Proposing a re-adapted successful aging model addressing chronic diseases in lowand middle-income countries Tara Rava Zolnikov
Quality of Life Research An International Journal of Quality of Life Aspects of Treatment, Care and Rehabilitation - Official Journal of the International Society of Quality of Life Research ISSN 0962-9343 Qual Life Res DOI 10.1007/s11136-015-1043-2
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Author's personal copy Qual Life Res DOI 10.1007/s11136-015-1043-2
BRIEF COMMUNICATION
Proposing a re-adapted successful aging model addressing chronic diseases in low- and middle-income countries Tara Rava Zolnikov1
Accepted: 5 June 2015 Ó Springer International Publishing Switzerland 2015
Abstract Purpose Global aging is a phenomenon experienced throughout the world. Research demonstrates an increased incidence of chronic diseases due to global aging in lowand middle-income countries. Before addressing chronic diseases, a platform for change must be created. Methods A basic review was conducted on successful aging, adaptations to Rowe and Kahn’s model of successful aging, and environmental challenges in low- and middleincome countries. Results The successful aging model by Rowe and Kahn includes trajectories based on various biological and environmental components and determines how lifetime experiences contribute to adverse health effects, such as chronic diseases, in aging populations. This model was primarily designed for high-income populations and may not be transferable to populations in low- and middle-income countries. Suggested changes to the current model have been made and include optimal health activities and access to health care, but have not considered environmental contaminants or hazards. A re-adapted model should be encompassing and consider the environment as well as successful aging elements, optimal aging activities, and access to health care. Conclusion The overall goal of this commentary is to theoretically propose a novel successful aging model that may be used to target chronic diseases in aging populations in low- and middle-income countries. This model can then
& Tara Rava Zolnikov
[email protected] 1
School of Health and Human Services, National University, 3678 Aero Court, San Diego, CA 92123, USA
be used as a theoretical foundation for health promotion and disease prevention. Keywords Chronic disease Global health Aging populations Successful aging Development models Health promotion Environment
Introduction Population growth has been unprecedented in the last halfcentury; during this time frame, the population has increased by approximately 4 billion people, with the strongest growth trends noticeable in low- and middle-income countries [4]. Over the last couple decades, the world’s population grew from 5 to 7.06 billion people [9, 14]. Low- and middle-income countries currently account for 80 % of the world’s population and 97 % of the population growth [9, 14]. Between 1960 and 1999, global population rates averaged 1.33–2.04 % annually [9]; however, the highest population rates occur in sub-Saharan Africa at an increase of approximately 2.3 % per year [9]. Projected world population growth peaks are projected to occur in the year 2075 and are estimated to be 8.9 billion [21]; however, if the rate is constant to rates of today, the population projection of 2050 could be 12.8 billion with 11.6 billion (90 %) people living in less developed regions [38]. Life expectancy has also dramatically increased in the last 40 years [30]. Birth to death lifespan range has improved by approximately 30 % [30]. Globally, the number of people over 60 years of age is projected to triple in the next 50 years, and by 2030, more than 60 countries will have at least 2 million people over the age of 60 [36, 37]. Currently, approximately 64 % of the world’s
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population greater than 60 years of age resides in low- and middle-income countries and is projected to increase by 73 % by 2030 [40]. These aging trends are evolving differently throughout the world; peak levels will reach Japan in the near future, while populations in sub-Saharan Africa will peak in approximately 100 years [21]. Unfortunately, aging populations in low- and middleincome countries of low socioeconomic status (SES) may be a particularly vulnerable group. As such, these individuals likely experience higher rates of obesity, smoking, substance, and alcohol abuse, are more physically inactive and have poor access to health care [13, 33, 39]. Outcomes from these adversities include low physical functioning, a decreased ability to engage in life, and an increased prevalence of non-communicable and chronic diseases [19, 21, 25, 26]. The World Health Organization’s Global Burden of Disease report confirms these significant contributors. The report discloses risk factors, including high blood pressure, high blood glucose, obesity, tobacco, and alcohol use, that contribute to chronic diseases in these settings [44]. As a result, chronic diseases (e.g., cardiovascular disease, non-insulin dependent diabetes, and chronic respiratory disease) frequently occur and cause 80 % of mortality in low- and middle-income countries [1, 20, 44]. By 2015, inclusive of current public health outreach and patterns, chronic diseases are expected to contribute to over 41 million deaths worldwide [42]. By 2030, the majority of chronic diseases are expected to significantly increase in low- to middle-income countries [28, 42]. To reduce the growing burden of disease and comorbidity, urgent action is needed to develop strategies addressing accumulating chronic disease rates in ever-growing, aging populations. However, before implementing action, a theory-driven model for change should be created and considered.
Developing a model Rowe and Kahn [32] developed the most prominent successful aging model in human development. This model consists of a Venn diagram intersecting the following elements: low risk of disease and disease-related disability, high cognitive and physical function, and active engagement in life [32]. This framework challenged the view that aging consists of unavoidable decline and suggests agerelated loss that may be due to modifiable factors [5]. This model is actively circulated for understanding and promoting successful aging [5]. However, a consensus on successful aging does not exist; a single theory or model cannot determine all applicable meanings or actions that contribute to an individual’s ability to successfully age [2, 23, 32].
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While the model is prominent in some populations in the Western world, transferability of the successful aging model remains an unanswered question and developing an all-encompassing successful aging model for populations within low- and middle-income settings is a major issue that continues to be studied. Aldwin and colleagues [2] describe adverse consequences of demographic shifts worldwide and confirm the need to examine ways to promote aging and health in all populations. While there are variations in income levels worldwide and low socioeconomic conditions occur throughout the Western world, a model specific to low- and middle-income country populations has not been developed. Some adaptations to the current successful aging model have been proposed and could be transferable to a new model. McLaughlin et al. (2010) suggest additional aspects focusing on health and functioning, while Legg and Bernstein [18] highlight the importance of activities that promote optimal health (e.g., nutritional services) and at the same time avoid negative effects. Despite objective viewpoints, the emphasis on optimal aging maximizes independence and functioning as a person ages and should be considered [2]. Legg and Bernstein [18] propose optimal health to successfully age, though they suggest that these models may not be a possibility worldwide. Research confirms that chronic adversities in low socioeconomic conditions are cumulative in nature and may result in adverse health effects [15]; moreover, while avoiding noncommunicable and chronic disease is one primary element of the Rowe and Kahn [32] successful aging model, it would remain far more difficult to achieve in the low SES conditions of low- and middle-income countries. Chronic diseases are a difficult problem in low-income countries due to the inability to pursue healthy choices and the low priority of effective treatment and prevention efforts [11, 17, 35]. That said, prevention is key component to addressing chronic disease in low- and middle-income countries and can be achieved through sustained interventions [35]. Health care should also be an accessible deliverable to individuals currently affected by chronic diseases and should be considered in the new model. Miranda et al. [27] propose a potentially encompassing, theoretical model addressing non-communicable diseases, thereby allowing successful aging; the model focuses on a health care framework to strengthen existing health systems in the ability to provide comprehensive, accessible, and community-based care focusing specifically on the prevention, cure, and rehabilitation of chronic and non-communicable diseases [27]. This system specifically addresses both communicable and non-communicable disease and allows individuals to move beyond their disease, continue life, and age successfully [27].
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Lastly, other aspects have been revealed as risk factors or predictors for successful aging in low- or middle-income countries, but likely fit within the ‘active engagement in life’ or ‘high cognitive and physical functioning’ branches of the current successful aging model. Chaves and colleagues [8] determined that the number of living children was a risk factor, while neighborhood and family income were protective factors for successful aging. Cannuscio and colleagues [7] also confirm the importance of social capitol for successful aging. Similar to high-income countries, positive attitude toward aging and access or ability to manage money was also associated with successful aging [16]. Also, in lowincome countries, under- and over-nutrition is a significant factor associated with chronic diseases, and thus, proper dietary nutrition also promotes successful aging [31]. While these research studies and ideas are encouraging, one important factor was dismissed during the conceptualization of more worldwide approach to successful aging—the environment. Populations residing in these settings have an increased exposure to poor air quality, hazardous waste and pollutants, and elevated levels of contaminated water and soil [6, 10, 12, 34, 41, 43]. Socioeconomic status is associated with environmental risk exposure which inversely contributes to adverse health effects [10]. Exposures often have a long latency period and effects vary according to the amount of time an individual has been exposed [22]. It is particularly relevant to address chronic disease risk factors as early in life as possible in order to alter the course of the disease in elderly populations. Promoting successful aging in younger generations can contribute to successful aging in elderly populations. As previously mentioned, neither the Rowe and Kahn [32] model of successful aging nor any other current study considers country-wide populations affected by the environmental consequences of low socioeconomic conditions, but a re-adaptation of the model integrated with the original premises may provide an appropriate foundation for successful aging and chronic disease prevention.
Conclusion In conclusion, populations living in low socioeconomic conditions are disproportionately exposed to environmental contaminants, thereby contributing to adverse health consequences [10]. While low socioeconomic conditions occur in both high- and low- and middle-income countries, populations in low- and middle-income countries likely experience heightened environmental health impacts. Thus, the environment should be the primary concern due to the unrelenting effects of contaminants on high-density at-risk populations within these settings in order to alter negative health effects. Additionally, aging populations in these
settings are possibly more at risk due to lengthy exposure levels and immune-compromised or suppressed health. However, successful aging is one model that seeks to address health in order to promote positive health outcomes. Previously, successful aging in low- and middle-income countries has been studied and predictors and risk factors have been associated with negative or positive outcomes for aging [7, 8, 16, 31]. However, a model specific to these countries alongside the environment has not been developed. By achieving initial gains countering lifetime environmental exposures, a new model specific to these settings may be developed to counteract adverse health effects in aging populations. The novel model should be revised to include all of the aforementioned factors (e.g., health care framework, optimal health activities, and the components of the original successful aging model) alongside an environment free of environmental contaminants (Fig. 1). If employed within an intervention, people would be able to redirect focus on individual health-based needs instead of on avoiding contamination. This theoretical model can provide insight into the development of programs promoting health in these marginalized populations. This model can be used as a theoretical foundation for health promotion and disease prevention. The use of theory within health promotion programs reliably produces positive outcomes [29]. More specifically, before developing a program or intervention, the theoretical basis integrated within the intervention may ensure: understanding causal determinants in order to effectively target behavior change, the ability to test the theory forming the intervention, and using theory-based interventions as the foundation for improving upon or creating alternative theories or models across varying cultures and contexts [23]. Thus, this theory-based model strengthens the evidence for intervention design and may be applicable by public health practitioners, physicians, health promotion, or health education experts to promote successful aging. Ultimately, the model suggests a comprehensive approach that includes both the downstream aspects suggested by curative medicine and the upstream aspects of disease prevention [3]. All of these aspects are important to consider, as patient reported outcomes in research and practice continue to experience translational difficulties [45]. These difficulties occur due to the lack of consistency in the cultural adaptations to guidelines [45]. Thus, a final practical implication of this re-adapted model is its use as a culturally sensitive, universal guideline focusing on understanding aspects related to chronic diseases. In turn, this model consolidates information that could be extrapolated to populations in lowand middle-income countries worldwide and addresses some current translational challenges on targeting chronic diseases.
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Author's personal copy Qual Life Res Fig. 1 Original [32], model of successful aging re-adjusted for populations in low- and middleincome countries
Let us begin developing the foundation—a theoretical model addressing chronic diseases in low- and middle-income countries through various aspects of successful aging and the environment. Used as a guidance tool, the new successful aging model focuses on eliminating likely hazards within the environment and aims to promote health knowledge and accessible health care, thereby reducing negative outcomes and allowing a higher level of physical and mental functioning. This new model encourages people to successfully age in low- and middle-income countries.
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