AUSTRALIAN RESEARCH ON AGEING, FAMILIES, AND HEALTH PROMOTION.

Wells, Yvonne

INTRODUCTION

Both health promotion programmes and gerontology research are beginning to recognise the potential for improving the health of older people (Kane et al. 1990). Too often, one finds that this promising view of old age comes into conflict with a view that health promotion should invest mainly in young people. Shortsighted positions on either side of such debate ignore the fact that the old today were the young of yesterday, and the young of today are the old of tomorrow. Generations and cohorts are strongly bound by a sense of common fate and mutual concern fostered mainly through family relationships.

Central concepts in gerontology provide sound bases for research to address these issues. It is increasingly recognised that the situations of older people

reflect their life-long experiences as well as biological ageing; differences between the young and the old also arise from living formative years of one's life in different periods of history (Binstock and George 1996). There also is recognition of the diversity and strength of family relationships and the ongoing importance of inter-generational ties in many spheres of life (Kendig and Brooke 1997). These observations apply with particular force to the expanding knowledge on social aspects of the health of older people.

This paper presents findings from two studies from an Australian research programme which has aimed to provide a knowledge base for public action promoting the health and well-being of older people.(1) One study, Healthy and Independent Lives in Old Age, is a qualitative investigation (Kendig and Walker-Birckhead forthcoming).(2) The other study, the Health Status of Older People study, is a longitudinal survey of 1000 older people in Melbourne (Kendig et al. 1996).(3) The research parallels studies overseas, for example, work on ageing, health and behaviour sponsored by the US National Institute on Aging (Ory 1991; Abeles et al. 1994). A critical review of the international literature formed the first stage of our investigation (Teshuva et al. 1994).

OLDER PEOPLE'S VIEWS ON HEALTH AND THEIR LIFE HISTORIES -- THE HEALTHY AND INDEPENDENT LIVES STUDY

Relatively little attention has been given to the health histories of individuals entering old age, and ways in which they may continue or modify their health actions with advancing age. Yet understanding older people's own health perceptions and goals is essential for addressing issues which are significant and make sense to them. Of the many influences on health and well-being, potentially one of the most important is the sense of meaning in one's life (Antonovsky 1989).

An early Australian qualitative study (Job 1984) has provided valuable insights into the life histories of people who were born before the turn of the Century and who lived into their eighties. Health attitudes and beliefs formed in childhood were found to persist through later life. From parents and other close relatives they had learned the precariousness of life, the importance of hygiene and healthy eating, the limits of medicine and, perhaps most of all, an acceptance of illness, disability and death. Few children of the 1890s had much exposure to older relatives; many of their grandparents had either died before reaching old age or else had not migrated to Australia. Among this cohort of older survivors, interviewed nearly twenty years ago, relatively more men reported good health while more women reported feeling powerless to change events.

The "Healthy and Independent Lives in Old Age" study (Kendig and Walker-Birckhead forthcoming) provides qualitative research on the next cohort of older people. The Healthy Lives study was based on in-depth interviews with 60 informants from Melbourne and the Wodonga region (a provincial city and its rural hinterland approximately 200 kilometres north of Melbourne). Most of the older informants (65 years and older) had passed through childhood during the 1920s. While Job viewed health largely from a disease or illness paradigm, the Healthy Lives study was funded through a "Health and Well-being" research programme designed to inform health promotion and community development. The multi-disciplinary research team included an anthropologist, an occupational therapist, a nurse, several psychologists, and a social gerontologist.

The cohort in the Healthy Lives study had reached old age a full generation after those in Job's study, and most of these people were in their sixties or seventies at the time of interview in the early 1990s. The historical background, of course, was inseparable from the accounts of their individual lives. They were profoundly affected by living as children and then young adults during the Depression and World War II. They had been "toughened up", knew how to "keep going", and maintained a stoical and self-sufficient approach to their health (Stacey in press).

Childhood Experiences

The Healthy Lives study found that older people had developed "health identities" in which they sought continuity of meaningful activities, independence and well-being (Kendig et al. 1993). These identities emerged in childhood, and early health experiences set frameworks for interpreting health later in life. Family and other close personal bonds were central in forming and continuing health-related expectations and actions.

Personal meanings of health could be traced back to individuals' childhood experiences with their own or their parents' illnesses. What would seem to be decidedly negative factors could generate adaptive capacities rather than "sick" identities. One woman, who in childhood experienced chronic anaemia and her mother's early death, thereafter "looked after" herself because of her "weakness". She was trusting of doctors when cancer threatened in old age.

One man illustrates complexity in dealing with health and illness. As a child he had rheumatic fever and a heart murmur, and a father who was an outstanding sportsman. His doctor said, "you can cuddle yourself up and become a permanent invalid" or "you can go out and play sport and forget about it". The boy's determination to "never worry and play sport" sustained his active life. Through adulthood he was alternately careful with health or denying of symptoms. He and his fiancee visited a doctor to make sure that they were "compatible" before marriage. But in late middle age he went to the doctor for his skin cancers "too late ... it was my fault". He later retired after consulting a cardiologist who diagnosed his hypertension. More recently he went to hospital with a life-threatening infection only when his wife "made" him go.

The continuing effects of childhood were also seen in diet and physical activity. Older women in particular persisted with the daily routine of "three vegs and fresh fruit ... like everyone else -- nothing special". Women, particularly those raised in country areas, developed life-long habits of walking out of necessity. Some claimed to have "always been running in and out to dry the clothes and never had time to sit all day". A rural upbringing and visits to country relatives were often mentioned as a wholesome start in life and an ideal for health. Isolation from doctors or health services fostered a strong sense of self-sufficiency and, particularly for women, a sense of responsibility in caring for others.

Adult Experiences

Further health "trajectories" were set in adulthood. Health habits -- everything from eating and sleeping patterns through to smoking and physical activity -- were heavily influenced by spouses' stakes in each other and joint actions in households. When one partner had a continuing health problem, often war or work-related, the consequences could be seen in their spouse's health and also in their children's experiences of family life and health attitudes. For this cohort, men's health stories centred largely around work experiences while women's stories focused more on informal care and home.

A never-married woman had missed out on education and career as she cared for a succession of dying relatives. Yet she was not broken by her misfortunes. She says "I became myself and life began" in her fifties after all her close family had died. She inherited a house and continued caring for Church members (going on world trips between caring episodes).

Changing expert views on smoking risks were described by women who were virtually encouraged by doctors to start smoking as young mothers to relax. One continued smoking for many years along with her husband. She quit in her fifties only after her husband had already quit and she had stopped "temporarily" with a heavy cold. Now more than a decade later she is fighting lung cancer.

For a number of older people the most serious challenges to health and well-being arose from losses of loved ones and emotional traumas which had remained unresolved for decades. Yet even in these difficult circumstances, individuals showed considerable capacity for overcoming adversity. Remaining family, notably siblings and adult children, were mainstays of emotional support in care giving and bereavement. While some may have felt isolated and alone, many very old individuals perceived themselves as "survivors" capable of withstanding the threats of old age (Walker-Birckhead 1996).

Intergenerational Relations

In his analysis of good health from the Healthy Lives interviews, Stacey (in press) concluded that health information was an important aspect of ties between the generations:

 In their interests and activities a number of informants were conscious of
 setting an example to their children and grandchildren. This example
 certainly applied to health-related behaviour, to living a good healthy
 life. They regarded themselves as a resource of advice, skills and life
 experience. They were attempting to be a positive, moderating influence.
 This appeared to apply notably to food, alcohol, tobacco and drugs. Yet
 many participants were open to influences from their children; for example,
 on women's issues, SNAG(4) behaviour, and food choices and type of meals.
 It may be that daughters and sons who are "doing well" can readily
 influence older parents proud of their adult children's achievements.
 Finally, openness to influences from the rising generations surely helps
 older people to continue adjusting and adapting to changing life
 circumstances, and thus helps them to maintain their independence.

This mutual support within families demonstrates older people's strong "generational stake" in their younger relatives and the strong bonds between the young and old.

THE HEALTH STATUS OF OLDER PEOPLE STUDY

A substantial international literature is developing on quantitative studies showing ways in which family and other social support may protect against illness, enhance coping with stress, and improve illness outcomes (Pearlin et al. 1996). Australian research on ageing and social support now has a substantial health focus, largely due to the availability of research funding. However, until recently very little research had focused on more positive aspects of health promotion.

The Health Status of Older People (HSOP) survey is examining ways in which life span and social aspects of ageing relate to health-related actions and exposures (Kendig 1996). The focus on health promotion has led to an emphasis on understanding how people form and change their physical activity, social activity, eating patterns, and other aspects of life styles with a known impact on health and well-being (Teshuva et al. 1994). These areas had emerged as central to older people's own views of health in the Healthy Lives study reported above. The HSOP survey interviewed 1000 persons aged 65 years and over living in non-institutional settings in Melbourne in 1994. Respondents are being followed up by mail (annually) and by telephone (biennially) to at least 2000.

The HSOP study has shown that most older Australians lead independent, positive, and satisfying lives (Kendig et al. 1996). Having social support and being married were found to be major influences on well-being (Kendig, Browning and Young, in press). Even among older people having major illness or chronic pain, the majority still scored highly on well-being, particularly if they were able to maintain their independence and activities in daily life. The findings reveal positive aspects of ageing, for example, release from the stresses of having teenage children at home and from full-time paid employment. They suggest the resilience and adaptability of people when negotiating the changes of later life.

Life Span Perspectives on Health Actions

The HSOP survey asked respondents about their key health actions when they were aged 15 years, 40 years, and 60 years, as well as at present. For each of these ages, respondents were asked to self-rate their health, report on frequency of energetic and light exercise, indicate their levels of social activity and healthy eating, and report about other areas such as smoking, sleeping patterns, and use of medications. The Australian Research Council funded this sub-study.

By the older people's accounts, most had had quite healthy life styles at the age of 15 years. Surprisingly, health-related ways of life did not appear to vary systematically in terms of parents' occupations, nor whether respondents were living with a parent or both parents. This may reflect the much-vaunted egalitarianism of Australia's past. Other explanations may be lower expectations from more disadvantaged people or, more brutally, the fact that those with poor health habits are less likely to survive to old age.

Health trajectories set in childhood appear to have ongoing effects according to these self-reported findings. There are significant correlations between self-reported health actions at age 15 years and those at ages 40 years, 60 years, and at the time of interview (ages 65 to 93 years). As people moved towards old age, they reported the most rapid declines in general health between the ages of 15 and 40 years, with less change from ages 40 to 60 years and beyond. While energetic exercise declined sharply across all age increases, light exercise stayed fairly constant to age 60 years and was even reported to have increased afterwards. There was more stability than change in reported social activity and healthy eating across the life span.

Social Influences on Health Actions in Old Age

The Health Status of Older People survey asked the older people about factors which may facilitate or constrain them in their health-related actions. This perspective was applied to modules in the questionnaire on physical activity, social activity, and (to a lesser degree) eating patterns. The older people were more than willing to analyse their health actions in this systematic way.

For encouraging social activity, the most important enabling factors were reported to be (in order) social ties (family, friends and clubs), personal motivation or skills, and health. For the 20 per cent or so who felt they did not have enough social activity, the most common first reasons were social factors (such as death of family and friends), declining health, and socio-structural barriers (transport, cost, inadequate facilities). Less common reasons were lack of time and personal problems (poor motivation, low confidence, fear, etc.). It is not surprising that structural factors were noticed when they formed barriers, but apparently remained invisible when they were facilitative.

Perceptions of adequacy were lower with physical activity, particularly among women, and generally higher for eating patterns. As compared to social activity, physical activity was reported to be affected relatively more by health factors.

Encouragement from other people was much more important for social than physical activity. Overall, respondents were most likely to report being encouraged by wives (more than husbands), daughters (more than sons), and family and friends (more than health professionals). Further research, in progress, examines the relative importance of different family members and friends as influences on health-related activities.

Family Formation and Health Actions in Old Age

Marriage has been associated with survival and other positive health outcomes for older Australians (Mathers 1994). A seven year follow-up of respondents in the Ageing and the Family survey in Sydney found that married older people were far more likely than others to have remained in their homes with good health and well-being (McCallum et al. 1991a). The Australian Longitudinal Study of Ageing (Parnell et al. 1993) and Dubbo (McCallum et al. 1991b) studies also have found that the presence of a spouse is consistently related to lower morbidity and mortality.

Why might it be that marriage is associated with better health outcomes in old age? An important selection effect may be that some people do not marry nor have children because they are in poor health or have economic or other difficulties. One might also expect gender differences due to selection effects. For example, men are less likely to marry if they have lower status occupations while women are less likely to marry if they have higher status occupations (Rowland 1991).

Family circumstances also may have direct effects on health. Support from a spouse may reduce stress and assist when people are ill. As explored above, it may be more helpful to have a wife than a husband, and men may be more vulnerable than women when living on their own. People who live with others may lead healthier life styles because of informal pressures toward regularity of habits, for example, with sleeping and meals, and avoidance of bad habits such as smoking which can harm and annoy others. Parents may engage in healthier ways of life in order to serve as examples for children, who in turn may encourage desirable actions and discourage undesirable ones.

These ideas were largely confirmed in a study of marital and parental status as influences on health actions in old age (Kendig, Jyla, et al. in progress). The findings below are based on the Health Status of Older People data and the Australian Longitudinal Survey of Ageing conducted in Adelaide (Andrews et al. 1989):

* The meaning and interpretation of health vary with family context: for example, never married people are more likely than their married counterparts to view health in terms of capacities to remain independent in daily living.

* The self-rated health of older men was far higher among those who were married, especially so among those who had children, as compared to those who never married. Among older women, self-rated health varied little by either marital or childbearing status.

* In terms of healthy eating habits, women generally reported doing better than men. Eating patterns were reported to be better for men when married and better for women when they had never married. Those most likely to be overweight were men who had never married, and women who had married and had children.

* Current smoking rates were low among men and women who were currently married -- especially low among women who had never married - and much higher among previously married men and women.

* In terms of daily drinking, the highest rates were among previously and never married men and women, relative to their married counterparts.

* With trouble falling asleep, the evidence suggests that marriage reduced problems for men but increased them for women.

* Marriage increased the likelihood of having someone who encourages physical activity, for both men and women, particularly if they had children.

Overall, marriage and parenting appear to be associated with healthier ways of life among older men but to have relatively little effect, or else negative effects, for older women. Further analyses will compare these findings to those from Scandinavian and other countries, which may have different gender and family expectations. Analyses of European surveys with larger sample sizes will explore effects among minority groups.

Health Actions and Family Transitions in Old Age

Two major family transitions in old age are becoming a spouse caregiver, and widowhood. These experiences are closely linked because most older widows were formerly caregivers, and most spouse caregiving ends with widowhood. These transitions, of course, are experienced primarily by women, although men also are likely to have been caregivers if their wives have died before them. HSOP evidence on the consequences of these transitions, for specific health actions as well as global well-being, has been reported recently in Wells and Kendig (1997).

Findings from the HSOP community sample showed that the health and well-being consequences of spouse caregiving were far less severe than had been reported from self-selected samples of people seeking help. Spouse caregivers had been presented with a complex challenge that (after controlling for age and gender) was more likely to be taken on by healthier older people. There were no apparent effects overall on levels of physical and social activity nor on eating patterns. The most notable adverse consequences were elevated risks of feeling under strain, using tranquillisers, and an eroded sense of meaning of life.

The HSOP findings confirm the devastating and persistent effects of widowhood. After controlling for age and gender, widows were more bored, lonely and depressed. They also had worse self-rated health and were more likely to have a reduced appetite, to drink alcohol, and to take prescribed hypnotic drugs to help them sleep. Widows who had been spouse caregivers were less likely to be depressed, perhaps because they were better prepared emotionally for the loss. However, the effects of caregiving in reducing a sense of meaning in life appear to persist after widowhood. Seeing one's spouse in a state of dependency may profoundly violate expectations for the retirement years.

Policy and Research Directions

The health status research reported in this article relates closely to recent development of policies on ageing and health promotion. The Australian Healthy Ageing Strategy (1997:10) aims to improve health and well-being for all older Australians; to pursue a more "age friendly society"; and to "promote a holistic approach to health and well-being, incorporating physical, psychological, social, and emotional well-being". Health promotion is emerging as a prominent issue in the pending National Strategy for an Ageing Australia and action leading up to the 1999 International Year of Older Persons.

State governments also have considerable responsibilities in the Australian federal system. The Victorian Health Promotion Foundation applies a life span approach and includes older people as a priority group. Research and pilot programmes supported by the Foundation have contributed to the Government's comprehensive inquiry on Positive Ageing (Family and Community Development Committee 1997). The recommendations emphasise inter-sectoral action including housing, recreation, transport, and urban planning as well as health. Similar work is underway in New South Wales (1998) and other states.

Our research programme has provided the basis to quickly carry out applied research to specific areas of policy development. A study for the Department of Veterans Affairs is showing that the risk of social isolation is closely linked to health, family situations and gender (Gardner et al. forthcoming). Younger Vietnam Veterans, particularly those with continuing war-related health problems and disrupted marriages, were at very high risk of social isolation. War widows had a low risk of social isolation, even if they were in poor health, but they had a high prevalence of depression and loneliness. The study recommends health, social, and transport actions to prevent isolation and to ameliorate the consequences of isolation. Many of these measures need to be specific to the different needs of social groups across the life span.

Another study (Brooke et al. in press) has focused on the health and social needs of disadvantaged people who enter inner city public housing late in life. Many of the older men had very poor health habits (smoking, drinking, etc.) but their health-promotion priorities were to have safe, secure and affordable accommodation. While older women also benefited from the improved housing, they were much more likely than the men to benefit from opportunities to form friendships in age concentrated communities and good access to health and community services. The study concluded that this disadvantaged group would benefit from more integrated provision of health promotion, primary health care, community care and housing. It provides further evidence on the accumulating effects of social class on health over the life span (see also Kendig, Browning and Teshuva, in press).

There are many directions for furthering both qualitative and quantitative research agendas. Our Health Status survey has been extended into the longitudinal Health Behaviours and Outcomes in Ageing study.(5) This will provide a prospective basis for examining the impacts of life styles on outcomes such as well-being, independence, illness, service use, and survival. More research also is needed on relationships between generations, diversity in terms of ethnicity and other social factors, and the influence of older people on the health of their younger family members. There is much more to know about health aspects of ageing and inter-generational relationships in different social and cultural contexts.

CONCLUSION

This article has presented research findings on the life span experiences and family context of the health actions of older people. It has suggested that many influences on health are changeable and hence improvable. Most older people are aware of these influences and actively work towards maintaining health and well-being. Basic lifestyles and health-related attitudes are largely formed in childhood and they are further shaped by marriage and childbearing experiences in mid-life. Outcomes in old age are heavily influenced by whether or not one has a wife (less so a husband), has cared for or lost a spouse, or has had children or not. These findings indicate that health promotion policies need to take careful account of the different needs of people along the life span.

Families are widely recognised in care policy but they require more consideration in health promotion. There are substantial opportunities for life-span approaches that emphasise how families of origin set lasting patterns of healthy or unhealthy life styles. Care-giving and widowhood need to be more widely recognised as vulnerable times when well-being and use of psychotropic medicine need to be monitored carefully. Older men who have never married or who have divorced have heightened risk in terms of health actions and exposures. These vulnerabilities are heightened when people have low income, poor mobility, and other limitations.

The knowledge base for social and health policy depends heavily on research funding. Studies which are now informing Australian policy developments, as reported in this article, were made possible by forward thinking in the early 1990s by the Victorian Health Promotion Foundation and the Commonwealth Department of Health and Family Services. It is important to recognise that academics and policymakers not only have different time lines but they also have different languages and objectives. Yet notwithstanding these tensions, there is a strong complementarity between the knowledge base in academia and the policy actions of government. Comprehensive research strategies can provide sound information for developing and implementing policies and programmes.

(1) An earlier draft of this paper was presented to the Conference "Ageing and Intergenerational Relationships" organised by the Department of Psychology and the Health Services Research Centre, Victoria University of Wellington, 10 to 11 July, 1998. The research was conducted at the Lincoln Gerontology Centre for Education and Research, Latrobe University, with core support as a Key Centre of the Australian Research Council.

(2) Wendy Walker-Birckhead served as Co-Principal Investigator. Funding was provided by the Commonwealth Health and Community Services Research and Development Grants.

(3) Karen Teshuva, Deborah Osborne, and Barrie Stacey coordinated fieldwork. Funding was provided by the Victorian Health Promotion Foundation.

(4) Sensitive new-age guy.

(5) Funded by the National Health and Medical Research Council.

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Hal Kendig

Faculty of Health Sciences, University of Sydney

Colette Browning

School of Public Health, La Trobe University

Yvonne Wells

Lincoln Gerontology Centre, La Trobe University