Determinants of Healthy Ageing in European countries
Wim JA van den Heuvel1* and Marinela Olaroiu2
1 Share Research Institute, University Medical Centre, Netherlands
2Foundation Research and Advice in Care for Elderly (RACE), Heggerweg 2a, Netherlands
Submission: January 24, 2019; Published: February 26, 2019
*Corresponding author: Wim JA van den Heuvel, Share Research Institute, University Medical Centre, Netherlands
How to cite this article: Wim JA van den Heuvel, Marinela Olaroiu. Determinants of Healthy Ageing in European countries. OAJ Gerontol & Geriatric Med.
002 2019; 4(5): 555649. DO 10.19080/OAJGGM.2019.04.555649
Background and Objectives: The concept of healthy ageing is still at debate, although healthy ageing is recognized as an important policy objective internationally. Evidence of which determinants or policies at country level may affect healthy ageing is lacking. This study explores the relationship between vulnerability, social cohesion, and resilience, and healthy ageing in 31 European countries. Vulnerability at national level indicates the proportion of citizens at risk for poverty and access to services. Social cohesion at national level describes the extent to which citizens are willing to accept each other. Resilience at national level includes national resources for citizens, which may support them to overcome adverse events.
Research Design and Methods: This comparative study includes data from 2013 or 2014, based on validated, comparable international data sets, i.e. Eurostat and European Social Survey. Healthy ageing describes how many years a person is expected to live in good perceived health. Healthy ageing combines life expectancy with self-perceived health. Vulnerability, social cohesion and resilience are assessed using 10 indicators, selected from the mentioned data sets. Principal Component Analysis confirms these three components.
Results: Mean healthy ageing in the 31 European countries is 72.9 years; the difference between lowest and highest is over 15 years. Multiple correlation between the 3 components and healthy ageing explains 71% of the variance. Regression analysis shows a significant contribution of resilience and vulnerability as determinants of healthy ageing.
Discussion and Implications: Vulnerability, social cohesion, and resilience are interconnected and relevant determinants of healthy ageing, which indicates that an integrated approach is needed to realize healthy ageing. However, this finding question those policies, which are specifically targeted at older citizens. Resilience, assessed as investments in social security, education and health care by national governments, affects healthy ageing most. The conclusion is that a life span based, integrated policy, directed at resilience, vulnerability and social cohesion at national level, contributes to realize healthy ageing.
Keywords: Healthy ageing Vulnerability Social cohesion, Resilience.
Healthy ageing has been recognized as a priority policy objective in various countries, stimulated by reports of the European Union (EU) and the World Health Organization (WHO), with the objective to promote healthy ageing [1-3].The concept ‘healthy ageing’ is however still a matter of debate [3-5]. It is evident that a long life itself, i.e. a high life expectancy, is an insufficient indicator for healthy ageing. Various authors notice that the concept of healthy ageing seems similar to successful or active ageing [5-8]. Basically, three methods to assess healthy ageing have been developed in the last decade all using life expectancy (at birth) as starting point: disability-free life expectancy, based on self-reported limitations in daily activities, self-related health life expectancy, based on self-perceived health, and disease-free life expectancy , based on the absence of specific diseases [9-12]. Assessment of healthy ageing, based on self-reports, is affected by social and cultural factors, whilelife expectancy itself is based on the estimation, i.e. the average number of years a person is expected to life based on the current mortality
Choosing for one method or another makes some differences. European data on life expectancy and ‘healthy ageing life expectancy’ show, that in 2014 ‘life expectancy at birth’ was 82 years, ‘self-rated healthy age life expectancy’ was 73 years, and ‘healthy life expectancy without disabilities’ was 62 years [11,13]. Besides the discussion about the concept, policy makers, researchers and health care workers look for determinants, which may influence ‘healthy ageing’ [2,3,14,15]. Determinants of healthy ageing are found at individual level (health status, activity, resilience, social contacts, involvement) as well as at environmental/societal level (provisions for accessibility, housing, age-friendly communities, social security).
Researchers as well as policy documents formulate recommendations
and proposals for (public health) interventions to
promote healthy ageing [3,16,17]. The question is raised whether
such recommendations are tailored to the needs of older
adults . Whatever policy or intervention is recommended,
empirical evidence to show the effectiveness of such policy or
intervention, is absent. This may not be surprising, because the
discussion about concept and assessment of healthy ageing hinders
‘the creation of a comprehensive public health policy’ .
Policies and interventions to realize healthy ageing need a clear,
operational definition of ‘healthy ageing’, when looking for its
determinants. By analyzing the determinants per operational
definition, it will be possible to identify the main determinants
of healthy ageing and to recommend effective policy measures.
Our study aims to identify determinants of healthy ageing in
European countries at national (policy) level. To realize the objective
of this study, it is necessary to define and assess healthy
ageing and to choose determinants at national/societal level,
which could be relevant for ‘healthy ageing’ and to ensure these
determinants should be reliable and comparable internationally
The EU describes healthy ageing as “the process of optimizing
opportunities for physical, social and mental health to enable
older people to take an active part in society without discrimination
and to enjoy an independent, good quality of life”. The
WHO defines healthy ageing as “the process of developing and
maintaining the functional ability that enables well-being in older
age” . Two components are important in these definitions:
active participation respectively functional ability, and quality
of life respectively wellbeing. Although significant correlations
between the two components are found, the U-shape between
age and wellbeing questions a causal relationship between
functional ability and well-being [19,20]. The description in the
EU and WHO definitions as ‘the process’ suggests change and
continuity. Indeed, healthy ageing is primarily about accepting
changes in life and (therefore) changing aspirations of life .
Healthy ageing is part of a life-long process of learning from and
responding to challenges and adverse events . This process
of coping with challenges and adverse events is influenced by
individual capacities as well as by environmental, societal possibilities
and limitations. In this study healthy ageing describes
how many years a person is expected to live in good perceived
health, a measure used in European statistics which combines
life expectancy with self-rated health .
Determinants, formulated in policy documents, include
available/accessible proper (health and social security)
services, sustainable pension system, healthy life style, and
social participation/cohesion . The EU documents mention
determinants, which may influence healthy age directly
or indirectly: access to health care, rural/urban/physical
environment, transport and infra-structure, employment and
working conditions, housing, education, social issues, pensions,
poverty, justice, and violence and abuse . Key steps to promotehealthy ageing are accordingly WHO : active participation
of older persons, no age discrimination, and access to public
services for older persons. These steps are specifically focusing
on the older population.
Only a few studies are analyzing empirically the relationships
between determinants at national level and healthy ageing.
These studies show various factors to be related with healthy
age: well-being, material resources, socioeconomic status, life
style, social involvement and participation, and (by definition)
self-rated health [6,8,22-26]. Research looking for individual
determinants of healthy ageing focuses on concepts as frailty,
resilience, and social capital [15,16,25,27-30], which concepts
need to be translated to societal/national indicators to answer
our research question.
Sadana et al.  develop a framework in which contextual
systems (i.e. health and social care, physical environment, and
social, political and economic context) influence healthy ageing
directly as well as indirectly through the vulnerability/strength
of citizens (lifestyle, culture and environmental risk factors).
Cosco et al.  state, that greater resilience can be possible
fostered at a population level and that there is a great potential
to increase social and environmental resources through public
policy interventions. They suggest, that resilience should be
used as a public health concept and interventions, directed at
greater resilience, which might increase resources available
to older people. Based on the above-mentioned formulated
determinants and research [2,3,21,26,29,30] three concepts
seem predominant determinants of healthy ageing, i.e.
vulnerability, social cohesion, and resilience. We explore the
hypothesis - using comparative data from European countries -
that healthy ageing is related to vulnerability, social cohesion,
and resilience at national level. Vulnerability at national level
is defined as the proportion of citizens at risk for poverty and
access to services. By social cohesion at national level we mean
the extent to which citizens are willing to accept each other.
Resilience at national level describes national resources for
citizens, which support them to overcome adverse events.
We inventoried which indicators are assessing (aspects of)
vulnerability, social cohesion, and resilience in international,
comparative data sets, i.e. Eurostat  and European Social
Survey , given the description of the three concepts above.
For example, an indicator for vulnerability could be to which
extent is the population in a country is at risk for poverty; or
in de case of resilience: to which extent do people have excess
to social security and health care provisions. The inventory for
indicators resulted in 10 indicators (Table 1). The indicators are
calculated as the % of expenditures of GDP on specific provisions
or as % of people, which report on specific problems or believes
Assessment of healthy ageing and the indicators includes 31
European countries. If data are derived from ESS, design weights
are applied as required. In case of missing data of an indicator
in a country, which occurred once or twice in two countries, the
mean score of the remaining countries is used. Vulnerability
indicators include: % people per country, who are at risk for
poverty and social exclusion, who report unmet (health care)
needs, who consider the economic development in the country
problematic, and who tend to have no trust in local/regional
authorities. Social cohesion indicators are: % of people who
consider it to be (very) important to be equally treated, to care
for each other’s wellbeing, and to understand different people.
Indicators for resilience are: governmental expenditures oneducation, on social protection, and on health care as% of Gross
Domestic Product (GDP) (Table 1).
The coherence between the indicators is explored by
principal component analysis (PCA) with the criteria eigenvalue
1.0, communalities >50, and varimax rotation. Factor scores are
calculated for each component per country. Linear regression
analysis between healthy age and the three components is
executed to analyze the statistically significant contribution
of these components to healthy ageing, tested for collinearity.
Factor scores are tripartite divided (high, medium, low), and
based on this division, clusters of countries are presented
showing the connection between the assessed components and
healthy ageing per country.
Healthy ageing between the 31 European countries
vary from 64.7 years (Lithuania, number 31) to 80.3 years
(Switzerland, number 1). The mean healthy ageing is 72.9
years. Three components are identified as supposed by PCA:
vulnerability, social cohesion, and resilience, explaining 79% of
the variance. Communalities of each indicator are above > 500
and factor loadings above > 600 (Table 2). The indicators fit
well in the supposed components. Regression analysis between
healthy ageing and the three components (using factor scores)
explains 50% of the variance (adjusted score). Vulnerability
and resilience are statistically significant (p= .011 respectively
p=.000), social cohesion has a p-value of .064 (Table 3).
If in a country many citizens are vulnerable, i.e. they have
a high risk for poverty and social exclusion, report frequently
unmet needs, consider the economic situation in their country
as problematic, and they tend not to trust local/regional
authorities, citizens in these countries have a low healthy
ageing score. Citizens in countries, which governments spend
a relatively high % of their GDP to education, social protection,
and health care show a relatively high healthy ageing score. The
multiple correlation between ‘healthy age’ and the 3 concepts
explains 71 % of the variance.
Based on these findings, the 31 European countries are
clustered by resilience and vulnerability scores (Table 4). A
cluster of ‘high healthy ageing’ countries, includes the countries
with a preponderant positive score on resilience and vulnerability.
These countries are Belgium, Denmark, Finland, Netherlands,
and Sweden. On the other site are countries with a low scoreon resilience and a high one on vulnerability: Bulgaria, Croatia,
Hungary, Latvia, and Romania, which countries score on healthy
ageing is below 70 years. Globally, three clusters of countries
may be distinguished. A ‘north-west European’ cluster with high
healthy aging countries to which besides Belgium, Denmark,
Finland, Netherlands, and Sweden also belong Austria, Germany,
Iceland, Norway, and Switzerland. Citizens in these countries
are ‘ageing healthy’ and these countries have national resilience
provisions and their citizens have a low to medium vulnerability
score. Another cluster of countries with a ‘moderate healthy
ageing’ looks like a Mediterranean one with Cyprus, Greece, Italy,
Malta, Portugal, Slovenia and Spain. A third cluster with ‘low
healthy ageing’ is concentrated in Eastern Europe with Bulgaria,
Croatia, Hungary, Latvia, Lithuania, Poland, Slovak Republic, and
Romania. These countries have low scores on resilience and a
medium to high vulnerability
Despite recommendations in international policy documents
[2,3], it is not evident how to reach healthy ageing in societies.
Therefore, we explore which determinants are related to
‘healthy ageing’ societies, by using vulnerability, social cohesion,
and resilience, assessed at country level, as determinants of
healthy ageing. Principal Components Analysis shows, that the
3 components are reliable and comparative determinants at
national level - at least in European countries - related to healthy
ageing. It means, that using these determinants for policy
measures and interventions are effective to promote healthy
ageing. The relationship between the three determinantsindicates that an integrated approach is needed to realize healthy
ageing. The outcome of this study supports our hypothesis. The
determinants vulnerability, social cohesion, and resilience may
easily be formulated as policy objectives. Resilience for example
is realized by investments in education, social protection and
health care together by governments, which are governmental
These investments present total governmental expenditure
devoted to three different socio-economic functions (according
to the Classification of the Functions of Government - COFOG),
expressed as a ratio to GDP. The COFOG divisions covered are
‘health’, ‘education’ and ‘social protection’. Such investments
create a ‘enabling environment’, i.e. opportunities for resilience
for citizens, which stimulate healthy ageing. These investments
are not about the absolute amount of money invested, but
about the percentage of GDP. It means, that if lower income
countries would invest a same percentage of their GDP in these
determinants as higher income countries do, they could get
a same outcome: a healthy ageing population. Or as the OECD
states: it is about investment in human and social capital .
So, it is not the amount of money itself, which counts, but the
processes, which are stimulated through the investments in
education, social protection and health care. These investments
ensure human and social communities, in which citizens a reach
high, healthy age as the final award of all investments. In that
way our results support some conclusions of the OECD  and
the WHO  indirectly, i.e. an integral approach is essential and
ageing of a population does not necessarily mean exorbitant
increases in national (curative) health budgets .
The statement of Cosco et al. , that greater resilience
can be possible fostered by interventions at a population and
may have beneficial effects, is supported by our outcomes.
Empirically, resilience is the most important determinant
related to healthy ageing at national level. Resilience also affects
feelings of vulnerability of citizens, and vulnerability itself also
affect healthy ageing. Social cohesion does not independently
contribute to healthy ageing. But social cohesion is often seen as
a prerequisite or a result of a ‘resilience policy’. Social cohesion
is part of a process of integrated policy: if people believe it is
important to be treated equally and to take care for each other’s
wellbeing, they will support policies which ensure social security
and access to social and health care facilities on the one hand
and will feel less vulnerable on the other hand.
Our research outcomes question mark, whether governments
should design policies specifically targeted to older persons
to promote ‘healthy age’, as WHO suggests . The outcomes
indicate, that policies should be directed at the total population,
i.e. education, social protection, safety, and accessibility. Besides,
focusing on older citizens does not look as an integral approach
and it may affect intergenerational solidarity, so generate societal
tensions or conflicts and so inequity . Healthy ageing starts
at birth and needs a ‘safe environment’ life-long. A problem in
research on healthy ageing - and so in this study - is the stillongoing debate on what ‘healthy age’ means. We have chosen
for a concept of healthy ageing, which starts with ‘do people
themselves feel healthy?’. Starting with the health perception
of people themselves does not exclude at forehand people with
(long-term) chronic conditions or people with disabilities,
which - we believe - would be unjustified. Our definition fits
in what is called a ‘new definition of health’, which describes
health as the ability to adapt to physical limitations and to adjust
aspirations [19,34]. Nevertheless, research in determinants of
other operationalized concepts of healthy ageing is needed to
confirm the significance of various determinants
Another problem when executing international, comparative
research concerns methodological problems. Some of these have
to be mentioned as possible shortcomings in this study. One is
the absence of internationally accepted standards on how to
assess concepts like vulnerability, societal risks, social cohesion,
social capital, or resilience . So, some concepts are not all
well-defined and/or validated yet. It would be preferable if
internationally validated, accepted and applied instruments
are available, i.e. a validated set of ‘human development
indicators’ . At the same time, a strength of this study
includes the data we could use. They are based on international,
comparable data and collected with standardized instruments
and in representative populations [10,11,31]. This ensures the
reliability and comparability of our outcomes. The coherence
of the indicators as tested by Principal Component Analysis
indicates, that the constructs of the concepts are valid.
Two determinants are strongly related to healthy ageing
societies: resilience and vulnerability. Based on the data of 31
European countries we conclude, that healthy ageing may be
reached by governmental investments in ‘resilience’ (provisions
for education, health care, and social security) and in preventing
vulnerability in populations. If policy measures are implemented
to do so, in such societies people may become old and also feel
healthy. The interconnectedness between healthy ageing and
the used concepts underlines the need for an integral policy. It
is not money itself, but the way money is invested which makes
healthy ageing societies.
Wister A, Lear S, Schuumans N, MacKey D, Mitchell B, et al. (2018) Development and validation of a multi domain multi morbidity resilience index for an older population: results from the baseline Canadian Longitudinal Study on Aging. BMC Geriatrics 18: 170-183.