Acknowledgement
I draw in part on data collected as part of the Canadian Study of Health and
Aging. The core study was funded by the Seniors’ Independence Research Program,
through the National Health Research and Development Program (NHRDP) of Health
Canada (project no. 6606-3954-MC(S)). Additional funding was provided by Pfizer
Canada Incorporated through the Medical Research Council/Pharmaceutical Manufacturers
Association of Canada Health Activity Program, NHRDP (project no. 6603-1417-302(R),
Bayer Incorporated, and the British Columbia Health Research Foundation (projects
no. 38(93-2) and no. 34(96-1). The study was coordinated through the University
of Ottawa and the Division of Aging and Seniors, Health Canada. Additional funds
for this analysis were provided by the Social Sciences and Humanities Research
Council of Canada through the General Research Grants Program of the University
of Toronto. I thank my colleagues, Philippa J. Clarke (University of Toronto),
Carolyn J. Rosenthal (McMaster University), and Carol D. Ryff (University
of Wisconsin) for their participation in this project.
Let me begin by welcoming you all here and thanking you for coming today. I want also to thank our wonderful staff for their work organizing this event, and Gordon DeFriese, who, as Acting Director, brought the Institute into being so capably, making my job all the easier. If this were a film showing we would bill it a double feature. If it were a boxing match, we have for you a preliminary and a main event. My inaugural lecture is the preliminary event, and we move from it to the main event — the Institute’s Annual Poster Symposium on Aging, which is presented in the context of a reception. As a package, I hope that the next few hours will give you a better sense of the Institute on Aging and its mission, and a better sense of where I, as the Institute’s new director, am coming from and the directions in which I hope to lead the Institute.
I have been in office since July 1, and some of you will have already heard me talk about the Institute’s mandate as I see it. I am offering my view as part of a dialogue, in which I will welcome your critical response so that we might all collaborate in shaping a view of the Institute’s future.
I will begin by stating my understanding of the formal, mandated mission of the Institute, including the goal and the broad outlines of means to reach that goal. I will then touch on some of my own research that is consistent with that formal mandate. Finally, I will make some more programmatic observations of the directions I think the Institute should be taking to achieve its mandate.
The formal mandate of the Institute on Aging
I have studied the various “charter documents” of the Institute and come up with a one-sentence statement of the mandate of the University of North Carolina Institute on Aging: to enhance the well-being of older North Carolinians through statewide collaboration in research, education and service.
This is just one sentence but it is a loaded sentence and I will try to unpack it. But first let me be clear as to what I am talking about: the University of North Carolina Institute on Aging. It is fortunate to be situated on the wonderful campus of the University of North Carolina at Chapel Hill, but also fortunate enough to have a formal designation as belonging to the entire UNC system. Our mission is not only to serve the older people of the entire state, but to do so by working statewide in active collaboration with the other campuses of the system and, in fact, with private academic institutions and the community college system.
Now I would like to consider this term, collaboration.
Collaboration
Gerontology is a field of research, education and practice that focuses on the processes of aging, the lives of older people, and the ways in which individual and population aging affect other aspects of social life. When I say it is a “field”, I distinguish it from a discipline or a profession. I see gerontology as a field -- like Kenan Stadium is a field -- on which a number of disciplines and a number of professions play. I happen to be a sociologist by training, and that is one of the disciplines involved in the field of gerontology. Other important disciplines are biology, psychology, economics, epidemiology, demography, anthropology, history -- any one of the human or life sciences in fact. Disciplines create, through research, the knowledge of aging and the aged that is brought to the field of gerontology. On that field are also many professions — social work, clinical, community or applied psychology, public health, medicine, nursing, the allied health professions such as physical therapy, occupational therapy and speech-language pathology, who apply that knowledge in working with older people. Other professions may also apply that knowledge to focus not on older individuals but on the conditions that shape the lives of people as they age — so lawyers, economists, urban and transportation planners, librarians and information specialists, and so forth, acting as professionals playing on this field called gerontology, can draw on the fruits of many disciplines to help to enhance the lives of people as they age.
The excitement and the joy — for me at least — of working in, or on, the field of gerontology is the challenge of working in a multi-disciplinary and multi-professional environment, collaboratively making progress that, we all hope, will enhance the well-being of people as they age.
If we think of a collaboration among people from different disciplines and professions, we have to extend the collaboration further for it to reach older people themselves, because professionals are not the only people with something important to say or do about older people’s lives. That is why our collaboration has to be very broad, not least including older people themselves, the real, experiential experts on aging. Statewide collaboration in research, education and service also demands, of course, that we collaborate explicitly with the service sector, seniors organizations, government agencies, the corporate sector, and every kind of individual or entity that is captured in the broad phrase, “the aging network”.
All this collaboration across discipline, profession, and constituency is a challenge. It is rewarding and often fun, but also a challenge. And its purpose is to enhance well-being. So I want now to move to the concept of well-being.
Well-being in later life: A key concept for gerontology
There are many interesting things to learn about older people, but a great deal of research has been directed towards understanding their well-being. In fact, it may fairly be said that gerontologists have been preoccupied with the well-being of older people, especially if the wide range of indicators of well-being is considered . In early contributions to gerontology made in the two decades that followed the Second World War, sociologists focused on the social integration of the aged (Burgess, 1960; Rosow, 1976), on their adaptation to modern society, on their psychological adaptation to role loss (Cumming and Henry, 1961) and on their life satisfaction (Maddox, 1965, Palmore, 1968, 1987) or their psychological and cognitive state (Kozma, Stones and McNeil , 1991; Levin and Chatters, 1998). These various concepts, which group under the general term well-being, tapped several different dimensions, both sociological and psychological. Interest persists in all these dimensions of well-being, to which recent researchers have added various health indicators such as functional status (Kane, 1990).
Health itself is a general construct with many dimensions including the presence or absence of disease, or symptoms of disease, functional status, and the individual’s subjective sense of being healthy or not. The World Health Organization takes a very general perspective on health, saying that “Health is a state of complete physical, mental, and social well-being, and not merely the absence of disease or injury” (WHO 1947: 19). This definition is too broad to be useful, because it encompasses everything (Evans and Stoddard, 1990; Chappell, 1998). Could there be anything left over that is not health, when it is defined so broadly?
Since well-being has been defined in so many different ways, it is not surprising that investigators defined many different pathways to well-being, or barriers to achieving high levels of well-being. With multiple indicators of well-being, successful aging was variously held to result from maintenance of high role involvement (Maddox, 1965; Palmore, 1968), maintaining the ability to perform the specific important roles that contributed to the maintenance of society at large (Cowgill and Holmes, 1972; Burgess, 1960), the ability to voluntarily withdraw from active engagement in society (Cumming and Henry, 1961), the ability to maintain continuity with past roles and identities (Atchley, 1989) or the ability to maintain independence (Marshall et al., 1995; Martin Matthews and Shipsides, 1989a,b).
So, I come at last to my own view of well-being and its determinants.
Some of my own work, in collaboration with the psychologist Carol Ryff of the University of Wisconsin, has treated well-being as a subjective or psychological state, with six dimensions.
As shown in the slide, the dimensions are: self-acceptance, or positive attitudes
toward oneself; positive relations with others, including the ability to achieve
close unions with others; autonomy, including qualities of self-determination,
independence, and the regulation of behavior from within; environmental mastery,
which is the individual’s ability to engage in, and manage, activities in one’s
surrounding world; purpose in life, including the beliefs that give one the
feeling that there is purpose in and meaning to life; and personal growth, which
represents one’s continual development and striving to realize one’s potential
to grow and expand as a person.
Carol Ryff has developed a sound way to measure these six dimensions,
and shown that they are in fact different, in several American studies (Ryff,
1989a, b; Ryff and Keyes, 1995). The same measures were incorporated into the
Canadian Study of Health and Aging, and Ryff, my student Philippa Clarke, and
I have examined Canadian patterns of well-being in a nationally representative
sample.
Respondents rate themselves on each item according to a six-point scale
ranging from “strongly agree” to “strongly disagree”. I have time only to illustrate
these dimensions, using the next slide (see Clarke et al., in press).
These data are based on 4960 community-dwelling Canadian seniors, most
of whom were living in the community (only 142 lived in institutions).
More than 85% were between ages 70 and 85, with a mean age of 75.5 years.
The general finding in this sample of older Canadians is that well-being
is quite high. The slide presents limited data from just one indicator for each
of the six dimensions of well-being. The sample items here are all positively
worded (half of the items in the Ryff measures are negatively worded and reverse-scored).
The percent agreeing, or agreeing strongly, with these items suggests high well-being
overall in the sample.
When we used all the data on the six scale scores representing the different
dimensions of well-being, we found that, except for the self acceptance and
autonomy dimensions, the other four dimensions of well-being showed declines
with increasing age. This confirms that subjective well-being is multi-dimensional,
as does the fact that the different dimensions showed different patterns by
other factors. As we turn to these other factors, we move from the subjective
to the objective dimensions of well-being.
Objective Conditions Associated with Well-Being
First, there were gender differences. Women scored higher than men on the dimension, ‘positive relations with others’, which indicates that older women appear to have been more successful in nurturing warm and trusting interpersonal relationships in later life. Women also scored higher than men on the dimension of personal growth, but men scored higher than women on environmental mastery, purpose in life, and self-acceptance.
For the most part, these gender differences could not be accounted for by the fact that women were more likely to be widowed than men. However, marital status was beneficial for both men and women. Married seniors reported significantly higher scores than widowed and never-married seniors in the purpose in life dimension, and higher scores than divorced or separated seniors on the self-acceptance dimension. Married seniors also significantly outscored the never married or the divorced/separated seniors on the positive relations scale.
Multivariate analyses (Clarke, et al., in press) also show the importance of social class, as indicated by the importance of income and education. Again, there were differences by the dimension of well-being under consideration, but controlling for factors such as age, functional and subjective health, the general pattern was that higher education and income are associated with higher well-being scores.
I want now to look at the relationship of health to well-being. As found in other national surveys, the vast majority of seniors in the CSHA sample report health problems. Ninety-five percent of the 4960 individuals who completed the Ryff measures reported at least one chronic health problem. This was most likely to be arthritis or rheumatism (reported by 59% of seniors), but high blood pressure and heart or circulation problems were also common. Yet, in spite of the prevalence of health problems, when asked “how is your health these days”, 83% of seniors responded “very good” or “pretty good”, the top two categories on a five point scale.
These self-reported health ratings were found to resemble subjective well-being in Canadian seniors. Patterns of well-being according to self-rated health status are illustrated in the next slide.
As you can see, declines in self-reported health are generally mirrored by
declining scores on the six dimensions of well-being, suggesting that as seniors’
self-rated health declines their subjective sense of well-being also declines.
However, not all dimensions of well-being decline as health worsens. Seniors’
sense of autonomy remains relatively stable across all levels of self-rated
health.
We also found no relationship between seniors’ sense of autonomy and functional
status in later life. However, almost all the other dimensions of well-being
are significantly associated with functional status, in that greater functional
independence is associated with higher scores on the dimensions of well-being.
This is consistent with findings from the General Social Survey, another
representative Canadian survey, in an analysis which employed a general measure
of subjective well-being and was restricted to non-married respondents (Fox
and Gooding, 1998).
Why should we care about well-being?
Let me recapitulate the story so far. I argued that we should distinguish between objective and subjective aspects of well-being. I showed that subjective well-being is itself multi-dimensional and can be measured along six different dimensions. I also showed that subjective well-being is patterned by some objective dimension such as gender and age, as well as education and income, social relationships such as marital status, and health.
Subjective well-being is an important aspect of mental health, which can be defined as “the capacity of the individual, the group and the environment to interact with another in ways that promote subjective well-being, the optimal development and use of mental abilities (cognitive, affective and relational), the achievement of individual and collective goals consistent with justice and the attainment and preservation of conditions of fundamental equality” (Health and Welfare Canada, 1988, p. 4). It should surely, then, be important to have a criterion measure of social justice and conditions of equality. This leads me back to the objective dimensions of well-being and to the mandate and mission of the Institute.
The various factors I have mentioned as being associated with well-being can now be organized in terms of the following conceptual model.
In many instances, physical health problems are inevitably encountered with advancing age. But some people are able to maintain positive psychological states nevertheless. This fact shows the importance of conceptually distinguishing, and measuring, the distinctions between objective and subjective health and other dimensions of subjective well-being. Old age is a time of declines in physical health only for some, but if such decline occurs, it does not necessarily lead to unhappiness and low morale (Ryff, 1989b). Objective health does have a direct impact on subjective well-being, but it also has indirect effects through subjective health; and it is not the only factor influencing subjective well-being. Social class, indexed by education and income, also influences subjective well-being. And social integration makes a difference as well.
The subjective or psychological sense of well-being can then be viewed as caused by other factors, of which physical health is but one. It is useful to distinguish between objective and subjective well-being, because we can influence these objective factors through policies and programs. Thus, our model for the Institute on Aging is that subjective well-being in later life is contingent upon health, wealth, and social integration (Marshall et al., 1995); and our goals should be to increase objective well-being along these three axes.
These three dimensions are interacting. The common-sense view of this is that social integration should have an impact on health, but health should also have an impact on social integration. Research supports this common-sense view. In addition, economic security provided by income, assets, and employment benefits makes an enormous difference for health. For example, the difference in life expectancy in Canada between the top and bottom 20% in income exceeds the difference between men and women. Social class is associated with mortality and disability, but it is also true that the gap between rich and poor is increasing in America, and the effects of these differences are greater among the old than the young (Callahan, 1994; Ross and Wu, 1996). Wealth also makes possible a fuller participation in social life, enhancing social integration.
Finally, this model implies that our attention should not focus exclusively or directly on older people themselves, but should include attention to the institutions that shape the objective dimensions of well-being — often acting to create opportunities for, or, conversely, to pose barriers to, people’s abilities to secure well-being in later life. People’s life-long family history will affect both their social integration and their wealth -- and possibly their health as well. Their life-long labor force participation history will affect their wealth. In short, I believe we should take a life course approach to understanding aging, and we should recognize that these aspects of the life course are profoundly influenced by such factors as gender, race, where one lives, and so forth.
Institute Initiatives in Terms of the Model
How does all this conceptual work translate into the programs of the UNC Institute
on Aging?
Time does not allow me to give all the details, so I will share some of the
highlights. There is more information about Institute initiatives on our web
page (www.aging.unc.edu).
In terms of the health dimension, thanks to the very able leadership of my predecessor, Gordon Defriese, the Institute is already active in research and educational initiatives which, in turn, are supportive of service. North Carolina is the third most rapidly aging state in the United States, and even now it is recognized that our long-term care system needs help. Long term care and, more broadly, the continuum of care from the community to institutional care, has to be a focus of our efforts — and it is. This can be seen from some of the seed grants we have invested in, which you can learn about in the Poster Symposium which begins in just a few minutes. We have funded seed grants to young professors and graduate students to promote either research, service or educational initiatives, and the vast majority of these, you will see, focus on health and health care issues. This year, under the leadership of Dr Carol Hogue, our Associate Director for Research, we are increasing our budgetary commitment to this program by more than 25%. We are also re-organizing the competition to ensure that a greater proportion of the funding goes to predominantly service initiatives (and not just to research), and that a larger number of seed grants go to scholars outside the direct Chapel Hill orbit. We are also building a strong clinical component and partnership with the UNC School of Medicine’s Program on Aging, through Associate Director for Clinical Affairs, Dr Jan Busby-Whitehead. Jan is also Acting Director of the Program on Aging, and our two programs are working together to support education and research initiatives that will help to expand this campus’ efforts in geriatrics.
In terms of the wealth dimension, much needs to be done. Despite overall economic improvement in this booming economy, the gap between rich and poor is actually increasing. The aged — particularly very old people, widows, African-Americans and some in the rural areas affected adversely by such things as the decline of the tobacco industry or the shift away from the family farm to giant agri-business, are particularly vulnerable. We will seek funds through the University’s development campaign for an initiative on rural aging that will address some of these issues. An Institute-based research team is currently seeking funding from the National Institute on Aging to investigate the relationship between socio-economic status and health over the life course.
Social integration is another dimension. The marginalization of North
Carolina’s African-American and other ethnic or racial minorities must be taken
seriously. For example, African-Americans are more than twice as likely to live
in poverty than their white and Asian counterparts (37.7% vs 15.6% for whites,
15.2% for Asians, and 39.5% for American Indians). Fortunately, under the leadership
of Dr Betty Mutran, the Institute on Aging includes a Center on Minority Aging,
funded by the National Institutes of Health, whose main objective is to increase
the capacity of minority researchers to study minority issues in aging. The
Center has active partner relationships with East Carolina University, UNC-Charlotte,
Fayetteville State, North Carolina Central University, UNC-Greensboro and Winston-Salem
State University. It is conducting a survey of minority elders in Durham. The
Center on Minority Aging also has run a number of workshops for minority seniors
on health issues. In this area as well, we will seek resources through the university’s
development campaign, and we hope to broaden the scope of our initiatives by
transforming the CMA into a Center for Diversity and Aging, within the umbrella
of the Institute. Meanwhile, you can follow some of the Center on Minority Aging’s
initiatives through the Poster Symposium today.
Marital status is a major way in which people find social integration
and social support in their later years; yet women are typically disadvantaged
here because they lose the support of their husbands, who most often predecease
them. In fact, the research shows that married men benefit a lot more from spousal
support than do married women anyway; but widowhood further decreases social
integration by loss of a confidant and, usually, by reducing the financial security
of the surviving widow. Together with the fact that women live, on average,
almost eight years longer than men and suffer greater poverty, we will try to
find the funds, through the University’s capital campaign, for a chair in women
and aging. Meanwhile, we will try to attend to women’s issues throughout our
programs.
Research is important for us, but so is the translation of research into information that gives insights and solves problems. We will be sponsoring two seminar series this year on the Chapel Hill campus — one of long term care and another of work, retirement and income security issues. We will continue our Distinguished Lecture series, with two distinguished visitors this year who will visit not only Chapel Hill but at least three other campuses across the state system, speaking on productive aging, and diversity and aging.
Our educational initiatives seek to link research, education and practice. The Institute has financially supported the development of multidisciplinary certificate programs at UNC-Wilmington and at Chapel Hill, and is working with a half dozen campuses to develop a state-wide certificate program using distance education technologies. This initiative is chaired by Dr Jim Mitchell, of Eastern Carolina University, who is our Associate Director for Public Service and Extended Education.
We support, and will continue to do so, the wonderful “Leadership in an Aging Society Program” through which Duke University develops a cadre of leadership both among seniors and students.
We will also continue to support the Summer Symposium on Aging, providing
financial and administrative support to enhance its stability. The theme of
next summer’s symposium is in keeping with our objective dimensions of well-being:
“Gender, Race and Class: Enduring Inequalities in Later Life”. The symposium
will address not only the social conditions of North Carolina’s elders in these
terms, but the dilemmas of providing adequate services to clientele who are
stratified in this way, through a labor force which itself reflects the same
inequalities. As if this is not enough, we are also hosting the Southern Gerontological
Society’s annual conference, which will be held in Raleigh at the end of March.
Again, the theme we chose reflects Institute principles: “Aging in the New Century:
Linking Policy, Practice and Research”.
Finally, I would like to say a few words about our current special initiative
for disaster relief in light of the recent hurricanes and flooding, because
this initiative shows how research, education and service come together along
the three axes of health, wealth and social integration. The Institute will
undertake research to increase preparedness for any future disasters of a similar
nature. Already, we have used our international contacts to secure and make
available some research findings from Manitoba, Canada, about how older people
were affected by the ‘flood of the century’ in the Red River, in Minnesota and
Manitoba south of Winnipeg. We have just awarded three small partnership grants
to support a joint university-service sector initiative to provide relief to
older flood victims. We also co-sponsored a seminar, with the UNC-Chapel Hill
School of Social Work, on course training of students to work in disaster relief
— again making use of our Manitoba contacts. We hope to work closely in the
next year or two with the Division of Aging, other government agencies, different
universities and community colleges in the state, service agencies and seniors
organizations to conduct some action research that will lead to a better understanding
of how older North Carolinians are likely to be affected the next time we have
such a serious hurricane, or similar disaster, and will also lead to better
policy and practice guidelines for the front-line agencies.
Conclusion
Thank you coming today. I welcome your comments on the mandated mission of the
University of North Carolina Institute on Aging and the ways in which we hope
to pursue this mission. The challenges before us are enormous as we seek to
enhance the well-being of older North Carolinians through statewide collaboration
in research, education and practice. Please help us to sharpen that vision and
shape our future.
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