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Women's experiences of aging in the Western Pacific Region : a diversity of challenges and opportunities

31 décembre 1995 Organisation mondiale de la santé

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WOMEN'S HEALTH SEAlES volume 2

Women's Experiences of Aging in the Western Pacific Region: A Diversity of Challenges and Opportunities

WHO 'WP/!() LIBRilD "'lI.'lI,iJ/.a pa,~

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World Health Organization Regional Office for the Western Pacific Manila

1995

Pacific (WHOIWPRO) for general distribution. All rights are reserved. Subject to due acknowledgement to WHOIWPRO, this document may, however, be freely reviewed, abstracted, reproduced or translated, in part or in whole, provided that such is not done for or in conjunction with commercial purposes and provided that, if it is intended to translate or reproduce the entire work, or substantial portions thereof, prior application is made to the Maternal and Child Health Unit, WHOIWPRO, Manila, Philippines. The views expressed in this document are those by the principal contributor and do not necessarily reflect the policies of the World Health Organization.

Map of the WHO Western Pacific Region

NORTHERN . MARIANA ISLANDS

GUAM, MARSHALL FEDERATED STATES OF '. ISLANDS M.ICRONiOSlA

:.KIRIBATI

NAURU .. !OKELAU

SAMOA ." 'AMERICAN SAMOA NI!,JE TONGA COOK' ISLANDS FRENCH POLYNESIA

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NEW

CALEDONIA

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Contents Foreword Acknowledgements l. Introduction Background v vii

3 3 3 4 5 6

2.1

2.2 2.3 3.

Initiatives Global Regional Regional diversify Defining the older woman

Key issues

9 9 12 13 13 15 17 18 19 19 22

3.1

3.2

3.3

Changing demographics and the need to plan for the future lhe demographic shift is female Influences on health - the life course approach Political history in the lifetime of older women Economic history in the lifetime of older women Education and Health Religion and health Lack of adequate research and data Why women's health? Indicators of health status Health indicators in the Western Pacific Region Social indicators

23 24

llL

3.4

Morbidily and mortalily Morbidity Mortality Qualily of life Indicators for qualily of life Disabilily Adjusted Life Years (DALYs) and Qualily Adjusted Life Years (QALYs) Caring and health provisions Older women as providers of health care Older women as consumers of health care

26 26 28 31 31 32

3.5

3.6

38 39 40 42 45 47 47 ff)

3.7

Agism and sexism Death and dying

Country initiatives Issue No. 1 - Changing demographics Issue No.2 - Influences on health - life course approach the context of older women's health Issue No. 3 - Lack of data Issue No.4 - Mortalily and morbidily Issue No. 5 - Qualily of life Issue No. 6 - Communily care Issue NO.7 - Agism and sexism

52 55

61 63

75 79 79 80 89

Conclusions and recommendations Conclusions Recommendations

Bibliography

Foreword The objective of the monograph is to give voice to the diversity of health needs of current and future generations of older women in the Region. It thus aims to put into practice the key recommendations of forums addressing women's health concerns which have emerged over the past two decades since International Women's Year in 1975. The Western Pacific Region currently has one-third of the world's population over the age of 65. More than half are women. With dramatic changes in the demographic structure of both developed and developing countries in the Region the proportion of older women in the Western Pacific is likely to double by the year 2020. Significant forward planning needs to be undertaken to answer the needs of this expanding group in the 21st century. Two key issues need to be addressed in the development of policies to promote the health of older women: the rich cultural diversity of women's experiences of aging in the Western Pacific and the quality of life of older women. This monograph aims to reflect the diversity of women's experiences of aging from backgrounds rendered different by cultural practices, levels of economic development and life expectancy. It also emphasizes the importance of adding life to years rather than just years to life. It represents a synthesis of two fundamental aspects of health in the next century: the health of the aged and the health of women. Women's life expectancy varies in the countries of the Western Pacific from 47.5 years to 81.8 years. Cot;lOOCluentJy, any definition of 'older women' remains problematic. Using menopause as the cut-off point is also difficult since it locates women's health experiences solely within the reproductive realm. Women are more than an amalgam of reproductive organs: their social, economic and political location as women within society determine all aspects of their minds, their bodies and their health and'wellbeing experiences. In the preparation of this report we have dealt with these difficulties of definition by allowing countries to adopt their own definition of' older women'. Thus we do not exclude the experiences of the oldest women in societies where life expectancy for women is less than 50 years. For convenience, and acknowledging the limitations of adopting any cut-off point, the monograph has adopted the epidemiological convention of referring to the stages of aging. The life course approach recognizes that experiences and choices at every stage of life influence outcomes in old age.

: -L

The fourth United Nations World Conference on Women to be held in Beijing in September 1995 has started a flurry of activity on research on women. In the health field the World Health Organization has established the Global Commission on Women's Health: this has been complemented with preparatory activities at the regional and local levels. In WPRO, a series of documents, of which this is volume two, is being prepared to reflect the most recent research addressing key themes for action identified by the Commission. Readers might ask: Why after two decades of special attention to women's health (which started with the UN Decade for Women in 1975) do we need to launch yet another campaign to promote the health and well-being of a group of people dermed by gender? After all, if we use the least ambiguous measure of health status, mortality rates, in all countries of the WPR women outlive men by an average of five years. However, epidemiological data suggest, without exception, that in terms of reported morbidity, women are in the worse position. This is especially the case for women who outlive their male counterparts and suffer from the "compression" of morbidity into the last ten years of their lives. In relation to existing indicators of economic status, political power, leadership and social standing, women consistently score worse than men. This is exacerbated for older women in societies where women are valued largely for their reproductive capacity. However, it is in subjective reports of quality of life that gender differences become most apparent. Living longer is not necessarily seen as an advantage for women who have a poor quality of life. This monograph ideritifies some of the social, political, economic and cultural factors which circumscribe older women's health experiences and quality of life. However, the report acknowledges that older women are not just victims of their environment, but that they can be actively involved in bettering their environment. The monograph concludes by identifying new initiatives being undertaken by countries in the Region to help secure a better quality of life for older women, and making recommendations for healthy aging.

f)4~ S.T. Han, MD, Ph.D. Regional Director

Acknowledgements We would like to thank Dr Elizabeth Eckennann, principal contributor to this monograph. This report was based on information collected from around the Region including country reports and discussions with participants at the Regional Workshop on Community Care for the Elderly in Manila in March 1995. The contributions of the following individuals and organizations are greatly appreciated: Dr Kongsap Akkhavong, Chief of Intemational Clinic and Geriatrics, Mahosot Hospital, Lao People's Democratic Republic; Professor Gary Andrews, Centre for Aging Studies, Flinders University of South Australia; Heather Birch, Executive Office, Aged and Community Care Branch, Commonwealth Department of Human Services and Health, Melbourne, Australia, Dr Tak-kwong Au. Department of Health, Hong Kong; Dr Ruth Bonita, School of Medicine, the University of Auckland; Warwick Bruen, Assistant Secretary, Community Care Branch, Department of Human Services and Health; Carol D' Audney, Ministry of Health, New Zealand; Gilda Estipona, Department of Health, Philippines; Susan Feldman, Director, Alma Unit for Women and Ageing, Key Centre for Women's Health in Society, The University of Melbourne; Anna Howe, La Trobe University; Dr Sunia Foliaki, Ministry of Health, Tonga; Dr Salesi Katoanga, UNFPA, Fiji; Lee Cheong-Ja, Director, Resource Development Department, Korean Women's Development Unit; Diane Morris, Ministry of Women's Affairs, New Zealand; Mesepi Mulitalo, Health Department, Apia, Samoa; Lillian Nakamura, Office of the Ministry of Social Services, State Unit Agency in Aging, Republic of Palau; National Health Planning Unit, Ministry of Health, Republic of Vanuatu; Dr Nor Aini Bt. Mohd. Noor, Ministry of Health, Malaysia; Janette Padasian, Sabah Tourism Promotion Corporation; Anne Riggs, Research Fellow, Centre for the Body and Society, Deakin University; Hong-kwon Shin, Ministry of Health and Welfare, Republic of Korea; Dr Yoichi Takigawa, Ministry of Health and Welfare, Japan; Dr Tingika Tere, Medical Officer, Ministry of Health, Cook Islands; Professor Tran Duc Tho, National Institute of Gerontology, Vietnam; Heleena Togakilo, Women, Youth and Sports Officer, Department of Community Affairs, Government of Niue; Sister Mereani Tukana, Divisional Health Sister, Ministry of Health and Social Welfare, Fiji; Dr Gim Hong Yap, Tao Payoh Senior Citizens' Health Care Centre, Singapore; Dr Nhonh Bun Yay, Deputy Director, Ministry of Health, Cambodia; and Dr Zhu Han Min, Deputy Director, Hua Dong Hospital, Shanghai Geriatric Institute.

Introduction

This report examines the health status, experiences and needs of older women and the process of aging in the Western Pacific Region from a life course perspective, emphasizing that circumstances and choices at all points of the life course influence the individual's outcome in old age. Key issues are discussed and the implications of the health experiences of currentl y older women and predicted demographic and social changes are used as the basis to make recommendations for the future. Women's experiences of aging vary enormously across the Western Pacific Region due to a wide range of political, economic, social, cultural and physical circumstances. Countries in the Region include some of the most economically advanced and some of the least developed in the world. Populations range from over one billion to less than two thousand. The life expectancy at birth in Japan is over 80, almost double that in the Lao People's Democratic Republic. These huge variations mean not only that women's aging experiences are different, but that there is no simple _1_

way to define the older woman in the Region. The traditional cut-off points of age or post-menopause do not apply in countries where women rarely become old enough to reach menopause, or cultures where menopause is not considered a major transition for women. The WHO Regional Office for the Western Pacific (WPRO) has recognized the importance of the health needs and experiences of the growing numbers of older people in the Region as witnessed in its vision for the future: New Horizons in Health. The central concepts of health promotion, health protection and quality of life, coupled with the adoption of a life course approach, are critical for the formulation of strategies for older women now and in years to come. Despite recommendations on the need for gender-disaggregated, genderspecific and gender-sensitive data, adopted as far back as 1975 by the World Conference of International Women's Year in its World Plan of Action, very few statistics are gathered

Women's Experiences of Aging in the WPR: A Diversity of Challenges and Opportunities

on that basis anywhere in the world. Those that are collected and systematically recorded relate to reproduction, for example maternal mortality and fertility rates and level of breast-feeding. There is an implicit assumption in much health policy planning throughout the world that gender differences in health status and health experiences are only evident during the reproductive years of a woman's life, and that, prior to puberty and post-menopause, the health experiences of males and females converge. Thus the health needs of older women in the Western Pacific Region, like those of older women in the rest of the world, remain unknown. In 1993, the Asian Development Bank produced a regional publication entitled

the calls for gender-disaggregated data two decades ago, little has changed. At its inaugural meeting in Geneva in April 1994, the Global Commission on Women's Health, set up by WHO to develop global objectives to improve the health of women, reported the continuing problem of lack of data on older women's experiences of aging. Policy and planning processes directed at fostering healthy aging must be based on sound information and must cater for the current needs of older women (secondary prevention, provision of care and rehabilitation and attention to quality of life) and prepare the conditions for positive aging for subsequent generations of women (primary prevention and health promotion in preparation for life and for protection of life). This report examines the health context of the lives of Western Pacific older and aging women and the implications for policy. It complements the draft global report on 'Women, Aging and Health' prepared for the third meeting of the Global Commission on Women's Health (Perth, Australia, 1995), which provides more details of the demographic transition to older societies and a comprehensive coverage of the major health problems faced by older women.

Gender Indicators oj Developing Asian and Pacific Countries which disaggregated a number of demographic and socioeconomic indicators by gender and provided some gender-specific indicators. The United Nations published a Statistical Compendium on Women in Asia and the Pacific (ESCAP) in 1994. However, the majority offemaie-specific indicators still refer to aspects of reproductive functioning. The need for more comprehensive gender-sensitive and gender-specific data persists. Despite

..£..

Background

2.1 Global

Initiatives

A series of global initiatives addressing the issues of women and aging commenced with the United Nations Decade of Women launched in Mexico in 1975. This was followed by the 1982 Vienna Plan of Action on Aging, the Nairobi Forward-looking Strategies at the end of the UN Decade of Women in 1985 (where women and aging was addressed for the first time on an international scale), the 1986 United Nations Commission on the Status of Women, the 1991 United Nations Principles for Older Persons adopted in New York, the 1993 World Conference on Human Rights and the 1994 United Nations International Conference on Population and Development in Cairo. These initiatives will culminate in the Fourth World Conference on Women in Beijing in September 1995 and the United Nations Year of Older Persons in 1999.

The preparations for the Fourth World Conference on Women have prompted considerable research activity. In the health field, WHO has established a Global Commission on Women's Health and this has been complemented with preparatory activities at the regional, national and local levels. In Australia, the Prime Minister has committed A$3.5 million of the general budget to a longitudinal study of women's health, and similar initiatives are emerging in other parts of the world. The Beijing Conference will provide a forum to identify the issues associated with: planning for the gender imbalance in the demographic shift to 'older'societies including the provision of appropriate care; the political, economic, cultural, social and religious influences on women's health as they age; the problem of obtaining sufficient gendersensitive and gender-specific data to plan for the needs of older women and for the process of aging in women; the quality of life as well as the mortality and morbidity patterns for older women; the effects on women of continued agism and sexism; and the need to cater

Women's Experiences of Aging in the WPR: A Diversity of Challenges and Opportunities

for the huge diversity in women's experiences of aging. At the global level health indicators for Disability Adjusted Life Years (DALYs) and Quality Adjusted Life Years (QAL Ys), for example the WHOQOL, are being refined and developed to help researchers and policy-makers address the needs of the aging population. These are discussed in detail in Section 3.5.

comprehensive range of services for older people through cooperation between government, nongovernmental organizations and the private sector, and the importance of quality oflife in old age. The rights of older people to achieve a good quality of life in old age and to be provided with quality care when needed were reaffirmed, and these rights were considered to extend throughout the whole of life, including the right to die with the minimum of distress and with dignity. The conclusions of the seminar in the specific areas of health promotion and disease prevention, community health services and residential care, reflected the urgent need for national policy formulation, comprehensive planning of services and human resources, including training and education, and the funding implications of these needs in view of the increasing numbers and proportion of aged in all populations. The seminar proposed an action plan to monitor progress towards achieving a set of modest but important regional and national goals for the health of older people in the next three to five ,years (WHO-WPRO, 1993 b:2). A follow-up WPRO workshop on Community Health Care Approaches to Improve Quality of Life in the Elderly was held in Manila, March 20-24 1995. That forum recommended that, in accordance with the recommendations

Regional The publication of New Horizons in Health by WPRO highlights the changing approach to health issues in the light of changing circumstances in the Region. The document recognizes the importance of the life course approach to the health of older people, and takes into account the dramatic changes taking place in all aspects of life in the Region. Policies that address health promotion, health protection and quality of life will have direct consequences on the health and wellbeing of the older population, both now and in the future. The WHO Regional Office for the Western Pacific held a seminar in 1993 to review care of older people in the Region. The seminar addressed changing patterns of care and family support, the need to develop a

Background

of the 1982 World Assembly on Aging - Vienna Plan of Action, a National Council on Aging, or some equivalent governmental peak advisory body, should be created to coordinate the development of national responses to population aging and the needs of older people. It was recommended that this Council be complemented with the creation of an Office on Aging in each country to develop a national policy on health and care of older people. Appropriate multi-disciplinary workforce training, enhanced by the use of the recently published WPRO manual Quality Health Care for the Elderly, and continuing education to incorporate aspects of healthy aging into health practice, were emphasized. Preventing unnecessary, premature and involuntary institutionalization of older people by providing appropriate and comprehensi ve community and household services and support, for both older people .and their carers, was a key concern. The protection of older people's rights, quality of care standards and the development oflegislation and regulation to enforce such standards for both home and institutional care were also stressed. Of particular importance to the current analysis was the recommendation that all data be disaggregated by sex, ethnicity and other dimensions of difference and that gender-specific characteristics and needs for older women and men be given special consideration. Thus the diversity of experiences of aging was acknowledged.

2.2

Regional diversify

The Western Pacific Region extends from the South Island of New Zealand in the Southern Hemisphere to the nor1hem tip of Mongolia in the Nor1hem Hemisphere (see map). Its westernmost boundary is China's border with Pakistan and Tajikistan, and in the east the Region extends to French Polynesia It contains countries that are continents in themselves or parts of continents, and an array of islands of different sizes. The economies of the Region range from post-industrial to feudal to tribal subsistence. Some countries in the Region (for example Japan) are among the most economically advanced globally and have moved from industry-based to service-based economies founded on advanced forms of information technology and communication. Others (for example Papua New Guinea and Lao PDR) are amongst the least industrialized and the least economically developed in the world. Subsistence, capitalist and socialist modes of

Women's Experiences of Aging In the WPR: A Diversity of Challenges and Opportunities

economic production are all represented in the Region. The thirty-six countries and areas in the Western Pacific Region are normally divided into four categories, based on their levels of economic development and geographic location. l. Developed countries with highincome economies: Australia, Japan and New Zealand.

democratic states, to people's republics. These political differences are interlaid with extra-country and intra-country variations in cultural practices and differing life expectancies, hence there is a vast diversity of experiences of being old and growing old in the Western Pacific Region.

2.3

2. Newly-Industrializing Economies (NIEs): People's Republic of China, Hong Kong, Malaysia, Republic of Korea and Singapore. 3. Southeast Asia: Brunei Darussalam, Cambodia, Lao People's Democratic Republic, Macao, Mongolia, Philippines and Viet Nam. 4. Pacific island countries and areas: American Samoa, Commonwealth of the Northern Mariana Islands, Cook Islands, Fiji, French Polynesia, Guam, Kiribati, Marshall Islands, Micronesia, Nauru, New Caledonia, Niue, Papua New Guinea, Republic of Palau, Solomon Islands, Samoa, Tokelau, Tonga, Tuvalu, Vanuatu and Wallis and Futuna. The geographic and economic diversity is matched by political, social and cultural diversity. Within the Region's vast area, which contains one-third of the world's population over 65 years, there exists a huge array of political regimes from kingdoms, to centralized

Defining the older woman

Background

yet again on reproductive functioning to define women (Kaufert,1982; Danguilan, 1994; Eckermann, 1994d). The concept of menopause is not as straightforward as many epidemiologists would have us believe (Kaufert,1982; Lock, 1993b; Ripper, 1994; Klein, 1994; Dumble and Klein, 1994). Lock (1 993b:348) reports an interview with a Kobe gynaecologist who claimed that not all women experience menopausal symptoms. This perception is backed up by women themselves. Lock (1993b:350), in a survey of 1 738 Japanese women, found that 40 per cent of the Japanese women interviewed agreed with the statement made by a Kyoto factory worker (that) "Konenki (menopause) starts at different ages depending on the person. Some start in their late thirties and some never have any symptoms; they don't have konenki at all" (Lock, 1993b:351-2). Daly's (1994:28) Australian research suggests that even within cultural groups there are enormous differences. She divides menopausal experiences into 'women drowning, women battling and women gliding' with the 'gliders' hardly noticing menopause and the 'drowners' being severely depressed, even suicidal. Rice (1995) notes the systematic absence of menopausal symptoms among women from Lao PDR but argues that with exposure to mainstream Western medical services, their positive experience of menopause may be modified and they may be 'encouraged

A key problem in conducting research on 'older women' is defining the concept. The life expectancy of women at birth in the Western Pacific Region varies from 47.5 years in Lao PDR and 49.9 years in Cambodia to 81.8 years in Japan and 81.4 in Macao. Consequently, it is not possible to use an age-based cut-off point, say 60 years, to designate 'older women' across the Region because it would exclude those 'ol~er women' in countries where the life expectancy is less than 60. A common demarcation is menopause; however, this is problematic given the extension of the menopausal transition in some women to many years (for example in Japan) (Lock, 1993b), the continuing incidence of early menopause in some countries of the Region, the use of hormone replacement therapy to disguise the onset of menopause (Klein, 1994; Dumble and Klein, 1994; Coney, 1994) and the tendency to rely

Women's Experiences of Aging in the WPR: A Diversity of Challenges and Opportunities

to interpret menopause as a medicallyoriented event and thus experience menopausal symptoms in 1he way many Australian women do'. Do women who are on hormone replacement therapy and continue to menstruate count as 'older women'? What about countries where the majority of women do not even reach menopause? Do we deny them the right to call their chronologically senior women 'older women'?

For this analysis, we have chosen to let countries apply their own definitions of what constitutes 'older women', but for the purposes of establishing the demographic trends in the Region we have adopted the conventional epidemiological age delineations of 60 and 65 years. However, overall, the analysis adopts a life course approach which acknowledges the fact that social, economic, political and cultural circumstances as well as individual choices at all stages of life influence health outcomes at later stages of life.

Key issues

3.1

Changing demographics and the need to plan for the future

*Unless otherwise stated, figures are from WHO, WPRO, 1994b.

Women's Experiences of Aging in the WPR: A Diversity of Challenges and Opportunities

The largest population in the Region is found in China with one and a quarter billion people (1993). Japan is second with 125 million (1992), Viet Nam third with 68 million (1991) (ESCAP figures, 1994c, estimate over 72 million in 1994) and the Philippines a close fourth with 63 million (1992) (ESCAP, 1994c, estimates nearly 68 million in 1994). The Republic of Korea is fifth in size with over 44 million (1993). There is then a large jump in total population to Malaysia with over 19 million (1993) and Australia 18 million (1993). The islands in the Pacific have exceptionally small populations; at the bottom end of the scale Niue has 2,500 inhabitants (1990) and Tokelau only 1,700 (1992). Given these huge discrepancies in population size, one must be cautious of statistical artefacts in making comparisons between countries in the Region. Countries are at varying points in the demographic transition from high birth and death rates to low birth and death rates, but almost all are experiencing a dramatic increase in the mean age of the population and consequently in the proportion of older people. The process of rectangularization of the survival curve is at an advanced stage in developed countries with high income economies (Japan, Australia and New Zealand), and this process will be accelerated as the 'postwar baby boomers' start to reach retirement age in 2005.

In 1994, 15.63 per cent of New Zealand's population was over 65 years old and women made up 60 per cent of that group. The proportion over 65 in Japan and Australia was 12.6 per cent and 11.3 per cent, respectively (ASS, 1994). There was then a huge gap to the Cook Islands with 8 per cent of the population over 65, Tokelau with 7.4 per cent and Macao with 6.6 per cent. The majority of countries in the Region currently have between 6.3 and 3 per cent of their populations over 65 years old. At the bottom of the ladder comes Cambodia with 2.8 per cent, Papua New Guinea with 2.3 per cent and the Mariana Islands with 1.6 per cent. The reasons for such low proportions of older people in these countries relate to both birth and death rates. Figure 1: Relative proportion of the elderly in the populations of the Region compared to the proportion ofthe elder(v in the world 20r--------------------------,

1 ~

·~~~~~~r

---------------

=:= ~:~~:n __ I 2020

1990

2000 Year The Sex and Age Dislribulion ollhe World Populalion, U.N., 1992 revision

Source:

Key Issues

In some of the Pacific islands, birth and death rates remain high. For example in Tokelau, the total fertility rate is estimated at around 4 and the infant mortality rate is 65.2 per 1,000 live births. In Tuvalu the total fertility rate is 3 and the infant mortality rate is 73.6 per 1,000 live births. This contrasts sharply with places like Hong Kong with a fertility rate of 1.3 and an infant mortality rate of 4.9 per 1,000 live births and Japan's fertility rate of l.65 and infant mortality rate of 4.8 per 1,000 live births. The continued high fertility rate and reducing infant mortality rate in some of the Pacific and Southeast Asian countries means that there is not much variation in dependency ratios across the countries of the Region, although the age bracket of the dependent populations varies. The highest dependency ratios are found in Lao PDR, Vanuatu, and the Solomon Islands, all of which have over 40 per cent of their population below 14 years old. Singapore, Hong Kong, Australia, New Zealand and the Republic of Korea have the highest proportion of people over 60, but the lowest dependency ratios (ESCAP, 1994c). This reality seriously undermines the alarmist attitudes towards costs of aging populations. Donath (1994:24) argues that, in Australia 'by the year 2040 we will have just got back to about the point where we were in 1901 in terms of the total proportion of the population that still has to be cared for and looked after by those who are economically

active' and she questions the notion that it is more expensive to look after older people than younger people. Donath argues that the reason that alarm has been raised about the costs of a greying population is related to the high visibility of government spending for the aged compared to the relative invisibility of investment in the young. However, national figures can be deceiving and can disguise huge intranational variations. Immigrant and aboriginal populations within countries often have very different figures. For example, Australia has a low fertility rate (l.91) and a low infant mortality rate (7 per 1000 live births) but the situation for aboriginal Australians is very different. Aboriginals in Australia have four times the infant mortality rates of non-aboriginal Australians (AJHW, 1994). Similarly the New Zealand official statistic on the percentage of older women needs to be further disaggregated by race since this figure disguises massive intra-group variations. Bonita (I 993: 192) argues that 'compared with the Pakeha (white) population, ethnic minorities in New Zealand have more youthful age structures'; for example, in 1991 'only 2.5 per cent of Maori women (were) aged 65 and over' compared to 14 per cent for Pakeha women. Newly industrializing countries such as Malaysia also contain major variations in demographic characteristics. Malaysia has very different age profile!;

.li

Women's experiences of Aging In the WPR: A Diversity of Challenges and Opportunities

between the eastern states in Borneo and Peninsular Malaysia. For example, in contrast to the Peninsular states of Malaysia, Sabah has a high population growth of 3.79 per cent (1970-1981) and an extremely young population with a high fertility potential (Abdullah, 1992). The population over 65 years declined from 2.2 per cent in 1960 to 2 per cent by 1980 with slightly more males than females. However, commonly applied dependency ratios are not useful in Sabah, where many children in the rural areas enter the workforce from age 10 and many 50-55 year olds are 'already too old to participate actively in economic sectors which are agricultural in nature' (Abdullah, 1992:100). There is a continued tendency among the ruralbased ethnic groups towards a large family size to provide rural labour and as insurance in old age. Sabah also has a predominance of males in its population largely as a result of a large influx of immigrant labour. The total male/female ratio increased from 106.5 in 1951 to 109.4 in 1980. Consequently, Sabah faces a different policy decision on population and health from other states of Malaysia (Yusof, 1992:28-9). Even within Sabah there is large variation between the 26 ethnic groups. Kadazans are the largest group followed by Chinese, Bajaus, Indonesian immigrants, Muruts, Filipinos and Malays. In every ethnic group men outnumer women, and this is most marked in the old and new labour immigrant groups (Chinese, Malay,

Filipinos and Indonesians) (Abdullah, 1992). Historically, there were two patterns of transitions in Sabah, one for the 'Chinese in the towns and (another for) the local population in the rural peri phery'. Alongside this has been a massive 'depopulation among one of the indigenous groups, the Muruts' up until the 1950s largely as a result of 'malnutrition, imbalanced diet, and lower resistance to malaria, hook worm, gonorrhea and goitre'(Hadi, 1992). Despite the variations between and within countries in birth rates and mortality rates, the trend is towards significant decreases in' both of these demographic indicators in the newlyindustrializing nations, 1he Pacific islands and Southeast Asia towards the tum of the twenty-first century, in line with the experiences of the countries with established market economies in the Region.

The demographic shift is female In most countries of the Region the population over 65 years old is predominantly female, reflecting the better survival rates of females at all stages of the life course despite being outnumbered at birth. In Cambodia, women make up 58.8 per cent of those over 65 (Kingdom of Cambodia, 1994), in Australia the corresponding figure is 57.2 per cent (ABS, 1994) and in most countries (except for intra-country variations) the figure is between 50 and

Key Issues

60 per cent. However, although it has the largest population in the Region, China is anomalous in that the population over 65 years is predominantly male, a demographic characteristic brought about by the effects of a history of cultural preference for male children. This trend continues: 'China has one of the world's most skewed birth rates: in 1994 117 boys were born for every 100 girls; the worldwide average is 106 males for every 100 females' (Asiaweek, 1995: 32). This gender imbalance, across the life course, has long-term implications in relation to population policy and provision of services for older people in China

from those which shaped today's 65year-old women. The heterogeneity of needs and experiences amongst older women extends to their geographic location, their cultural and sub-cultural traditions and a raft of other dimensions of differentiation. Older women and aging women are not a homogeneous block with shared interests, values and needs. 'The last decade of the twentieth century is witnessing economic, political, social and technological changes on a scale rarely seen in the history of human beings ... while the health status and quality of life of both men and women will be affected, women will experience the health consequences of the change process in specific ways due to their biological, social, psychological and gender differences with men' (WHO, 1994b:6).

3.2

Influences on health - the life course approach

Political history in the lifetime of older women 'The march towards greater democratization is already having a significant effect on women' (WHO, 1994b:6). However, countries in the Western Pacific Region are marching at different paces and many older women have not recovered from the devastation of political disruption, including war. The current democratization should have significant effects on the health and well-being outcomes in old age of the currently

Today's girl toddlers are 2060's 65-year-old women. Their experiences of the world are going to be tempered by events which are vastly different

Women's Experiences of Aging In the WPR: A Diversity of Challenges and Opportunities

YOWlg, but in contemporary terms 'many women ... are still denied access to decision-making processes... there (remain) fWldarnentai contradictions in the democratic ideal' (WHO, 1994b6). Women in all COWltries of the Western Pacific Region are mobilizing to ensure that their basic human rights, as expressed in an array of international charters, are being respected (Cook, 1993; Hausemar.n, 1993), but 'while democracy opens up prospects for equal opportWlity between men and women, it does not necessarily provide the mechanisms for effective expression,

nor does it address the Wlderlying roots of discrimination which continue to flourish in democratic systems' (WHO, 1994:6-7). Women in Mongolia who have benefited from significant developments in social, economic and political freedom since 1921, are suffering from the political and economic changes brought about by the collapse of the Soviet Union. Their levels of employment and their gains in terms of child care and the social wage have been significantly eroded since the move to a market economy in Mongolia over the last five years.

Key Issues

Older women in Lao PDR, Cambodia and Viet Nam still bear the scars of the recent wars which raged through their countries for three decades. Civil strife as the aftermath of war continues in many countries. In Cambodia there has been a massive dislocation of families. Some fled as refugees, others stayed in Cambodia and witnessed the loss of a major part of a generation of men, and many households are now female-headed because of this. Although there is massive loss of male lives during wars, women also suffer significantly and continue to suffer in the aftermath of war. Women in all countries of the Region were expected to pick up the pieces after the Second World War. They were obliged to care for and nurture their traumatized husbands and sons who returned from the war physically, mentally and emotionally damaged. Women were removed from the workforce where they had been active in the absence of men during the war, and were expected to bear and raise what came to be known as the 'baby boom' generation. Essentially, women were expected to playa central role in creating and maintaining the conditions for peace. At the recent Third Women's Solidarity Forum on Military Sexual Slavery by Japan, in Seoul (February, 1995), Chinese, Filipino and Korean women still suffering the physical and psychological effects of their use as 'comfort women' during the Second

World War, demanded compensation for a lifetime of post-traumatic mental emotional and physical ill-health: Women in Japan continue to suffer the psychological, physical and genetic damage caused by the atomic bombs that were dropped on Hiroshima and Nagasaki.

Economic history in the lifetime of older women Women in developed countries were encouraged to give back jobs to returned servicemen after the Second World War and return to the domestic sphere to raise children, but the experiences of fulfilling employment during the war left a mark. By the 1950s, women in the developed economies of the Region were returning to the workforce in large numbers. This femininization of the labour force was reinforced with women's political struggles for equality in the second wave feminist movement which emerged from the civil rights movement in the 1960s. Women in the newly-industrializing countries were expected to provide labour f()r the emerging manufacturing industries and so became a flexible source of labour to be recruited in times of need. Women in the Pacific islands have not increased their labour force participation rates to the same degree as women in the developed and newly-industrializing nations and Southeast Asia (Asian Development Bank, 1993). Women's labour participation rates are highest in

Women's experiences of Aging In the WPR: A Diversity of Challenges and Opportunities

China (75 per cent), although there are significant differences across the life course with participation rates for women in the 50 to 54 age cohort being around 60 per cent, where they closely approach the levels for men. In Viet Nam, the overall female labour participation rate is over 60 per cent, which is about the same level for women 50 to 54 years old. In the Philippines and Korea, women's labour participation rates are higher for the 50 to 54 cohort than for the 30 to 34 cohort, which reflects the tendency with growing affluence for women to withdraw from the labour force during child-rearing. The increase in women's labour participation has had a significant effect on women's economic freedom. However, we need to be cautious in seeing this as an upward trend. In most countries of the Region, women's labour, especially manual labour, is seen as flexible and women are the first workers to be laid 'Off in times of recession. This makes women particularly vulnerable to the effects of privatization and the vagaries of the market as exemplified in the case of Mongolia. The concept of a welfare safety net, yet to be developed in some countries of the Region, is under threat in the more developed countries of the Region. Women remain economically disadvantaged compared to men in all countries of the Region.

•

In some countries planned state investment in the social sectors has corne to a complete halt, and private expenditures on education and health have been constrained by declining incomes and increasing poverty. Today, the ranks of the poor are disproportionately filled by singlewomen-headed households. The coping strategies of such women and the extent to which they can count on assistance from absent partners and fathers is largely unknown. Poor women resort to coping strategies which include recourse to accepting work with high health risks, or prostitution. Many of them are easy prey for the rising number of criminal prostitution rings (WHO, 1994b: 9-1 0).

•

Women have been adaptable in earning money in the informal market during times of hardship. In some cases this involves street vending and cottage industries. For some women the opportunities are not so open. A later volume in this series deals with the specific issues of sex workers in the Region. Suffice to say here, the long-term physical and psychological effects of prostitution are understudied. Women are vulnerable

Key Issues

increasingly evident as the welfare systems of the established market economies erode. The long-term effects of repetitive strain injury, neglect of family nutrition and recruitment within the family of child labour (with associated absenteeism from school) to assist with piece-work are as yet unknown.

Education and Health One of the strongest social indicators of health is women's level of literacy and education. Powles (1977) found that the state of Kerala in India, although having one of the highest population iensities and being one of the poorest states in the country, had the lowest general mortality and infant mortality rates in India The factor used to explain this was the high rates of female literacy in Kerala. These findings have been used as a benchmark for equating higher literacy rates with better health. However, there are conflicting statistics on levels of literacy. In the Western Pacific Region, adult literacy rates are high compared with the rest of the world. The Cook Islands, New Caledonia and Japan report 100 per cent literacy rates. French Polynesia, Brunei, Australia, Guam, Kiribati Macao Mariana Islands, the Marshail Islands, New Zealand, the Republic of Korea, Samoa, Singapore, Tokelau, Tonga and Tuvalu all report over 90 per cent literacy. The lowest

to sexually transmitted diseases, including AIDS, l:>ecame of religious and client-demand problems in using condoms, to fluctuating demand, exploitative pimps and redundancy and ostracism as they age. Some women take on outwork, especially in the clothing industry, to make ends meet when they cannot gain employment in the formal employment market. This is the experience of women in nearly all the countries of the Region regardless of their level of economic development, and will be

Women's Experiences of Aging In the WPR: A Diversity of Challenges and Opportunities

reported rates of adult literacy are in Vanuatu (33 per cent), Cambodia (35.2 per cent) and Papua New Guinea (45 per cent). The Pacific islands, with the exception of Vanuatu, have the highest literacy rates and the lowest discrepancies between the sexes in literacy rates. Their literacy rates and gender differentials are better than for some of the developed high income market economies, including Australia and New Zealand. Yet their general and infant mortality rates are among the highest in the Region. For example, Tokelau has a female literacy rate of 99 per cent but an infant mortality rate of 65.2 per 1000 live births. Australia has a female literacy rate of only 82 per cent compared to 90 to 100 per cent in the Pacific Islands, yet a low infant mortality rate of7 per 1000 live births. The largest gender discrepancies in literacy rates are in Lao PDR (male 65 per cent and female 36 per cent), Malaysia (male 80 per cent, female 64 per cent), Viet Nam, Australia, Brunei and Fiji. The Philippines, which has one of the highest median years of educational attainment for women of the Asian Pacific region (ADB, 1993; ESCAP, 1994a), still has high infant and maternal mortality rates. In this case, high levels of female literacy cannot be used as a de facto indicator of health status as measured by mortality. In Lao PDR and Cambodia, both with low literacy rates for women and high infant

mortality rates of 117 per 1000 live births, the Powles thesis applies. Thus, caution is needed in using female literacy rates as an indirect indicator of health status largely because of conflicting defmitions of ,literacy' used in data collection. The health status of populations has to be analysed at the national level (if not regions within national boundaries) to isolate social, economic, cultural, political and administrative factors that may contribute to unique health outcomes and those that do not fit expectations. Indicators of morbidity, quality oflife and general well-being may equate more closely with levels of educational attainment and literacy rates than mortality rates.

Religion and health The positive health and well-being effects of religious beliefs are well documented. Durkheim (1965) noted the relationship between high levels of religious adherence, social cohesion and low rates of suicide. Quality of life and well-being scales (including 1fle new WHOQOL 100) often include spirituality as a key dimension in assessing quality of life. However, despite philosophies to improve life, adherence to religious beliefs can have some unintended negative health consequences. The observance of cultural interpretations of

Key Issues

Koran teachings in relation to female genital mutilation amongst Muslims in the Region is a case in point. The longterm effects of radical genital mutilation are particularly important during childbirth. In parts of the Region, a less radical form of female circurnsion is performed to reduce sexual sensation in women. The question arises of whether health policy should be relative in this area of women's health or more absolute. The effects on women's sexuality of any level of genital mutilation is an issue which must be debated. Christian religious teachings and practices can have equally damaging negative consequences to health and well-being. For example, Catholic teachings against contraception, abortion and divorce can have serious long-term consequences for women. Unwanted and/or many closely-spaced pregnancies may involve economic, social, relationship and mental and physical health disadvantages. Similarly, sanctions against divorce may keep a woman in a marriage which may be unsatisfactory or which may expose her to domestic violence, and can have longterm consequences for her sense of well-being as well as her physical and mental health. Guilt generated by the teachings of the Christian churches may significantly influence women's wellbeing, as witnessed in the experiences of women who self-starve (Eckermann, 1993).

3.3

lack of adequate research and data

Policies for older women's health need to be based on the appropriate research and information, but the Global Commission on Women's Health reported at its first meeting in Geneva, April 1994, that 'little data exists on the health conditions of the elderly female population except in industrialized countries from which extrapolation is made' (WHO, 1994b:27).

Why women's health? The question arises of why, after nearly two decades of special attention to women's health (which included the UN decade for women), do we need to launch yet another crusade to promote the health and well-being of a group of people defined by their gender'? After all, if we use mortality rates, the least ambiguous measure of health status, in most countries men's life expectancy at all ages is less than women's (WHO, 1994a). Thus it would seem appropriate to ask the question that Broom (1991:32) does: 'Why women's health rather than men's health or people's health?'

Women's Experiences of Aging In the WPR: A Diversity of Challenges and Opportunities

This question was raised at a public level in Australia recently with a legal challenge to designated women's health services in that country (Broom, 1994). The case hinged partly on the problem of the use of indicators of health status. Broom (1991 :vii) encapsulates the argument for gender specificity, beyond reproductive issues, in her claim that 'One great gift of the women's movement has been its insistence that there is no neutral, genderless, objective position from which to view the world or speak about it'. This claim does not support an essentialist argument that 'the female body is a preexisting, timeless essence' but rather that the body 'as studied or lived is always in the process of being produced socially, culturally and psychically' (Broom, 1991:149). Given current social, political and economic arrangements between the sexes in all parts of the world (Asian Development Bank, 1993; World Bank, 1993), it is inevitable that women will experience their bodies, as well as their health and illness, differently from men. That is not to say that biology does not playa part, but the experience of that biology is tempered by social, economic, political and cultural forces, including the cultural forces that define who can be healers or health promoters in each society. The need for gender specificity in areas other than reproductive functioning is based on arguments about sex and gender. Sex is biologically defined, and

if we assume that biological functioning alone determines the differences between men's and women's experiences of their bodies, we would only need specific data for women in reproductive areas. Gender refers to the cultural, social, temporal and political construction of men and women. The implications for health, and the type of information that we need to assess women's health, of adopting a gender perspective rather than a sex perspective are profound. Broom (1991 :46) argues that 'a woman's body has been constituted throughout her life through distinct psychic and cultural processes that do not cease to apply simply because the organ in question is also present in male bodies'. However, these arguments can also be used against women, as in the case where the woman's whole body and her economic and social functioning is assumed to be pervaded by her sex. The example of late luteal phase dysphoric disorder (or pre-menstrual tension) points to the trend in much medical literature to emphasize the allpervasiveness of sexual organs"and/or hormones in influencing women's minds, bodies and activities 'which lodges women's "otherness" in every cell of her being' (Ripper,1994:117). The same sort of endocrine-determinism has been applied to women's health in relation to menopause (Lock, 1993a; 1993b; Kaufert,1982). Broom (1991:46) uses hysteria to illustrate the tendency for

Key Issues

'apparently asexual processes and parts of the body (to) become "sexualized'" . Malestream methodologies and malestream data do not necessarily reflect either women's objective or their subjective experiences of health, illness and disability. Androgenizing, 'total population' tendencies in health promotion research have been particularly inappropriate for women. For example, the use of the Body Mass Index and total weight (rather than relative distribution of weight) to establish risk of heart disease is not only inappropriate for women, but may also have serious unintended consequences as acknowledged by a key report on eating disorders in Australia (Ben-Tovim & Morton, 1989). Their Report argued that:

The same case can be made for population-based cholesterol-lowering campaigns, since the scientific data supporting the need for such campaigns is currently being seriously disputed (Hughes, 1994). Similarly, the 'untoward effects' of such campaigns systematically affect women more than men (Eckermann, 1994b) given that women 'make up 90 per cent of the diagnosed cases of anorexia nervosa and bulimia' (Ben-Tovim & Morton, 1989). Numerous examples of the problems of assuming the 'globalization of risk' and applying aggregated data to specific populations can be found in the nutrition area Applying inappropriate data to specific populations was glaringly illustrated in the following report in one of Australia's more respectable newspapers:

Women's Experiences of Aging in the WPR: A Diversity of Challenges and Opportunities

Further reading revealed that the article was based on preliminary results from an American study of 400 males aged 15 to 34 years. In the health field, just any body or group of bodies will not do to standardize measures and develop health campaigns to be used in heterogeneous populations articulated by gender, age, social class, race, ethnicity, geographical location and other dimensions of difference. We cannot have single generic health promotion messages such as 'eat less fat, less sugar, less salt'. For a young woman on starvation rations of a lettuce leaf and a wafer biscuit a day, such a message means 'cut out the wafer biscuit'. Similarly, for third world populations whose calorific intake is inadequate, such global messages make no sense. Yet some populations within 'developed countries' contain groups of people living under third world conditions (for example in some Australian Aboriginal communities). These examples illustrate the need for gender-disaggregated, gender-sensitive and gender-specific indicators in nonreproductive areas of health. As McBride and McBride (1981) argue, to gain a clear picture of people's health status we need to find out about their lived experiences of their bodies, and lived bodies are gendered bodies. Similarly, very little information is available on women's experiences of mental health. Indicators of health status need to be developed which reflect women's psychological and emotional health and illness experiences.

Indicators of health status The World Health Organization's Global Strategy for Health for All by the Year 2000', based on the Declaration of Alma Ata, was adopted by the Thirty-fourth World Health Assembly in Geneva in May 1979. The Strategy represented a watershed in approaches to primary health care by reinforcing the notion that health is a positive attribute, not just the absence of disease, and in its emphasis on the intersectoral nature of health promotion and disease prevention. It also qualifies WHO's (1946) broad defmition of health, which emphasizes the rhetoric of human rights, to specify 'health for all' as 'a level of health that permits all people to live a socially and economically productive life' (WHO, 1981a). Thus there is a strong social justice and human rights agenda in WHO's call for improved health status via application of the Global Strategy, but also an emphasis on the value of productivity. Passed under resolution WHA 34.36, the Strategy emphasized the need for regular monitoring and evaluation of the Strategy and its implementation at the global, regional and national levels. The Strategy statement acknowledges the need to be somewhat flexible in interpreting the guidelines. The minimal list of indicators for which data are gathered on a global level, under the terms of the Strategy, cover social and economic measures as well as traditional mortality and morbidity

Key Issues

assessment. They include measures of political commitment to the Strategy on an official governmental as well as community level, GNP, proportion of GNP spent on health (and specifically local health care), equity in distribution of and access to resources (safe water, sanitation, immunization, essential drugs, trained personnel for pregnancy and childbirth), nutritional status of children (birthweight and weight for age), infant mortality, life expectancy, and adUlt literacy rates. The guidelines (WHO, 1981b) which are offered to regions and countries to develop their own indicators stress both human rights issues and pragmatic issues. They propose four categories of indicators: 'health policy indicators; social and economic indicators; indicators of the provision of health care; and indicators of health status including quality of life'. The guidelines are 'intended to help countries to select indicators based on their assessment of the organizational, technical and financial feasibility of collecting and analysing the information required' (WHO, 1981b:9). Thus a large discretionary element is built into the specifications.

rate, economically active population in the primary sector, percentage of GDP derived from manufacturing industries at constant factor cost, daily per capita calorie and protein supply, ten leading causes of communicable diseases morbidity, ten leading causes of mortality, and cases and deaths from 18 selected diseases (Health Information Unit, 1992). Despite the strong insistence in Alma Ata on the context of health and adopting a positive defInition of health and promoting human rights and social justice, the Global Strategy for Health for All 2000 Report emphasizes 'manageability' and 'practical feasibility' as the key criteria for selecting indicators. The question arises of whether this is achieved at the expense of 'meaningfulness'. Do the indicators chosen for their 'practical feasibility' accurately reflect people's understandings and beliefs about their health? For example, in Tagalog language and culture (in Manila and neighbouring provinces) the concept of 'binat' (most closely translated as 'relapse') is central in Tagalog-speaking Filipinos' understanding of health. People are seen as particularly vulnerable to 'binat' after surgery and after childbirth. A major factor in preventing 'binat' after childbirth is for the birth attendant Chilo!') to take over household tasks and to keep the mother's nutritional level high. Bisayaspeaking Filipinos from Visayas and Mindanao have a similar concept called

Health indicators In the Western Pacific Region Several indicators were added to the global list of twelve in the Western Pacific Regional Office of WHO. These were maternal rnortaIity, fertility

Women's Experiences of Aging In the WPR: A Diversity of Challenges and Opportunities

'bughat', which is prevented by the birth attendant taking responsibility for household activities, providing massages, feeding the mother special foods, ensuring that the mother does not bathe or leave the house for ten days after the birth, practising 'tuob' which involves smoking the mother in incense under a blanket and bathing the mother in a herbal bath for her first bath (Mendoza,1994). If Western measures of 'successful' birthing ignore these beliefs and values, such indicators will not accurately reflect women's experiences of well-being in childbirth. Fabros (1994) argues that the degree of sharing of household tasks would be an important indicator of Tagalogspeaking Filipino women's well-being. However, data in areas such as share of household tasks have in the past been dismissed by most data-gathering agencies on both feasibility and 'scientific' grounds. Such data have been viewed as difficnlt and expensive to collect as well as scientifically suspect, especially if qualitative research methodologies are employed to access the data. There is some evidence of a shift in attitudes towards qualitative data (Baurn,1993) on the part of health and medical researchers, which may eventually filter into health indicator research (AIHW,1994b). Similarly, Rice's (1994) research with Hmong immigrants (from Lao PDR) living in Australia suggests that 'morbidity' after caesarean section in

Hmong women relates more to cultural fears and beliefs about the 'spirit' leaving the body after 'cutting' than to post-natal depression or the physical aftermath of surgery. Relief of such 'morbidity' comes from cultural rituals conducted by Hmong priests in the theatre where the surgery took place rather than by psychiatric care or pharmaceutical and medical intervention. Rice points to strategies to deal with the resistance on the part of hospital administrations and health professionals to cater to the specific cultural needs of health consumers, in this case immigrant women.

Social indicators Women consistently score worse than men in relation to existing indicators of economic status, political power, leadership and social standing. If we compare the situation for women on these indicators a decade ago (Sandelowski,1981; Johnson,1983) with current figures (Asian Development Bank, 1993; ESCAP, 1994a & b), we observe little change. For example indicators of women's share of GNP, women's wages compared to men's, women's levels of unemployment, and women's participation in public life and governance still show that the inequities between the sexes consistently favour men (Asian Development Bank,1993). Kickbusch's (l994a) research in Eastern Europe reveals that in not one country in that region are women

Key Issues

treated as well as men in sociaI, political and economic terms. The situation is no different in the Western Pacific Region (ESCAP, 1994a & b). Illiteracy rates for women over 15 years in China, Malaysia, Indochina and Papua New Guinea, are nearly double those of men and these gender differentials are projected to persist in the 21st century. For example illiteracy rates for men in Cambodia fell from 58.7 per cent in 1985 to 51.8 per cent in 1990 and are expected to fall to 38.9 per cent in 2000. The corresponding illiteracy rates for women in Cambodia are 83.4 per cent (1985), 77.6 per cent (1990) and 64.9 per cent (2000) which remain almost double those for men (ESCAP, 1994a:4). On the other hand, there is very little sex difference in literacy rates in Japan, Australia, New Zealand and the Philippines. Without exception, countries of the Western Pacific Region continue to display significant wage differentials between men and women in all sectors of the labour market. Women's wages as a percentage of men's wages in manufacturing in Japan remained constant at approximately 43 per cent between 1981 and 1991. In Hong Kong between 1982 and 1991, women's wages as a percentage of men's, fell from 77.71 per cent to 69.47 per cent. This pattern is repeated across the Region and is coupled with higher unemployment levels for women in China, Japan and the Philippines

(ESCAP, 1994a) and increasing levels of unemployment in Mongolia The percentage of women in administrative and managerial positions in the Region for 1980-1989 varies from 30 per cent in Australia to 39 per cent in the Republic of Korea, however, the figure may be even lower for countries which do not report gender disaggregated statistics on employment.

In terms of political participation, women were not given the right to vote or to stand for election until the 1920s in Mongolia, the 1930s in the Philippines, the 1940s in Japan, Lao POR, the Republic of Korea, Singapore, Viet Nam and the Solomon Islands, the 1950s in Malaysia, the 1970s in Kiribati and the 1980s in Vanuatu. The Solomon Islands and Tonga have still not had any women in their national parliaments and Singapore elected its first woman parliamentarian in 1984. Mongolia was the first country in the Region to vote a woman into its national parliament in 1923, but in 1991 women still only occupied two per cent of the seats in parliament in that country (the highest figure for the Region being 21 per cent for China) (ESCAP, 1994a). Kim Sun-uk and Kim Myung-sook (1993: 238) note the situation in the Republic of Korea where women are 'legally ensured equal rights for political and public life in accordance with the constitution' but have very low rates of

Women's Experiences of Aging in the WPR: A Diversity of Challenges and Opportunities

participation in politics. They argue that this anomaly between legal rights and exercise of rights is attributable to continuing 'social prejudice against women' which results in the political arena being dominated by males and allows few opportunities for women to gain training in politics. One emmot separate health from issues such as education, employment and domestic arrangements (South Australian Health Commission,1992). Social aspects of life are critical contributors to a person's sense of quality oflife and well-being. This fact is reflected in the WHO definition of health as a 'state of complete physical, mental and social well-being' and the articulation of that broad concept of health in the Health for All Strategy. For example, levels of education for women have been used as a key summary indicator of health status (Asian Development Bank, 1993). However, as stated above, in the case of educational attainment and maternal mortality, the relationship between social indicators and traditional health indicators (mortality and morbidity) is often convoluted rather than straightforward. This is particularly the case where global, regional or national indicators disguise massive intra-group differentials, such as among the Aborigines in Australia

3,4

Morbidity and mortality

Morbidity Official morbidity statistics are problematic because they are usually based on hospitalizations and hospital separations. The morbidity experienced outside the hospital setting goes unreported. It is also difficult to get gender-disaggregated data on morbidity. The major cause of general morbidity outside obstetric problems, by hospital records, seems to remain infectious diseases across most of the countries of the Region. Respiratory problems are among the top four causes of morbidity in most countries. In China, Japan and the Republic of Korea, digestive diseases top the list. Influenza dominates the causes of illness in Guam, the northern Mariana Islands, Samoa, Tokelau and Tonga, while injuries and poisonings are the major cause of illness in the Cook Islands, Hong Kong and Singapore. Other key sources of morbidity are circulatory diseases (Fiji, Hong Kong, Japan), skin diseases (Tuvalu, French Polynesia, Vanuatu), malaria (Lao PDR, Solomon Islands), diarrhoeal diseases (Papua New Guinea, Viet Nam, Lao PDR, Philippines, Tonga, Tuvalu) and pneumonia (Philippines, Samoa). Given the high level of medicalization of childbirth in some

Key Issues

countries, both normal delivery and complications of childbirth and pregnancy loom large in morbidity statistics, for example in Australia, Malaysia and New Zealand. Other types of morbidity in the Region which are of interest are the incidence of under-nourishment in the Philippines, Papua New Guinea, Lao PDR and Cambodia. This is contrasted by problems of overnutrition in Australia, New Zealand, Tonga, and Niue. Societal responses to these contrasts vary. In Papua New Guinea, women's loss of weight with age is seen as a normal process (Jenkins, 1995) and thiness in old age is seen as aesthetically pleasing (Hughes, 1993). In Niue, obesity in middle-aged and older women is seen as normal by the population at large although health authorities see it as a IIll\ior health problem and the basis for major health promotion campaigns (Togakilo, 1995, personal communication)'. Breast and cervical cancer, heart disease, diabetes, hypertension, osteoporosis, incontinence, dementia, arthritis and rheumatism, insomnia as well as tension, nervousness, emotional and depressive problems are emerging as major causes of death, morbidity and disability amongst older women, alongside the traditional diseases of pneumonia, influenza, bronchitis and emphysema, deafness and eye problems in the newlyindustrialized countries as more women reach the 'old old' age group (see Draft Global Report 'Women's Aging and

Health' WHO, 1995). In relation to morbidity resultng from menopause, it is not possible to generalize as women's experiences of menopause are so varied even within cultural groups (Daly, 1994; Coney, 1994; Dumble and Klein, 1994). Without exception, epidemiological data suggest that women in the Western Pacific Region are worse off than men in terms of reported morbidity. This is especially the case for females who outlive their male counterparts and suffer from the compression of morbidity in the last 20 years of their lives. In provider-reported and selfreported health care-seeking, women also outscore men significantly (Nathason, 1977; WHO,1994a; AIHW, 1990,1992,1994a). Women seem to fare far worse on all measures of nonfatal morbidity and disability (Saltman, 1991; Sandelowski,1981). This may be partly an artefact of the diagnostic and accounting processes used to ascertain morbidity levels. Saltman (1991 :66-68) suggests that using hospital admissions and separations as an indicator of morbidity skews morbidity rates by gender because of a culturaI bias towards hospital-based childbirth and the compression of chronic illness in the 'old old' women who outlive men. Similarly, Saltman argues that the use of visits to the doctor and sickness certification as indicators of levels of illness masks the cultural tendencies to medicalize transitions or major 'events in the life cycle of women' such as

Women's Experiences of Aging In the WPR: A Diversity of Challenges and Opportunities

menopause and to view sickness as the only legitimate excuse for absence from work. Verbrugge (1983 :226) suggests that 'women are more sensitive to physical discomforts; more likely to interpret them as signs of illness; more willing to restrict activities, seek professional health care, and take more drugs' and are more inclined to seek out and use health services. Thus it is little wonder that 'national health surveys commonly find that women have higher rates of acute and chronic morbidity than men, and also higher rates of shortterm disability' (Verbrugge,1983:226). The reason for gender differences in morbidity has thus often been put down to women's propensity to seek health care (Mechanic, 1978). In a research project using the Nottingham Health Profile as an instrument to measure subjective health status, Hunt et aI (1981:226-7) found that 'women are more likely to report problems in the emotional and social domains (which) suggests that there is no general tendency for women to report problems more readily but rather that sex differences lie in differential ability to admit to certain kinds of problems' (see also Mechanic, 1978). Just because cultural and psychosocial factors may be 'important in people's perceived experience of illness and injury and their curative actions' (Verbrugge,1983:226) does not mean that the experienced illness or injury is 'not real'. The differentials between men and women remain significant and worthy of

investigation no matter whether the source of the difference is biological, cultural or psychosocial.

Mortality In most countries of the world, women outlive men. Life expectancy at birth is higher for men in very few countries. The WHO (l994a) summary of progress towards health for all identifies Pakistan, Afghanistan, Bangladesh, Bhutan, Djibouti, Iraq and Nepal as the only countries where official reports claim that men outlive women. In most other countries the situation is reversed, with the highest discrepancies being for the former Soviet Socialist Republics of Byelorussia and Ukraine, where men's reported life expectancy at birth is 10 years less than for women (19835); France comes a close third with women outliving men by 9.3 years (1986-88). Czechoslovakia, Hungary, the Bahamas, EI Salvador and Finland follow, each with a reported eight-year mortality disadvantage for men at birth. In the Western Pacific Region the differentials are not quite so marked, but they are still significant. The most recent records of gender disparities in life expectancy at birth (wpRO,1994b) range from eight years in the Republic of Korea in 1994 (men 67.7 years, women 75.7 years) and 7.7 years in American Samoa in 1985 (men 67.8 years, women 75.5 years), in favour of women, to only a 1.5-year advantage

Key issues

for women in 1he Solomon Islands (men 59.9 years, women 61.4 years in 1988) and a 2-year advantage in Fiji (men 68 years, women 70 years in 1994), Papua New Guinea (men 48.7 years, women 50.7 years in 1983) and Samoa (men 63 years, women 65 years in 1988). The different reference years for each country make comparison difficult, but these are the latest official statistics available from each of the countries. The average advantage in terms oflife expectancy at birth for women in the Region, taking account of 1he problem of differing reference years, is estimated at about 5.5 years in 1994. There appears to be a relationship between aggregated life expectancy at birth and gender differentials. Those countries with the lowest life expectancies for both sexes have the smallest discrepancy between the sexes. For example, Cambodia with a total life expectancy at birth of 48.5 years (1991 reference year) has a sex discrepancy of2.9 years and Lao PDR had a total life expectancy at birth of 45 years in 1985 and a sex discrepancy of 3 years. Papua New Guinea's low discrepancy is also related to a short life course (see above). There are a few exceptions (e.g. the Commonwealth of the Northern Mariana Islands where the total life expectancy is 50 years and the longevity advantage for women is 5 years) but, as a rule in the Region, as total life expectancy increases, the differential between men and women's longevity increases.

Some of the possible reasons for such a gender difference have been well documented for a variety of developed and developing countries (Lopez & Ruzicka, 1983; Ohadike,1983; Lopez,

Women's Experiences of Aging In the WPR: A Diversity of Challenges and Opportunities

1983; Pool, 1983; Bonita, 1993). The proposed causes range from hormonal, genetic and biological factors (Waldron, 1983) to cultural practices and behavioural choices (Bhatia, 1983) to economic, occupational and social roles (Verbrugge, 1983; Sandelowski, 1981) and leisure activities, stress and coping behaviours, or a combination of all of the above (Bonita, 1993). The move from infectious diseases to chronic diseases as the major cause of mortality and reduced levels of maternal mortality in the more westernized parts of the Region may account for some of the gender differences, but as yet we have few clues about the reasons for the gender pattern in each country. Bonita (1993: 194) argues that currently available evidence points to 'environmental exposure, health habits and social and cultural behaviour', especially smoking and alcohol, as accounting for 'two-thirds of the difference in life expe~tancy between men and women'. Going by current trends of a high level of uptake of cigarette smoking by younger women, and increasing consumption of alcohol by women, the life expectancy gap may close in the next 50 years. What are women currently dying of in the Western Pacific Region? Broadly speaking, the countries of the Region can be divided into two groups, one where the major causes of death for both sexes are infectious diseases and a larger group of countries where

chronic diseases dominate the causes of death for both men and women. Malaria, pneumonia, acute respiratory infection, tuberculosis, cholera and other diarrhoeal diseases and dengue fever are amongst the major killers of both sexes in Cambodia, Lao PDR, Viet Narn, Niue, Papua New Guinea and the Solomon Islands. For most other countries (both developed and developing) the major causes of death are lifestyle-related, namely heart disease, other circulatory system diseases and malignant neoplasms. A few countries, for example Kiribati, the Marshall Islands, Tonga and the Philippines, have a mix of infectious and chronic diseases among their major causes of death, with diabetes being a significant cause in Tonga and the Marshall Islands. There are no data on mortality causes in Nauru and Wallis and Futuna. Other than for maternal mortality (AbouZahr & Royston, 1991; Asian Development Bank,1993), very little gender disaggregation of mortality data is available. On the whole, women die of the same diseases as men but they die at a later stage. For example in Australia,the same pattern of diseases cause death in men and women, namely diseases of the circulatory system, malignant neoplasms and diseases of the respiratory system, the only differences being in the site of neoplasms.

Key Issues

3.5

Quality of life

The projected increase in the Region of life expectancy at birth from 67.7 years in 1990 to 74.7 years in 2020 has heightened concern for maintaining a high quality of life for older people. As part of its New Horizons planning,

Technology-based interventions required to allow individuals to live lives of good quality are expensive, complicated and, in many instances, of doubtful effectiveness.

the WHO Regional Office for the Western Pacific has set up three work groups on preparation for life, protection of life and quality of life. Four major issues for quality of life have been identified:

The older population is expected to increase as promotive, protective and curative health interventions continue to have a positive impact on the life expectancies of populations. Urbanization, population growth and other socioeconomic changes have altered the level and character of family, community and institutional support which enable individuals to attain a high quality of life. The numbers of people with chronic illness and disabilities in all age groups are increasing due to the rise of degenerative diseases, accidents and other health problems associated with modernization.

It has long been recognized in the phenomenological tradition that there may be major discrepancies between receivers' and providers' perceptions of health and illness (Toombs, 1987). Health researchers, too, are starting to acknowledge that 'people may not have the same priority in their health needs as providers and are very likely to focus on the impacts of illness such as pain, feeling "down" and inability to perform normal roles rather than upon disease categories and conditions' (McCallum in AIHW, 1994 b:ll). McCallum argues that the development of quality of life indicators, such as the SF36 'allows valid assessment of general health status from the point of view of the health consumer'.

Indicators for quality of life If quality of life issues are to be included in policy planning for older people of the future, then indicators are needed to assess quality of life among the diverse populations of older people, particularly older women, in the Region. There remain profound ethical issues about policies and practices affecting the quantity and quality of later life.

Women's Experiences of Aging In the WPR: A Diversity of Challenges and Opportunities

Can key indicators of quality oflife ever be decided? These are the choices and issues created by social, economic and medical developments which have produced aging societies in Australia and throughout the world. ( McCallwn, 1990:235-7) Social indicators tell us something about possible quality of life experiences, 1hey refer to some of the preconditions for achieving quality oflife, but they do not tell us whether such quality is actually experienced or not. Quality of life indicators allow us to examine the relationship between subjective and objective health states. 'What matters in the 20th century is how the patient feels, rather than how doctors think they ought to feel on the basis of clinical measurement. Symptom response or survival rates are no longer enough ... therapy has to be evaluated in terms of whether it is more or less likely to lead to an outcome oflife wor1h living in social and psychological, as well as physical, terms' (Bowling, 1991:1).

Disability Adjusted Life Years (DALYs) and Quality Adjusted Life Years (QALYs) These two kinds of indicator have been developed from combined efforts by epidemiologists, economists, psychiatrists and psychologists to produce 'a single composite measure of the effect of health programmes that includes both additional life years and quality of those

years' (Maynard, 1991:38). Within this process, psychologists have tended to emphasize the concept of well-being whereas economists have emphasized the quantification of life quality. However, Headey (1993:97-99) argues that although 1he theories of 'traditional welfare economics and contemporary social psychology ... are almost completely different both in content and epistemiologicallIDderpinoings', they do converge in their focus on well-being (albeit a different kind of well-being). Heady claims that welfare/well-being in traditional welfare economics is based on three assumptions, (1) leisure is pleasure, work is pain, (2) consumption levels are a major determinant of well-being, and (3) nothing else matters much. Thus 'the economist defmes a happy person as a lazy fellow with a full shopping basket', no attempt is made to measure welfarel well-being directly. Headey suggests that psychologists, on the other hand, do 'seek to measure subjective wellbeing directly' and 'tend to regard wellbeing as multidimensional'. Headey (1993: 111-113) makes the claim that 'economists have the right framework and psychologists the right variables for explaining differences in subjective wellbeing', the implication being that a way forward in social indicator development may be 'to insert (sic) the psychologist's variables into an economist's framework'. Some quality oflife scales have attempted to achieve such a union, such as the SF-36 used in the 19941995 Australian National Health Survey.

Key Issues

However, DALYs and QALYs address different aspects of health largely because of divergent rationales for gathering the data. DALYs are assessed for comparative purposes on a population level to gain a global picture of differential burdens of disease across regions, age groups, gender and type of disease or injury. The DALY measure is derivative of conventional indicators of mortality and morbidity and involves objective assessment of illness status and degree of severity of disability. Some QALYs combine objective and subjective assessments of health, wellbeing and quality of life, others concentrate on subjective evaluation. They are used to assess health status and for outcome evaluation on an individual basis as well on a population level. DALY. A global measure of the effects of non-fatal morbidity, the DALY was developed by WHO in collaboration with the World Bank for the World Development Report 1993: Investing in Health. The measure drew attention to the need to take account of the economic and human costs of various disabilities. The World Bank's publication attempts to move beyond crude analysis of mortality data by using the DALY method to measure differential burdens of disease by age, by region, by risk factor, by sex and by disease grouping. The methodology involves summarizing large amounts of data to a single comprehensive measure. The DALY method combines

death and disability losses from 109 diseases and injuries (ICD9) to produce a quantifiable account of the 'full loss of healthy life' (World Bank, 1993). The unit of measurement is time lost along a continuum of time. It thus involves a far more sophisticated epidemiological technique than casecounting. The use of this method represents a major step beyond the calculation of aggregated and disaggregated mortality and morbidity rates as the only indicators of a country's health status. The Global Burden of Disease concept recognizes that much of the burden of disease of countries is the result of non-fatal illness and this recognition is of particular significance to women who, as a group, suffer a much higher burden of morbidity and its disabling outcomes, than men (WHO, 1994a). The DALY method could be adapted for use as a framework to follow the trajectory of women diagnosed with a particular disease or injury in terms of their physical, mental and social well-being outcomes, over years or even decades (Lopez, 1994). The major shortcomings of the DALY method are generic to all epidemiological research or population science. The outcome is only as good as the data which is available and if the data is incomplete or inappropriate, the methodology cannot produce the desired results. Similarly, the framework within which the method is used, in this case

Women's Experiences of Aging In the WPR: A Diversity of Challenges and Opportunities

the Global Burden of Disease framework, circumscribes the methodological opportunities for innovation. As used in the Global Burden of Disease project, the DALY method was applied to clinically-defined diseases and outcome states. Thus feelings of ill health which 'have no name' and lie outside the ICD9 classification were ignored. Similarly, the population level emphasis meant that the method was unable to represent the health experiences of indi vidual members of the communities of each country. The use of data which was based on the premise that health is absence of disease or disability and the reliance on health experts, rather than health consumers, to quantify disease burden and the costs of disability, produced content problems which hindered the potential for an innovative meth<Xlology. Disability weightings and degree ofloss estimates were conducted by 'international health experts' rather than by those who experienced disability. Subjective evaluation ofloss of quality of life was not taken into account in setting the disability weightings. Although the authors of the World Bank Report acknowledge that 'calculation of the disease burden is based on several assumptions, some of which involve decisions about ethical values and social preferences' (The World Bank, 1993:213), the lack of consultation with those who experience disability in

calculating the disability weightings, renders such measures invalid as a reflection of the lived experience of the disabled. Rather, the DALY scale is a measure of how health professionals or 'experts' perceive the disruptions and inconvenience that disabilities cause to their 'patients'. Interestingly, the terms of reference of the World Development Report were to examine investment in health, yet the measure developed specifically for the Report (GBD) deals only with death, ill-health and disability. Health is not even mentioned other than in terms of the absence of disease or disability. This tendency does not match with the current (albeit utopian) WHO definition of health 'as a state of complete physical, mental and social well-being and not merely the absence of disease and infirmity' (WHO Constitution 1946). The use ofDALYs as the key indicator of health status equates more closely with the limited 'absence of disease' definition of health. Although the DALY measure was developed within an economic rational framework, it does move in the direction of acknowledging the social as well as the economic costs of disability. However, the less tangible personal costs are given scant regard.

As the authors of the Report themselves acknowledge: 'Even as broad a measure as the GBD does not capture all the consequences of disease or injury

Key Issues

... (and) ... excludes the social costs of disfigurement' (The World Bank, 1993:25). Similarly the Report's authors recognize that 'comparisons of absolute numbers of DALYs lost may be misleading because the sizes and age structures of the populations at risk are not the same'. However, the DALY holds much potential in terms of assessing women's burden of disease in comparison to men's on a total population level and this could be complemented with more individually based and subjective QALY measures.

applied to health generally refers to aspects of daily living beyond physical and social conditions and beyond physiological functioning to include 'perceptions of well-being, a basic level of satisfaction and a general sense of self-worth' or empowerment (Bowling, 1991 :9). The nebulous nature of the concept makes it difficult to operationalize and accounts for the resistance on the part of researchers to expand their range of indicators of health status and intervention outcome. Bowling (1991: 11) argues that many of the measures that have been developed incorporating quality oflife dimensions 'have serious limitations in terms of reliability, validity and techniques of analysis', especially those that are 'derived from professional conceptions of well-being'. However, some of the reliability and validity problems are being addressed with modifications such as an increase in the use oflay populations to establish the dimensions to be measured. Quality of life scales attempt to tap people's positive experiences ofh~th and thus move beyond a disease and illness assessment of health status. QALY s are used to support both economic-rational and human rights agendas. Human rights values and economic rational values are inherent not only in the measures themselves, but are also evident in the use to which the measures are put (McTurk, 1993).

QALY. Numerous studies (for example, Schneider,l976; Wasserman & Chua, 1980; Kuz,1978) have revealed 'no consistent relationship between objective social conditions ... and perceived well-being of inhabitants'(Davis & Fine-Davis,1991). The concept of 'quality of life' as

Women's experiences of Aging in the WPR: A Diversity of Challenges and Opportunitles

Bowling (1991) reviews over 50 quality of life scales. The field has expanded exponentially since the publication of Bowling's book. Cummins (1993) suggests that there have been over 100 scales developed using the QOL construct. Although the various scales developed to measure quality of life do not share the same definition or dimensions of well-being and quality of existence, they share an emphasis on examining people's subj ecti ve assessment of their own health (alongside objective measures) and on measuring the health context of individuals. For example Cummins' ComQol (1993), which attempts to combine the best elements of a variety ofQOL scales, is 'multidimensional', covering seven domains: material wellbeing, health, productivity, intimacy, safety, place in community, and emotional well-being (Cummins, 1993:3). ComQol is also 'multi-axial' in that it separately measures objective and subjective dimensiOns, acknowledging that the two rarely correlate. Within the subjective dimensions each domain is further articulated by 'importance to the individual' and 'perceived satisfaction'. Quality of life scales thus tend to adopt a more contextual approach to measuring health. They acknowledge the importance of individuals' subjective experiences of health and include the dimensions of social and emotional wellbeing, thus rendering them more reflective of WHO's official definition of health. However, in relation to this

particular project, the question arises of whether QOLs can reflect the lived health and well-being experiences of women. Very few of the measures are gender sensitive. Most are based on gender-neutral assumptions about health experience. The ComQol measure has separate versions for adolescents and people with cognitive impairment but not for women. Age and disability are seen as the key variables of differentiation in health experience. Al1hough 1he SF-36 scale is not designed in a gender-specific format, there is an underlying assumption,' based on empirical research, that women will score lower than men 'reflecting poorer perceived health' (Jenkinson et ai, 1993: 1438; Brazier et ai, 1992). On the whole, this hypothesis is supported in application of the questionnaire. However Jenkinson et aI (1993: 1438) found that women reported poorer health on all variables, 'except for general health perception'. In their large-scale survey to establish population noons for SF-36, 'significant differences for the sample as a whole were found between scores for women and men on all variables of the questionnaire'. It is therefore gender sensitive, differentiating between men's and women's experiences of health. Such a result would suggest that the differences could be further explored if gender specific items were included. Jenkinson et aI (1993) suggest that it may be appropriate to develop group-

Key Issues

specific questionnaires for the aged. The same case could be made for women. WHOQOL is an initiative by the World Health Organization to develop a global quality of life scale related to health and health care which takes account of people's subjective experiences of their health, ill health and disabilities. It aims to 'allow an inquiry into the perception of individuals of their own position in life in the context of the culture and value systems in which they live and in relation to their goals, exp~ctations, standards and concerns' (WHOQOL Group, 1995). The group developing the measure is transnational, with representatives from a variety countries from Croatia, to Panama, to Thailand and Australia This initiative derives from 'a need for a genuinely international measure of quality of life' as identified in the World Bank Report in 1993 and from problems associated with former disease-oriented, rather than health, indicators of health status. It is seen, therefore, as more closely reflecting WHO's definition of health than traditional indicators, socioeconomic indicators and the DALY. Despite its global coverage, the designers of WHOQOL claim that the scale will be sensitive to differing cultural and social contexts since there was cognizance of the cultural, social and environmental embeddedness of subjective health experiences in the design of the instrument.

The domains covered by the WHOQOL include the physical domain, the psychological domain, level of independence, social relationships, environment and spirituality/religion! personal bf'liefs. It is anticipated that the instrument will be used in the clinical setting, in clinical trials to establish baseline data and change after intervention, in epidemiological studies, and in policy planning and monitoring. It is anticipated that a core instrument will be developed which can accommodate later 'add-on modules'. Five priority areas for module development have been identified by WHO (WHOQOL Group, 1995:19): a. b. c. persons suffering from chronic diseases, caregivers of the ill and disabled, persons living in highly stressful situations (eg elderly people living in poorly-run institutions, refugees in camps), persons with difficulties communicating, and

children.

Flexibility is also introduced :nto the scale by making provision for culturally specific components to be added to (or replace existing sections of) the scale. Such flexibility could also extend to gender and age specificity such that the instrument provides a means of

Women's Experiences of Aging In the WPR: A Diversity of Challenges and Opportunities

assessing the quality of life of older women. The use of the scale with carers for older people and disabled is of particular significance to older women, who are responsible for the majority of such care.

3.6

Caring and health provisions

Research on the effects of population aging on family structure is consensual about the continuing role of the immediate and extended family as the primary institution of care for older persons in all countries of the Region. Most countries have adopted this central role for the family in their policies on aging. However, th.ere is some debate about the rate of decline of the role of the family in caring for aging parents and grandparents (Knodel & Debavalya, 1992) and on the transportability of Western theories of the needs of the elderly to developing countries (Keith, 1992). Some analysts propose convergence between East and West, suggesting that the rate of decline in non-Western countries will parallel developments in the highly industrialized countries of the world. Family decline is seen as an integral part of industrialization, urbanization and migration, which means that all countries in the Pacific will face massive funding crises to fill the caring

gap left by disintegrating family obligations. However, other analysts cite Japan as a case in point to support the notion that traditions die hard despite 'modernization' and that in cultures where there is a strong tradition of care for elders, this practice persists despite changes in the way societies live (Mason, 1992). Mason (1992:19) argues that 'family systems in Asia vary considerably and did so long before urbanization, industrialization and migration came to have a major impact on family organization'. She claims that there is some continuity despite massive macroeconomic and sociopolitical change such that any reorganization of the family 'seems likely to reflect the pre-existing nature of the family system'. Mason thus puts forward the thesis that the 'situation of the elderly ... var(ies) ... in different parts of Asia and the Pacific, not only because of differing levels of economic development or modernization, but also because of varying types of traditional family arrangements' (see also Kendig, Hashimoto & Coppard, 1992). Consequently, the thesis concludes. that 'industrialization, urbanization and migration have mixed consequences for family systems, some of them detrimental to the elderly and others beneficial or neutral' (Mason, 1992:25). All researchers in the area, however, agree that any changes that do occur in family structure and roles will have the most impact on women. Mason (1992:29) shares with most researchers

Key Issues

in the area (Andrews et ai, 1986; Martin,1988) the prediction that 'the problem of care for the elderly is likely to be especially acute for older women, who constitute the majority of the elderly in virtually all low mortality populations'. However, policy needs to be developed in context. Keith (1992:28) suggests that to get a clearer picture for policy formulation and 'to provide the support needed to reinforce patterns of caretaking essential to the well-being of the increasing numbers of older people around the world, it is necessary to map the cultural context in which care-taking occurs'. The country profiles, in section 4.6 below, on initiatives developed for care of older people represent an attempt to set the parameters for such a map for the Western Pacific. Very few of the initiatives mention genderspecific aspects of aging, but since the majority of these countries have more older women than olt;ler men, the measures outlined have an impact on older women.

Older women as providers of health care Despite significant economic changes, with concomitant changes in the type of health care delivery, women continue to provide health care as traditional healers, shaman, as carers for the disabled and as lay healers across the Region. In the Philippines, 'hilots' are older women whose healing knowledge is passed down through the maternal line. In Kadazan culture in Sabah, East Malaysia, high priestesses ('bobohizan') are responsible for the spiritual and physical well-being of the community. Their special knowledge and skills are also passed down through generations along the maternal line. Developing the skills and knowledge to perform this role takes a lifetime, so only older women are bobohizan. In both developed and developing nations, women still make up the majority of providers of nursing care and in the informal sector in lay healing, lay prevention, lay rehabilitation and lay care (often using traditional healing substances and practices such as herbs and massage). Researcb on the amount oflay healing and treatment which occurs in the home and in informal healing networks is underdeveloped, although there is a growing research interest in women as carers. In developed countries, compendia of home remedies are often included in recipe books or treated as quaint historical curios rather than as part of the database informing health

Women's Experiences of Aging In the WPR: A Diversity of Challenges and Opportunities

Islands meeting on Yanuca island, Fiji, in March 1995 addressed the issue of traditional medicine and traditional healers. The Conference agreed to investigate, analyse and document traditional and herbal medicines that can be used in Pacific countries. This is of particular import to older women who are the key providers of traditional health care, and who are the heaviest users of pharmaceutical drugs in the Region.

Older women as consumers of health care There is a continued tendency to medicalize major transitions in a woman's life and the process of aging (including multiple prescribing). The current health flUlding arrangements of most cOlUltries in the Region make medical and pharmacological choices cheaper than non-medical and nonpharmacological alternatives for the consumer of health services. Women as gendered subjects lUldoubtedly bring different experiences to the health arena than men as gendered subjects. Women are articulated by class, ethnicity, race, age, geographical location and disability/ ability status. They therefore come to the health system with a complex arrangement of subject positions. The literature suggests that women are conceived of as inherently and potentiall y 'sick' (perhaps even neurotic) in comparison to men. Thus

practices. Lay healing and traditional healers and herbal medicines are taken more seriously in Asia and the COlUltries of the Pacific. One of the key recommendations from the Conference of Ministers of Health of the Pacific

Key issues

women are seen as consumers of health services, men as providers (Broom, 1989). Women's bodies are seen as having the potential to 'tum nasty' on them. This is seen as one of the disadvantages of inhering in nature rather than in culture (Martin, 1987). However, women are not necessarily passive consumers. They do not only inhabit the natural world, the environment, along with 'disease'. They act as powerful embodied agents whose bodies have potential as well as limitations (Foucault, 1980). The historical process of delegitimizing women's healing powers (Weedon, 1987) has not been completed. Women still retain a reservoir of knowledge about self-healing which is often overlooked in research on utilization of health resources. To legitimize the knowledge that women have of their own bodies and of their healing potential would undermine the current epistemological basis of what passes for health knowledge. The consumer revolt against allopathic health services is being led by women. In many ways women are acting as discerning consumers of health services. Rather than handing their bodies over to health professionals, they are deciding which ailments are appropriately addressed by self care and home remedies, which by alternative therapists and which by mainstream scientific medicine (Eckennann, 1994a).

A problem arises in translating women's unique approaches to the consumption of health care into policy. It is hard enough to translate consumer perspectives generally into concrete policy proposals, although such a task has been done admirably in recent years in Australia (Broom, 1991). For example, historically, physical symptoms for which there is no clear diagnosis have been psychosomatized and women in particular have been subjected to the stereotype of the 'nervous women' (Foucault, 1980) as evidenced in the diagnosis of chlorosis (Figlio, 1978), repetitive strain injury (Willis, 1986) and anorexia nervosa (Robertson, 1993). In each case of these conditions, which are labelled 'mental illness', the individuals 'atllicted' are observed and diagnosed according to diagnostic criteria which take no account of subjective experience. Recent feminist analysis of self-starvation (Celermajer, 1987; Robertson, 1993; Eckermann, 1994b) suggests that many people who are diagnosed as suffering from anorexia nervosa see their self-starving activities as a solution rather than as a psychiatric problem. How one responds to such a discrepancy between objective and subjective perceptions in the case of life-threatening activities becomes an issue for ethical consideration rather than merely a scientific, technical or clinical deliberation.

Women's Experiences of Aging in the WPR: A Diversity of Challenges and Opportunities

3,7

Agism and sexism

Some social constructions of aging in the countries of the Western Pacific are pejorative, others are honorific. In Australia and New Zealand, aging tends to be viewed negatively on both an individual and a population level, although there is some celebration of the achievements of older women. Newspaper reports often refer to the 'aging crisis' or the elderly as a 'drain on resources', suggesting that high levels of economic and social dependency are an inevitable outcome of the 'greying' of the population and that such dependency affects the living standards of subsequent generations. Massive amounts of money go into advertising campaigns for products which claim to retard or reverse the aging process. On an individual level, consumption of such products is seen as a panacea against the negative status conferred on those showing visible signs of aging. Countries at a different level of socioeconomic development such as Malaysia, the Philippines, and Pacific countries such as Fiji, are not immune

from such influences. The advertisement in the Philippines for a skin exfoliating cream entitled 'Let Wrinkles and the Signs of Aging Fade Away Beautifully' (Manila Bulletin, Wed Feb 221995 piS) is typical of the attempts by advertisers in newlydeveloping countries to tap into negative feelings about the physical signs of aging, providing product solutions to restore a positive self-concept. The negative connotations of aging are based on 'disengagement theory' (Cumming & Henry, 1961) which assumes biological decline and associated social and economic withdrawal as the natural course of events after a certain chronological age is reached. The set retirement age still found in most countries of the Region is based on such a perspective. An associated assumption is that it is natural and correct for each generation to make way for the next. However, there are many exceptions to this rule. Both developed and newly-industrializing countries in the Region are governed by gerontocracies. However, very few senior politicians and statespeople are women. Women's continued political, social and economic involvement in society later in life often takes a more humble form. A cigarette and sweet seller in Manila who has carried on her business as part of the informal economy for over 40 years, and who is in her 80s, shows no signs of disengaging. In fact her primitive 'stall', of a plastic chair and a tin box on

Key Issues

wheels, serves as a focal point for social interactions. 'Activity theory' (Havighurst, 1963) is invoked (as opposed to disengagement theory) to encourage the continuation of the activities of middle age into old age or the development of new active roles and this forms the basis of many health promotion campaigns in both developed and developing countries. In Australia, a popular billboard poster shows a woman in her seventies walking vigorously, wearing shorts and running shoes, with the caption, 'If life is catching up to you, then walk a little faster'. In The Manila Bulletin, February 26, 1995 readers were informed that continued sexual activity in old age provided an excellent source of exercise to protect individuals from heart disease and also to enhance mental health, with the proviso that it occur within marriage to prevent the detrimental effcts to, mental health of guilt associated with sex outside of marriage. Thus contrary to the women who continue to participate in economic life in old age largely for economic reasons, in activity theory-based health promotion, people are encouraged to continue involvement in public life and social interaction to enhance their mental, physical and emotional health. Activity in old age becomes part of the project of the healthy self. Turner (1994: 109) suggests that the low status of the aged, like the low status of youth, is explained in disengagement

theory by the notion of lack of reciprocity associated with dependency. Advocates of biological decline and disengagement theories propose a 'reciprocity maturation curve' whereby as one matures 'engagement in social relations increases with employment, marriage, parenthood and wealth. Reciprocity (is seen to) necessarily decline with aging which traditionally involved retirement, illness, separation and bereavement'. The 'modem life course' inherent in this trajectory for the individual 'presupposed a unitary and linear model of individual development from childhood through to retirement'. Turner argues that social change has brought about a radical transformation of the aging process, at least in the developed world, in the late twentieth century and the 'modem life course' has been replaced by a diverse and fragmentary life course produced by the 'feminization of labour', the 'transformation of information and communication systems, the end of mass employment and increasing flexibility of labour, employment and time'. The result of these social changes along with legislative changes, 'including legislation against age discrimination, some erosion of compulsory retirement for men and women and a growing diversity of household formations, is a fragmented, discontinuous form of employment' throughout the life cycle (Turner, 1994: 110). However, the experience of women in developing countries does not necessarily follow the same pattern.

Women's experiences of Aging in the WPR: A Diversity of Challenges and Opportunities

A further change, which impacts upon the experience of aging, is the transformation of the notion of the body in relation to the self (Turner, 1994; Shilling, 1993; Eckerrnann, 1994c). The advertisement from the Manila Bulletin referred to above, is a reflection of that transformation. For the middle classes in both developed and developing countries, 'maintaining a good image requires extensive body work such as jogging and dieting in middle life' (Turner, 1994:110) as well as surgical intervention and consumption of youthenhancing products. If we accept the notion that the body becomes part of the 'project of the self (Giddens, 1991) in late modem societies, 'in a society which has this emphasis on the body beautiful, the ageing process presents an enormous difficulty in terms of sustaining a continuous uniform self (Turner, 1994:110). Turnerarguesthat the 'commitment to a continuous self is threatened and undimnined by the very discontinuity of the body'. Turner claims that this disjuncture between 'the ageing body' and the 'continuous self produces a 'mask of ageing'.

Alongside this ambiguous relationship between the body and self, there has been a transformation of intimacy (Giddens, 1992) in the modem Western household. Turner argues that:

Key Issues

In a post-industrial, post-Fordist era, the key issue that emerges in relation to aging is 'the question of identity'. Tumer argues that 'in a society where social roles are highly structured and where rites of passage are clearly known identity follows status without any ambiguity.' However, in 'postmodern societies these status transitions within the life-cycle have been fractured and rendered ambiguous. The maintenance of identity is further complicated by an emphasis on the body beautiful. With the inevitable ageing of the body, the continuity of self and identity is exposed' (Turner, 1994:111). 'The notion of a structured and uniform life-course or life-cycle is difficult to sustain in such a context ofpostmodernity'.

Death and dying The reminder of the inevitability of death associated with exposure to aging bodies appears to be one of the underlying causes of aversion to the aged (Tumer,1994), and in particular to older women in developed countries (Fenton,1993). One way to avoid facing the vulnerability of human life is to make those who show visible signs of frailty and fragility (for example women with a 'dowager's hump') invisible. Older women rarely appear on television or in film in strong and responsible roles and very few product advertisements show older women as independent and healthy people. Women's major visibility is in advertisements for incontinence pads. The situation is no different in

some less-developed societIes. For example, amongst the Huli in the highlands of Papua New Guinea 'weight loss and white hair mark the individual as "lapun tru"(really old)' (Hughes, 1993) and no longer capable of leadership, their frailty is a mark of imminent death and they are shunned. Women who have stopped menstruating are shunned by their husbands as 'sexual intercourse with postmenopausal women is said to be fatal for men as the uterus is believed to have closed up' (Hughes, 1993:5). However, in contrast to the negative quality of life outcome' for many 'shunned' older women in the West, Huli women see menopause and the physical signs of aging as 'a time of great happiness for women as no further children could be born and they could send their husbands on their way' and aging is in fact easier for women than men 'as men's roles disappear while women live in close contact with their families and maintain their usefulness by... services such as the informal adoption of '" grandchildren' (Hughes, 1993:5). Death, as the end point of the aging process, has been a taboo subject in many societies in the Region. However, as quality of life issues emerge on the health and human rights agendas of many countries, death and dying reenter philosophical debates. This process is reinforced by technological change and changing economic circumstances.

Women's Experiences of Aging In the WPR: A Diversity of Challenges and Opportunities

The concept of dying with dignity has become popular in quality of life literature as the ideal end event of the life course. Ironically this sentiment emerges at the same time as technological innovations become available to significantly prolong life, or more accurately, extend illness and prolong dying. The definition of death has become blurred as technology develops fuat can 'keep !he heart beating almost indefinitely even after the brain has ceased to function' (Neyland, 1990:53). Religious and legal sanctions against euthanasia conflict with humanist philosophies and 'the decision to prolong life or to allow dea1h to occur becomes fue province of an increasing number of gatekeepers'. The Hippocratic Oath enshrines the sanctity of human life and 'doctors often use every means possible to prolong life with no regard for its quality'(Fenton,1993). This is partly a result of the lack of a societal consensus on euthanasia Fenton (1993:18) argues that some medical professionals are 'beginning to recognize

the futility of cure in certain situations (and) are willing to focus instead on making the person's last days as painless and free of trauma as possible'. lbis trend is likely to continue, not only on humanitarian grounds, but also on economic grounds given the enormous resources that will be needed as the proportion of the population reaching 85 years increases. AIl countries in the Region are experiencing IJUYor cutbacks in their health budgets, a trend exacerbated by the world recession. No country can afford to invest in the technology to extend the life of all its citizens. Many countries in the Region are debating the arguments for and against passive euthanasia, but only the Northern Territory in Australia (which legalized voluntary euthanasia in May 1995) has as yet legalized euthanasia. Religious and legal sanctions against assisted death and suicide are balanced against the use of suicide as a defence of honour in some cultures (for example Japan) and more positive attitudes to death in Buddhist and Hindu teachings.

Country initiatives

Initiatives from a variety of countries are presented to illustrate activities undertaken in the Region which address the seven issues referred to in Section 3. This list of initiatives is by no means exhaustive but it provides a crosssection of what countries are doing:

to address the damaging effects on women of the dual discrimination of agism and sexism. Issue No. 1 - Changing demographics

•

to respond to the changing demographic structure of their populations, to develop policy which is sensitive to the diversity of needs and circumstances of older women and agingl women across the life course, to collect appropriate information, including gender-sensitive and gender-specific data, to inform policy for older women, to address the unequal experiences of older women in relation to morbidity, mortality and quality of life, to make adequate provision for holistic community care for the growing numbers of older women, and

•

Most countries within the Region have initiated family planning programmes to reduce fertility rates and improve infant and maternal mortality rates. Most countries are starting to realign national budgets to finance the needs of their burgeoning older populations. However, not all countries have developed services and policies that take account of the gender imbalance in the aging population or the specific needs of older women now and in the future. Many of the country initiatives deal with either the issues associated with aging or those pertinent to women. Very few initiatives have been developed that deal with both together. The challenge is to develop initiatives that deal with the specific issues relevant to older women.

•

Women's Experiences of Aging in the WPR: A Diversity of Challenges and Opportunities

Macao Macao has an unusual demographic sex distribution pattern. Males outnumber females in the 0-19 years and 35-59 years age groups. Women significantly outnumber men in the 20-34 years and the over 60 age groups. The reasons for this bulge of women in the 20-34 years group probably relate to migration patterns where young men leave Macao to work in other countries and young women immigrate to work in Macao. In 1993 the number of women in the 15-19 ~e group was 11793 and in the 20-24 age group 20224 rising to 22234 in the 25-29 age group and the largest gender-disaggregated cohort concentra1ion of25053 in the 30-34 age group. As this cohort ages, the skew by sex of the popula1ion over 60 years will be even more marked. Provision of services for older people in Macao reflects this sex-skewed demographic pattern with five of the eight homes for older people being exclusively for women. (Ferreira, personal communication, May 1995).

and Macao, is currently experiencing the process of population aging. In 1993, Malaysia's population of older people (defined as 65 years and above) was 4.0 per cent, an increase from 3.6 per cent in 1980 and 3.7 per cent in 1990. In terms of absolute figures, the population of older people (65 years and above) was 736 000 in 1993 (Masitah, 1994). Although the population of Malaysia is still young, it is projected that the proportion of those over 65 years will reach the 7.0 per cent.lev~l cut-off point for an aging populatIon m the year 2020, when Malaysia is expected to become a fully developed country (Nor, 1995).

Malaysia - Sabah To deal with the continuing demographic pattern of high fertility rates and high infant and general mortality rates, the Sabah State Government, in association with the Malaysian Federal Government, is stressing that family planning should be focused on very young women and older women in order to reduce infant mortality as well as to reduce fertility. Family planning is being integrated with maternal and child health in order to encourage breast-feeding. Sabah's distinct demographic pattern, of a continuing high fertility rate, is exacerbated by the influx of large numbers of male immigrants from the Philippines and Indonesia This skews the gender composition of the population

Malaysia Population aging, which is usually seen as being exclusively a phenomenon of developed countries, has now also become the concern of developing countries (Masitah, 1994). Malaysia, like other ASEAN and Asian countries and areas such as Hong Kong, Japan

Country initiatives

and has contributed to a wide range of socioeconomic and health issues which need to be urgently resolved. Sabah of all states (in Malaysia) is facing a unique policy decision on population and health and is taking steps to reduce the burden of costs associated with a high child dependency ratio (Yusof in Johari & Amirdad, 1992:28-9), mainly through promoting family planning programmes.

- 4.4 per cent of women, 3.6 per cent of men) and redirecting its resources to prevention of diseases in later life (Mongolia, country report, 1995).

Republic of Korea 'Women's health has improved markedly in recent years due to better economic growth, improved public hygiene, better nutrition, and expanded medical facilities. Women account for 62.8 per cent of the population above the age of 65, an age group which has been growing in size and comprises 5.4 per cent of the total population.' The average life expectancy for women is 75.7 years, 8.0 years more than the 67.7 years of men. Nowadays, the number of independent older persons is increasing due to growing nuclearization of the family, which accounts for 5.2 per cent of all households. Among them, the number of older women living alone is increasing and their proportion of public assistance is also growing. In 1991, only 0.3 per cent of the older were living in residential care or homes for the elderly, 72.9 per cent of which were women. 'The Welfare Law for the Elderly was enacted in 1981 and revised in 1993, followed by the proclamation of the Charter on Respect for Elder Persons in 1989. In accordance with this law, the government has steadily developed policies to provide free medical examination, expand comfortable welfare facilities for the aged, give

Mongolia During the Socialist period, in response to perceived under-population, Mongolia

had a determinedly pro-natalist population policy. Abortion was illegal, although not uncommon, and contraceptives were mostly available. Mothers were given medals (Order of Mothers' Glory I, II), upon delivery of their fifth and eighth child, respectively. Total fertility rates reached 7.53 in the early 1970s and population growth peaked in the rnid-1970s at 2.97 per cent. In 1990, the pro-natalist policy was abandoned, abortion was legalized and contraceptives began to be distributed through the health care system. Fertility has declined rapidly partIy because of high rates of abortion (445.4 per 1000 births in 1991). Fertility rates declines from 7.49 in 1973 to 5.54 in 1983 and 3.84 in 1991, the most substantial reduction occurring among women between the ages of 35 and 49. The country is thus preparing for an aging population (despite its current low proportion of people over 65 years

Women's experiences of Aging In the WPR: A Diversity of Challenges and Opportunities

allowances to aged persons protected under 1he Livelihood Protection Act, and operate 1he home maker service for the elderly' (Korean Women's Development Institute, 1994).

methods or sterilization are given. personal (Emmanuel, SC, communication, 1995). The legalization of abortion in Singapore means that morbidity associated with unwanted and closely-sequenced pregnancies will be minimized for women in later life.

Singapore Family planning services are provided by obstetrics and gynaecology specialists, general practitioners and at the maternal and child health clinic. Various forms of contraceptive me1hods are available and women are given advice on the various aspects offamily planning. Ano1her important service introduced in Singapore (which will have long tenn effects on women's health) is legalized abortion which was implemented to protect the health of women. Although abortion is available on request, over the years, restrictive clauses have been introduced to ensure a high standard of provision of facilities and skills of doctors who perform abortions. Abortion counselling was introduced in Singapore in 1987. It is mandatory for medical practitioners, who carry out treatment to terminate pregnancies, to provide post-abortion counselling. Preabortion counselling is offered to married women who have less than three children, and who can afford to have more, to encourage them to keep their pregnancies. Repeat abortions, which are harmful to health, are discouraged and advice on proper contraceptive

Issue No. 2 - Influences on health - life course approach - the context of older women's health The extent to which the diversity of circumstances of older women's lives is being addressed in the Region varies among countries.

Australia Cultural sensitivity to the context of women's health In Australia, culturally sensitive policy and provision of services is statting to appear. Aboriginal women in the Norlhem Territory have set up their own birthing services which allow women to carry out the rituals around birth that are central to their sense of cultural identity. This empowers both traditional birth attendants (who are usually older women) and the mothers for whom a sense of Aboriginal identity is crucial to their mental, social and physical health as they age.

Country Initiatives

However, this process is still in its infancy given the conditions of health for aboriginal people recently reported in the Women's Budget Statement (1995-1996). 'In the Northem Territory the average life expectancy of newborn indigenous girls is up to 14 years shorter than for non-indigenous girls.' The 1995-1996 Budget includes measures to improve the health of indigenous Australians. These measures recognize that the health of indigenous Australians is linked to the land and to social well-being, including the capacity to get a good education and find jobs. The Native Title Act, the establishment of the Aboriginal and Torres Strait Islander Land Fund and other social justice measures are addressing the extent to which context is a detennining factor in health outcomes. The 199519% Budget includes Aus$1 03.4 million over four years for indigenous health programmes. Included in its raft of programmes to promote Aboriginal and Torres Strait Islander health is recognition of the 'importance of indigenous women in promoting and maintaining the health of their communities' (Budget 1995-1996). The Government has committed itself to encouraging the participation of indigenous women in decisions on developing, delivering and assessing health programmes. The particular needs of Aboriginal and Torres Strait Islander women in rural and remote areas are being addressed.

Rice's (1994) work with Hmong immigrants in Australia also points to potential for culturally-sensitive service provision. Rice found that 'morbidity' after caesarean section in Hmong women relates more to cultural fears and beliefs about one of the 'spirits' leaving the body after 'cutting' than to post-natal depression or the physical aftermath of surgery. Relief of such 'morbidity' comes from cultural rituals conducted by Hmong priests in the theatre where the surgery took place rather than by psychiatric care or phannaceutical and medical intervention. Restoration of the spirit is essential for women to feel a sense of wholeness throughout their lives. Rice was able to convince a large hospital in Victoria to agree to such a ritual. This represents an isolated example. CulturaJ sensitivity, gender sensitivity and age sensitivity still have a long way to go. However, cultural relativity also has its limits. On the cultural practice offemaJe genital mutilation, the Federal Government has taken a stand arguing that it is an 'unacceptable practice' for which a 'dual strategy of educatior'l' and specific offence legislation has been developed' (Budget 1995-1996). The main focus of the strategy will be on education programmes. Through early, skillful and culturally-appropriate intervention, this programme will aim to prevent female genital mutilation. It will also help migrants and others living in Australia (including older women)

Women's Experiences of Aging In the WPR: A Diversity of Challenges and Opportunities

'who have been subjected to this harmful practice'. However, 'specific legislation banning the practice will also be introduced to reinforce the message that female genital mutilation is not an acceptable practice in Australia' (Budget 1995-1996, Fact Sheet).

some official recognition that circumstances surrounding women's lives influence their health status.

Issue No. 3 data

Lack of

Philippines Importance of context Some official governmental recognition of the context of women's lives affecting their health status was evident at the 1994 Women's Day rally in Manila (March 8, 1994, Folk Arts Centre). In an impassioned speech, the Speaker of the Philippines House of Assembly announced that 50 million pesos (approximately A$2.5 million) would be provided to conduct research on women's health and development. This position was reinforced in the keynote speech by President Fidel Ramos announcing legislative changes to the laws against rape. Bills were in fact introduced into parliament in 1995 to change the wording of the law from its current designation as 'rape against chastity' to 'rape against the person' including rape in marriage. These legislative reforms have been reinforced with the establishment of hospitals and other support services for 'battered women' and changes to the penal code in 1995 to ensure prosecution for violence against women. This points to

Lack of adequate gender-specific, gender-sensitive and genderdis aggregated data and research continues to be a stumbling block to developing appropriate policy for older women's health in all countries of the Region. However, a few countries are starting to attend to such gaps in information.

Australia Longitudinal study on women's health In February 1993, the Prime Minister, Paul Keating, announced that A$3.5million would be committed to undertake a longitudinal study of women's health in AustralilJ.. In response to that initiative, a workshop of key researchers in women's health was called to develop a set of recommendations. One of those recommendations (which echoes the sentiments of the National Women's Health Policy) was that the cohort study should involve the development of indicators of health status more

Country Initiatives

appropriate to women's experience. The funding for a longitudinal study, which has been granted to a consortium around the University of Newcastle, provides the perfect opportunity to put into practice the compelling theoretical arguments for more gender-sensitive indicators in health research. The study will follow the health experiences of 60,000 Australian women over 20 years. The three initial cohorts will be women aged 18-22 years, 45-49 years and 7074 years. Thus the research will provide information on currently older women and on the aging process for women. The Centre for Aging Studies at Flinders University has fimding for a longitudinal study on aging which will provide data for health policy and service planning for older people and on the process of aging. The data gathered will be gender dis aggregated to provide detailed information on the health conditions, choices, needs and experiences of women as they age. The Australian Bureau of Statistics published Women's Health in 1994 which provides gender-disaggregated data on demographic and social characteristics, mortality, health status, health actions, lifestyle, reproductive health, illness and health by occupation and the health of selected groups, namely, Aboriginal and Torres Strait Islander Women, Overseas Born Women, Women with Disabilities and

Older Women. It also covers issues such as violence against women, awareness and use of preventive health, health labour force, health expenditure on women and private health insurance. The categories covered were decided upon after extensive community consultations with women's groups and researchers on women's issues. Most states of Australia have policies on health and aging for which they commission research, but the particular issues for older women are as yet unexplored.

Malaysia - SObah Advisory body on data collection The Health Subcommittee of the Sabah Women's Advisory Council was set up to 'evaluate the present health status of women in Sabah, identify factors affecting the physical and mental health of women, assess the present health facilities in the state, monitor the health education programme of the family health care facilities and formulate recommendations for the improvement of the health of women and the family.'

In the light of the health problems for women in Sabah, the Health Subcommittee of the Sabah Women's Advisory Council is taking steps to improve the health status of women, including older women. These include:

Women's Experiences of Aging In the WPR: A Diversity Of Challenges and Opportunities

'1.

Promoting, encouraging, supporting and assisting any governmental and nongovernmental organizations that carry out health-related projects for the well-being of the women in Sabah. All health data collected should be analysed and disaggregated by gender in order to identify the risk factors and problems specific to women's health for more accurate policy planning and project formulation. Womenshouldbegivenagreater role in formulating and fonvarding their ideas, planning and in decision-making on all healthrelated matters that affect their community. A comprehensive ongoing health education programme relating to women's health which focuses on nutrition, breast self-examination, breast-feeding, weaning and safe motherhood, avoidance of high risk pregnancy, family planning, cleanliness, avoiding and coping with stress, detection of common signs of illness and preventive health should be established, widely publicized and implemented. Such health education programmes could be introduced and emphasized in the school curriculum.

Women at the grass-roots level should be identified, selected and trained as voluntary community health promoters or family health care facilitators who would act as a bridge or a liaison officer between the community and health services. Women should be encouraged to form their own resource support groups to deal with health related problems and should not display too much dependency on government health services. The government should encourage nongovernmental organizations and voluntary organizations to be actively and effectively involved in programmes and measures directed at improving the health of women. Women's organizations which have health programmes should be given financial, technical, advisory and institutional support from the government. Existing laws relating to the protection of health and disparate medical benefits for women workers should be reviewed and amended. These existing laws should be stringently implemented to reduce occupational health hazards in both the public and pri vate sectors.

Country initiatives

Research should be conducted in the area of the differing health and nu1ritional needs of urban and rural women, women with mental or physical disabilities, appropriate reproductive and family planning technology and rights of women, occupational health hazards and the impact of advances in medical science and technology on women. Such research fmdings would assist policy-makers in fonnulating new strategies which would aim at promoting the development of healthy and productive women citizens' (Ho & Kan, 1992:62-63).

conferences and conducts surveys on the socioeconomic and pathological characteristics and geographicallydetermined differences in aging populations (highland, plain, seacoast and urban). It also provides printed infonnation on the health status and needs of older people. (Tran Duc Tho, personal communication, 1995)

Issue No. 4 - Mortality and morbidity Although in all countries women outlive men, life expectancy for women is still short in some areas of the Region as a result of prevalence of infectious diseases, lack of adequate sanitation, undernutrition, poverty, lack of education and excessive manual work under harsh conditions. All countries continue to experience high selfreported and provider-reported morbidity rates (physical, mental and emotional) among women.

Viet Nam Research initiatives A geriatric project was set up in 1970, in 1980 a geriatric research unit was created, then in 1983 the Institute of Gerontology was established to carry out research on mental, physical and pathological characteristics of older people in Viet Nam and to search for models of health care appropriate to the living conditions in Viet Nam. The Institute also provides postgraduate and further training courses for geriatric doctors and health workers throughout the country, knowledge and training on self-health care and hygiene, and care of the poor and lonely. It organizes workshops which include WHO consultants, organizes scientific

Australia Every Australian has access to affordable medical and hospital care under Medicare (the national health insurance programme) and to essential prescription drugs under the Pharmaceutical Benefits Scheme. In its 1995-1996 Budget, the Federal Government committed more funds to support the National Women's Health Programme to deal with the particular

Women's Experiences of Aging In the WPR: A Diversity of Challenges and Opportunities

health needs of women as the biggest consumers of health services, in their own right and as child bearers and carers. The purpose of the Programme is to develop a network of care services for women with emphasis on health promotion, information, counselling and referral. Major cervical and breast cancer screening programmes have been developed for secondary prevention of these cancers in women, including a National Cervical Screening Programme. Pap smear testing is available free of charge, for all women, at community health centres and women's health centres. Under the National Programme for the Early Detection of Breast Cancer, women over 50 years old receive free mammography screening as part of the platform for women's health. Each state has a major health promotion body which coordinates large scale media and community education antismoking campaigns, drink-driving prevention campaigns (emphasizing gender differences in the amount consumed before driving capacity is impaired), and healthy eating and exercise campaigns. There is also a national "Life Be In It" campaign \\hich addresses these issues nationally along the lines recommended by the "Better Health Programme" which identified Australia's health-for-all targets for the year 2000.

Significant differentials exist in health status between indigenous and nonindigenous populations in Australia For example, the 1995-1996 Women's Budget Statement notes that the 'mortality of Northern Territory Aboriginal women has increased, while that of non-indigenous women has decreased, and Aboriginal infant and stillbirth mortality is nearly four times higher than the all-Australia rates. Circulatory and respiratory diseases each account for a quarter of the excess mortality in indigenous women' (Women's Budget Statement 1995-1996: 20). Thus initiatives are being undertaken to ·significantly improve the health of indigenous Australians \\hich recognize that the context of lives of Aboriginal and Torres Strait Island Australians has a large impact on their health status. Alongside specialist birthing centres for Aboriginal women, other services will be mainstreamed to ensure effective delivery of services to rural and remote communities and the Department of Human Services and Health will take over prime responsibility for primary, secondary and tertiary health care in Aboriginal communities (this responsibility formerly lay with the Aboriginal and Torres Strait Islander Commission).

Country Initiatives

Fiji Programmes to prevent chronic disabling diseases include strategies to:

areas identified by research ... to develop a public health programme on breastfeeding.' (Yusof, 1992) The major health promotion and illness prevention campaigns include family health programmes, rural curative services, nutritional services, environmental sanitation programmes, vectorborne disease control programmes, food quality control programmes, leprosy control programmes, occupational health programmes and preventive dental care. (Johari & Arnirdad, 1992). A holistic approach to health care for women is offered by the Health Subcommittee of the Sabah Women's Advisory Council (Ho, 1992), which concentrates on all matters 'relating to the physical and mental health of women and family'.

decrease the prevalence of hypertension, diabetes mellitus, obesity, heart disease, stroke and chronic lung disease in the population of Fiji (primary prevention); decrease the complications resulting from the common noncommunicable diseases (secondary prevention); and decrease the disability resulting from the complications of these noncommunicable diseases (tertiary prevention) (Tukana, 1995).

Malaysia - Sabah Niue Sabah health statistics have identified diseases which have a clear relationship to the environment and economic development. The most telling are malnutrition, communicable and environmental diseases. Many of them are related to public health issues. 'Political will and allocation of resources to achieve success can be realized at minimum cost... Sabah already has a comprehensive health care system .. [however further work is needed to] ensure the general availability of water and sanitation especially in high risk The standard of health in Niue is, in general, very high. All medical and dental services are provided ftee of charge to patients. Lord Liverpool Hospital is the only hospital, with 30 beds. The hospital has a female doctor and family planning information and contraceptive methods are readily available to married women. Family planning is made available to single women if it is feared that their health may be at risk or they have excessive numbers of children (Purlea 1986). Oral

Women's Experiences of Aging in the WPR: A Diversity of Challenges and Opportunities

contraceptives, injections of Depo Provera and the intra-uterine device (IUD) are the most common types of contraceptives used. In Niue contraceptives are used more for the spacing of children rather than for reducing the number of births.

years, with about 60 per cent of women in these age groups obese. (Extract from the report on the Status of Women in Niue prepared by the Community Affairs Department, 1995). In response to these health problems, a series of Diet and Healthy Lifestyle workshops is being run by the department of Community Affairs in each village in the quest to curb the noncommunicable diseases that are common in Niue. The target group is the women of Niue, especially the older women. Assistance and expertise from both the Health and Agriculture Departments is used in prevention programmes. A national weight-loss competition is being held. A great response has been reported to the competition. On World Food Day in October 1995, prizes will be presented to the winners. The 'Diet' workshop series will be complemented with another series of workshops in the villages developing cervical and breast cancer awareness (Togakilo, 1995).

In 1986 there were 48 births, 50 in 1987, 55 in 1988, 49 in 1989 and 52 in 1990. There were no details for infant mortality under a year old in 1987 and 1988 but there was one per thousand for 1986, 1989 and 1990. Maternal and child health services are available to all families and every child born in Niue is subject to compulsory vaccination against diptheria, whooping cough, tetanus, poliomyelitis, measles and rubella A woman's life expectancy has risen steadily since 1971 from 64 years to 68. Breast and cervical cancers for women are prevalent but not common compared to other types of cancer in Niue. According to the 1987 National Nutrition and Dietary Survey of Niue, the height of Niuean women in the past 40 years has increased by 5 cm. In addition, there is slightly more obesity in women who remain at home to work than in those engaged in government, business or other occupations. Overweight and obesity are major nutritional problems for women on Niue. The overall prevalence of obesity was 46 per cent and 38 per cent overweight. The problem was more prevalent in women in the middle age groups, 30-59

Palau Statistics show an increasing number of older women are developing chronic diseases. This is mainly due to nutritional problems and lack of exercise, lack of medical technologies, equipment and specialists. Therefore, health promotion and disease prevention are of great importance. Health education and promotion among older people have been implemented by

Country Initiatives

health workers, religious groups and some other women's organizations. (lngeang Rimirch, personal communications, 1995).

Philippines A major study on the health situation of older people was conducted in the Philippines in the 1980s. Although older people generally perceived themselves as healthy, the majority of them also admitted being weak and inactive. Concomitant poor eyesight, hearing and dental conditions are accepted as part of growing old. Quite a number suffered from povertyrelated diseases such as pulmonary tuberculosis and weak lungs, anaemia and rheumatism. Thus the Philippine Government is continuing to address these conditions alongside chronic diseases (UST Social Research Centre, 1989).

genetically-transmitted abnormalities. These services cover a wide range of genetic diseases. Thalassaemia is one of the most common genetically transmitted diseases in Singapore. A National Thalassaemia Registry was set up in 1992 to provide counselling and screening for families carrying the thalassaemia gene. Newly-wed women are encouraged to go for screening for this disease. Their carrier status and, if indicated, their husband's as well, are determined. If they are found to be carriers of the same thalassaemia gene, counselling is given and pre-natal diagnosis will be necessary.

Well-women clinics Singapore's well-women clinics are provided at the MCHC. At these clinics, women are provided with comprehensive screening tests at an affordable cost. These include: general medical check up, screening for hypertension and diabetes mellitus, breast examination for neoplasms, including lessons in breast selfexamination, and pap smears for cancer of the cervix. Breast cancer is the leading cancer among females in Singapore.

Singapore Secondary prevention via screening is a major response to managing Singapore's health problems, for example:

Genetic screening As congenital abnormalities are the leading cause of death among infants in Singapore, genetic counselling clinics and cytogenic laboratories have been established to screen and detect

Health education at the clinic level At the MCHC, health education is carried out through formal group sessions and also on a one-to-one basis. Mothers are advised to discard harmful health beliefs and practices and to adopt

Women's Experiences of Aging In the WPR: A DIYersity of Challenges and Opportunities

healthy lifestyles for themselves and their families. Talks are supplemented with audio visual aids and pamphlets. Nutrition demonstrations are held to show mothers how to prepare simple and well-balanced meals for their families and children. In the private sector, general pmctitioners typically provide health education on a one-to-one basis.

Singapore: health promotion and education The Government of Singapore is fully committed to maintaining and improving the health of Singaporeans. It launched the National Healthy Lifestyle Programme (NHLP) in 1992 to encourage Singaporeans to be responsible for their own health by adopting healthy lifestyles. Target groups for intervention programmes under the NHLP have been identified, including the young, uniformed groups, women and the working population, and older people. Targets for risk factor levels for the major diseases of importance in Singapore have been set for the year 2000. surveys are carried out at regular mtervals to determine the prevalence of the diseases of importance and their risk factor levels and the progress in reaching the targets set. ~ational

Specialist Hospital for women and children A 738-bed public sector hospital for women and children is currently being built to replace an old maternity hospital, the Kandang Kerbau Hospital. It will be the specialist institute in Singapore providing obstetric and postnatal services and treatment for gynaecological disorders. These services are also available in other public and private hospitals in Singapore.

Health education Health education is an important component of health care provision. Mass health education is undertaken by the Government. Health messages are transmitted to the population via mass media such as TV, newspapers, radio etc. Health education programmes for various target groups, such as students, mothers and various segments of the population, are planned and provided by the Training and Health Education Department of the Ministry of Health. (Emmanuel, S C, personal correspondence, 1995).

Training of medical manpower The Singapore Government has a central plan to train the required number of specialists to meet the needs of the population. This includes the required number of specialists and sub-specialists in obstetrics and gynaecology, geriatrics, etc. In the ~edical manpower training plan is mcluded the training of ancillary health personnel to support the progmmrnes being planned and implemented.

Country Initiatives

Vanuatu Health reporting systems indicate that cancers of the breast and cervix are the key causes of mortality and morbidity. Cancer of the breast and cervix are usually present at a later stage and affect older women beyond the child-bearing age who have little regular contact with health services. An estimate of five to six new cases of cervical cancer per year are reported incidence rates (total popUlation 165,000). A nationwide cancer screening project is recommended, al1hough lack of contact poses problems for implemmtation. Ano1her major issue reflecting health of women is violent assault and lack of regard for the aged. Presently, increasing urbanization has led to much neglect of older women who are often engaged in child caring, and no allowances or government initiatives are in place to care for them. Often care from the family is expected but does not happen. However, retirement benefits are provided for the employed through the National Providmt Fund and some life insurance and heal1h insurance policies through private companies. The govemment has not yet set up a health insurance company, and the disabled, the insane and inherited diseases are not covered by the other schemes. Older women suffer more in these categories and are often subject to much exploitation and neglect (National Health Planning Unit, Ministry of Health, Vanuatu,1995).

Issue No. 5 - Quality of life Experiences of quality oflife between men and women are unequal, and the instruments to measure them qualitatively and quantitatively are poorly developed.

Australia SF-36 QOL for the 1995 Australian National Health Survey Health policy institutions in Australia have long recognized that using morbidity and mortality data alone as measures of health intervention outcome is inadequate. The Australian Institute for Health and Welfare (AIHW) examined a range of general health status measures as potential candidates for the 1995 National Health Survey. The AIHW, the National Centre for Epidemiology and Population Heal1h and various levels of government health departments recommended that the latest short form of the United States Medial Outcomes Study, the 36-item quality oflife questionnaire SF-36, 'with some minor "Australianising" modifications' be adopted as 'the general health measure for Australia for inclusion in the 1995 ABS National Health Survey, and in epidemiological surveys where a general health status measure is appropriate' (AIHW, 1994b:3). Modifications to the SF-36

J !i

Women's experiences of Aging In the WPR: A Diversity of Challenges and Opportunities

have been kept to a minimum so it can still be used as an effective tool for 'national and international comparison of health status' (McCallum, 1993 :2). The SF-36 contains several dimensions, including physical functioning, role limitations due to physical health problems, social functioning, bodily pain, general mental health (psychological distress and psychological well-being), vitality (energy/fatigue) and general health perceptions. The scale thus taps into subjective experiences of health.

rated their health in far more positive terms than those in towns or cities. Women's self-rated health was significantly lower than men's: 27 per cent of women in the country, 33 per cent of women in the towns and 31 per cent of women in cities rated their health as bad or very bad compared to corresponding figures of 22 percent (country), 27 per cent (towns), and 26 per cent (city) for men. (Wue De-qing, 1995).

Euthanasia The Northern Territory legalized voluntary euthanasia in May 1995. This represents the first initiati ve in the Region to allow those terminally ill patients who are of sound mind and over the age of 18 the right to end their lives and die with dignity.

Philippines Quality of life scales Several initiatives to develop new health indicators that reflect Filipinas' conceptions of their health have begun. These involve adaptation of theory and methodology to local circumstances and an elaboration of unique cultural experiences of health and well-being. Garcia et al (1993) developed a measurement scale for the Filipino concept of subjective well-being, 'kabuuang pagkatao' in Tagalog. The researchers used lllaigenous conversational methodologies 'ginabayang talakayan' (akin to focus group methodology) and 'pag tatanungtanong' (conversation) to establish raw dimensions of a scale which was subjected to validity and reliability testing to produce a fmal instrument of 63 items and 7 sub-scales. The sub-

China In China, quality of life scales such as the Daily Life Survey are being used by the Research Centre of Older Populations, Institute of Population Research, Peking University. A daily life survey of older populations in Tianjing, Hangzhou and Wuxi provinces in 1987 which was disaggregated by sex and location (city, town, country) revealed that the majority of people rated their health as 'very well' to 'not bad', but that older people in the country

Country Inltlatlvell

scales were: (1) distress, (2) comfort, (3) peace, contentment and trust, (4) happiness, (5) entire life, (6) pessimism and (7) spirituality. The researchers stressed the importance of spirituality in Filipino conceptions ofhea1th, which is not reflected in the more secular Western measures of well-being, quality of life and health. Although these measures are able to pick up significant differences between men and women on the various scales because they are gender sensitive, they are not gender specific. The same scale is applied to both sexes. The University of the Philippines, Department of Health Quality of Life Scale developed by Ramiro and Ngelangel (1994) was designed to fill a need for a 'culturally-appropriate instrument that could measure the QOL of Filipino cancer patients'. The UPDOH QOL has five subsets - physical wellness, emotional well-being, social/ economic status, cognitive ability, self care and other related functions. Women made up 70% of the sample on which the test was standardized so, although there is no gender-specific subscale, the high content validity suggests that the scale is sensitive to women's experiences of cancer. The majority of the standardization sample were in the 32-68 age range so older women's experiences are well represented.

Issue No. 6 Community care Most countries in the Region have addressed the issue of the provision of appropriate institutional and community care for older women. This was witnessed in the March 1995 Regional Workshop on Community Care for the Elderly where 16 countries presented reports on their activities on community care for the elderly. Summaries of some of those reports are presented here. The issue of community care also addresses initiatives to provide more holistic health care, including the use of traditional healing practices and substances, alongside scientific medicine. Older women form the majority of traditional healers in the countries of the Region. Older women are an invaluable resource as lay and traditional healers and as carers for the older old and the disabled, and their role is starting to be recognized at both the country and regional levels (witness the recommendation of the recent Pacific Island Health Ministers meeting in Fiji that traditional healers and traditional healing substances become part of a holistic approach to health care). Despite this trend, there is a continued tendency to medicalize major transitions in a woman's life and the process of aging (including multiple prescribing). The current health funding arrangements of most countries in the Region make medical and

Women's Experiences of Aging In the WPR: A Diversity of Challenges and Opportunities

pharmacological choices cheaper for the consumer of health services than nonmedical and non-pharmacological alternati ves.

care for those rendered homeless by the closure of institutions for care. Australia also has a wide network of the "University of the Third Age", where older people undertake courses in a variety of subject areas and meet regularly in reading and discussion groups. Older women also take advantage of the widespread provision of distance education and flexible delivery modes in adult education offered by many institutions throughout the country. The more recent Open Learning initiative, where higher education is offered via the national television station backed up with printed learning modules, has provided substantial opportunities for disabled older people confined to their homes and in remote areas. The mlYor initiative undertaken by the Australian Government to address issues of the care of the elderly is the Home and Community Care Programme (HACC). The HACC programme is directed at assisting frail, aged persons at risk of being admitted to long-term residential care (nursing homes or 'hostels') where they do not need to be, younger persons with moderate or severe disabilities, carers of frail-aged and disabled people. The programme aims to provide a range of basic support and maintenance services aimed at enhancing people's independence in the community and avoiding premature or inappropriate

Australia Self-help groups are encouraged where older women can be in control of their own health needs. The Northcote Hydrotherapy and Massage Group was set up by a group of older women who suffer from arthritis and rheumatism who decided to break out of overdependence on pain-relieving drugs and the immobility and isolation associated with this crippling disease. They meet regularly at the local swimming pool where they use various forms of hydrotherapy and massage to relieve the pain and to keep mobile. The group also plays an important social role in keeping the members actively involved in discussion aJ;ld social contact. Many initiatives have been developed to humanize institutional care and to provide community and home back-up, for example, meals-on-wheels, home handymen services provided by local councils and domiciliary care. Problems identified in the Burdekin Report (1993) on the care of the elderly and mentally ill include homelessness as result of deinstitutionalization (Burdekin Report, 1993). These problems are currently being addressed by the state and federal governments in terms of providing appropriate alternative community-based

Country Inltlatlws

admission to long-tenn residential care. The national government provides 60 per cent of the funds and the state governments 40 per cent of the funds. In some states, municipal or 'local', governments provide some of the states contribution. The HACC programme provides funds for community nursing, home care services, personal care services, meals on wheels, community transport, respite care, day care centres, allied health care, home maintenance and repairs, home modifications (ramps, rails etc.), training and programme development and evaluation. The programme does not fund medical care. In Australia, almost all community doctors are private doctors who charge fees. Australia has a universal health insurance scheme called Medicare, financed through income tax, which helps pay most of the medical costs for all Australians. The HACC programme is based on three assumptions for which there are considerable research data available: older people prefer to stay in their own homes when they can, older people are healthier and more independent staying in their own homes, and it is cheaper to care for people in their own homes than in institutions. Another programme that is funded separately from HACC is carer support. Carer support is a crucial aspect of care of the elderly. In Australia, 70 per cent of care is provided by relatives or

friends. Support is provided to these carers through information kits, carers associations and respite care programmes to give carers a 'holiday'. (Bruen, 1995) Thus, the government supports official recognition of older women as carers for husbands, grandchildren and the disabled. Activities independent of the government include commercial ventures such as the South Australian 'rent a granny' scheme, where older women provide a childminding and 'grandparent' role to families without grandparents. The 'grannies' earn an income and playa socially important rple. Self-help groups and political lobby groups such as the Older Persons Action Centre are developing allover the country. Women's health centres operate across Australia and address the specific physical, social and mental needs of women, including older women. Specialist women's services such as mammography screening clinics are provided free of charge for women over 50 years old. 'The Australian Government monitors standards of care in government funded aged care residential services. The government has developed a Charter of Resident's Rights and a resident! proprietor agreement for nursing home residents. There are government funded independent advocacy services for residents and the department

Women's Experiences of Aging In the WPR: A Diversity of Challenges and Opportunlues

investigates complaints about the quality of care.' (Bruen, 1995) The Older Women's Health Project 1994, a Victorian Educational Project for the promotion of older women's health, funded by the National Women's Health Program has recently produced a resource kit called "Being Our Age Older Women's Voices". The resource was developed through consultation with over 400 older women in Victoria aged between 50 and ?O years. The resource kit "aims to assist older women to take more control in achieving their optimal health and to assist workers with older women to provide services which are responsible to older women's needs." Issues addressed in the kit include the impacts of environment and geographic location, belonging to a marginalised group and requirements to ensure good quality interactions between older women and health workers. 'The National Women's Health Programme has also funded projects such as the Older Women's Network (NSW), Health matters for Women Over 60 (NSW) and Healthy Older Women's Service (NSW). The Older Women's Network has now extended to most other states of Australia.'

Examples of other projects funded lUlder the National Women's Health Programme are a. The Queensland Health Department funds a "60 and Better" Program which enables older people at a local community level to participate in decisions and activities which affect their health and well being. b. Sport and Recreation Victoria fund a research project "Active Seniors" which is about investigation of adult education opportlUlities and development of recommendations for future policymaking and agency action. c. The National Health Advancement Programme funded the development of a Nutrition and Older People Video and Resource Kit to assist older people to improve their nutrition. Development of dietary guidelines for older people will be conducted by the National Health and Medical Research COlUlcil in 1995. d. The Older Persons Action Centre in Victoria has supported two other projects which mainly target women - the Pills and Older People Project (about alternatives to medication and wide use of medicines) and the Self Help for Older People Project.

Country Initiatives

There is a Foster Grandparents Progranune in Victoria which matches older people with children with disabilities, many of whom have no grandparents or close family members. The Minister for Human Services and Health has established Older Australians Advisory Councils in each Statel Territory. These Councils are composed of older people (mostly women), and provide advice to the Minister on matters relating to the care and well-being of older Australians from an older person's perspective. The Department of Human Services and Health, in consultation with other commonweal1h departments, is currently developing a structure for action on healthy aging and well-being. The Australian Government recently endorsed a framework for developing and implementing policies for Older Australians. The overall theme is "continuing participation in community life" and one of the elements is "community participation and healthy

participation of older people in a range of physical and intellectuaI activities in the life of the community" (Birch, personal communication, 1995).

China China, like many of the cOWltries in the Region, sees its ml\ior resource for the care of the elderly as the family. However, in the light of demographic, social, political and economic changes which have started to erode some of the functions of the family, China is making provisions for . alternative sources of care. These include the provision of community service centres (where assistance is given with housework and day care) and neighbourhood and village committee structures where volunteers assist the elderly, self-help networks are set up and alarm buttons, connected to the neighbourhood office, are installed in the homes of older people. In addition, the Department of Civil affairs provides economic assistance to the poor; in 1993, 37 million people received economic assistance. Volunteer activities are supported by the Chinese Government to provide assistance to the elderly. More than 26,000 volunteers in Beijing alone, drawn from local government, enterprises, workers unions, young people's organizations and religious

aging". The Department of Human Services and Health's directions are broadly in the areas of disease and ill-health prevention, and maintenance of "physical, emotional and spiritual wellbeing, including encouraging intergenerational linkages and the

Women's experiences of Aging In the WPR: A Diversity of Challenges and Opportunities

groups, are responsible for helping 5200 older people living alone. Special schools for the aged have been established in urban areas. People can learn anyfuing from painting to sociology. In rural areas, schools for the aged tend to supply more practical technological education and skills. Centres for the aged have also been set up where recreation is the focus. Home visiting by community health care professionals is a widespread practice and health promotion among the elderly is actively encouraged, reinforcing the traditional practices of public group morning tai chi and exercise. It is estimated 1hat 36 per cent of elderly people in urban areas practice regular group exercise. There are community-based rehabilitation services which were started in four provinces in 1987 under a programme proposed by WHO. There are also special clinics for the aged and extensive training programmes for community health workers.

Cook Islands Care for the elderly and those wi1h longterm illnesses in the Cook Islands is the responsibility of the family, extended family and sometimes friends. The extended family is very strong, and traditional preference is to care for family members as long as it is possible before considering hospitalization (fere, personal communication, 1995). Churches have special days for visiting and determining the needs of older people. The Assembly of God Church is especially active in providing for older people. Other initiatives include nutrition programmes for older people and family health programmes for older women. Domiciliary care is emerging in both the government and nongovernmental sectors.

Fiji The policy on heaI1h care of older people in Fiji focuses on preserving the dignity, independence and autonomy of older people in the context of the family and community in such a way that aging is a positive and fulfilling phase of a complete life. Access to acute care systems involves improving the efficiency and effectiveness of acute care services for the elderly. Strategies include: providing equity of access to acute care for 1he elderly; providing efficient referral to

In 1991, a Five-Year Plan for Health Care of the Elderly was developed by 1he Ministry ofHeal1h, and in 1993, 1he Plan of Action for Fur1her Development of Community Service in China was adopted by the Ministry of Civil affairs, the Ministry of Health, the National Committee of Planning and eleven other departments.

country Initiatives

providing good quality acute care which is appropriate to the clinical and social needs of the elderly and consistent with the available resources. Post-acute care (hospital-based, community-based) includes strategies to: improve the quality of hospital-based and community rehabilitation services; and improve the quality of communitybased ongoing care for persons with disabilities or chronic diseases. Special residential care includes providing nursing homes for persons with care needs that can only be provided in such facilities. Strengthening cooperation between government and nongovernmental organizations aims to: develop formal governmental coordinating structures and processes; strengthen formal nongovernmental organization coordinating structures and processes; and provide divisional anq subdivisional coordination of government and nongovemmental organizations. The main emphasis of this policy is to seek care that is accessible, effective and of good quality, and, importantly, is sensitive to support of family-care givers, particularly women, as well as the older people themselves (Tukana, personal correspondence, 1995).

acute care for the elderly; and

Japan The new care system proposed for Japan emphasizes prevention and rehabilitation to support the independence of older people. The four focal areas being addressed are: selecting care services based on older people's own desires including the provision of consumer-planned home care support, unifying the home and institutional care services, establishing a care management system with care teams to provide a range of services to older people, and introducing a social insurance system, thus acknowledging that care for older people is a public responsibility.

Kiribati A three-day workshop entitled 'Group Educational Activity of Community Leaders for the Health of the Elderly' was held in December 1994. Twenty older people (ten women and ten men) participated. The objectives were to promote the understanding by community leaders of the importance of maintaining good health and behavioural leadership of older people, to promote public awareness regarding the roles and responsibilities of individuals, families, voluntary organizations, legal institutions and the community towards the care, protection

Women's Experiences of Aging In the WPR: A Diversity of Challenges and Opportunities

and promotion of health for older people, to identify effective strategies on how to promote and implement positive measures regarding health for older people, and to compile recommendations for a plan of action. The demographic situation in Kiribati and its relationship with social, cultural, political and economic progress were examined to assess and identify healthrelated issues and problems faced by older people. Participants discussed how traditional culture conflicts with social change and values, and how this affected the health of older people. (Dr Thein Dan, 1995)

are day care centres for older people whose caregivers work during the day, which provide personal and limited nursing care, recreational and health promoting activities and education programmes. There are also social centres for older people, and multiservice centres that include canteens, laundries and bathing facilities as well as counselling, social and recreational activities and education. A fleet of buses is provided by a nongovernmental organization for outings. Outreach teams identify and refer older people at risk to appropriate care services.

Hong Kong Studies (Chow and Kwan, 1986; Walker, 1987) have shown that the Chinese tradition of caring for older people is changing as more families rely on older family members to care for grandchildren or take r~ponsibility for the housekeeping. As society becomes more materialistic and women participate in the workforce in greater numbers, it is unrealistic to rely on the family to provide community care for older people. Home care services include domestic help and escorts for older people who are infirm or weak and have no family members or friends to help them There are 84 home teams operated by nongovernmental organizations. There

Lao People's Democratic Republic The Ministry of Health formed a committee in charge of a programme of health for older people in 1990. The activities of this committee have been limited. Mahosot hospital has established a small Geriatrics Unit with ten beds. The Unit provides treatment and health education for retired and older people, and holds an outpatient clinic once a week. Many patients are unable to afford medicines, and the hospital distributes drugs without charge when possible. Many older people in the Lao PDR live with their families. Morning visits to the temple to give offerings to the monks provide an opportunity for social

Country Inlt/at/ves

interactions with other older people. Religion plays an important role in the life of older people. Health problems resulting from malnutrition, infectious diseases and chronic diseases are the most common. The Govemment does not have a clearly defined policy on the health of older people at present. Hospitalization and treatment are provided free to those who are retired as part of social welfare. There is no system of community services, and, at the village level, traditional healers act as caregivers.

which the welfare of the people will revolve not around the state or the individual but around a strong and resilient family system.' (Prime Minister's Department of Malaysia, 1991). In response to this, the Ministry of Health has included health care of older people as part of its Seventh Malaysia Plan, which is a five-year plan running from 1996 to the year 2000.

New Zealand The New Zealand Government announced major new directions in policies for support for people with disabilities, including the frail aged, in 1992. One objective of the reforms is to release resources from the institutional sector to provide better support for people at home and in the community In 1991, the New Zealand Government announced wide-reaching reforms of both the health and disability sectors. One purpose of the reforms was to enable a shift in the balance of care through more flexible and cost-effective use of their finite resources. The desired outcome is a system which is better able to meet the needs of people with disabilities, including older people experiencing age-related disability, for quality health and disability support services.

Malaysia In 1993, Malaysia's population of older people (defined as those above 65 years of age) was 4 per cent, an increase from 3.6 per cent in 1980 and 3.7 per cent in 1990. An aging population is considered to be one where 7 per cent of the population is over 65, and Malysia will reach this by 2020. There is no comprehensive policy on the provision of health care for older people. However, community involvement in care and support for members of the community has been emphasized by the Malaysian Prime Minister as one of the nine challenges that Malaysia must meet to become a fully developed country. '... the challenge of establishing a fully caring society will come before self, in

Women's Experiences of Aging in the WPR: A Diversity of Challenges and Opportunities

It is expected that an increase in home support services will reduce the incidence of institutionalization and increase the satisfaction of older people and caregivers leading to older people remaining in their homes and communities for longer periods of time. The cost of providing home support services is generally believed to be less than the cost of a rest home or longterm hospital care although this has yet to be proved.

Department of Social Welfare and the Ministry of Health provides policy advice on health and disability support issues (D' Audney, 1995).

Palau Older women in Palau are mostly cared for by their families according to traditional values of the younger generation caring for their elders. Most caregivers are immediate women family members. There is no long-term institutional care. The Ministry of Health provides inpatient, outpatient and dental services to older people. There are also two private clinics. Dispensary services and trained nurses serve rural areas which do not have access to central care. Some areas are still without even these services due to lack of funds, facilities or trained personnel. Public health and geriatric nurses provide periodic home visits for older people when necessary (Ingeang Rimirch, personal communication, 1995).

Caregiver support Some regional health authorities are giving increased emphasis to purchasing caregiver support for families and other voluntary caregivers. This is in recognition of the value of the work they provide and to ensure caregivers are able to go on caring for older people in the community when that is the most appropriate option. The aid to families programme is specifically focused on the needs of the caregiver.

Political infrastructure A political infrastructure to ensure that the needs of older people are considered in policy development and decisions exists in New Zealand. There is a Minister for Senior Citizens, a Minister of Health (health and disability support) and a Minister of Social Welfare (income support). Policy advice pertaining to a wide range of issues relating to older people is obtained from the Social Policy Agency of the

Philippines Geriatric centres are planned for each municipality as a venue for social activities, exercises suitable for older people and rehabilitation facilities. Community-based programmes for older people in some areas could easily be expanded to include community-based health care. The Asia Training Center on Aging in collaboration with St Luke's

Country Initiatives

Hospital held a workshop on Gerontological Nursing Models in 1995 as a first initiative in training nurses and other caregivers of older people. The workshop produced training modules to be used in future training programmes. 'The majority of (older people) in the Philippines are not eligible for social security benefits. Hence economic security for old age is more of (an) individual and family initiative. Education for children was cited as the best insurance for old age with the implicit assumption that the children are going to care for them.. .' (University of Santo Tomas, Social Research Center, 1989).

145000 in 1993. There are 50 nursing homes (36 free and 14 at a low cost to residents) that cater for about 2800 older people. The Government plans to introduce a Health Promotion law for the Elderly. The law will strengthen health education regarding lifestyles, ensure regular check-ups for the prevention and detection of chronic diseases, introduce home visits by nurses for older people in need, especially those living alone, and increase nursing and treatment facilities. The Government intends to put more emphasis on community-based health care for older people through establishing physical therapy rooms in all treatment centres, providing financial assistance to equip and staff these rooms and posting specially-trained nurses in health centres and regional welfare agencies. (Shin, 1995)

Republic of Korea The Republic of Korea has several major national health programmes for older people that cover medical insurance, medicalassistan.;e and institutional care. The medical assistance programme provides free or low-cost-treatment and services to older people who meet certain criteria. In 1994, about US$116 million was spent on 276 000 persons aged 65 and above. People aged over 65 have received free health check-ups since 1990, including follow-up testing if required. This programme contributes to the early detection and proper treatment of diseases, and the total number of beneficiaries was about

Samoa Currently, 6.6 per cent of Samoa's population is over the age of 65. Traditionally, older people are looked after and cared for at home by their family. Although Samoa is not a true welfare state, the Government has recognized and supported the elderly population in the community. Prescribed medicines and inter-island travel are free of charge. Care of older people at home is integrated into community health nursing and is now established as part

Women's Experiences of Aging In the WPR: A Diversity of Challenges and Opportunities

of the responsibilities of community health nurses. Each health area is compiling a register of older patients needing care and support. Activities for care of older people include home visiting, consultation, health assessmmt, treatment, counselling, mental health and guidance regarding hygiene, diet and cleanliness. There is a home for the aged operated by the Catholic mission, Little Sisters of the Poor.

emphasis will be given to effective rehabilitation. Geriatric services will be delivered through three regions to better integrate various levels of care, and careful needs assessments will be made by doctors, social worker, therapists and geriatricians. Quality assurance programmes should be built into all community health service programmes to promote rapid and effective reductions in morbidity and mortality among older people.

Singapore Viet Nam Outpatient geriatric care constitutes the main bulk of the ambulatory care of the elderly sick. Most cases are managed by polyclinic doctors. Standards of outpatient care need to be improved to reduce referrals and hospitalization. There will be more homebound older people as the number of older people increases, . and a greater demand for domiciliary care. More affordable home medical services should be made available. This type of home service is currently taken up by a charitable organization, but their operations are restricted by limited resources. A survey of 6000 people aged over 55 years will be conducted to assess the needs of older people staying in the community and to improve planning for care. Community-based care services such as home nursing and home help services will be expanded. More The National Institute of Gerontology estimates the efficacy of medicaments extracted from domestic materials and application of the experiences of traditional medicine in treating illness and improving the health of older people. The traditional practitioners in the community are often the frontline healers. These are supplemented with medical practitioners at government stations and in urban areas, and a few specialized nurses or agencies who undertake the health care of &Ider people. International Day of the Elderly (October 1) is celebrated each year in Viet Nam. The activities of communitybased clubs and associations for older people are widely advertised. Only 0.4 per cent of older people live in state and nongovernment residential care facilities for the aged and infirm.

country Initiatives

The Ministry of Health has developed a basic health care system covering the whole country. Every commune has its own commune health centre staffed with trained health workers. Problems that cannot be handled at the local level can be referred to district, provincial or specialized hospitals. Recent economic reform measures have encouraged private initiatives in health. There are plans to establish a more comprehensive health system for the aged including: home nursing centres, senior citizen health care centres, day care and respite facilities, health education and health screening facilities, day centres, day hospitals. At present the only department of geriatric medicine in Viet Nam is a 30-bed ward attached to the National Institute of Gerontology (Viet Nam Country report, 1995).

Kiribati The Government supports traditonal attitudes towards older people which gives them high status. To be given the status of elderly in Kiribati (age 5080+) is a very high honour and older people receive respect from the family unit and the community. Anybody who is the oldest in the family may be given that title. The whole family leaves the decision-making to the oldest person. Matters affecting the family such as marriage, land and family ceremonial matters, are referred to elders (Tekarei Russell-Aia Maea Ain,en, personal communication, Kiribati Women's Organization, personal communication, 1995).

Macao All measures are taken to avoid gender and age discrimination in the care of older people in Macao. The 18 fundamental principles of rights for aged persons, adopted by the United Nations General Assembly, are used as the guiding framework for provision of services for the aged. These principles include access to adequate food, water, education, health services, clothing, accommodation and family and community support. The opportunity for older people to remain integrated in their communities, to have power over decisions which affect them, to use their knowledge and experiences in the

Issue No. 7 - Agism and sexism The dual discrimination of agism and sexism suffered by older women has serious consequences for older women's physical, mental and emotional health and well-being. The response of policy-makers has largely be~n indifference but older women wIll become a major political voice, especially given their burgeoning numbers.

Women's Experiences of Aging In the WPR: A Diversity of Challenges and Opportunities

community, to form movements and associations are protected in the array of domiciliary care services, institutional and home care facilities, day centres and health services provided free by the State to those over 60 years old. The predominance of females in this age group is catered for by the provision of women-only aged care homes. Of the eight homes for older people in Macao, five are for women only, two are for both sexes and one is for men only. Women are the major beneficiaries of home help services. On a policy level, deliberate measures are put in place to ensure the dignity, safety and care of older people and to cater for the special needs of older women (Maria de Fatima S, personal communication, 1995).

bloc' (UNDP, Mongolian Country Report, 1995). Thus the gains that women made after 1921 in education, employment, state-provided child care and equality in marriage contacts are being eroded. Their achievements in the economic and social field since 1921 were not mirrored in the political and technocratic spheres and the 'political leadership is now entirely male.' In 1990, 'women accounted for over half (51.5 per cent) of Mongolia's workforce. In the banking, health and education sectors they dominate (60 to 80 per cent)', as well as in 'communications, trade, technology, utility services, public canteens and insurance'. The erosion of the gains women have made since 1991 includes 'loss of jobs and loss of social services that enabled them to participate fully in the labour market. The loss to Mongolia of its female human capital is enormous, as is the loss of women's voice. The picture we have of female poverty in early 1994 is of a rapid slide from general and equitable well-being into severe dislocation.' However, 'women have not remained passive during the last four years of retrenchment'. Sexism and erosion of rights is being fought by both younger and older women with an increase in female social and political activism and entry into the private sector' Nongovemmental organizations such as the Mongolian Women's Federation and

Mongolia Gender equity has been promoted in Mongolia since the 1921 Revolution. Mongolia has achieved major steps towards equality for women, including having the first female member of parliament for the Region in 1923. Thus currently older women in Mongolia have been brought up to expect and exercise equal rights with men. However, 'the active policy on women's development during the socialist period, and the generous support given to women's issues, have been undermined by the political changes that have swept across all the countries of the former Soviet

Country Initiatives

collective consortia such as the Women's Consultative Group are part of a network with a broad agenda for women. 'The agenda includes equal access to work, equity in housing, legal issues and education, access of women to credit, generating employment, crisis intervention in health care for mothers and infants, promotion of the women's movement, formal and vocational education for girls and women, a clearing house and an independent data base.' (UNDP, Mongolian Country Report, 1995) 'The Mongolian 1992 Constitution does guarantee equal rights for men ~d women in political, economic, SOCIal, cultural and family life. The Law on the Government has charged the government with elaborating state policies for children, youth, women and the elderly' but the nongovernmental organizations in recent years have been most effective in supporting women's rights (UNDP, Mongolian Country Report, 1995).

The Federation has a commitment to providing a powerful voice for women health consumers and to act as an advocate for them.

Philippines Cognizant of the needs of older people, Republic Act 7432 was passed by the legislative body. This law recognizes the contributions of senior citizens to nation-building and grants benefits and privileges to them. Senior citizens have banded together in many municipalities and have organized regional federations and a national federation. The National Federation of Elderly Persons is composed of 14 regional federations, whose members include 3650 associations with membership of205600 elderly persons throughout the country. These local and national associations can empower older people to plan/run community health care services in their respective areas. (Estipona, 1995) The Philippines is also setting up women's banks and putting in place legislation to guarantee the rights of women, including legislation against violence towards women. A growing number of women are moving to senior positions in the Philippine Government, and in the health field, a woman is the acting undersecretary for public health services in the Department of Health.

New Zealand The Federation of Women's Health Councils Aotearoa-New Zealand is a national umbrella organization for women's health councils in 25 regions throughout New Zealand. Each Women's Health Council (WHC) is an umbrella group for organizations and individual women in the region who have an interest in women's health.

ll...

Women's Experiences of Aging in the WPR: A Diversity of Challenges and Opportunities

Republic of Korea The Welfare Law for the Elderly was enacted in 1981 and revised in 1993, followed by the proclamation of the Charter on Respect for Elder Persons in 1989. In accordance with this law, the Government has steadily developed policies to provide free medical examination, expand comfortable welfare facilities for the aged, give allowances to aged persons protected under the Livelihood Protection Act, and operate the home-maker service for the older people (Korean Women's Development Institute, 1994).

Tuvalu The Tuvalu government has formulated and started to implement a national policy for women in development This commenced with the establishment in 1994 of a Women's Bureau designed to oversee all activities related to

women in Tuvalu. The policy also includes the development of incomegenerating projects for women's organizations in the country, with a special focus on those on the outer islands. To ensure the coordinated development of a national policy for women, the Government has facilitated networking among the women's organizations in Tuvalu and with women's organizations overseas. This is reflected in the promotion of Tuvalu's participation in forums and discussions on issues related to women in development both at a regional and an international level. An example of the determination to put Tuvalu women's health issues on the international agenda was the initiative by the Tuvalu Prime Minister, Mr Latosi, to promote Women's Health Development Programmes through Cervical Screening and Environmental Health Training Schemes (Apisai Ielemia, Acting Secretary, Ministry of Health, Sports and Human Resources Development, Tuvalu).

5. Conclusions and recom mendations

Conclusions Older women's lives and their health experiences are influenced by a variety of temporal, geographical, economic, political, religious, social and cultural circumstances which vary markedly across the Western Pacific Region. However, women are not just victims of these circumstances. Both individually and collectively, women allover the world are changing the way health services are provided, pushing new initiatives in health policy and legislation which affect health (for example the legislation against violence towards women in the Philippines passed in 1995) and making changes and choices in their own lives (such as leaving marriages where they are exposed to violence) backed up by appropriate public and community support. They do have some agency and power to influence their health experiences and outcomes, although it is acknowledged that the degree of freedom to exercise such power varies with circumstances.

Morbidity and mortality rates for women in the Region remain high as a result of prevalence of infectious diseases, lack of adequate sanitation, undernutrition, poverty, lack of education and excessive manual work under harsh conditions. This is coupled with the chronic diseases characteristic of the developed world which are gradually emerging in the newly-industrializing countries, Southeast Asia and the Pacific islands and areas. The dual discrimination of agism and sexism suffered by older women has serious consequences for older women's physical, mental and emotional health and well-being. This results in older women being invisible and silent The response of policy-makers has largely been indifference, but older women will become a major political voice as their numbers increase. Developing effective policy for aging women will involve expanding the scope of analysis to men since, unless men's attitudes to women and to the aging process change, significant barriers to cultural, social and economic change will

Women's Experiences of Aging In the WPR: A Diversity of Challenges and Opportunities

remain. For example, suggesting that women's quality of life might be enhanced by more equitable distribution of household tasks involves major reeducation of men. Putting an emphasis on women's health does not preclude the need for investment and initiatives in men's health. This analysis does not suggest that older women's health should be enhanced at the expense of other groups in society such as young and middle-aged women, and men of all ages. If anything, this report acknowledges that all women will age, so the analysis concerns all women young and old, and should be read alongside the other volumes of the series, especially Volume 1 on reproductive health. It could be argued that differences among women on racial, ethnic, cultural, geographical, age and class lines may override their sex difference from men. However, there is enough evidence to argue that women are still systematically discriminated against around the globe for there to be an advocacy agenda in favour of women. It is hoped that, by the middle of the twenty-first century, the inequities discussed in this report may have been addressed to the extent that people's health can become the focus of global attention. However, there will always be a need to address the particular health needs of women, especially older women, not only because of their different biology but because of their experiences of being gendered subjects.

The challenge is to celebrate the differences between men and women and to support the notion of 'different but equal' rather than use difference to support inequality and discrimination. This applies also to other dimensions of difference such as age, race, ethnicity, culture and geographical location. Where difference leads to inequalities, such as socioeconomic class differentials, policies must be put in place to eliminate or minimize that difference. To achieve these aims, it is important that appropriate gender-specific and culture-specific information be available to inform policy. Only under such circumstances is it possible to address the diversity of opportunities and challenges associated with women's experiences of aging in the Western Pacific Region.

Recommendations Many issues are relevant to women through their life course. How these issues are dealt with now, for females from the uterus to the grave, will have long-term implications. The list of recommendations which is presented here is not exhaustive. They should be read in combination with the recommendations of the global reports on women's health and the other reports for the Western Pacific Region which appear in this series of monographs. However, several priority issues are highlighted, with associated

Conclusions and recommendations

recommendations, which, if acted upon, are likely to make the most difference to the experience of aging for women in the Region and ensure that the greatest number of women age more healthfully and increase their health and quality oflife potential having reached old age. Existing country initiatives should be supported and fostered by WHO and the Global Commission on Women's Health and countries should be encouraged to share their experiences in global and regional forums and through publications.

inequality, it should be respected and accounted for in policy. Where difference is based on systematic discrimination, affirmative action must be taken to correct the imbalance. Unequal representation of women among all age groups, including the 'old old' in some countries, as a result of systematic cultural preference for male children must be addressed with a population policy that eliminates this systematic discrimination. Governments must be encouraged to ban the practice of prenatal diagnosis for sex determination purposes only. The Global Commission could take an advocacy role on behalf of unborn female children and female infants to ensure that they have the same chance to thrive as males.

Issue No. 1 - The demographic shift and the need to plan for the future

Recommendations In planning for future accommodation, service, transport, income and health needs of the increasing numbers of older people, women should be consulted and their specific needs recognized.

Issue No. 2 - Influences on health: the life course approach and the context of women's lives We need to celebrate diversity across time and space. The heterogeneity of needs and experiences among older women extends to their geographical location, their cultural and sub-cultural traditions and a raft of other dimensions of differentiation. Older women and aging women are not a homogeneous block with shared interests, values and

Although the demographic shift is universal, it must not be assumed that even among women, the needs of people are universal. Diversity in women's life situations, including their life histories, should be accounted for and where difference is not based on

Women's Experiences of Aging In the WPR: A Diversity of Challenges and Opportunities

needs. 'The appreciation of .. , differences is essential in the provision of quality health care and successful public health programs' (Legge & Westbrook, 1994: 179).

income for women, sex-role stereotyping, body image problems, women's access to policy-making and governance need to be addressed. Policy formulation must acknowledge the differences between countries in relation to economic development and continue to work towards alleviating harsh living and work environments.

Recommendations Research on aging women needs to adopt an analytical and policy-oriented life course approach rather than merely a descriptive cross-sectional approach if significant implications for policy are to be drawn. This is not to suggest that it is too late to provide services and ameliorate conditions for currently older women. That is an important part of any platform on women and aging. However, drawing such a descriptive picture is not enough to inform health promotion and illness prevention programmes and to plan for improved quality of life for older women. Appropriate primary, secondary and tertiary prevention campaigns must be instituted to enhance women's health tr~ectory across the life course. Issues that bring about high morbidity rates for women, including work conditions, domestic arrangements and

An intersectoral approach should be adopted. Health authorities must work together with workforce planners, agricultural departments, town planners, educational institutions and engineers to plan for the best possible physical and work environments. There must be transfer of funds and resources to women at both the public policy level and the household level. Initiatives like distance education, flexible delivery learning and the University of the Third Age must be extended to areas with more remote populations so that women can take advantage of the greater social mobility, greater personal, economic and social power and improved health status that come with higher levels of education.

ConclusIons and recommendations

Issue No. 3 - Lack of adequate research and data on which to base policy tor older women's health

4. 5.

deal with specific reproductive health issues of women, and are gender specific in other (nonreproductive) areas of health.

Recom mendations Indicators should be developed which more accurately reflect women's experiences of health, illness and disability and women's quality of life. To carry out research which examines the inequities referred to in the previous sections we need to use all four of the types of indicators listed in the above text, i.e. morbidity, mortality, social indicators and subjective measures of quality of life. For each type we need indicators that: 1.

Older women should be integrally involved in designing health research projects which deal with issues of their health.

Issue No. 4 - Mortality and morbidity Continued low life expectancy persists for women in some areaS of Western Pacific Region as a result of prevalence of infectious diseases, lack of adequate sanitation, undernutrition, poverty, lack of education and excessive manual work under harsh conditions coupled with emerging lifestyle diseases. The higher incidence of morbidity for women across the life course and amongst older women with the compression of morbidity in the last 20 years of life needs urgent attention.

are general for all people but which are gender disaggregated, are gender sensitive, acknowledge the heterogeneity amongst both women and men i. e. articulated by age, race, ethnicity, ability/disability status, geographical location and social class,

Recommendations A set of health priorities for older and aging women should be developed such that maximum benefit can be gained from primary, secondary and tertiary prevention programmes.

Women's experiences of Aging In the WPR: A Diversity of Challenges and Opportunities

The high rates among women ofmajor preventable conditions, such as communicable diseases and lifestyle diseases, need effective and coordinated primary prevention programmes on global, regional, country and district levels. Primary prevention of the chronic disabling conditions suffered by older women, such as arthritis, osteoporosis and incontinence, should be directed at the youngest cohorts of women; secondary prevention, including appropriate screening, for women in midlife; and tertiary prevention, including pain relief, rehabilitation and care for those who already have the conditions. A variety offorms of tertiary care need to be addressed including the role of self-help groups. Further research is needed into prevention of mental illnesses such as depression and dementia. Tertiary prevention and care for older women with mental illness is underserviced and needs major funding. Screening programmes such as mammography screening need to be critically assessed and evaluated to ensure that they do not have debilitating unintended consequences such as undue stress caused by false negative and false positive test results.

Health promotion campaigns need to be evaluated in terms of unintended consequences for women associated with the generation of guilt, excessive exercising and self-starvation.

Issue No. 5 - Quality of life Unequal experiences of quality of life between men and women need addressing. Lack of adequate measurement on a population level exacerbates the problem.

Recommendations Following on from the recommendations above, it is clear that the need exists to develop gender-sensitive and genderspecific measures of quality of life which tell us about women's subjective experiences of health. Subjective experience of quality oflife, rather than health-provider assessment oflife quality, must be used in decisions about health care provision and should significantly influence decisions about using technology to prolong life.

Conclusions and recommendations

Issue No. 6 Community care There is a continued tendency to medicalize major transitions in a woman's life and the process of aging (including multiple prescribing). The current health funding arrangements of most countries in the Region make medical and pharmacological choices cheaper for the consumer of health services than non-medical and nonpharmacological alternatives.

Women should be empowered to choose their own form of intervention, if it is necessary. This is particularly the case for menopause and the use of hormone replacement therapy (Klein, 1994; Dumble and Klein, 1994; Coney, 1994). Women should have all research findings on proposed interventions made available to them in an accessible form and be told of possible side-effects (both long- and short-term) so that they can make informed choices. Health centres and hospitals in all countries of the Region must be encouraged to provide women with information on alternatives to surgical or pharmacological intervention, including self-help groups, efficacious traditional healing practices, dietary changes, meditation, massage etc. A holistic approach to illness management, health promotion and illness prevention will enable women to make informed choices (Trickey, 1994). All healthful choices should be affordable choices for all women which will mean ensuring that non-medical interventions cost no more to the individual. This would involve restructuring of health insurance arrangements so that the costs of attending non-medical services and using non-pharmacological remedies are subsidized to the same degree as medical services. Steps could be taken,

Recom mendations Health planners should be encouraged to adopt a transdisciplinary approach to aging with the funding implications of such a broadening of the platform of what constitutes health care. Aging and transitions in women's lives such as the onset of menstruation, the birth of children and menopause are social and cultural events as well as physical 'passages' in women's lives. Women across cultures and subcultures experience these transitions differently. Only in some cases is medical intervention needed; often, selfhelp groups or other non-medical assistance is more appropriate. We need to develop alternative approaches to the medical approach in understanding such transitions (Trickey, 1994).

Women's experiences of Aging In the WPR: A Dlwralty of Challenges and opportunities

including registration legislation and accountability measures, to avoid unscrupulous practitioners taking advantage of deregulation of the health industry. Carers in the community should be supported both financially and with appropriate respite and back-up health services. National peak advisory bodies should be set up in each country to coordinate the provision of community and institutional care for older women. The health workforce should be appropriately trained to take account of the particular needs of older women. This should include multiprofessional education and appreciation of the value of traditional and lay healing methods and substances to produce a holistic response to the health needs of older women. The preference for most older people to remain independent and stay in their own homes must be translated into policy and the provision of services to support home-based care. Women's roles as traditional healers lay healers and care givers should b~ supported and made more visible.

Issue No. 7 - Agism and sexism The dual discrimination of agism and sexism suffered by older women has serious consequences for older women's physical, mental and emotional health and well-being. This results in women being invisible and silent. The response of policy makers has largely been indifference but older women have the potential to become a major political voice. Cultural attitudes towards the aged are deeply ingrained and resistant to change. Any change that does occur will be extremely slow. However, that should not discourage policy-makers, women's groups and the Global Commission on Women's Health from taking on this daunting task.

Recommendations Positive images of older women should be presented and promoted to counter popular perceptions of older women as dependent, frail and isolated. Affirmative action should be adopted in the film, newspaper and television industries, backed up by antidiscrimination legislation, to present older women as strong role models.

ConclusIons and recommendations

The Global Commission could raise the debate about the retirement age and voluntary retirement should be dscussed in the light of fears that even higher rates of unemployment in younger cohorts may appear should the retirement age be deregulated. The official language to describe older women should be reviewed. The commonly-used term 'the elderly' implies a homogeneous group of people. Negative cultural conceptions of death and dying should be addressed to remove this aspect of the prejudice against older people. Public campaigns could be instituted, for example in preparation for the Year of Older Persons in 1999, to celebrate and make widely known the skills and knowledge of traditional healers in all societies and women's important roles in the informal sector of the economy, for example in handicraft production, child care, as carers for the disabled, maintaining cultural knowledge through oral history, positive role models for younger women, patrons of organizations, as tourist guides, money raisers for charities, sitting on boards and committees as lay representatives, and voluntary work.

Public campaigns and individual and group consciousness raising need to be developed to engender an appreciation of the physical signs of aging and what they symbolize. As older women develop an increasing political voice, it is important that policymakers allow older women to choose the words with which to speak, otherwise the advocacy role of other groups will highjack the agency that women themselves are able to muster. Women are not just victims of the social system and this fact must be recognized. However, we must be careful to avoid the problem ofvalorizing old age. Aging has both positive and negative aspects. Aging policy and services for the aged need to be wary of setting unrealistic standards for 'successful aging' (e.g., as implied in activity theory) and minimizing women's genuine concerns about the aging process (Kamler, 1994). It is possible to err on the side of optimism and glorification of age, which ultimately has the same effect as the glorification and g1amourizatjon of you1h.

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Informations clés

Organisation Organisation mondiale de la santé (OMS)

Type de document Publications

Date d'adoption 31 décembre 1995

Source Organisation mondiale de la santé