Review of Wellbeing Indicators



Conceptual Framework: definition of termsThe purpose of this document is to define key terms used in the Healthy and Positive Ageing Initiative (HaPAI) National Indicators Project project. These terms include: Positive Ageing, Ageing, Healthy, Wellbeing and Quality of Life, Life course and Indicator.Positive Ageing A 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” (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 National Positive Ageing Strategy (Government of Ireland, 2013) 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. AgeingAgeing 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 on Ageing (TILDA) and the Survey of Health, Ageing and Retirement in Europe (SHARE) collect data from adults aged 50 and over. HealthHealth 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).WellbeingWellbeing 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 LifeThe 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. Life CourseIn 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). IndicatorThe 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” (WHO, 2004, p.78).ReferencesAssociation of Public Health Observatories. (2008). The Good Indicators Guide: Understanding how to use and choose indicators. NHS Institute for Innovation and Improvement.Baltes, M., & Carstensen, L. (1996). The Process of Successful Ageing. 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Well-being, agency and freedom: the Dewey lectures 1984. Journal of Philosophy 82 (4), 169–221.Sen, A., 1985b. Commodities and Capabilities. Amsterdam, North-Holland.Sen, A., 1999. Development as Freedom. OUP, Oxford.SNIPH. (2007). Healthy ageing: A Challenge for Europe. Retrieved from Ageing - A Challenge for Europe.pdfStiglitz, J., Sen, A., & Fitoussi, J.-P. (2009). Report by the Commission on the Measurement of Economic Performance and Social Progress (2009). SSRN Electronic Journal.WHOQOL Group. (1997). Programme on Mental Health. WHOQOL Measuring Quality of Life. Geneva.World Health Organisation. (2002). Active Ageing: A Policy Framework. Retrieved from Health Organisation Centre for Health Development. (2004). Glossary of Terms for Community Health Care and Services for Older Persons. Kobe, Japan: World Health Organisation Centre for Health Development. Retrieved from ................
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