oswald & Powdthavee, 2008). The extent to which someone adapts to disability may depend on a person’s level of resilience, which can depend on factors specific to the person and their contextual circumstances (Smith & Hayslip, 2012). Resilience is an important characteristic for all people but can be particularly so for older people as the ability to recover from negative life events (such as ill-health or death of friends or partner) becomes more necessary. Healthy Ageing: Health behaviourWhile adapting to disability is an important component of positive ageing, so is preventing disability in the first place. Many common chronic conditions are not life threatening, but can lead to disability, particularly if left untreated. Preventative services therefore play an increasingly important part in primary care for older people. There has been a welcome increase in services such as influenza immunization (Crawford, O’Hanlon, & McGee, 2011) and other preventative interventions among older people such as cancer screening (National Screening Service, 2015).Lifestyle and behavioural health are also critical for prevention of disease and disability. The behaviours that are associated with healthy or successful ageing are well known: not smoking, being physically active, maintaining weight within moderate ranges and consuming alcohol in moderation (Peel, McClure, & Bartlett, 2005). A recent review of relevant studies indicated that adults who have all four healthy behaviours have a 66% reduced risk of mortality (Loef & Walach, 2012). Even in a cohort of relatively affluent older adult college graduates, the cumulative lifetime disability for those who were obese, smoked and did not exercise was four times as great as in those who were lean, exercised, and did not smoke (Fries, 2003). Physical activity and not smoking have also been found to protect against decline in cognitive function (Allerhand et al., 2014).While the cumulative effects of behaviour over the life-course is important, the extent to which older adults continue to engage in healthy or unhealthy behaviours also has a critical effect on outcomes. One study of adults aged 65+ reporting that smoking, low consumption of fruit and vegetables and low physical activity were associated with an increased risk of disability over a 12 year period (Artaud et al., 2013). Physical activity was identified as the strongest predictor of disability. Healthy lifestyle behaviours are also associated with better quality of life outcomes (Perales, Del Pozo-Cruz, Del Pozo-Cruz, & Del Pozo-Cruz, 2014; Schmitz, Ph, Kruse, & Kugler, 2003; Ul-Haq et al., 2014; Ul-Haq, Mackay, Fenwick, & Pell, 2012). Exercise may reduce the risk of depression (Baker et al., 2005) and the chances of developing dementia, although it is difficult to disentangle the benefits of exercise from closely related factors such as social networks (Callaghan 2004). Nevertheless, exercise has been described as the, “best preventive medicine for old age” (World Health Organisation, 2002), significantly reducing the risk of dependency in old age (SNIPH, 2007). There is evidence that a range of activities - even simple types of exercise such as gardening (Ferrer-i-Carbonell & Gowdy, 2007) may be associated with higher life satisfaction, and that this may be especially important for the over 60s (Baker, Cahalin, Gerst, & Burr, 2005). Despite extensive evidence for the benefits of health behaviours however, many older adults do not have healthy lifestyles - in Ireland, a third of the population aged 50 and over is obese (Leahy, Nolan, O’Connell, & Kenny, 2014), one in five smoke, one in three have low physical activity and one in 20 have problematic alcohol consumption (Barrett, Savva, Timonen, & Kenny, 2011). Between the first (2010/11) and second waves of TILDA (2012/13) rates of smoking declined, while rates of low physical activity and problematic alcohol consumption increased. Healthy Ageing: End-of-life careBeing supported to die well or with dignity is increasingly seen as a key part of positive ageing. In a WHO study carried out to develop a measure of quality of life specifically for older people (the WHOQOL-Old), “Death and dying” was identified as a key domain of quality of later life (Power, Quinn, & Schmidt, 2005). This domain included feelings of uncertainty and fear around death, not feeling in control of how you die, and fear of being in pain before death. In Ireland, while 74% of adults would prefer to die at home, only 26% do (Weafer, 2014). In contrast, among adults who are cared for by specialist palliative care teams, 41% die at home (Murray, McLoughlin, & Foley, 2013). This highlights the need for and importance of access to specialist palliative care for older adults with advanced illness. Healthy Ageing: Focus on at-risk groupsSocioeconomic disadvantage, social exclusion and enduring health inequalities experienced by indigenous populations and ethnic groups are commonly cited as motivation for a specific focus on these sub-groups and as they age (King et al., 2009; Stephens et al., 2011) This is consistent with the life course approach to healthy ageing discussed previously which emphasises the role of institutional contexts, social norms and expectations in shaping psychological, behavioural and health related trajectories of individuals and groups as they age. In Ireland, Irish Travellers are a small indigenous minority group that has been part of Irish society for centuries. Their distinctive lifestyle and culture, based on a nomadic tradition, sets them apart from the general population which enables them to retain their identity as an ethnic group but often in the face of opposition and pressure to conform to societal norms (Ni Shuinear, 1994). Their experience of low social status and exclusion can prevent them from participating as equals in society (Helleiner, 2000) which has implications for positive and healthy ageing. Considerable health disparities are experienced by the Traveller population including lower life expectancy and higher chronic disease prevalence compared with the general population (AITHS, 2010). However the All Ireland Traveller Health Study Team (2010) note that there are many positive aspects of the Traveller population which are consistent with the concept of social capital; social supports, family ties, kinship, community participation and intergenerational respect and solidarity are hallmarks of the Traveller communities and importantly, these characteristics are regarded as indicators of health and wellbeing more broadly (Gmelch and Gmelch, 1976). Another group that is particularly at risk of poor health and wellbeing is those providing informal care for relatives or friends. Caregivers are at risk of poorer health on a range of physical and mental outcomes, but particularly stress and depression (Schulz & Sherwood, 2008; Vitaliano, Zhang, & Scanlan, 2003). Caregiver health appears to be particularly dependent on the characteristics of the care recipient, in terms of their level of physical and cognitive function, and the duration and intensity of care required. However, it is also important to acknowledge the potential benefits of the caring role, as helping others can result in improved sense of purpose, self-esteem and wellbeing. There is some evidence that caring for others may be beneficial up to a certain level of time and commitment, with the risk of harm increasing once the number of hours and level of burden passes a specific threshold (Heisler et al., 2012; Winter, Bouldin, & Andresen, 2010). This highlights the need for state support, such as home care packages and respite care, to ensure that family caregivers are not overwhelmed. Examples of policy interventions to improve healthPhysical activity can be improved through screening programmes, counselling and interventions (e.g. prescribing exercise); by providing affordable physical activity opportunities (e.g. subsidised leisure centres); and by designing the built environment to maximise opportunities for walking and cycling (Kohl et al., 2012). The rates of falls in the population can be reduced through exercise interventions, home safety assessment and modification programmes, and reducing inappropriate prescribing of psychotropic medication (Gillespie et al., 2009). Integrated disease management programmes, which involve co-ordinated multi-disciplinary care, have been found to improve health outcomes or quality of life across several chronic conditions, including diabetes, chronic obstructive pulmonary disease (COPD) and heart failure (Martínez-González, Berchtold, Ullman, Busato, & Egger, 2014). Interventions involving cognitive stimulation, such as memory training, mental stimulation and mental compensation strategies can improve neural plasticity, which in boosts cognitive reserve and helps to maintain or improve cognitive functioning (Cruz-Jentoft et al., 2009)The National Carer’s Strategy outlines a number of policies to support carer health and wellbeing, including income supports, respite services, and enabling carers to maintain participation in employment or training. Security: Income and Financial securityThere is considerable evidence that older adults with fewer socioeconomic resources have worse health (Korda, Paige, Yiengprugsawan, Latz, & Friel, 2014). This includes a higher risk of multiple chronic conditions (Orueta & Nu?o-Solinís, 2013), greater functional impairment (McMunn, Nazroo, & Breeze, 2009), and worse disability at the same level of co-morbidity (Barbareschi, Sanderman, Kempen, & Ranchor, 2009). There are a number of pathways by which socioeconomic resources are likely to influence health (House, Lantz, & Herd, 2005; Taylor, 2010). Higher income is associated with better education, which in turn is associated with improved behavioural health. Financial resources are also important in themselves, particularly for slowing the increase in disability after onset. The link between income and happiness is less clear than the link between income and health. Overall, the evidence suggests that older adults with higher income or socioeconomic status also tend to report better subjective wellbeing or quality of life (Knesebeck, Wahrendorf, Hyde, & Siegrist, 2007; Pinquart & Sorensen, 2000), including in Ireland (Barrett et al., 2011). The effect of income on wellbeing tends to be strongly influenced by relativities - people tend to compare themselves with a particular reference group and be less satisfied with increases in income if others in their reference group receive a similar increase (Dorn, Fischer, Kirchg?ssner, & Sousa-Poza, 2007; Ferrer-i-Carbonell, 2005). In addition, extreme poverty or unemployment may be associated with markedly lower well-being (Argyle, 1999; Layte et al., 2013).It is likely that wellbeing is not influenced by income on its own – rather, higher income is associated with a range of positive outcomes that in turn affect wellbeing. For example, research with TILDA found social class, assets and income made no difference to quality of life once the effects of health, social relationships and mental health were accounted for (Layte et al., 2013). Income may become particularly important for wellbeing in adverse circumstances, such as poor physical health. For example, financial resources have been found to have a buffering effect on well-being against the detrimental effects of disability (D. M. Smith, Langa, Kabeto, & Ubel, 2011). This effect of wealth was strongest relatively soon after a new disability, and was fading by 2 years after the reported onset. On the other hand, people with a higher income may have greater expectations and standards for their health, leading them to evaluate their health as worse given a similar health status as someone on a lower income (Delpierre et al., 2012).There are several challenges associated with income-based measures of poverty and deprivation among older people specifically. Relative income-based measures of poverty rely on arbitrary divisions between poor and non-poor, particularly where the poverty line is located in a dense part of the income distribution. Material deprivation measures capture whether people can afford specific necessities. McKay (2008) noted that older people are less likely to disclose not being able to afford necessities but rather may report that they do not want them (McKay, 2008). Deprivation questions are not applicable to all groups in the population, or all age groups, life stages and circumstance and it is important to consider spending preferences and cognitive processes involved in answering questions about enforced lack of essential items (Berthoud, Blekesaune, & Hancock, 2006; Dominy & Kempson, 2006; Finch & Kemp, 2006).Health status, receiving help from others, and assets and savings should also be taken into account when measuring material deprivation among older people (McKay, 2008). Ill health, disability and mobility influence both living standards and deprivation and the associated between health status poverty and deprivation can vary depending on social and family characteristics, for example between those who are widowed and cohabiting couples (Berthound et al. 2006). The health status of partners is also important for household resources. Low levels of deprivation among older people on low incomes may be attributed to financial and non-financial help from others in the form of durable items, holidays, furniture, transport (car), and help with utility bills and food (McKay, 2008). Such support is not limited to older people and it remains to be seen whether such support is a response to poverty or just represents a level of expected reciprocity and cultural norm of typical exchanges between family members and friends.The life cycle view of saving suggests that savings reach a maximum for any individual around retirement and decline thereafter. Much empirical evidence on the finances of older people indicates that many older people continue to save despite being on low incomes which supports their ability to afford items (Finch and Kemp, 2006). Examples of policy interventions for financial securityPension policy, in terms of the balance of risks placed on the individual, the level of benefits, and the level of coverage, can have important effects on poverty and financial security in older adults.Non-pension benefits, such as the fuel allowance and the medical card, can help older adults to meet the costs associated with staying healthy in later life. Options for older adults to continue in paid employment after retirement age (e.g. flexible work place practices, gradual retirement) can contribute to financial security, as it reduces reliance on pension income. At the same time, it is important to ensure that older adults are not compelled to work where it has a detrimental effect on their physical or mental health (see section on employment and education, page 8). Security: HomeAs people grow older, they spend relatively more time in their homes; on average, very old people tend to spend 80% of their time at home (M. M. Baltes, Maas, Wilms, Borchelt, & Little, 1999).The conditions in which people live and the appropriateness of the home environment to the older person’s needs are therefore likely to have a big impact on their quality of life and health. Irish people in particular have a strong regard for being assisted to remain in their homes for as long as possible. A Eurobarometer report (2008) found that virtually all Irish people were in favour of using public budgets for support services allowing older people to stay longer in their homes - 76% felt that this was very important, compared with an EU average of 61% (Gallup Organization, 2008). Only 31% of Irish people would consider moving to a smaller house in retirement (compared to almost 60% of Danish people or 57% of Dutch people), while only 4.5% would consider moving to sheltered housing (compared to 40% of Slovenians or 24% of Austrians). Remaining in the same home as a person ages or “ageing-in-place” can have a number of positive benefits. For many people the home is a place that allows them to have control of everyday life (Rioux, 2005). For example, the familiarity with the interior of a house that develops over a lifetime living in the same home can play a significant part in helping to compensate for vision impairment or for the early stages of dementia (Boerner, 2004). Ageing in place can also support continued social contact and relationships with family, neighbours and friends. Remaining in the same community can contribute to wellbeing and quality of life by allowing people to maintain local friendships and ties, shop and obtain medical care in familiar places and rely on neighbours for emergency support. As families become more geographically dispersed, these community relationships may become more important for many older people (Wethington & Kavey, 2000).As people grow older they may become more attached to their own home and community, but that is also accompanied by increased sensitivity to the social and physical environment (Gilleard, Hyde, & Higgs, 2007). The benefits of staying home may therefore depend of the condition and quality of the home, which is an important determinant of physical and mental health (Thomson, Petticrew, & Morrison, 2001). Poor housing conditions (e.g., poor lighting and poor state of repair) are associated with increased risk of injuries or falls, and increasing disability over time (Garin et al., 2014). Older people are especially vulnerable to inadequate heating, and cold has been found to be a predictor of poorer respiratory symptoms and overall health status among older people (Garin et al., 2014; Windle, Burholt, & Edwards, 2006). Damp and mould has also been associated with higher rates of asthma and respiratory symptoms among people who spend a lot of time at home (Howden-Chapman, Crane, & Signal, 1999).Sixsmith et al highlight several challenges for older people remaining at home (A. Sixsmith & Sixsmith, 2008). These include the need for adaptations to the home; dependence on informal care which may not be adequately supported by the state; difficulties in getting around neighbourhoods with poor walkability and limited social support structures; and difficulties in accessing adequate formal care. In addition, adaptations may be perceived as intrusive or threatening to a person’s identity (J. Sixsmith et al., 2014). People may want their home to stay as it has always been, even if it is more difficult to live in. And in fact, those challenges (such as stairs) can be seen as important for maintaining physical and cognitive capacities. Home improvements therefore need to balance the symbolic meanings attached to home with practical considerations. It is also important to acknowledge that not all older people own their homes. Older adults who rent their home tend to report worse health and wellbeing relative to owner-occupiers, likely due to worse housing quality and poorer area-level characteristics (Connolly, 2012). Renters also have a higher risk of admission to long-term care compared with owner-occupiers, independent of wealth. Examples of policy interventions to support ageing in placeHome modifications to improve accessibility and usability (supported by home adaptation grants) can improve older adults sense of safety and control in their own home, while allowing them to remain in the same house for longer (Hwang, Cummings, Sixsmith, & Sixsmith, 2011). Assistive technologies (e.g. monitoring alarms or sensors) could play a role in helping older adults to stay at home longer. Evidence from a recent large-scale clinical trial found that telecare was associated with reduced emergency hospital admissions (Steventon et al., 2012), but not reduced admission to long-term care (Steventon et al., 2013). However, the follow-up time (12 months) may have been too short to capture any benefits for remaining at home.Security: Age-Friendly EnvironmentsAs people age, the distance they can conveniently travel reduces for a variety of reasons, such as slower driving and walking speeds, and increased use of slower modes of transport. Consequently, many older people spend a great deal of time in their local neighbourhood, shopping locally, using public facilities such as libraries and parks and participating in local social and recreation activities. Through the planning, designing and building of environments that are safe and accessible to older people, local authorities can support older people in continuing to live in their own homes and local communities. Satisfaction with the local area and neighbourhood quality have been identified as key determinants of wellbeing and quality of life among older people (Garin et al., 2014). Mobility in later life is an important influence on positive ageing, as it helps people to maintain control over their lives, and engage in valued and worthwhile activities outside of the home. A recent study from the US found that the extent of a person’s movement outside their home, neighbourhood and town was an important determinant of physical and mental health (Bentley et al., 2013). Walking is a low-cost, low-impact way of maintaining mobility which provides the added benefit of promoting good health and social connectivity for older people. However, environmental barriers such as distance, poor quality footpaths and lack of places to rest can reduce the walkability of an area. Current evidence suggest that older adults who live in areas with inadequate lighting, poor street conditions, heavy traffic and poor walkability are more likely to rate their own health as poorer, and report higher levels of disability (Garin et al., 2014). Traffic and safety from traffic have also been linked with wellbeing and quality of life (Garin et al., 2014). In Dublin, the time allocated by pedestrian crossing may also be problematic for older adults, who tend to have a lower average walking speed relative to younger adults (Romero-Ortuno, Cogan, Cunningham, & Kenny, 2009) On the positive side, availability and accessibility of local shopping areas, pedestrian areas and footpaths are linked to increased levels of activity (Michael, Green, & Farquhar, 2011). Access to driving is important for social inclusion and well-being: driving cessation is associated with increased risk of nursing home entry (Freeman, Gange, Mu?oz, & West, 2006) as well as lifestyle losses, including lower life satisfaction, reduced role engagement, and restricted activity patterns (Liddle & McKenna, 2003). In the future growing numbers of older people will want to continue to lead an active life and transport and mobility are key factors in facilitating active ageing (WHO, 2002). Public spaces that are attractive and have natural environments or natural elements can promote increased physical activity, opportunities for social engagement and increased well-being among users (Sugiyama, Thompson, & Alves, 2009; Sugiyama & Ward Thompson, 2007). Similarly, environments with poorer facilities and fewer or no recreational spaces are associated with a reduction in physical function in older people and lower levels of physical activity (Booth, Owen, Bauman, Clavisi, & Leslie, 2000).Accessing advice and information is an important part of creating an age-friendly community. Changing functional ability, including age-related impairments in sensory and cognitive function can act as a barrier to accessing information. Accessible information is therefore crucial to ensure older adults are aware of key services and opportunities for social and leisure activities. Information also plays a key role in the management of transitions associated with later life such as securing access to more suitable housing or accessing supports to allow them to continue to live autonomously, making decisions about their own lives as their needs change (Age UK, 2013). Examples of policy interventions for age-friendly environmentsLocal authorities and planners can make cities and towns more age-friendly by ensuring there are accessible green spaces, well-maintained public spaces (especially footpaths), adequate lighting and seating, services are close enough together to ensure walkability and sufficient pedestrian crossings. Transport authorities play an important role in ensuring that the areas in which older people live are served by frequent, accessible and affordable public transport. Voluntary transport schemes can be supported in areas where public transport is not feasible. Providers need to bear in mind the particular needs of older people by communicating information in a clear, digestible format, avoiding information overload, complexity and potential confusion. Security: Personal SafetyA feeling of safety when out and about or at home is a very important factor in sustaining independence and engagement. While all age groups need to feel safe in their own homes and neighbourhoods, there is some evidence that older people are more fearful for their own safety. This fear may be linked to the potential vulnerability of older people both within their own homes and in the surrounding environment. In particular, adults who are aged 80 and over tend to report greater feelings of unsafety relative to younger-old adults (aged 60-79) (de Donder, de Witte, Dury, Buffel, & Verté, 2012). Older people identify safety at home and in their neighbourhood as key elements of good quality of life (Gabriel & Bowling, 2004). Consistent with this, older adults who live in unsafe or deprived areas tend to report lower life satisfaction (Ferrer-i-Carbonell & Gowdy, 2007; Lelkes, 2006; Shields & Wheatley Price, 2005). Feelings of unsafety or fear of crime are more common among adults who live in areas with low social cohesion, or who feel that society is ageist, (de Donder et al., 2012; Schweitzer, Kim, & Mackin, 1999). Fear and loneliness can perpetuate each other – feeling unsafe may lead to increased social isolation, which in turn increases feelings of being unsafe (Jakobsson & Hallberg, 2005). In addition to fear of crime, older adults may be afraid to go outside for health reasons, particularly fear of falling. However, this fear may have a further negative effect on health, as evidence suggests that older adults who say that they are afraid to go outside are more likely to have increased difficulties walking 6 months later, compared with those who are not afraid (Rantakokko et al., 2009). Older adults who perceive their neighbourhoods as unsafe, particularly at night, tend to engage in less physical activity, regardless of socioeconomic status (Bennett et al., 2007; Tucker-Seeley, Subramanian, Li, & Sorensen, 2009). Elder abuse is increasingly recognised as a threat to the personal safety of older adults. The WHO has defined elder abuse as a“single or repeated act or lack of appropriate action occurring within any relationship where there is an expectation of trust, which causes harm or distress to an older person” (WHO 2002: 3). Mistreatment can be physical, psychological or sexual, or involve neglect. Estimates of the prevalence of elder abuse vary widely, from less than 1 in 100 in Spain one to 1 in 3 in Israel (Naughton et al., 2010). A recent survey in Ireland suggested that 2.2% or one in 45 adults aged 65 or over had experienced abuse in the previous 12 months (Naughton et al., 2010). This equates to just over 10,000 people. Women, the oldest-old, and older adults with poorer physical health appear to be more likely to experience abuse. Elder abuse can have severe psychological and physical consequences and often goes un-reported. Examples of policy interventions for safetyPolicies related to age-friendly environments and home modifications are likely to improve real and perceived physical safety among older adults. Burglary reduction initiatives (such as providing monitored attack alarms) have been found to be effective when targeted at groups of older adults identified as being at high risk of burglary (Phillipson & Scharf, 2004). Fear of crime can be combated by increased visibility of patrols and/or neighbourhood policing.The National Policy on Elder Abuse outlines a number of policies and procedures in the areas of prevention and risk management, including awareness raising, access to advocacy, staff training and a zero tolerance culture, risk assessment and information sharing. Ageism and Attitudes to AgeingAttitudes towards older people in society have clear and important implications for positive ageing. The presence of negative attitudes towards older people in a society can affect access to services and facilities, and can leave older adults feeling insecure, socially isolated and excluded. In addition, older adults may internalise negative stereotypes, resulting in older adults perceiving themselves more negatively as they age. For example, they may believe that ageing is a time of inevitable physical and mental decline, and that it is not possible to remain healthy and active. These types of negative self-perceptions can make older adults less likely to engage in health promoting behaviours (Yeom, 2013), and also lead to withdrawal from social activities. Such perceptions may even turn out to be a self-fulfilling prophecy, as people who perceive ageing as having negative consequences actually experience a sharper decline in physical function (Robertson, Savva, King-Kallimanis, & Kenny, 2015). Subjective Wellbeing Subjective wellbeing measures capture a person’s evaluation of their own life satisfaction, their experience of positive and negative emotions, and their sense of meaning and purpose in life. Throughout this section, evidence has been identified of how multiple factors, including social relationships, disability, the home and neighbourhood environments, financial security and physical security, can all influence a person’s subjective wellbeing. In order to fully capture positive ageing, we need to not only measure the life domains that are important for a person’s wellbeing, but also capture subjective wellbeing itself. In recent years, something of a consensus has emerged regarding the components which should be included when measuring subjective wellbeing. A recent OECD report concluded that there are three key components: 1) evaluation, which relates to life satisfaction, 2) experience, which relates to emotional wellbeing or mood and 3) eudaimonic, which incorporates purpose, autonomy and relations with others (OECD, 2013). This definition corresponds well to the Healthy Ireland definition of wellbeing as “positive mental health” (Department of Health 2013. p.9). Age itself is an important influence on wellbeing. Studies consistently find that subjective wellbeing increases with age, declining or staying constant from approximately age 70 (Blanchflower & Oswald, 2008; George, 2010; Jivraj, Nazroo, Vanhoutte, & Chandola, 2014; Netuveli, Wiggins, Hildon, Montgomery, & Blane, 2006).There has been considerable interest in the literature on what types of factors influence people’s subjective wellbeing (Diener, Inglehart, & Tay, 2012; Diener et al., 1999; Kahneman, Krueger, Schkade, Schwarz, & Stonr, 2004; Marks & Shah, 2005). Genetics are thought to be an important influence, particularly insofar as they shape a person’s temperament or personality. Life circumstances, including health and financial security, are also an important influence, although some suggest that they may explain only a small proportion of variance in life satisfaction (around 10%). Subjective wellbeing can also be influenced by how a person thinks or what they do, including intentional activities such as setting and achieving goals, having a sense of curiosity or willingness to learn new things (Kashdan et al, 2004) participating in activities that are enjoyable, engaging and challenging (Csikszentmihalyi, 1997). It is likely that effects of specific factors vary across different dimensions of wellbeing. For example, a person’s evaluation of their overall satisfaction with life may be influenced by life circumstances such as financial security, while their mood or emotional wellbeing may be more strongly influenced by personality and relationship quality (Kahneman et al., 2004). In addition, purpose in life may be enhanced by certain activities, such as care-giving or working, that are associated with reduced enjoyment or pleasure over the short-term (Dolan, 2014). There is some debate in the literature regarding the extent to which the effects of life circumstances on subjective wellbeing are only temporary, with happiness or life satisfaction returning to a given “set-point” after a certain time period (Diener, Lucas, & Scollon, 2006). As outlined above in relation to disability, there is strong evidence that people can and do adapt to adverse life circumstances (Oswald & Powdthavee, 2008). Research with the Australian Unity Wellbeing Index has shown that subjective well-being tends to be highly predictable and remains at a constant level. Adversity or challenges can make it fall or rise, but it normally returns to its set point (Cummins et al., 2010). However, adaptation is by no means inevitable, and is often incomplete (Diener, 2012). The same Australian research also identified a number of groups who are below the normal range, such as the unemployed, those living alone, those on low incomes and (especially) informal carers. This highlights that adaptation in itself is an important component of positive ageing. As outlined above in relation to health, there is increasing research interest in the concept of resilience in later life. Resilience can be viewed as a process, whereby outcomes of adverse circumstances are determined by the interplay of multiple factors relating to both the person themselves and their environment (Ong, Bergeman, & Boker, 2009; Smith & Hayslip, 2012). The effect of adverse conditions, such as poor health or bereavement, on subjective wellbeing may depend on a person’s personality or coping resources, but it may also depend on their access to contextual resources, such as family supports, income or decent living conditions. The importance of resilience processes again highlights the need to take a multi-dimensional approach to positive ageing. Finally, it is also important to note the increasing evidence that higher subjective wellbeing prospectively predicts better physical and cognitive health and function (Gerstorf et al., 2007; Howell, Kern, & Lyubomirsky, 2007; Palgi, Shrira, & Zaslavsky, 2015; Ryff, Friedman, Morozink, & Tsenkova, 2012; Steptoe, Oliveira, Demakakos, & Zaninotto, 2014). This suggests that subjective wellbeing is an important component of positive ageing in and of itself, but can also have a beneficial effect on other life domains. Monitoring Positive AgeingWellbeing as a measure of societal progressHistorically, measures of gross domestic product (GDP) have been used as the dominant indicator of societal progress. GDP is undoubtedly a useful indicator, and tends to be strongly correlated with key progress indicators such as life expectancy, mortality and literacy rates. Internationally, GDP is also strongly correlated with life satisfaction. However, it is also true that many developing country populations report high life satisfaction (e.g. Costa Rica). In addition, within developed countries such as Canada or the UK, life satisfaction has not increased at the same pace over time as GDP (Marks & Shah, 2005). There have thus been calls from a range of cross-national institutions, such as the European Commission and the OECD, to develop measures of societal progress that go “beyond GDP” (EU Commission, 2009). In 2008, international experts were commissioned by the French government to explore new approaches to measuring societal progress involving a “shift [of] emphasis from measuring economic production to measuring people’s well-being” (Stiglitz et al. 2009) (p. 12). The report of the Commission on the Measurement of Economic Performance and Social Progress offered a convincing critique of GDP as a measure of social progress, and offered a number of recommendations. In particular, the authors emphasised the importance of measuring multiple dimensions of wellbeing. This includes objective and subjective measures of multiple life domains, including material living standards, health, education, work, political participation, social connectedness, environment and security (economic and physical). Measures of wellbeing should not rely solely on peoples subjective evaluations, for example life satisfaction measures, but on their opportunities and capabilities, which are dependent on objective living conditions and factors such as health, participation and security. In recent years, there have been a number of initiatives internationally that have sought to identify indicators of societal wellbeing that are more comprehensive than GDP. Some constitute sets of indicators which are reported separately. Others are aggregated into an overall index. Some notable examples include:The Office of National Statistics (ONS) National Wellbeing programme: OECD How’s Life – Measuring Wellbeing: Social Progress Index: Canadian Wellbeing Index: Australian Unity Wellbeing Index: particularly relevant development for the Irish context is the steps that Northern Ireland have recently taken to develop a national framework for the measurement of wellbeing: wellbeing in older populationsAt the same time, international and regional institutions have been actively promoting the use of indicators to monitor particular groups in society such as older persons or children. Some examples of these indicator sets are outlined below, with the domains included in each set displayed in Table 1. Each set varies to some extent in the domains examined, generally depending on the overall purpose of the indicator set. For example, the UN’s Active Ageing Index is primarily focussed on measuring how active and productive older people are and the choice of indicators reflects that emphasis. In addition, different sets tend to examine similar domains but describe them differently. For example, all examine economic circumstances, but variably describe them as “Material wellbeing”, “Income and wealth” or “Economics”. Some are designed to monitor progress in the specific goals or policies contained within a strategy or plan; others are primarily for stimulating discussion and comparing wellbeing across countries and/or time. The Active Ageing Index The Active Ageing Index (AAI) is a project managed jointly by the European Commission's Directorate General for Employment, Social Affairs and Inclusion (DG EMPL), and the Population Unit of the United Nations Economic Commission for Europe (UNECE). It is intended for use as a tool for evidence-based policy making in dealing with the challenges of population ageing and its impacts on society in Europe. It produces an index which can be used to track and monitor active ageing in the EU as a whole, and to compare across EU states. Each state can be benchmarked against the EU average, and the best performing state. The emphasis is on the productive aspects of positive ageing: Employment, Participation in Society and Independent living; and the resources necessary to facilitate productivity: Capacity for active ageing (e.g. education, mental health). Global Agewatch Index Global Agewatch Index produces an index of quality of life and wellbeing in older adults in 96 countries. It aims to highlight both progress and shortcomings in how different countries are responding to the challenge of population ageing. It focuses on a small set of indicators for which there is relevant and comparable data across countries. Countries can be compared across each indicator, domain, and by total index ranking. For example, Ireland is ranked 17th out of 96 on the overall index, 20th on income security, 17th on health status, 34th on capability (which relates to employment and education) and 16th on enabling environments (which includes safety, transport and social connections). Older Americans Key Indicators of Wellbeing indicator set draws on multiple datasets which provide data on the wellbeing of older adults in the US population aged 65 and over. It is intended to facilitate discussions between policy makers and the public, and to encourage dialogue between those who produce the data and those who use it. A broad range of indicators is included, with the aim of maximising identification of areas in which wellbeing is improving, and those that require more attention and effort. NZ Positive Ageing Indicators New Zealand, the Office for Senior Citizens and the Ministry of Social Development developed the positive ageing indicators to monitor the implementation of the NZ Positive Ageing Strategy and to assess the level of well-being experienced by older people (Ministry of Social Development, 2007). This approach is the closest international example of the stated objective of the Irish National Positive Ageing Strategy. The indicator set is based on a large number of domains (34). Each indicator is compared over time and across groups, defined by, for example, age, sex, income level, and ethnic groups. WHO Core Indicators for Age-Friendly Cities WHO core indicators set is currently in development, with cities around the world piloting a draft set. The indicators are aimed primarily at monitoring the quality of urban environments, and to a lesser extent, rural environments. It is intended that regions or cities will be able to adapt or add to a final set of core indicators, depending on their own specific circumstances. These indicators will then help cities to monitor and evaluate progress in making their city “age-friendly”. This involves maximising inclusion and accessibility, and optimising opportunities for participation, health and security. This in turn will contribute to the quality of life and dignity of older adults. Madrid International Plan of Action on Ageing (MIPAA) Progress Indicators Madrid plan of action (2002) was a UN initiative which set out a series of key goals and objectives in relation to ageing populations. It was intended as a practical tool to aid policy makers internationally by identifying specific priorities that countries should focus on. The three priorities were development (which included participation and financial security), health and wellbeing and supportive environments. Within each priority, a series of detailed objectives and actions were specified. As part of the “Mainstreaming Ageing: Indicators to Monitor Implementation” (MA:MI) project, a set of indicators were identified to monitor progress in the implementation of MIPAA in the European region. The indicators were identified through consultation with experts at and between a series of meetings and workshops. SCL/PRB Index of Well-Being for Older Populations index was developed in Stanford University in the United States, with the objective of comparing wellbeing across the United States and a number of countries in Europe, using the harmonised Health and Retirement Survey (HRS) and the Survey of Health, Ageing and Retirement in Europe (SHARE). The cross-national comparative approach was intended to facilitate investigation of how specific policy contexts shape wellbeing outcomes in later life. Values on a Grey Scale – Elderly Policy Monitor (The Netherlands – 2008) Elderly Policy Monitor was developed with the aim of tracking progress in the achievement of targets in relation to specific policy objectives identified by the Dutch government. The targets were in the following areas: health, contribution to society, purchasing power, mobility, housing, care dependency and end of life. The monitor measures progress against very specific targets, for example, for 45% of adults aged 65 and over to meet the recommended levels of physical activity. The monitor indicates whether the target has been achieved, the longer term trend (e.g. rising or falling) and any population sub-groups where the target has not been met (e.g. ethnic minorities, low income groups). Table 1 displays a comparison of the domains included in each of these indices or indicator sets. A detailed comparison with information on the specific indicators is displayed in the Appendix on page 28. Almost all indicators sets include the following indicators:Poverty or deprivationLife expectancy or Healthy life expectancyLabour force participation or employmentVolunteering Participation in cultural or social activitiesAccess to transportPhysical activityOther commonly included indicators include educational attainment, current participation in education, provision of informal care, depression or anxiety, life satisfaction, access to health or social care, perceived safety and use of the internet. A large number of indicators are included in only one or two indicator sets: for example, chronic disease, sensory impairments, falls, use of healthcare services, end-of-life care and housing tenure. Many indicator sets also provide certain contextual indicators, for example in relation to current and projected demographic structure. These are sometimes included within the indicator set, and sometimes reported alongside it.ConclusionPositive ageing is not determined by outcomes in a single life domain. Rather, positive ageing is multi-dimensional, and relates to outcomes in the areas of social participation, education and employment, health, housing, the built environment, financial security and subjective wellbeing. Achieving a positive outcome in one area is likely to have further benefits for other areas. For example, improving the walkability of a neighbourhood can enhance participation and physical activity, which in turn improve physical and mental health, and subjective wellbeing. In addition, positive ageing does not require optimal outcomes across all domains. For example, an older adult may have a poor physical function and multiple chronic conditions, but nevertheless have high levels of social participation and positive mental health. This highlights the importance of a multi-dimensional approach to measuring positive ageing. Internationally, there have been a number of initiatives to develop indicator sets or indices to track progress in positive ageing. All initiatives vary in how positive ageing is defined, and in precisely which indicators are measured. However, all include indicators of physical and mental health; social relationships and participation; and material circumstances, with most including at least some indicators related to safety and the built environment. The choice of indicators in each set tends to reflect both the evidence in relation to what is important for positive ageing, but also the specific values or policy priorities of the country or region in question. Table 1: Comparison of International Indicator SetsNameActive Ageing IndexGlobal Agewatch Index Older Americans Key Indicators of WellbeingNZ Positive Ageing IndicatorsWHO Global Age Friendly Cities (Indicator set in development)MA:MI progress indicatrsSCL/PRB Index of Well-Being for Older PopulationsThe Netherlands - Values on a Grey Scale Overall index?aYYNNNNYNNo. of domains44694448No. of indicators2213373416251214DomainsEmploymentParticipation in SocietyIndependent, healthy and secure living Capacity for active ageingIncomeHealthCapabilityEnabling EnvironmentPopulation EconomicsHealth statusHealth risks and behavioursHealth careEnd of LifeHealthHousingTransportLiving in the CommunityMaori Cultural IdentityAccess to Facilities and ServicesAttitudesEmploymentOpportunitiesPhysical environmentSocial environmentEquity Impact on wellbeingDemographic Indicators and Health expectancy Income and wealthLabour market participationSocial protection and financial sustainability Material WellbeingPhysical WellbeingSocial WellbeingEmotional WellbeingPaid work Unpaid workIncomeMobilityHousingHealth CareDying with dignityaCan the indicators be used to calculate either a domain-level or overall index of positive ageing? Appendix: Detailed Comparison of Indicator SetsHaPAI long-listSCL/PRB Index of WellBeing for Older PopulationsThe Netherlands - Values on a Grey Scale Active Ageing IndexWHO Global Age Friendly Cities MIPAA progress indicatorsGlobal Agewatch IndexOlder Americans Key Indicators of WellbeingNZ Positive Ageing IndicatorsDemographicsNumber and % of population above a specific age (e.g. aged 60+; 65+)XXPopulation projectionsXXDependency ratioXEthnic compositionXParticipationEmployment & RetirementLabour force participationXXXXXEmployment rateXXXXXXPart-time work post-retirementXAverage hourly earningsXReasons for early retirementXMandatory retirement ageXFlexible retirement corridorsXProtection laws against forced retirementXAge differential in statutory retirement ageXHaPAI long-listSCL/PRB Index of WellBeing for Older PopulationsThe Netherlands - Values on a Grey Scale Active Ageing IndexWHO Global Age Friendly Cities MIPAA progress indicatorsGlobal Agewatch IndexOlder Americans Key Indicators of WellbeingNZ Positive Ageing IndicatorsEducation & Lifelong learningLiteracy and numeracyXEducational attainmentXXXXCurrent participation in education (formal and informal) XXXXActive Citizenship & VolunteeringProvision of informal care XXXXVotingXParticipation in politics/decision makingXXXParticipation in community organisationsXXVolunteeringXXXXXSocial and Cultural ParticipationLiving arrangements XXXRelationships with childrenXXFrequency of contact with relatives/friends/colleaguesXXParticipation in cultural activitiesXXXXXParticipation in social activitiesXXSocial IntegrationXHaPAI long-listSCL/PRB Index of WellBeing for Older PopulationsThe Netherlands - Values on a Grey Scale Active Ageing IndexWHO Global Age Friendly Cities MIPAA progress indicatorsGlobal Agewatch IndexOlder Americans Key Indicators of WellbeingNZ Positive Ageing IndicatorsCultural identity of ethnic minoritiesXSocial supportXXSocial cohesion – e.g. trust in others, sense of communityXXAccess to transport XXXXXTime use (e.g. time spent each day doing selected activities)XHealthPhysical HealthLife ExpectancyXXXXXXXHealthy Life ExpectancyXXXXXMortalityXMorbidity (chronic disease)XXSensory ImpairmentsXXOral healthXSelf-rated healthXXXLimitations in Basic/Instrumental Activities of daily livingXXXLimitations in basic physical activitiesXXXHaPAI long-listSCL/PRB Index of WellBeing for Older PopulationsThe Netherlands - Values on a Grey Scale Active Ageing IndexWHO Global Age Friendly Cities MIPAA progress indicatorsGlobal Agewatch IndexOlder Americans Key Indicators of WellbeingNZ Positive Ageing IndicatorsChronic PainFrailtyXFallsXXXCognitive HealthPrevalence of dementiaMild cognitive impairmentIntellectual disabilityMental HealthDepression/Anxiety/Emotional wellbeingXXXXSuicide RateXLife satisfactionXXXXPurpose or meaning in lifeXXFreedom or autonomy in lifeXXLonelinessXXXHealth-related quality of life XHealth BehavioursPhysical activityXXXXXAlcoholXSmokingXXXHaPAI long-listSCL/PRB Index of WellBeing for Older PopulationsThe Netherlands - Values on a Grey Scale Active Ageing IndexWHO Global Age Friendly Cities MIPAA progress indicatorsGlobal Agewatch IndexOlder Americans Key Indicators of WellbeingNZ Positive Ageing IndicatorsDiet/NutritionXObesityXXXDifficulty taking medicationsXHealth CareUse of preventative services (e.g. vaccination, cancer screening)XXXUse of healthcare services (e.g. inpatient care, primary care)XXUse of prescription drugsXXUse of assistive equipmentXXUse of personal careXXHealthcare costsXHealth insurance coverageXAccess to health and social care services (e.g. unmet need)XXXXSatisfaction with healthcareXUse of long term careXXNursing homes meeting quality standardsXQuality and appropriateness of long term careXXHaPAI long-listSCL/PRB Index of WellBeing for Older PopulationsThe Netherlands - Values on a Grey Scale Active Ageing IndexWHO Global Age Friendly Cities MIPAA progress indicatorsGlobal Agewatch IndexOlder Americans Key Indicators of WellbeingNZ Positive Ageing IndicatorsWaiting listsXEnd of life careXXPolypharmacyXSecurityFinancial SecuritySources of incomeXXXMean/median income or disposable incomeXXXXPoverty/deprivation XXXXXXXXXRelative welfareXXHousehold expenditureX% of older population covered by a pension / other income supportXXXMean Assets/WealthXGDP per capitaXPublic pension spending as % of GDPXSystem dependency ratio in public pension schemesXPension take-up ratioXPublic pension benefit ratioXHaPAI long-listSCL/PRB Index of WellBeing for Older PopulationsThe Netherlands - Values on a Grey Scale Active Ageing IndexWHO Global Age Friendly Cities MIPAA progress indicatorsGlobal Agewatch IndexOlder Americans Key Indicators of WellbeingNZ Positive Ageing IndicatorsReceipt of disability benefitXPerceived social position of older adultsXSafetyPerceived safety at home or in the neighbourhoodXXXXExperience of crimeXElder abuseBuilt EnvironmentHousing tenureXXHousing suitability (e.g. stairs)XXHousing conditionsXXXHousing affordabilityXXXUse of aids and appliancesXAir qualityXAccess to public buildings and services (e.g. bank, shops)XXXAccess to green spacesXXXWalkabilityXNeighbourhood quality (e.g. litter)XHaPAI long-listSCL/PRB Index of WellBeing for Older PopulationsThe Netherlands - Values on a Grey Scale Active Ageing IndexWHO Global Age Friendly Cities MIPAA progress indicatorsGlobal Agewatch IndexOlder Americans Key Indicators of WellbeingNZ Positive Ageing IndicatorsInformationUse of and access to ICT XXXXAvailability of informationXXHealth literacyXAgeismPerceived age discrimination/attitudes to older peopleXXXAgeing perceptionsXEquity/Inequality (e.g. variation in outcomes across groups)XReferencesAge UK. 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