Twenty years ago, in many regions of the world, it would have been an unusual sight to observe a 70-year-old woman enthusiastically exercising in a public place. At that time, throughout many countries and cultures, old age was considered to be a time in which older persons were expected to take it easy and gradually disengage from many of the trials and tribulations associated with employment and other adult responsibilities. The prevailing models of retirement encouraged older adults to adopt relatively passive lifestyle choices and overtly or subtly discouraged seniors from being physically active (McPherson, 1995). This emphasis on passivity and disengagement was inconsistent with a growing body of knowledge that was emerging at that time regarding the adverse health consequences of sedentary living and the importance of remaining physically active across the life course (Chodzko-Zajko, 2001).
To develop a cohesive strategy with respect to the promotion of health and well-being of older persons throughout the world, in April 1995, the World Health Organization (WHO) launched a new program on aging and health. The goal of this program was to respond to the challenges of population aging in a dynamic, life course oriented fashion. Writing in an editorial in the Journal of Aging and Physical Activity, Alexandre Kalache, the director of the WHO Aging and Health Program, stressed that a major role of the WHO Aging and Health Program would be to raise awareness of the importance of lifestyle factors in healthy aging through a combination of advocacy, training, and research (Kalache, 1996).
One of the first initiatives of the new program was to focus on educating health professionals and public policy makers about the importance of avoiding sedentary and disengaged lifestyles in old age. To increase awareness and build consensus among decision makers and other influential professionals, the WHO decided to commission a consensus statement about the importance of physically active lifestyles in old age. In December 1995, a scientific advisory panel composed of researchers, public health officers, and policy makers from each of the six WHO regions met in Germany to formulate a working draft of a scientific consensus statement about physical activity. This draft was subsequently disseminated widely for comment and revision and presented to the scientific community at the fourth World Congress on Physical Activity, Aging, and Sport, which was held in Heidelberg, Germany, in August 1996. The final WHO Heidelberg Guidelines for Promoting Physical Activity Among Older Persons were published and translated into numerous languages and disseminated broadly through a wide variety of governmental, nongovernmental, academic, and social outlets.
The Heidelberg Guidelines presented, for the first time, a clear and unambiguous statement from the WHO endorsing the crucial role of regular physical activity as an integral component of healthy aging. The Guidelines were not intended to be either a comprehensive review of the scientific literature or a practical handbook on how to exercise; rather, the Guidelines were designed to be a definitive and authoritative statement of consensus from the scientific community that was endorsed and disseminated by the World Health Organization. The Guidelines confirmed, with the full weight of the WHO behind them, that the evidence was clear: Regular physical activity should be a part of the daily routine for the vast majority of older persons, and regular physical activity is one of the most effective means whereby individuals can influence their own health and functional abilities.
An almost immediate impact of the publication of the WHO Guidelines was an increase in interest in the promotion of physical activity in the older adult population across virtually all regions of the WHO. Universities and colleges in many member states began to develop courses and specializations focusing on physical activity for older adults. Consensus curriculum guidelines were published by the International Society for Aging and Physical Activity and endorsed by the WHO (ISAPA, 2004). Gradually, more physical activity opportunities for older adults began to emerge across the member states. Physicians and health professionals around the world were becoming more willing to encourage their patients to participate in exercise and physical activity. A gradual consensus was emerging that WHO member states had a responsibility to promote physical activity as an essential component of an effective national strategy to promote healthy aging.
Educating the Public and Building Consumer Demand
Although the publication of the WHO Heidelberg Guidelines marked an important first step in the WHO campaign to promote physically active lifestyles in the older adult population, the Guidelines were targeted primarily at professional audiences, and they were not designed to increase general public awareness of the importance of maintaining physically active lifestyles. The next phase of the WHO strategy was to initiate a coordinated public information campaign to bring the issue of physical activity to the attention of the general public around the world.
The WHO chose to launch its public information campaign about the importance of physical activity for older persons in the fall of 1999. This was a particularly appropriate time for the WHO to focus on active aging because its parent organization, the United Nations, had designated 1999 to be the International Year of Older Persons (IYOP). The International Year of Older Persons focused the attention of the world on the many challenges facing society as a result of the remarkable aging of the population that had occurred throughout the 20th century. Alexandre Sidorenko, Officer-in-Charge of the United Nations Program on Aging, noted that the IYOP was not intended as a purely celebratory event, but rather 1999 should be viewed as a springboard for launching a wide variety of long-term strategies on aging at both the national and international levels (Sidorenko, 1999). In excess of 300 national and international scientific congresses were organized in conjunction with the IYOP. Conferences were held in more than 75 countries, thousands of symposia and workshops were organized, and tens of thousands of papers were presented.
In conjunction with these efforts around the world, on October 2, 1999, the WHO Aging and Health Program launched a campaign to increase public awareness of the importance of physical activity. A central feature of the campaign was a series of coordinated walks for older persons collectively known as the Global Embrace. The goal of the Global Embrace was to emphasize the importance of active and successful aging by organizing walking events across the world synchronized in such a way as to start at the same time of day in every time zone throughout the globe (WHO, 2000). The first walk of the day began in New Zealand and was followed by Australia, Japan, China, India, Africa, and the Middle East, Europe, and the Americas. It is estimated that by the end of the last walk of the day, well over 5,000 communities and in excess of two million individuals had participated in the Global Embrace. The WHO estimates that the Global Embrace was the single largest health-promotion event in history (WHO, 2000).
The extensive media participation in the Global Embrace greatly magnified the reach of this transnational event beyond the two million walkers to a much larger audience around the globe. The wide variety of different types of events serves to underscore the critical importance of developing culturally appropriate messages when attempting to communicate with the general population about important health behaviors.
In addition to its leadership role in high-visibility individual events such as Global Embrace, the WHO Aging and Health Program has also worked closely with partners around the world to promote physically active lifestyles through a series of multifaceted public information campaigns. One of the most widespread of these initiatives is the Agita Mundo campaign that was launched in conjunction with the World Health Day in 2002. The primary purpose of the Agita Mundo campaign is to promote physical activity as a healthy behavior for people of all ages around the world. The Agita Mundo campaign is designed to stimulate and encourage the dissemination of information on the health benefits of physical activity and effective strategies to increase physical activity, advocate for physical activity and health, and support the development of national and local programs for physical activity promotion.
There can be little doubt that the WHO efforts to publicize the importance of physical activity for older adults have been successful in bringing these issues to the attention of both health and policy professionals and the general public at large. Events such as the Global Embrace and campaigns such as Agita Mundo have focused the attention of the world on issues related to active and successful aging. However, these initiatives have focused primarily on disseminating information about the importance of physical activity and have paid limited attention to how to integrate physical activity opportunities into a broader and more comprehensive public policy framework in the area of aging.
Building the Active Aging Public Policy Framework
The WHO began to focus more explicitly on public policy considerations. In the past, the WHO Aging and Health Program had advocated for the adoption of specific health promotion strategies without fully considering the economic, cultural, and political realities under which such strategies were to be implemented. As part of the WHO’s contribution to the 2002 World Assembly on Aging, the WHO developed an international policy whitepaper titled Active Aging: A Public Policy Framework. The WHO Policy Framework argues that all strategies to promote active and successful aging must be integrated into a comprehensive and far-reaching public policy that embraces a multisectoral approach to successful aging (WHO, 2002).
Specifically, the WHO vision of healthy and active aging in the 21st century requires the simultaneous involvement and engagement of many sectors of society including health and social services, education, employment and labor, finance, social security, housing, transportation, and both rural and urban development. Physical activity promotion is no longer considered to be the responsibility of the health and academic sectors alone; rather, a multisectoral coalition will need to be mobilized if our policies and programs are to be effective. The realization that effective health promotion strategies cannot exist in isolation but rather must be consistent with and reflective of the economic, political, and cultural realities of the societies in which they are to be implemented marked an important advance in the WHO strategy to promote physical activity.
The WHO Active Aging Policy Framework reminds us that all effective health promotion strategies will need to be firmly grounded within the local, national, and regional reality. These realities must take into consideration such factors as epidemiological transition, rapid changes in the health sector, globalization, urbanization, changing family patterns, and environmental degradation, as well as persistent inequalities and poverty, particularly in developing countries where the majority of older persons live. Furthermore, the WHO Active Aging Policy Framework recognizes that effective policies and programs designed to promote health and well-being in old age will need to adopt a life-course perspective that acknowledges that many of the determinants of chronic conditions and disability in old age have their roots in childhood and young and middle-age adult life. A “one size fits all” model of successful aging simply will not work.
But perhaps the most significant message to emerge out of the WHO Active Aging Policy Framework is the notion that there are numerous and diverse determinants associated with active and successful aging. To truly prepare for successful and active aging, national strategies will need to acknowledge a complex combination of economic, social, personal, environmental, and behavioral determinants. To age successfully, older persons will need to be not only physically active, but also socially, intellectually, culturally, and (for many seniors) spiritually active. Somewhat surprisingly, to date, professionals in the area of physical activity and aging have focused little attention to the development and implementation of integrated programming opportunities for seniors. One of the challenges for our profession will be to learn how to integrate physical activity into the wider social, cultural, and economic context of active aging as a whole.
Refining, Evolving, and Expanding the Model
A logical extension of the WHO Multiple Determinants Model of Active Aging has been a move away from the promotion of individual physical activity interventions or campaigns in favor of more complex public health initiatives in which physical activity is embedded as an integral component of a much broader health promotion and disease prevention strategy. For example, in 2007, the WHO launched a worldwide initiative to support the development of Global Age-Friendly Cities.
The goal of the WHO Global Age-Friendly Cities Guide is to encourage communities around the world to take action to make the environment more supportive and accommodating to persons of all ages (WHO, 2007). The WHO report suggests that making cities age friendly is one of the most effective policy approaches for responding to global aging. An age-friendly community is one in which policies, services, and structures in both the physical and social environment are designed in such a way as to enable older persons to age actively, to be secure, to enjoy good health, and to participate fully in society.
Shortly after the release of the Global Age-Friendly City report, the WHO began work on the development of a consensus statement about falls prevention in older age. The WHO Global Report on Falls Prevention in Older Age is a further example of how WHO strategy in the area of physical activity promotion has evolved from one that focuses on physical activity alone, into one that develops more complex initiatives that include physical activity as part of a broader public health agenda (WHO, 2008). The WHO Falls Prevention Report describes a cohesive, multisectoral approach to falls prevention that is built on the foundation of a proactive and flexible public health policy grounded in the principles of health promotion and disease prevention.
The WHO report notes that falls among older people are a large and increasing cause of injury, treatment costs, disability, and death in virtually all regions of the world. For injuries of the same severity, older people experience more disability, longer hospital stays, extended periods of rehabilitation, and a higher risk of subsequent dependency, as well as a higher risk of dying. Fortunately, there is now compelling evidence that risk factors for falling can be influenced by the implementation of targeted intervention strategies designed to modify the various intrinsic and extrinsic determinants known to increase the likelihood of falling.
The WHO Falls Prevention Model provides a comprehensive multisectoral framework for reducing falls and fall-related injuries among older persons. The model is designed to identify policies, practices, and procedures that will build awareness of the importance of falls prevention and treatment among older persons; that will improve the assessment of individual, environmental, and societal factors that increase the likelihood of falls; and that will facilitate the design and implementation of culturally appropriate, evidence-based interventions that will significantly reduce the number of falls among older persons.
The WHO report notes that regular physical activity has been shown to prevent and/or lower an older person’s risk for falling in community and home settings. For healthy older adults at low risk for falls, engaging in a broad range of physical activities on a regular basis is likely to be sufficient to substantially reduce the risk for falling. In contrast, older adults at higher risk for falls will benefit from engaging in structured exercise programs that systematically target the risk factors amenable to change. Older adults identified at the highest risk for falls will benefit from an individually tailored exercise program that is embedded within a larger, multifactorial intervention approach.
References
Chodzko-Zajko, W. (2000). Successful aging in the new millennium—The role of regular physical activity. Quest, 52, 333–343.
ICAPA. (2004). International curriculum guidelines for older adults. International Coalition for Aging and Physical Activity.
Kalache, A. (1996). Aging and health. Journal of Aging and Physical Activity, 4(2), 103–104.
McPherson, B.D. (1994). Sociocultural perspectives on aging and physical activity. Journal of Aging and Physical Activity, 2(4), 329–353.
Sidorenko, A. (1999). The international year of older persons. Journal of Aging and Physical Activity, 7(1), 1–2.
WHO. (1999). Global embrace, WHO aging and life course program. Retrieved from http://www.who.int/docstore/globalmovement/embrace1999/index.htm
WHO. (2002). Active aging—A policy framework. Retrieved from http://whqlibdoc.who.int/hq/2002/WHO_NMH_NPH_02.8.pdf
WHO. (2007). Global age-friendly cities: A guide. Retrieved from http://www.who.int/ageing/publications/Global_age_friendly_cities_Guide_English.pdf
WHO. (2008). Fall prevention in older age. Retrieved from http://www.who.int/ageing/projects/falls_prevention_older_age/en/index.html
This history was written by Wojtek Chodzko-Zajko, PhD, and Andiara Schwingel, PhD, who are with the Department of Kinesiology and Community Health, University of Illinois at Urbana-Champaign, United States. If you would like to contribute information about the history of active aging, please send information to us.
