Summer 2005
Featured Article

The Public Health Perspective on Aging

By Steven P. Wallace, guest editor

The number of older people in the United States will double in the next thirty years. The public discussion about this growing number of elders often focuses on the increased demand they will create for retirement income as well as for health and social services. Health issues play a particularly important role in these discussions because healthcare is a major cost in governmental budgets and because good health is a priority for everyone.

The discipline of public health contributes to this discussion from a unique perspective. Public health is dedicated to promoting the conditions under which people can be healthy (Institute of Medicine, 2002). Three key elements characterize public health efforts: an emphasis on health rather than disease, a proactive rather than reactive approach, and a focus on the population rather than the individual. Each of these elements contributes to the unique approach of public health to the issue of health and aging. In addition, the "public" aspect of public health means that its programs and policies are designed to address the collective good, whether or not they contribute to the private gains of any particular individual person or entity.

A Health Emphasis

In January 2000, the U.S. Department of Health and Human Services established updated national guidelines for health promotion and disease prevention. One of the guidelines' two goals is "extending the years of healthy life," a concept that embodies both physical and mental health within a physical and social context (U.S. Department of Health and Human Services, 2000, p.10). For over fifty years the World Health Organization has defined health as more than the absence of disease, but rather encompassing the physical, mental, and social well-being of populations. For older people in particular, the issue of health includes the element of physical function, but also encompasses social and psychological issues (see Damron-Rodriguez et al., this issue).

The philosophy that underlies most public health activities is that all people have a right to health and that everyone in a society benefits when its members are healthy. As a public good, the health of the public is the collective responsibility of our public institutions, especially government. Many public health measures require collaboration among various sectors of the society (see Lang et al., this issue), and many have requirements that are not adequately met by the marketplace.

For example, a large social benefit in the form of improved health and function comes from promoting exercise among older people, but no private company profits if older adults walk around their neighborhood every morning. Drug companies have well-funded marketing machines to promote the latest medications for diabetes, but no company runs ads or hosts physician conferences at resorts to teach about the research that shows that diet and exercise can be more effective than medications in preventing diabetes (Knowler et al., 2002). The approach to public health as a social good also underlies the field's characteristic concern with equitable access to healthcare and the conditions necessary for health, as well as the interest in promoting the quality of services that people of all ages receive.

A Proactive Approach

Public health takes a proactive rather than a reactive stance. It fosters good health and anticipates challenges to health, rather than waiting for a problem to occur and then working to fix or cure it. As part of this proactive approach, public health distinguishes three different levels of health promotion and disease prevention -- primary, secondary, and tertiary.

Primary prevention refers to efforts to prevent health problems from occurring in healthy people. Public health's roots are in the so-called sanitary movements of the nineteenth century, which included efforts to create safe sewage disposal, reduce overcrowded housing, pasteurize milk, and otherwise keep disease from spreading.

Contemporary examples of primary prevention include influenza immunizations, promoting healthy diets and exercise (see Hughes et al., this issue), restricting smoking in public, and mandating use of seatbelts in automobiles. Concern about the physical environment remains a public health issue. Aspects that affect older people in particular include reducing air pollution, which is associated with respiratory problems, and creating programs to reduce deaths from heat waves, which primarily affect the elderly (see Sykes et al., this issue). Since public health also encompasses the organization and financing of health services, primary prevention also includes organizational designs that reduce medical mistakes and promote culturally competent healthcare organizations to improve the quality of care (see Goins et al., this issue).

Secondary prevention refers to proactive efforts to detect health problems early so that they can be treated before they cause more serious health consequences. A common example is hypertension screening and treatment that reduce the risk of heart disease, stroke, and renal failure. In this realm, public health works in three ways: first, to encourage older people to seek screening, second, to develop ways to improve the response of the healthcare system to treat those with hypertension, and, third, to design communities in ways that make healthcare more accessible.

Tertiary prevention is the proactive effort to maximize the health of people who already have disabilities and other health problems. For older people tertiary prevention typically includes efforts to maintain the independence of a functionally impaired person. Programs that provide caregiver support would also be considered tertiary prevention, since the intervention is not to treat the cause of the stress (in this case, caregiving), but to maximize the quality of life of the caregiver. Similarly, self-management techniques for people with chronic diseases are meant to improve their quality of life (see Lang et al., this issue). Another example is promotion of palliative care to maximize the quality of the end of life (see Miller et al., this issue).

A Population Approach

A population approach uses interventions that address the health of groups of people by changing the conditions they live in, rather than trying to change one person at a time. Many examples show how focusing on the community or the environment to solve a health problem is more effective than focusing on the individual. For example, it would be more effective to prevent "heat islands" from forming in cities by planting trees and using reflective roofing at a community level (see Sykes et al., this issue)than to only provide information to individual elders about how to prevent heat stroke.

From a public health perspective, educational interventions tend to take a mass media or other collective approach (see Levy-Storms, this issue), rather than counseling individuals only. Some of the most effective public health interventions affect the entire population in ways that do not even require their conscious participation; fluoridating water to reduce tooth decay is a well-known example. Changing voluntary health-related behaviors like choice of diet and physical activity has become a major public health focus in recent years. While changes in diet and physical activity of course can be prompted by persuading individuals to modify their habits, the most effective interventions are when those behaviors become normative for groups of people, and the environmental conditions support those changes. Examples of such interventions are increasing the availability of low-cost fresh fruits and vegetables or increasing access to safe parks where people can exercise.

In the realm of public policy, a population approach focuses on the conditions, or community-level factors, under which older people can be healthy. A report by the Institute of Medicine (2005) notes that the fear of crime and weak social support networks kept many elders indoors and isolated during the 1995 heat wave in Chicago, contributing to a high number of heat-related deaths. The report explains that older people are particularly sensitive to the built environment within which they live.

Public Health Strategies

Public health interventions work through groups of individuals, institutions, and the social system. Groups of individuals are typically targeted by educational approaches to promoting health, whether it is education about reducing risk factors (primary prevention, e.g., Hughes et al., this issue) or education about the early signs of disease that merit attention. Public health has learned from successful strategies in commercial marketing and applied them in efforts to change attitudes and behavior. Public health therefore uses "social marketing" to increase public demand for pneumonia shots, mammograms, and available fresh fruits and vegetables, and to decrease public demand for tobacco.

Institutional practices that reflect a public health approach include programs that track health and illness patterns so that resources can be directed appropriately. In hospitals, public health monitors the quality of care so that outcomes can be improved. In some cases, public health promotes the formation of new programs to enhance the health and independence of older people. Developing hospices is one example (see Miller et al., this issue). Some public health research also identifies ways to improve the efficacy and coverage of existing programs that promote elder health (see Evashwick and Ory, and Palumbo et al., this issue). The public health system monitors communicable and chronic illnesses as well as injury in the community so that the right influenza vaccine is prepared, injury rates can be tracked, and the risk factors for major health conditions are identified and reduced (see Albert, and Stevens et al., this issue).

Public health interventions at the societal level primarily occur through government actions. Some interventions have been sparked by grassroots social movements that have worked to influence public laws. Examples are efforts to restrict secondhand smoke and to pass laws reflecting other environmental concerns. Other societal interventions have primarily been driven by professionals and advocacy groups through efforts to shape public laws, such as those that regulate the safety and efficacy of medications, fund healthcare and social services, and pay for health-related research. It is difficult to envision a working public health system and effective public health interventions that do not depend upon a central role for government, yet this circumstance makes it challenging for public health to work well during periods of tax cuts and the resulting governmental budget reductions.

The following public health and aging topics illustrate the key elements of a public health approach to aging laid out above. The first two topics, healthy aging and urinary incontinence, are concerns that are amenable to programs targeting groups of individuals, institutions, and society. The second two, aging-friendly communities and health equity, are concerns that only exist at the collective level and demonstrate why public health includes system-change goals when working in the area of health and aging.

Promoting Healthy Aging

Rowe and Kahn (1997) have identified three aspects of healthy aging: physical health, mental health, and an engagement with life. Damron-Rodriguez and colleagues (this issue) found similar domains in their focus groups with a diverse population of older people, and Lang and colleagues (this issue) describe how the federal agency responsible for public health programs (Centers for Disease Control and Prevention [CDC]) promotes healthy aging. The dimension of being engaged with life, however, merits additional discussion as part of a public health approach to healthy aging. Engagement with life is more than the passive, individualized consumption involved in sitting in front of a television day in and day out. Engagement with life could come from close relationships with family members, active participation in religion or politics, or any other relationship with the world.

There are many ways to promote later-life engagement with the world. Senior centers, lifelong learning programs (like Oasis [www.oasisnet.org] and Elderhostel [www.elderhostel.org]), and recreational opportunities promote social engagement, as do organized activities that promote the engagement of older people in the larger community. The senior leadership program described by Romero and Minkler (this issue) exemplifies an intervention that supports the work of older people who are leading projects in their communities, benefiting both the older person and the community. These programs are aimed at groups of individuals.

Institutional changes that promote social ties and an engagement with life include designing transportation systems so that older people retain the flexibility they require to get to shops, friends' houses, and other places in addition to the doctor's office. At the social-system level, policies can support intergenerational families by such means as zoning changes that allow "granny flats" in single-family neighborhoods so that older people can live independently and still be near their relatives. The age discrimination act that barred mandatory retirement has allowed people who are engaged in their work to continue in that activity. These policies foster the conditions that allow older people to remain engaged with life, and thus they promote healthy aging.

When promoting high levels of physical, mental, and social capacity, it is important to realize that those with lower levels of capacity can also be healthy. Many older people with multiple chronic conditions report that they have "excellent" health, indicating that they see themselves as doing well despite the presence of disease or disability. For those individuals, assistive devices such as hearing aids or physical therapy to reduce pain may be what they need to continue to lead a "healthy" life.

Reducing Urinary Incontinence

Urinary incontinence (UI) is one health problem addressed by clinical medicine that would benefit from a public health approach. UI does not receive much public health attention because it is not a potentially fatal condition like heart disease or a physically disabling condition like osteoporosis. But UI significantly reduces an older person's quality of life, contributes to social isolation, and in combination with other disabilities can increase the risk of the person's being placed in an institution. The interest of public health in health, prevention, and populations is particularly useful for addressing the problem of UI.

The prevalence of UI increases with age and is more common among women. Approximately 28 percent of women ages 65-74 and 40 percent age 75 and older have experienced incontinence in the past year; men's rates are about half as high. UI is highly stigmatized and is not adequately diagnosed or treated. In one study, only one-third of older patients with current UI reported that their primary care doctor had talked with them about it in the past year.

The most common approach to UI is using disposable adult undergarments. Use of adult diapers deals with the symptom rather than the cause, is stigmatizing, and contributes to the solid waste landfill problems of many communities. Of the almost 3.5 million tons of disposable diapers ending up in municipal waste streams every year, as much as one million tons is from adult incontinence products. Thus UI is an environmental problem in addition to a problem for older people.

A public health approach to UI from the public sector is likely to address the needs of older people in a way that is better than the current efforts of the medical system or the consumer-products industry. At the individual level, low-cost treatments can reduce or eliminate the incontinence suffered by many older adults. Clinical trials have found that behavioral modifications or pelvic-floor exercises that increase sphincter control are more effective than medications for treating incontinence (Burgio et al., 1998). These approaches are secondary prevention because they would identify and treat a condition before it had caused significant harm. At an institutional level, changes could be made in primary medical care protocols to increase the rates at which physicians discuss incontinence with their older patients. But physician education alone has not proven to change diagnosis and treatment rates of UI.

Many older people erroneously see incontinence as a "normal" and untreatable part of aging. A national campaign to diagnose and treat incontinence, such as has occurred with breast cancer screening, could be effective in raising awareness and treatment of the condition. Eliminating incontinence when possible rather than simply expecting people to use adult diapers and live with it would improve the quality of life of many older people and would reduce landfill use.

Developing Aging-Friendly Communities

Developing aging-friendly communities is clearly within public health's mandate to "foster the conditions under which people can be healthy." While some people move to age-segregated environments in later life, the majority grow old where they lived earlier. The ability of older people to "age in place" in good health is shaped by the neighborhoods and communities within which they live.

A growing body of research links the neighborhood context to the health of its residents. Community-level factors affect the resident's health, including the quality of housing, environmental quality, concentrated poverty, and closeness to stores and services. Neighborhood social relationships and norms, sometimes conceptualized as "social capital," are also related to health. Social capital is more than social support, since social capital includes norms of trust and reciprocity, the community's approach to inequality and human needs, and the community's support of healthful and engaging activities.

There is a common set of community characteristics that older people identify as important elements of an aging-friendly community (Feldman and Oberlink, 2003, also www.vnsny.org/advantage). Basic needs include housing, safety, adequate nutrition, and information. Optimizing physical health includes factors that promote healthy behaviors, access to preventive services, and access to medical services. Independence requires adequate transportation, caregiver support, and other community supports. And finally, civic engagement provides opportunities for developing meaningful connections with others in the community, and a community that prioritizes aging issues.

City and regional interventions can enhance the age-friendliness of communities. Zoning laws dictate housing construction and can foster more concentrated, mixed-use, and transit-rich areas. Universal design standards mandate barrier-free housing. Elements of universal design include minimizing steps, reinforcing bathroom walls for future installation of grab bars, a bedroom and full bath on the first floor, and making doorways wide enough for wheelchairs.

Zoning laws and public agencies also structure the quantity and quality of outdoor space for physical activity and the availability of programs for lifelong learning and engagement. And safe neighborhoods, well maintained sidewalks, and adequate lighting in public places are health-promoting for people of all ages.

Health Equity

The concern for population-level health makes equity key to a public health approach. Since older people have the highest rates of illness and the highest use of medical care, equity is particularly important for them. In addition, older people who have suffered throughout their lives in unfavorable social and economic contexts will bear a cumulative burden that will affect their health and well-being in later life (Estes and Wallace, 2005).

The World Health Organization's (2000) criteria for healthcare systems give equity in the distribution of services the same weight as the economic efficiency of the system. The organization evaluates health systems according to equity in health outcomes (mortality, disease), financing, and responsiveness (treating patients with dignity and respecting their autonomy).

Equitable systems of care should have minimal differences between the care received by rich and poor elders, elders of color and white elders, and older men and older women. Public health systems provide the surveillance data that allow us to monitor equity by collecting data on income, race, and gender (see Albert, this issue). Public health offers solutions to disparities in health status and healthcare, and public health promotes community organizing and policy development to enact the solutions to those inequities. Goins and Spencer (this issue) provide a public health perspective on causes and solutions to the inequities faced by American Indian elders, in particular.

Conclusion

Public health, with a mission of fostering the conditions under which people can be healthy, brings unique perspectives and tools to the issue of health and aging. If we are to add life to years, not just years to life, we need to include the goals of promoting the health of and preventing disease and disability among the older population. Achieving these goals requires collective efforts that focus on groups of individuals, institutions, and the society as a whole. When public health networks collaborate with aging networks on these issues we are most likely to see effective strategies developed and implemented. This issue of Generations describes concerns for which a public health and aging perspective can be particularly effective, identifies the knowledge and skills needed, and offers suggestions for interventions that will improve health and aging.

REFERENCES

Burgio, K. L., et al. 1998. "Behavioral vs. Drug Treatment for Urge Urinary Incontinence in Older Women: A Randomized Controlled Trial." Journal of the American Medical Association 280(23): 1995-2000.

Estes, C. L., and Wallace, S. P. 2005. "Older People." In B. S. Levy and V. W. Sidel, eds., Social Injustice and Public Health, pp. 113-129. New York: Oxford University Press.

Feldman, P. H., and Oberlink, M. R. 2003. "Developing Community Indicators to Promote the Health and Well-Being of Older People." Family and Community Health 26(4): 268-74.

Institute of Medicine. 2002. The Future of the Public's Health in the 21st Century. Washington, D.C.: National Academy Press.

Institute of Medicine. 2005. Does the Built Environment Influence Physical Activity? Special Report 282. Transportation Research Board. Washington, D.C.: National Academy Press.

Knowler, W. C., et al. 2002. "Reduction in the Incidence of Type 2 Diabetes with Lifestyle Intervention or Metformin." The New England Journal of Medicine 346(6): 393-403.

Rowe, J. W., and Kahn, R. L. 1997. "Successful Aging." Gerontologist 37(4): 433-40.

U.S. Department of Health and Human Services. 2000. Healthy People 2010 .Washington, D.C.: U.S. Government Printing Office. http://www.healthypeople.gov.

World Health Organization. 2000. The World Health Report 2000: Health Systems, Improving Performance. Geneva: World Health Organization. http://www.who.int/whr/2000/en/index.html.

From Generations Summer 2005 issue, 29(2): 5-10. © 2005 American Society on Aging

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