Population Ageing: Challenges for Health Promotion

Abbreviations

GDP: Gross Domestic Product, AE: Active Ageing; WHO: World Health Organization.

Editorial

The aging process indicates that it is related to: genetic inheritance; physical activity; lifestyle; diet; environment; social support, emotional and mental ability to deal with life’s crises; among others. The 20th century has seen a significant increase in population ageing, changing the demographic and epidemiological profiles in developed and developing countries. Demographic ageing and individual ageing are distinct concepts. Demographic ageing results from a change in the population’s age structure, characterized by an increase in the proportion of elderly individuals. This phenomenon can be reversed by factors such as the immigration of young people, an increase in the fertility rate and/or an increase in mortality at older ages. On the other hand, individual ageing, although a continuous process, is often associated with old age and frailty. However, chronological age is not an absolute indicator of frailty and old age, as the aging process is heterogeneous and varies between individuals. Despite this, age has become the main marker of human ageing due to its simplicity of measurement. Most countries adopt 60 or 65 years as the threshold for defining an elderly person. In Brazil, the Statute of the Elderly considers the person who reaches the age of 60 to be elderly [1].

The phenomenon of an ageing population is driven by an increase in life expectancy and a reduction in fertility rates, factors that promote substantial changes in the population structure. These transformations require a reassessment of the allocation of public resources, with a view to implementing more effective social policies aimed at guaranteeing rights throughout life. In the Latin American context, especially in Brazil, the population age pyramid is undergoing a process of inversion due to the significant increase in the elderly population. According to the 2022 Demographic Census, the elderly represented 15.6% of the total population. Projections indicate that, by 2060, this proportion will reach 32.2%. Over the 37-year period (2023 to 2060), the elderly population will more than double, with an estimated growth of 118.11% [2]. In this sense, as well as having an impact on the supply of health services, this growth will also cause obstacles to the development of the Gross Domestic Product (GDP) and the growth of national per capita income, consequently resulting in challenges for the social security and protection sectors, as well as for health.

Demographic change, together with the advance of the ageing process, has the potential to open up new perspectives in relation to social well-being, depending on the formulation and implementation of appropriate public policies to deal with future demographic dividends. It should be borne in mind that social factors contribute to the creation of disparities in health issues and the ageing process in various populations. These inequalities are observed in various socio-economic contexts, and are particularly evident in developing countries. It is crucial to consider the direct impact of social inequalities on the ability of the most vulnerable families to assume the responsibilities associated with caring for and meeting the needs of older people. These disparities can perpetuate a cycle of inequality, negatively influencing health outcomes and the process of active ageing [3]. Furthermore, although the increase in the prevalence of chronic and degenerative diseases and their consequences (such as disability and functional dependence) is one of the main concerns of contemporary epidemiology and public health, other causes of the Brazilian epidemiological situation cannot be ignored, so it is essential to permanently resolve the problems of the past, such as neglected diseases and hunger.

In order to mitigate the negative externalities associated with an ageing population, it is necessary to take coordinated action by the state, family institutions and the private sector, as well as implementing interventions and policies aimed at reducing social inequalities, providing support and resources to the most vulnerable populations. It is necessary to recognize and address the underlying factors of the aging process, including the creation of strategies that meet the immediate needs of these populations and promote long- term social and economic inclusion. Such strategies involve ensuring equitable access to health services, education and housing, as well as developing programs that strengthen the community and family support network, regardless of socioeconomic position or geographical location [4]. The public authorities must implement effective public policy strategies to guarantee a quality old age, regardless of socio- economic circumstances, as well as preparing professionals to help the elderly identify risk situations and seek solutions to their problems, as well as stimulating skills, preventing the resumption or relapse of habits that are harmful to health and preparing them to deal with the stress caused by changes.

In this context, the concept of health promotion has emerged as an essential approach to tackling the challenges faced by older people in situations of vulnerability, with the aim of preventing and managing their health conditions. This allows these people to exercise greater autonomy in managing their own well-being, promoting a significant improvement in their quality of life [5]. Health promotion, as defined by the Ottawa Charter and widely discussed in health literature, emphasizes empowerment, allowing individuals and communities to exercise control over their health. This process involves a series of essential factors for a healthy life and highlights the importance of social participation and intersectoral integration for its implementation and achievement. However, addressing this concept faces several obstacles, as health is a multifactorial phenomenon that depends on basic structural changes, such as income, housing, employment and education. These changes have become increasingly difficult to achieve in neoliberal economic models and in contexts of threats to democracy, as has recently occurred in Brazil.

In Brazil, the National Health Policy for the Elderly and the National Policy for the Elderly were established to regulate the rights of the elderly, promoting their autonomy, integration and effective participation in society. These policies ensure fundamental rights, such as the right to life and health, through the prevention of health problems, promotion, protection and recovery, as well as guaranteeing dignified ageing. However, despite these rights being clearly outlined, few people in Brazil reach old age fully enjoying the benefits provided. Thus, although policies encourage these rights, they do not guarantee their effective realization.

In the 21st century, studies on old age have focused their attention on constructs that cover the diversity of factors that determine ageing, considering quality of life independently of the presence of chronic diseases. Considering the longevity of the population and the need to age with quality of life, the debate on Active Ageing (AE) is becoming increasingly relevant. The concept of active ageing applies to both individuals and population groups, enabling people to maximize their physical, social and mental well-being throughout their lives. It involves continuous participation in social, economic, cultural, spiritual and civil activities, as well as ensuring protection, safety and adequate care when needed. The word “active” highlights the importance of continuous social participation, regardless of physical ability or employment. Even in retirement or with special needs, older people can continue to make a significant contribution to their families, communities and society. The World Health Organization (WHO) proposes that, for active ageing, it is essential to improve quality of life, encompassing not only health, but also maintaining citizenship. This approach is based on four pillars: health, lifelong learning, social participation and safety/protection [6].

The concept of Active Ageing (AE) is broader than that of “healthy ageing”, as it recognizes, in addition to health care, other factors that influence the way individuals and populations age. The life course perspective for active ageing recognizes that older people are not a homogeneous group and that diversity among individuals tends to increase with age. Culture is a transversal determining factor in understanding active ageing, influencing all the other determining factors. It shapes the way in which we age, encompassing all people and populations. Cultural values and traditions play a crucial role in the way society perceives older people and the ageing process. Societies that associate symptoms of illness with ageing tend to offer fewer services for prevention, early detection and appropriate treatment. In addition, culture influences whether or not intergenerational living in the same household is the preferred lifestyle [7]. In addition, participation in activities in old age is related to traditional gender roles, influencing men’s and women’s different access to resources and services. Differences in active ageing between the sexes increase with age, with older men participating less in physical activities and paid work, while older women have less participation in socio-cultural activities and the labor market [5].

However, although longevity is one of the greatest global achievements, active old age is not yet a universal reality. There has been an increase in the incidence of illnesses, dementia and, above all, chronic diseases, since longer life expectancy has brought with it the prevalence of pathologies associated with ageing. This scenario demands greater attention from the family, the state and civil society in caring for the elderly. Most of the time, care is provided by family members, neighbors and/or caregivers. In the absence or insufficiency of these, the need for institutionalization arises.