Report on life-course theory

I was asked to attend a WHO meeting on life-course theory as part of my internship with the World Health Organization’s Regional Office for Europe. While I was there, I was working on the topics of eHealth and the Global Network of Age-Friendly Cities (and trying to bridge the two). I was working in the Division of Non-communicable diseases and health promotion – Ageing, disability and long-term care. The team I was part of worked on the full spectrum of life, from before conception to aging, all with a focus on health promotion and reduction of non-communicable diseases.

This particular meeting was a brainstorming session on how the WHO is using the life-course perspective to address health promotion. I was particularly excited to attend because of my background in psychology and gerontology, where life-course theory has it’s roots.

I spent a significant amount of time preparing this report and preparing for the brainstorming session, also because I had been specifically asked to attend based on my education and expertise. But, it quickly became apparent that they did not want to discuss the theoretical perspective they are claiming (they claim a life-course perspective, but discuss a life-stage perspective – and they are two very different things).

Life-course theory focuses on the history of a person’s life and experiences to describe their current state and project future states. Life stage perspective would look at what stage a person is in (childhood, adulthood, etc.), in that stage alone. And when discussing health, there is a big difference.

Even in their brochure on Life-course, they state the importance of different stages in people’s lives,

Key stages in people’s lives have particular relevance for their health. The life-course approach is about recognizing the importance of these stages, and WHO/Europe addresses them in four programmes: Maternal and newborn health, Child and adolescent health, Sexual and reproductive health, and Healthy ageing.

So, while they may really want to be using the life-course approach, they are not. They are clearly using a life stage approach, but wanting to give the impression that it is life-course.

During the meeting, when I would ask for clarification on if they didn’t mean life stage perspective, rather than life-course perspective, I heard comments like “we don’t have time for all this theoretical talk.” Or when I tried to address how the life-course really focuses on healthy aging, since that is where the course of life leads (to aging), I was met with “we aren’t really focusing on the older adults, though,” which made me wonder why they were even looking for interns in this division if they didn’t really want them to work on issues for aging adults.

I know I sound like a Debbie Downer here, but I was really excited and motivated for the internship and to improve the lives of aging adults around the world. This meeting really knocked the wind out of my sails, to be met with so much negativity and resistance. I wish I could say that the internship work was appreciated, but this was not the only time where I would hear that healthy aging would be last on the agenda, or we would see if we had time to discuss it, or even ageist comments from employees. It was really frustrating and disappointing. But, on the bright side, I have now realized that I enjoy working with smaller companies, organizations, and institutions better and am probably not suited for continuing to work with the UN 🙂

Intern Summary Report – Carrie Peterson DNP-ADC

Thursday, 10 January 2013 

The life-course perspective, particularly how it applies to healthy ageing (spanning from birth to death)

Background on Life-course perspective

Life-course has a background in Psychology and Gerontology:

Theories

Theory of life span development

Stimulation will promote and support healthy aging through encouragement, engagement and maintenance of activities, health states and social connections.

Compression of Morbidity hypothesis

The age at which chronic deterioration of health states is postponed until closer to death, compressing the time between onset of chronic illness or frailty and death, the burden of illness (personal and national) will be reduced.

• Gerontechnology/eHealth can fit into the Compression of Morbidity hypothesis by providing solutions that can extend abilities for self-care and independent living, making the home environment a healthier and safer place to Age in Place.

Activity Theory

Particularly useful in qualitative research as it supplies a conceptual framework to understand and analyze phenomena through consideration of the entire activity system, including the actor and their history and culture, environment, motivation, role of the artifact (i.e. technological device) and the complexity of activities in life.

• The idea is that activities are plastic in nature and subject to transformations
• The individuals adapt to and advance activities while activities also adapt to and advance individuals in a cycle of co-creation = Life-course and individuals co-create each other

Subculture theorists

Argue that the aged are likely to form a subculture because they share physical limitations and role losses.  We could highlight this as role transitions rather than loss, i.e. increase volunteer opportunities after retirement

Political economy theory

Concerned with explaining how and why social resources are unequally distributed. A central focus of research stemming from the political economy tradition is on how public policies reproduce existing forms of inequality. We should strive to avoid this, particularly by not excluding late adulthood and old age from key life phases/stages

Theory of cumulative disadvantage

Inequality is not a static outcome but rather is a cumulative process that unfolds over the life-course. Women and members of racial and ethnic minorities have lower incomes and higher rates of poverty in old age than white males because of earlier experiences and opportunities.

• The basic sociological approach to stratification views inequality as a product of social processes, not innate differences between individuals. The central question in the study of stratification is how social inequality is produced, maintained, and transmitted from one generation to another.

Age integration theory

Recognizes that societies use chronological age as a criterion for entrance, exit, or participation.

• We dismantle this in regards to health and work

Theory of adult development

One of the only which suggests development and growth occurs well into the adult years.

• At the center of Levinson’s theory is the life structure = an underlying pattern of an individual’s life at any given point in time.
• 2 key concepts:

1. Stable Period – The time when a person makes crucial choices in life.
2. Transitional Period – The end of a person’s stage and the beginning of a new one.

young people become old

young people can become disabled

old people can become disabled

disabled people become old

Applying the Life Course Perspective to Health 2020

                Tailored towards health

Definition of life-course – A sequence of socio-culturally defined events and roles that the individual enacts over time. It is, in essence, the culmination of a person’s entire health life and the factors that have shaped it and how. It is an expression denoting an individuals passage through life, analyzed as a sequence of significant life events, including birth, education, economic and social contribution (work), partnering, parenting and retirement.

Defining life-course perspective – This theoretical perspective is a multidisciplinary paradigm for the study of people’s lives, structural contexts and social change. It encompasses ideas and observations from an array of disciplines, notably history, sociology, demography, developmental psychology, biology, public health and economics.The approach focuses on the connection between individuals and the historical and socioeconomic context in which these individuals lived and how this has affected their health.

These events and roles do not necessarily proceed in a given sequence, but rather constitute the sum total of the person’s actual experience and resulting health outcomes.

The life-course perspective elaborates the importance of time, context, process and meaning on human development and health.

The life-course approach examines an individual’s life history and sees, for example, how early events influence future decisions and events, such as marriage, engagement in crime or disease incidence. It is a retrospective look at a person’s life history; we can take a forward-looking approach to preventing or delaying unhealthy states and disease incidence.

Ageing and developmental change, therefore, are continuous processes that are experienced throughout life. As such, the life course reflects the intersection of social and historical factors with personal biography and development within which the study of family life and social change can ensue.

Life-course framework

Alwin, Duane F. (2012)

Detailed research of literatures across disciplines revealed 5 different uses of the term “life course”:

1. a) life course as time or age,
2. b) life course as life stages,
3. c) life course as events, transitions, and trajectories,
4. d) life course as life-span human development, and
5. e) life course as early life influences (and their cumulation) on later adult outcomes.

To the extent the concept of life course has a multiplicity of meanings that are at variance with one another, this is problematic, as communication is thereby hindered. On the other hand, to the extent the concept of life course involves a rich tapestry of different emphases, this is a good thing, and the diversity of meanings should be retained

Alwin’s Life-course framework embeds the concept of “life course” within a broader perspective of life-span development. This framework is proposed as an integrated perspective for studying the causes and consequences of “life course events and transitions” and understanding the manner by which “life events” and the role transitions they signify influence the life-span development of outcomes of interest across stages of the life cycle.

HOME/FAMILY

Marital satisfaction

Studies of marital satisfaction over the life course consistently show a decline during the childrearing years. In part, the decline during the child-rearing years is caused by role strain. As the children leave home, marital satisfaction rises, peaking in the retirement years. The later-life satisfaction peak may also be a function of divorce-that is, those who remain married are the survivors. Still, the research is consistent enough to suggest that marriage is very satisfying for most people in old age. Studies show that being married is positively correlated with longevity and health in men.

Sibling relationships

There is a life course pattern to sibling relationships. Many siblings feel close as young children, then drift apart to attend to the needs of their own families. As siblings grow older, they often become close once again. Siblings mostly provide emotional support but some, especially sisters, also care for each other in old age. Studies show that having a sister or a close female friend is positively correlated with longevity and health.

Parent-child relationships

Relationships established earlier in life affect the quality of interaction between parents and children in later life.

• Children who recall their childhood in a positive way are more concerned about their aging parents than those who perceived parental rejection.
• People who have been divorced have less contact with their adult children and report less positive interaction than those who remain married. Losing touch with children after a divorce is especially a problem for men.

Grandparent-grandchild relationship

The relationship between parents and their children is often passed on to the grandchildren. When parents and grandparents are close, the grandchildren see their grandparents more often and feel closer to them.

• When parents divorce, the grandparent-grandchild relationship is affected. The paternal grandparents are most likely to lose contact with their grandchildren.
• Divorce does not necessarily mean a severing of familial ties, however, for some parents remain close to their former daughters-in-law.
• With the divorce and remarriage of parents, family ties may multiply.

Gender, race, and ethnicity affect a person’s health

• Women have poorer health and higher levels of disability than do men. Both biological and behavioral factors appear to account for the differences.
• Older minorities have poorer health than whites on several measures. As they age, they are more likely to develop a serious illness and more likely to rate their health poorly.

Caregiving

Caregiving may strain family relationships, but it may also enhance them.

• A child may be disturbed by personality changes in an aging parent or by the role reversal that may occur when the parent becomes dependent.
• Siblings may quarrel over the division of caregiving tasks.
• Marriages may be strained when spouses have less time for each other because of caregiving burdens.
• When the burden is shared equally, however, family members may appreciate each other and feel that familial ties have been strengthened.
• Although the majority of caregivers are not in the labor force, approximately one-third are employed.
• Caregiving affects work in several ways.

o   Even if employed caregivers continue working full-time, caregiving responsibilities may force them to work fewer hours, rearrange schedules, and take time off.

o   Some caregivers quit work or retire earlier than planned if their caregiving responsibilities create conflicts with their ability to perform their jobs.

• Surprisingly, although women employed outside the home seemingly have a higher burden than non-employed women, they report less stress. It may be that satisfaction from work and contact with the outside world reduces stress, despite greater responsibilities from dual roles.

WORK

Not just maintaining work ability but promoting work ability – Occupational Health Therapists

Reduce age-related unemployment

Satisfaction in retirement partly depends on lifestyle factors.

• People with adequate income, good health, and a social support system are most likely to be satisfied in retirement.
• People who retire unwillingly are least likely to be satisfied.
• Women who retire for family reasons such as caring for an aging parent or ailing spouse are the most dissatisfied.

SOCIETY

Major historical events, i.e. economic crisis, affect the life-course of a whole generation

Although there is insufficient longitudinal data to test all the ideas researchers have about the long-term consequences of early life experiences, some research has been able to overcome these limitations.

• Studies show that the impact of early experiences such as living through an economic depression can influence the life course of an entire generation.
• However, the consequences vary depending on the individual’s age at the time the event occurred and on what decisions were made about how to deal with that event.

Government policy can affect the life-course

When government policies give particular rights, responsibilities, and public benefits to citizens at specific ages and life stages (i.e. ages:  childhood immunizations, stages:  maternal care or retirement benefits), then it has helped to standardize the life-course.

• Currently, there are three clearly demarcated stages in the life-course:education, work, and leisure.
• As society and the economy grow more complex, the challenge now is to explore ways policies can be restructured to allow more flexibility over the life-course.

Lifestyles and social support systems affect health

Lifestyles have a large impact on health over the life course. The increasing significance of healthy lifestyles means that medicine is no longer the sole answer to dealing with threats to health. Social support systems also play a role in health outcomes. Having a strong social support system improves morale, reduces the risk of depression, and even enhances recovery from surgery.

Measure of a person’s socioeconomic status, and connection to health

The best measure of an elderly person’s socioeconomic status is education. People of higher SES have better health in old age than people of lower SES. One reason is that they have better access to health care. People of lower SES are more likely to have worked in stressful jobs where they could be injured. They also have more resources that give them the opportunity to engage in positive health practices.

Cultural attitudes toward death

There are enormous variations across societies and over time in attitudes toward death.

• Some societies engage in death avoidance while others celebrate the communion between the living and the dead.
• There has been an immense change in the process of dying from the nineteenth century to the present. This change is partly due to a shift in the average age of death and the association of dying with old age.
• It is also caused by a change in the causes of death. At one time most people died from acute illnesses that struck swiftly. Now people are more likely to die from a chronic illness that leads to a slow death.
• The setting for death has also changed. Most deaths once occurred in the home. Now death typically takes place in an institutional setting such as a hospital or nursing home.

o   Now moving back to the home via hospice, palliative care and right to die advocacy

Racial and ethnic groups vary in terms of their economic security in old age

Compared to whites, African Americans have had higher rates of unemployment, more sporadic employment, and lower wages.

• Sporadic employment also means less opportunity to become vested in private pension systems and less opportunity to accumulate pension savings.
• Because of past and continuing discrimination in the sale of housing, older blacks and Hispanics are less likely than whites to own a home.
• Further, because of segregated housing patterns, the homes owned by blacks are less valuable than those of whites.
• Among the Hispanic aged, poverty rates vary by country of origin. They are highest among Puerto Ricans, relatively high among Mexicans, and just slightly more than whites among Cubans.
• Asian American aged are the most prosperous group of immigrants. They have the highest median family income, lowest poverty rates, and highest rates of home ownership.
• American Indians have the highest unemployment rates and the highest mortality rates of any minority. The high levels of poverty among elderly American Indians reflect the results of more than a century of federal policy toward indigenous people.

o   The federal government has the responsibility for providing health care for American Indians.

Questions

1. How does this help the outlined activities?

1. Invest in health through a life-course approach and empower citizens

b.     The changing demographics of the European Region require an effective life-course strategy that gives priority to new approaches: empowering people and building resilience and capacity, to promote health and prevent disease.

1. Children with a good start in life learn better and have more productive lives. Adults with control over their lives have greater capacity for economic and social participation and for living healthier lives. Healthy older people can continue to contribute actively to society

1. Developing policies to address the social gradient in health directly through interventions that are proportionate to the level of health and social need.

• Are we aiming to gather an evidence base to support/direct the activities/policy?*

SUGGESTIONS

In Gerontology, the focus in recent years has been on aging well at home, at work and in society – I would suggest we also incorporate these three in Health 2020.

Since WHO includes preconception and prenatal health issues and policies, I strongly advocate to also including health issues and policies in palliative care and death (for all ages), to fully cover the life-course.

If we are primarily working towards 2014-2015 at this point, I suggest breaking down the work in phases, e.g. 1) Education 2014-2015, 2) Prevention 2015-2017, and 3) Intervention 2017-2020. In this way, we can first focus on educating countries and the European region on focused issues and how they will be addressed in the policy; then, implementing prevention strategies, now that the public is aware that they are issues and what they mean to health over the life-course. This could include targeted education towards vulnerable groups, e.g. women ages 15-35 on the importance of ….. as well as preliminary screening. And, finally, working on implementing the actions the policy proposes to avert disease or delay disability as well as manage/treat the focused health issues.

1. Briefly define the concept of life-course and emphasize that we take a life-course perspective in the implementation of Health 2020 guidelines and activities
2. Empowering peoples investment in their own health during the life-course
3. Utilize health promotion, not just prevention and treatment
4. Education on disease awareness and prevention
5. Including early detection
6. Promote utilization of interventions
7. Major health challenges during the life-course
8. Tackling health challenges for the individual and for society
9. Tackling health challenges during the “stages” of the life-course, with the ultimate goal of (a version of) compressed morbidity
10. This means looking at the most common health challenges for a population during the entire life-course and targeting prevention strategies
11. Effective evaluation strategies need to be in place in order to determine if, in which ways and to what extent the policy is fulfilling goals.

Age-friendly communities

1. Grocery, i.e. Tesco in UK, Kaiser in DE, with magnifying glasses on shelves and trolleys, wider aisles, benches, seats on trolleys, brighter lighting, etc.
2. Longer crosswalk times
3. Make hospitals, clinics age friendly (historically focus on younger and acute care)
4. Address rural and remote communities (busses to pharmacy, grocery, implement telehealth systems to reduce travel via virtual consultations)

Don’t let the digital divide widen the health divide!

5. Promote intergenerational activities in social and health care
6. Foster Grandparent Programs (see programs in NYC as example)
7. Volunteer programs at nurseries as Baby Cuddlers (premature)
8. Teaching/mentoring young and new mothers
9. Utilized as a positive influence for special and exceptional needs children and “at-risk” youths
10. Volunteer programs to assist children who would otherwise get breakfast and ready for school in the mornings alone, i.e. when parent(s) are already at work
11. Emotional support to child victims of abuse and neglect, tutoring children who lag behind in reading, mentoring troubled teenagers, and socialization for children with physical disabilities and severe illnesses
12. Senior-to-senior companions (for home-bound older adults)
13. Ombudsman and advocacy in government

PLASTICITY is key

• We could say that life-course is about adapting to “life” circumstances as one ages – age effect rather than age grade.

o   Adaptation is a strong predictor of biological survival and psychological health.

Health 2020 puts special emphasis on the key role of ministers of health as advocates and catalysts of action for health both within and beyond the boundaries of the health sector. Another positive development is the increasing involvement in decision-making of patients and citizens, who are no longer passive but, thanks to information technology, are more empowered than ever before to take more responsibility for their health in a different relationship with the health system. The Health 2020 framework will be built on the Health for All strategy and other key European health policy frameworks including the Tallinn Charter: “Health Systems for Health and Wealth”.

• Participatory process, formally and informally

o   Not (only) a documented policy, but also a vehicle to generate interest, debate and commitment to action for health and equity nationally, locally, transnationally, internationally

o   Ultimately, a movement to promote health as a whole‐of government responsibility engaging and connecting with decision‐makers and civil society

o   Utilizing eHealth forums is a great way for citizens to quickly and efficiently express which issues are important to them – also allows for feedback

Key terms:

Age effect  A difference due to chronological age or life-course stage.

Age grade  Use of age as a social category to group people by status-the expectations for when the transition from one role to another should occur.

Age stratification theory  Underlying proposition is that all societies group people into social categories and that these groupings provide people with social identities; age is one principle of ranking, along with wealth, gender, and race.

Chronological age  Number of years a person has lived.

Continuity theory  A more formal elaboration of activity theory; uses a life-course perspective to define normal aging and to distinguish it from pathological aging.

Convergence theory  A theory of aging that views old age as a great leveler, which reduces inequality that was evident at earlier stages of the life-course.

Convoy model of social relations  A theoretical model stating that each person moves through life surrounded by a group of people to whom he or she is related through the exchange of social support; dynamic and lifelong in nature.

Coping  A state of compatibility between the individual and the environment so that the individual maintains a sense of well-being or satisfaction with quality of life.

Countertransition  A life course transition produced by the role changes of others.

Life-course  The interaction between historical events, personal decisions, and individual opportunities; experiences early in life affect subsequent outcomes.

Life-course framework  An approach to the study of aging that combines the study of the changing age structure with the aging experiences of individuals.
Period effect  The impact of an historical event on the people who live through it.

Role  The expected behaviors associated with a given status; also a status and the behaviors associated with it.

Role allocation  Processes by which roles are assigned to individuals and the dynamics of role entry and exit.

Role conflict  An inability to meet competing demands of two or more roles; occurs when two or more roles are partially or wholly incompatible.

Role reversal  Reversal of parent-child role, with the child becoming the decision maker.

Role transition  Role changes individuals make as they leave school, take a job, marry, have children, retire.

Self-concept  The organized and integrated perception of self; consists of such aspects as self-esteem, self-image, beliefs, and personality traits.

Social clock  The age norms that provide a prescriptive timetable, which orders major life events.

 Note the difference between

• Universal ageing – age changes that all people share

• Probabilistic ageing – age changes that may happen to some, but not all people as they grow older including diseases, such as type two diabetes

• Chronological ageing – numerical

• Social ageing – cultural age-expectations of how people should act as they grow older

• Biological ageing – an organism’s physical state as it ages

• Proximal ageing – age-based effects that come about because of factors in the recent past

• Distal ageing – age-based differences that can be traced back to a cause early in person’s life, such as childhood polio