Home >> IAG Events & Initiatives >> Other Initiatives >> Valencia Report

IAG Events & Initiatives:
The Valencia Report

A Report on Outcomes of a Meeting of Gerontological Researchers, Educators and Providers 

PROVIDING AN EVIDENCE BASE IN SUPPORT OF THE INTERNATIONAL PLAN OF ACTION ON AGEING 2002
 

Held under the auspices of 
the International Association of Gerontology
in Valencia, Spain 1-4 April 2002

8 April 2002

Letter of Transmittal to the Second World Assembly on Ageing

A meeting was held in Valencia, Spain 1-4 April 2002 under the auspices of the International Association of Gerontology to engage a range of the world’s leading researchers, educators and practitioners in ageing.

Hosted by the Government of the Autonomous Region of Valencia, the principal government sponsor and the Spanish Society for Geriatrics and Gerontology. The Valencia Forum was co-sponsored by the United Nations Population Fund with the participation of the UN Programme on Ageing, the World Health Organization, Help Age International and Help the Aged (UK).

The Forum was supported by the Novartis Foundation for Gerontology and the Spanish Institute of Migration and Social Services who were the major government sponsor.

The meeting included keynote addresses from eminent speakers, symposia, round table discussions, workshops, individual papers and posters. In addition a drafting team recorded key points of presentations and important discussion and debate throughout the Forum. A process was established leading to the production of this report focused on key issues, considerations and recommendations relevant to the work of the Second World Assembly on Ageing.

This report, submitted to the Second World Assembly on Ageing, offers support for the World Assembly’s deliberations by providing perspectives, reflections and advice for the global scientific, educator and practitioner gerontological community.

Appended to the Valencia Forum Report is the Research Agenda on Ageing for the 21^st Century which was endorsed at the Forum by the Council of the International Association of Gerontology.

The Valencia Report, a compilation of key findings and recommendations from Valencia Forum participants is submitted without the explicit endorsement of the International Association of Gerontology or any of the sponsoring or supporting organizations involved in the Forum. It is the voice of scientists, teachers and practitioners of gerontology who participated in the Forum.

Respectfully submitted on behalf of the Forum participants.

Gary Andrews
Convenor
 
 

Preface

Purposes

This Report of the Valencia Forum is provided to the Second World Assembly on Ageing for consideration by delegates discussing major issues of global aging and directed towards achieving quality of life, health and well being for members of societies at all ages.

Background

In 1982, in support of the First World Assembly on Ageing, the International Association of Gerontology (IAG) published New Perspectives on Old Age: A message to decision makers. This document, in response to the United Nations resolution (A/Res/33.52) calling for a World Assembly on Ageing outlined contributions gerontological sciences on ageing for a policy for the aged in the 1980s and beyond.

The IAG report identified the extent to which

In the twenty years since this statement was presented considerable strides have been taken to advance research and information across these areas and to expand our knowledge and understanding of ageing.

The Research Agenda on Ageing for the 21^st Century, a project undertaken jointly by the UN program on ageing and the International Association of Gerontology, identified major research priorities and methodological challenges to be addressed in the immediate future and is appended to this Report.

In the formulation of the International Plan of Action on Ageing 2002 and subsequently in the implementation policy and program outcomes of the Plan member nations and UN agencies should draw on scientific studies and best practices for effective implementation.

Research processes to continue policy development for individual and population ageing should link and inform policy and program decisions important to our improved understanding and knowledge of ageing. 

1. PRIORITY DIRECTION 1: OLDER PERSONS AND DEVELOPMENT

1.1 Issue 1: Active participation in society and development

1.1.1 Research, Practice and Education Implications

Knowledge and understanding of the barriers to participation of persons as they age in social, economic, cultural and other activities of society is needed. In addition, measures of social, economic and political contributions of persons as they age in different societies need to be developed and applied. Basic education of children should reinforce positive images of older persons in society; negative stereotypes depicting older persons as decrepit, incompetent, or fragile should be combated. People should have access to life long learning opportunities that reinforce their capacity to contribute to society. Effort should be made to teach people how to participate effectively in community activities. People working with persons as they age should receive training, and information on ageing that reinforces understanding of the needs and rights of older persons as they age to remain active and to reinforce their involvement in planning, monitoring services for themselves and their communities.

1.1.2 Key Messages from the Valencia Forum

Research

• Operational definitions are necessary for concepts such as active ageing, productivity at older ages and also relationships between these ideas and quality of life are needed.
• Harmonised international measures and indicators need to be developed.
• Psycho-social determinants of active ageing should be identified and explored.
• Research on effective methods of involving older adults in their continuing active participation in educational, political and other aspects of community life is needed.

• Society-wide education strategies are needed to achieve the following measurable outcomes:
• Maximising individual life satisfaction
• Increasing healthy active life expectancy
• Improving efficiency of formal and informal care and support for people with disability.
• Education for children should foster positive, and discourage negative, views of older people

• Education is an important determinant of life expectancy and disability-free life expectancy. Therefore it is important that:
• Ageing education should be provided throughout the life course.
• Training and education in determinants of active ageing (including psychosocial determinants) should be stressed.
• Assurance should be given that elders can contribute their experience, knowledge and expertise in teaching and training.
• In development of policies and programs specific needs of the target population must be considered and older persons should be involved. 

1.2.1 Research, Practice and Education Implications

Research should be carried out on the capabilities of people as they age in the work force and current perceptions and practices which may discriminate against them in working situations should be eradicated. Further research is needed in areas such as the dynamics and consequences of demographic changes leading to an older work force. Educational opportunities for people at all ages need to be provided to facilitate capacities for changing work roles with ageing. Assessment and rehabilitation services for older persons should include considerations of capacity and preferences for continuing active participation in the work force which may require provision of assistive devices engineered especially for older workers.

1.2.2 Key Messages from the Valencia Forum

Research

• It has been demonstrated that the pension crisis is an example of apocalyptic demography, the exaggeration and oversimplification of a demographic trend that leads to a "doom and gloom" outlook often used to justify policy changes involving cuts to health and social services. There is little evidence to support this perception; more intensive research of these issues is needed.
• The impact of global aging on economic growth and particularly on personal savings and investment behaviours needs investigation to allay myths associated with these phenomena.
• The contributions of men and women in undertaking unpaid work that contributes to wellbeing of all generations should be examined systematically.

• Workers of all ages should have access to appropriately designed training and retraining programs to increase their ability to participate in the work force.

• A global understanding of work, retirement and pension systems necessitates recognition of the relationships among population ageing, globalisation, and economic well being of nations.
• There are strong arguments for the idea of development of minimal income security provisions in all countries to support the right to retire especially for those unable to work at older ages.
• Social policy must transcend traditional demographic and economic models and include a socially responsible notion of productivity and security.
• To combat age discrimination in the workplace and job markets, societies should correct ageist portrayals of elderly workers.
• Work should be restructured to create greater flexibility and allow persons to accommodate increasingly diverse work and migratory transitions. Meaningful work and clean and safe workplaces equate with enhanced productivity.
• State support should allow women and men with family responsibilities to work when they are able. Combining this with increased work opportunities for older workers who desire to continue in the paid workforce will help balance projected numerical declines in other parts of some national labour forces.
• There is a need to recognize equitable conceptualizations and models of paid and unpaid work.
• International competition affects the development of welfare systems and threatens to break down established systems, which have been important for old-age poverty reduction in many nations.
• Social movements that support the advancement of alternative models of development must be supported to balance the growing power of major neo-liberal global economic institutions that determine social policy.
• Pension systems should be linked to individuals rather than spouses. 

1.3.1 Research, Practice and Education Implications 

Research is needed in all aspects of the impact of rural development and ageing of individuals and populations. In addition educational opportunities should be available to persons in rural areas as they age. Use of modern technology such as the internet (World Wide Web) and other remote educational technologies should be developed and employed to assist those isolated from access to educational opportunities. Provision of services and personnel to support the needs of people as they age in rural and remote areas need attention. In particular, technologies such as tele-health should be exploited to the full extent possible.

1.3.2 Key Messages from the Valencia Forum

Research

• Patterns, trends and outcomes of urban rural migration need to be explored systematically 
• The consequences of urbanisation for health and well-being of older persons need to be researched thoroughly with particular attention to ways of overcoming the negative consequences of rural social isolation.
• Multidisciplinary research to understand the social, economic and psychological impact on persons in remote areas is needed. Cross national studies may further expand knowledge and improve practice.

• Training and education should be provided to support the development of systems of primary care for community members whose well-being is threatened by the effects of rural development, urbanization, migration and isolation.
• Education on rural issues is important for those working in any ageing related area.
• Opportunities for lifelong education should be provided in rural areas.

• Rural development policies should take account of population ageing and the needs of older persons;
• Coordinated and integrated public health and care services are essential for older persons in rural areas;
• Support for non-governmental organizations and community group efforts and greater use of new technologies for communication are vital to sustainable programs.

1.4.1 Research, Practice and Education Implications 

Research is needed into changes occurring in learning processes with ageing and the outcomes of formal education and training. The relative effectiveness of different educational modalities at all ages needed evaluation. Those persons dealing with ageing and older persons themselves should be taught to understand and appreciate education capacities and needs of people as they become older. Educational needs of persons as they age should be taken into account in the provision of services and care.

1.4.2 Key Messages from the Valencia Forum

Research

Rigorous evaluation of emerging distant learning technologies are need to ensure the inevitable expansion of this field will have scientific foundations.

Education

• Education should be viewed as a lifelong activity to enable individuals to contribute to society and the workforce.

• Access to information and education should be sensitive to cohort- and age-associated differences in learning processes.

Policies and practices that use the most effective and efficient methods of learning for older adults should be implemented by policy makers and practitioners in the areas of preventative health care (lifestyle and medical interventions), use of social structures (e.g. financial provisions, health services); self help with health and disability challenges (where appropriate), and involvement in political and community organizations.

1.5 Issue 5: Intergenerational solidarity

1.5.1 Research, Practice and Education Implications 

Research that describes and explains intergenerational relationships, dynamics and consequences is needed. Intergenerational issues are an essential component in any comprehensive curriculum dealing with ageing. Educational approaches may be important in dealing with and preventing intergenerational conflict. Intergenerational issues need to be considered in all aspects of policy, program design and delivery of ageing related services.

1.5.2 Key Messages from the Valencia Forum

Research

• Research should be undertaken on the determinants of positive intergenerational relationships.
• Research is needed on the outcomes (at individual, family, community and society levels) of intergenerational relationships.

• Fostering cooperation and preventing antagonism between generations should form an integral part of societal education and acculturation in human rights.
• There is considerable evidence that family members are often ill informed and poorly prepared to cope with demands placed upon them. Family members and other caregivers are often confused by the complexity of community health care for older persons with disabilities. Accordingly, health and welfare programs that inform family or non-related caregivers about proper techniques and options could lower caregiver stress and prolong their ability to provide care.

• Active participation of older generations in decisions affecting them is of primary importance.
• Central components of an integrated health and welfare approach to care for older adults should be programs and policies that support, encourage and accommodate family and social care networks.
• Respite programs for caregivers and flexible work schedules are examples of caregiver support programs that have been successful for helping caregivers do a good job of caring for older family members with disabilities. 

1.6.1 Research, Practice and Education Implications 

The profound effects of poverty as a most significant determinant of health and well being in ageing populations needs to be better understood. More needs to be understood on the causation and dynamics of poverty among older persons and families especially in the poorer developing countries. The different effects of poverty on vulnerable groups such as women and older persons need to be explored in depth. Educational strategies will be important in combating poverty at all levels. Education and raising awareness among decision makers on the effects of ill health, pain and the long term cost consequences of not addressing poverty will help decision makers to adopt informed policies. 

1.6.2 Key Messages from the Valencia Forum

Research

• Research should be undertaken to identify effective strategies for empowerment of older persons.
• Research on the effects of empowerment on self-efficacy and productivity will provide understanding of the consequences of empowerment among older persons.
• Research to audit the policies and activities of major intergovernmental organizations as well as trans-national corporations relating to old age economic security and poverty. 
• Research to establish experiences and perceptions of poverty, income security and expectations of material security in old age among older and younger (i.e. the future old) generations. 
• Research to record in national contexts, nationally representative quantitative and qualitative data on
• the scale of old age poverty, especially in relation to other age-groups
• the needs, perceptions, attitudes and values of older and younger generations regarding economic security in old age.
• Research is needed to
• document the effects of public provision of old age income security on older people, younger generations and communities in low income countries which have established such schemes. 
• document the efficacy, adequacy and impact of contributory social insurance schemes in low income countries.
• provide evidence on the capacity of families to provide sufficient economic security to older people, as well as to the younger generations. 
• Research incorporating a life course approach is essential to identify effective and appropriate strategies to prevent or postpone the onset of chronic disease and ill-health in later life.
• Participatory research enables scientists to identify in local contexts the kinds of strategies or schemes that are most needed, appropriate and effective.
• Research to chart, in local contexts and among younger and older generations, the prevailing patterns of intergenerational economic support, as well as the underlying normative attitudes, expectations and values regarding family support in old age will enable planners to develop responsive programs.
• Research to monitor and evaluate the implementation of policies and plans of action. Continuous audits of ageing policy development and implementation at national and international level are proposed.

• Training and education should be available to people of all ages to enable them to contribute to the productivity of their communities.

• Action needs to be taken by governments in economic and social policy arenas to reduce poverty.
• Poverty is pervasive among older people in the developing world and especially among women. Poverty can impact differentially on certain groups, for example on refugees, disabled persons, ethnic minorities and other vulnerable persons.
• Poverty is the main threat to well-being in old age: It goes beyond material deprivation and exposes older people to social exclusion, abuse, chronic ill-health, lack of autonomy, and vulnerability in emergency situations.
• Poverty in old age must be viewed from a life course perspective: Poverty deepens and is exacerbated in old age for those who have a long history of living in poverty. 
• Poverty in old age must be viewed from an intergenerational perspective: it impacts not only on older persons but also on the well-being of younger generations. Poverty in old age is inextricably linked to income insecurity, declining family and community support as well as poor health status
• Policies for eradication of old age poverty must:
• Eliminate poverty in the present generation of older people, and must prevent poverty among future generations of older people
• Be developed in individual national contexts, drawing on the needs, wishes and expectations of older people, as well as of younger generations – those who will be old in the coming decades.
• Recognize and address negative and positive impacts of globalization on the security of older people, and promote the rights of older people throughout the world. 
• Public sector leadership is crucial for ensuring material security for older people. The family, though central in providing old age support does not have the capacity to, and should not be expected to provide adequate economic security to older people. Similarly, contributory social insurance schemes based on earning ability alone do not, and cannot, provide sufficient economic security in a context of pervasive poverty. 
• At the same time, growing evidence on the impact of public minimum old age schemes shows that, in addition to the benefit for the older person, there are significant redistributive effects of such schemes: i.e. beneficial impacts also on younger generations as well as on economic activity and income generation. Such schemes should thus be considered as tools for development of poverty alleviation.
• Evidence clearly suggests that the introduction of public old age income security schemes is economically feasible and not incompatible with economic growth. There is growing evidence that such schemes can facilitate family support such as family caregiving and respect for the old.
• Poor health throughout the life course is a key determinant of poverty, and especially poverty in old age. In turn, poverty in old age further undermines older people’s health status and functional capacity - both at the level of health care provision and in terms of individual’s lack of access to services. Strategies designed to improve health throughout the life course and prevent chronic illness and disability as people age are a crucial part of policies to eradicate poverty among older people.
• In addition to public sector provision of minimum income security, strategies are needed to open opportunities for economic activities for older people, particularly in rural areas. Examples include micro-credit, income generation or other community based schemes. However, policies must allow older people the choice of whether or not to engage in economic activity.
• Strategies are needed to encourage and facilitate provision of family support to older people. However, these policies must be appropriate to the norms, values and wishes prevailing in respective populations today, among older people as well as younger generations.

1.7.1 Research, Practice and Education Implications 

Studies of international variations in provision of social protection and social security provision are needed. The different experiences and impacts of income assurance schemes on gender, widowhood and advanced age need further investigation. Knowledge and understanding of social protection and social security systems should be included in gerontological training curricula and also should be provided through formal and informal educational means to decision makers and advocacy groups. Those working with older persons need to understand issues around social protection, social security provisions and pension entitlements and uptake.

1.7.2 Key Messages from the Valencia Forum

Research

• Study of psychological factors which reinforce retirement preparation is needed and attention should be given to the roles and responsibilities of partners in retirement.

• Knowledge and understanding of social protection and social security systems should be included in the training programs of all personnel with responsibilities for care and support of people at risk of poverty or disability.

• There are prominent gender issues in this debate, with privatization proposals tending to shift various responsibilities from the state to women. From a progressive perspective, old age security reform is a movement toward universal entitlement, i.e. toward increasing public responsibility and fairness vis-à-vis gender, race and social class.
• There is much to be considered regarding the importance of non-contributory pensions as an overall national development tool. Data from Brazil and South Africa show that the expansion of rural pensions has an effect on reducing family and childhood poverty. Questions arise, however, with regard to the administrative, fiscal and political sustainability of such programs. Pension systems need to b e customized to fit particular social systems.
• What are the structural factors and policies that encourage or inhibit labour force participation at older ages, and likewise activities after "retirement"? We need to assemble studies of best practices to reverse the marginalization of older persons and enhance patterns of social inclusion.
• We need a rigorous examination of the concept of productivity. Economic productivity may not decline significantly with age in modern and modernizing economies. Conceptualization of productivity must include volunteerism, caregiving, and other unpaid spheres, as well as novel forms of income generation, etc.
• There are critical interrelations among the work/retirement/pension nexus and other social domains, particularly health. Multidisciplinary, longitudinal research must be undertaken to understand the interactions among domains, which ultimately affect the public-private pension debate. Nations should recognize the importance of intergenerational support and reciprocity, education and training, human rights, abuse and neglect, and the quality of housing, transportation and living environments.
• Societies need to recognize that there are emerging concerns about the strategic dimensions of population ageing, including an array of macroeconomic impacts on industrialized economies, potentially destabilizing impacts on less-developed societies, global military ramifications, and important implications regarding population migration streams.

1.8.1 Research, Practice and Education Implications 

The impact of emergency situations on the lives, health and well being of older persons needs to be better understood especially in relation to their physical, mental and health vulnerabilities. Training of those working with older persons should include reference to issues about emergency situations and ageing. Especially those working in humanitarian relief situations should be cognizant of the impact and potential contribution of older persons in emergencies. 

1.8.2 Key Messages from the Valencia Forum

Research

• Effects of coping styles in emergency situations need to be analysed.

• Older people and those with responsibilities for them should be aware of the early signs and symptoms of common forms of ill health.

• Healthcare personnel responsible for providing emergency care should have received specific training in geriatrics.

• Victims and workers involved in emergency situations need substantial and timely relief, supplies, and moral support. Lessons learned from emergency situations and disasters of various kinds need to be recorded and shared as emergencies arise.

2.1 Issue 1: Health promotion and well-being throughout life

2.1.1 Research, Practice and Education Implications 

Improved knowledge and understanding of the factors contributing to maintenance and enhancement of health status over the life course is required. Interaction and the dynamics of elements contributing to achievement of healthy ageing needs intensive research. Research in these arenas should be multidisciplinary, cross-national, cross-cultural and longitudinal. Training in age related areas should include appreciation for the importance of maintenance and promotion of health with ageing and the means to achieve healthy ageing. Practitioners and policy makers in diverse fields can contribute to health promotion and preventive strategies with ageing.

2.1.2 Key Messages from the Valencia Forum

Research

• Assessments of well-being and quality of life must place older persons at the centre.
• International harmonisation of well-being measures will enable researchers to predict and influence outcomes.
• Improved knowledge and understanding of behavioural and psychological determinants of health such as self-efficacy and adaptive coping styles is required.
• While recent research acknowledges the multidimensionality of quality of life in older people, to date few published studies have used comprehensive, multi-dimensional measures of quality of life to examine cross-cultural differences in healthy versus unhealthy ageing.
• Further research is needed to examine common features that generalise across cultures that can be used to improve quality of life in older adults and to build a foundation for policy and decision-making.
• Public health experts ought to assess the impact of services and of various health and social care structures on the quality of life of older adults. Measures are needed that examine and identify areas that potentially produce large health and quality of life gains in older people. 

• Education about behavioural and psychological determinants of health is needed by consumers and practitioners. 
• Education should be promoted as an important determinant of health and an active life expectancy.
• Professional training and public education should emphasize effective means to promote and maintain good health and functional abilities at all ages.

• Policies need to be based upon the identification of personal, social and cultural factors that contribute to healthy ageing. Quality of life measures provide one instrument to evaluate whether policies meet these goals

• In most European countries, health and social services are compartmentalised and reactive in nature. This process has set up barriers that are counterproductive to person-centred approaches with potentially negative health effects and services that may be ineffective or inappropriate. 
• Demonstrations shall reveal how intersectoral cooperation at local and other policy levels can lead to improved health for older people. Projects should connect policy levels and be based on an out-reach, person-centred and asset model. This approach will address ethical ways of resource allocation. 
• Disability is not inevitable in old age and its onset can often be delayed or prevented. Disability is not only defined by the characteristics of the older person with functional limitations but also by the characteristics of the home and community environment in which that person lives. For example, properly modified housing and ageing friendly communities facilitate an older person’s ability for self-care despite significant physical limitations. An integrated health and welfare service approach is to identify malleable aspects of the physical and social environment that will optimize the functional capacity of older persons within the community. 

2.2.1 Research, Practice and Education Implications 

The costs and benefits of universal and equitable access to health care services need to be explored. Alternative approaches to achieving this goal must be compared and evaluated. Training of primary health care workers and others providing basic service to older persons should include gerontology and geriatrics. Improved coordination of primary health care, long-term care, social services and other community services is essential. In many situations there is an urgent need to address neglected areas of health including oral health care and prevention, sensory problems and mental health issues especially depression and dementia.

2.2.2 Key Messages from the Valencia Forum

Research

• Research provides essential evidence for effective polices and programs. Knowledge is necessary to understand how individual health and social support systems are part of a caring system. 
• There is special need to evaluate emerging community health care approaches regarding the menu of services, access individuals have to essential services and the manner in which members of the care team work together.
• The ultimate outcomes of effective health care policy, system and services applied to the older persons in their communities need careful analyses. The lack of systematically organized collective information and reports on community health care policies and programs for older populations restricts evaluators from producing results that can inform public policy and private practice..
• There is a special need for evaluative research that will test and refine various adaptations of the proposed Community Health Care approach to clarify the relative merits of various iterations.
• Applied research can inform preferred approaches towards implementing integrated health and welfare systems. The scope for international experience sharing and comparison are substantial and must be encouraged. 
• Public and private partnerships are essential for successful development of health and welfare systems for ageing populations. The private sector is an essential provider of cost-effective community health care for older persons in order to maximize their functioning, health and quality of life.
• The private sector can often experiment with new practice models more easily than larger publicly supported programs. The various roles and responsibilities for the public and private sectors in the development of integrated health and welfare systems in ageing societies need further examination and clarification. 
• Quality assurance is essential for ensuring appropriate quality of care and protection of care recipients.
• Applied research is required to refine the definitions of measurable outcomes of community health care policy and program endeavours in different settings and nations. Although health and welfare systems often present challenges to maintaining quality control across complex organizational structures, the experience in some countries demonstrates ways that this challenge can be successfully addressed.
• Considerable work will be necessary to tailor examples of successful quality control approaches to other settings and countries.

All personnel involved in the delivery of health care should be aware of the rights of people of all ages to the benefits of health care services.

Policy and Practice

• A new thinking on health and welfare systems development is needed. 1978 Alma-Ata Declaration inspired the primary health care approach. It was a strategic process to improve world health involving a partnership with multiple sectors and activities that influence health. The public health strategy has been credited with advancing health around the world. .
• Further the public health approach does not adequately cover the full continuum of care needed in ageing societies. A new approach should encourage active involvement of the community and be person-centred and not provider driven. 
• Systems that integrate and coordinate health and welfare programs will be both more effective and efficient in addressing the type of health care needs of older persons. Integration is a basic requirement both within and among health and welfare service sectors.
• The community health care framework is proposed as a means to update the public health approach to address needs of older adults. The community approach provides a framework for integrating health and welfare systems and strengthens older peoples’ connection to their family and communities regardless of ability or disability.
• The proposed community health approach compliments the World Health Organization’s New Active Ageing Framework and could be a useful tool for implementing policy and programmatic recommendations of that document. 

2.3.1 Research, Practice and Education Implications 

Special aspects of HIV/AIDS related to ageing and especially very old age need to be researched fully including both issues of prevention and treatment of the disease, and the care demands upon older persons for dying adult children and dependent grandchildren. HIV/AIDS as an issue related to aging needs emphasis. Training of carers for HIV/AIDS patients as well as others in the long term care system need special training and support. Public health and preventive strategies against HIV/AIDS should be included in health program delivery.

2.3.2 Key Messages from the Valencia Forum

Policy makers and personnel involved in HIV/AIDS programs should be aware of the direct and indirect impact of the epidemic on older members of the community and be responsive to their needs.

2.4 Issue 4: Training of care providers and health professionals

2.4.1 Research, Practice and Education Implications 

Research is needed about the dynamics of teaching gerontology and geriatrics in diverse arenas and at different levels. An important principle in gerontological and geriatric training is ‘train-the-trainer’ methodology so investment in training and education can have multiplier effects. Training should be incorporated in program activities at all levels to ensure enhancement of quality care and best practice.

2.4.2 Key Messages from the Valencia Forum

Research

• Research is required to identify best methods to achieve educational objectives in training of those working in ageing.
• Educational methodologies and modes of instruction need to be further explored and tested.
• Pedagogical research should be undertaken for all kinds of ageing related instruction especially in terms of the need for inculcation of appropriate attitudes as well as necessary knowledge and skills related to working with ageing people.

• Multidisciplinary approaches are most effective.
• Training elders as facilitators and models is an important strategy.
• There should be appropriate multidisciplinary education programs for all personnel contributing to care for ageing people. Programs should be mandatory for statutory care staff and readily available for informal carers.
• Training should inculcate necessary skills in the management of and participation in multidisciplinary care systems and in ethical decision-making.

• To ensure the appropriateness of programs, older people should be actively involved in their planning and delivery.
• Continuing education of people working in fields associated with ageing is important as knowledge and understanding and the application of new technologies continues to develop rapidly.

2.5.1 Research, Practice and Education Implications 

Greater investment is called for in research into aspects of mental health and ageing. Investigation of causes, manifestations and treatment of depression and dementia with ageing is particularly important. Curricula on gerontology and geriatrics should incorporate instruction in mental health issues on ageing. Programs for assessment, treatment, management, care and rehabilitation including community based programs should emphasize mental health aspects of ageing.

2.5.2 Key Messages from the Valencia Forum

Research

• Research on the causes, prevention, protective factors, early detection, treatment and rehabilitation issues in psychiatric disorders especially depression, anxiety and psychotic disorders is critically important. Special attention should be paid to differential diagnostic factors with multiple psychiatric, social, medical problems and protective factors such as nutrition and exercise.
• Research on dementia, including causes, prevention, treatment and care and support systems for detection, assisting home caregivers, supportive and sensitive housing, and adaptive devices and environments will produce not only policies but also informed clinical practice.
• Research on care giving for people with mental health problems including support and education for home care-givers in rural or isolated environments is absolutely essential. Analysis should include gender and other issues and the effectiveness and cost of various models of care.
• Research on the ecology and psychology of death and dying especially as it relates to the mental health of the person, family and caregivers will assist practitioners in their responsibilities.
• Research on systems for delivering mental health care to provide timely access, evidence-based, user-friendly and efficient services to both the person and family will be useful to professionals and consumers working to improve the care of persons suffering with mental disorders.

• Curricula in gerontology and geriatrics should incorporate appropriate instruction on the range of mental health problems of older people including modern knowledge about detection, assessment, treatment, rehabilitation, referral and systems.
• Education on mental health issues of older people should include a multidisciplinary perspective because of the multiple needs of people with mental health problems and their family caregivers.
• Specific instruction in this area should include psychopathological components; protective factors (e.g. cognitive tasks in dementia and pleasant events in depression and cognitive behavioural rehearsal in anxiety); treatment (medication, psychological, cognitive behavioural etc); rehabilitation and support especially of family caregivers, stigma reduction, spirituality and death and dying issues. 

• Policy at such levels of governance as national, state, municipal, and facility should articulate the importance of addressing mental health needs of older people within the context of health and social services for all ages but policy should recognize special assistance is needed by older people and their families. 
• Policies should encourage access and cost effective services for older people through the use of primary care models backed by specialist services.
• Practitioners need to be sensitive to the needs of older persons presenting with mental health problems in terms of the greater interplay of physical and mental problems, multiple loses, gender issues, spiritual issues and their psychological needs around major life events.

2.6.1 Research, Practice and Education Implications 

Greater understanding is needed of the relationship between ageing and the emergence of various forms of disability. Also the way in which disabled persons respond to ageing needs to be explored. Alternative approaches to measuring disability and its consequences should be explored. Training in concepts, manifestations and outcomes of disability should be incorporated in all curricula for gerontology and geriatrics. Programs concerned with ageing and care of the aged should incorporate considerations of disability and seek integration of services with those primarily focussed on dealing with various forms of disability as appropriate.

2.6.2 Key Messages from the Valencia Forum

Research

• Research in social participation of disabled elders should be conducted to strengthen programs and achieve positive outcomes. 
• As persons who have lived with disabilities during their early lifetime become older, the consequences of age-related chronic conditions exacerbate pre-existing disabilities and require new understanding of how best to serve these individuals effectively. Research is a key to this understanding.
• Curricula in gerontology and geriatrics should include instruction on disability and physical, mental, environmental and socio-cultural factors involved in its genesis and remediation.

• National policies should provide for the integration of social and health care to facilitate access to programs and to ensure effective coordination of services.

3.1 Issue 1: Housing and the living environment

3.1.1 Research, Practice and Education Implications 

Where one lives is critically important to one’s well-being. Older persons throughout the world often face their later years isolated or in crowded and unsafe housing. For those older persons living alone, their homes should be the place they receive the services they need. The relationships among health, well-being, housing and the environment need to be understood and supportive housing programs need to be developed in all parts of the globe to enable older people to live as long as possible in familiar settings, near family and services and to do so within their limited budgets. Governments, NGOs and private enterprises should work together to ensure that every older person has appropriate shelter and access to the services needed. Housing and environmental situations are an important part of comprehensive assessment and need to be considered in care plans for older persons. Transportation services in particular need to respond to the special needs of persons with age related physical or mental incapacities.

3.1.2 Key Messages from the Valencia Forum

Research

Uncomplicated assessment instruments are needed to evaluate living arrangements and facilities as part of a person’s comprehensive assessment. Evaluation tools are needed to assess the extent to which one’s residence is barrier free, supportive of the resident’s life style and close to the services people require to remain independent. 

Communities need to develop check lists to ensure that the community is elder-friendly and supportive of an elders strong preference to remain independent.

Research on person-environment interactions should be reviewed, adapted to changing conditions, and applied to both new developments and the maintenance and improvement of older housing.

Education

The effects of environmental conditions, including particularly one’s home, on health and disability should be emphasised in gerontological and geriatric training.

Persons responsible for special living arrangements, housing projects or neighbourhoods in which many elders live need opportunities for training about how to enable older residents to age safely in place and to recognize when a move may be indicated. Training about ways to connect older residents with community services will enhance a manager or coordinator’s capacity to serve the older residents.

Policy and Practice

Governments, NGOs, faith-based organizations and other groups should develop policies to ensure that elders have affordable, appropriate housing. Subsidies will be required for the poorest older persons in the community.

• There is a need for basic services delivered to or available in one’s home. Innovative policies and programs have emerged that warrant adaptation and replication that provide information about what works for older residents and the providers who serve them.
• While the state should have a major role in assuring safe and affordable housing for older people, NGOs and the private sector should work together to ensure that elders have the housing they need.
• Housing programs can utilize various assistive technologies to enable older people to live relatively independently despite increasing need for support.
• Policies for active ageing and for the late stages of frailty need to ensure that housing is adequate, accessible and affordable.
• Attention must be paid to the role housing plays in promoting health and independence and to the negative long-term impact which poor housing has on health. 
• Home is critically important to older people; ageing in place is the overwhelming preference of most elders throughout the world. However, when that home can no longer meet a resident’s need for safety and services, the community and the family should ensure that alternatives are available including, but not limited to, care facilities.
• Research supports the first principle of the UN for older people which states that independence includes "being able to reside at home for as long as possible." To achieve this there needs to be a focus on the adaptation of homes. However, for some a move to somewhere more convenient, nearer amenities or family will be the right decision.
• Housing policies need to be linked with other polices and services. And for older people to have a choice they need basic income to pay for their housing and services. 
• Family support, where available and wanted by both the older person and the family, can be enhanced by policies and, when necessary, housing subsidies. While most older people may find appropriate shelter in the community, others may require special accommodation and supportive living arrangements. 

As younger people continue to move for employment older people often choose to join them to seek a better life. In many parts of the world, with younger people moving to urban areas, older people are left behind, often with grandchildren to care for. There are implications for both the communities they leave and those they join. The world community must direct special attention to those older people who move because of disasters or who are refugees. Others become migrants in their own communities for lack of housing. The homeless, refugees, and victims of disasters and wars of all ages deserve interventions that secure their safety, provide for their basic needs, and provide hope for resettlement. Often massive efforts by nations and international NGOs are required to resolve the complex problems to restore living arrangements, jobs, food and transport.

Research

• Serious studies of the conditions that affect, indeed cause migration, from rural to urban areas, from poor countries to richer countries need to be done to bolster the efforts of nations, communities, regions and UN agencies to change the perverse effects of migration forced by conditions and circumstances.
• Research into the conditions migrants face in new countries and urban areas need to be undertaken to inform strategies to alter the flow of migrants, as appropriate, and provide living conditions and employment that will reduce the need for people to move, at risk, from places they know well to a new environment.
• Analyses of government policies and practices that affect migration are needed to identify changes that are needed, incentives that should be created, and play critical roles in the well-being of migrants.

The need to prepare a talented cadre of administrators, researchers, teachers, and practitioners who are needed to manage the flow of migrants and refugees is huge. Efforts to prepare those key personnel to understand older people with the special needs and circumstances must be launched preferably through international programs created to fill this need.

Policy

Current policies and practices and the consequences of apathy among nations has resulted in a world situation that causes thousands of people to cross borders, often a great personal cost; Until development plans succeed in enabling people to achieve their dreams for employment, education, shelter and dignity within their countries and communities, migration will continue to uproot people and lead to terrible conditions.

Transport

Transportation has been called the glue that connects older people, essential services and the social and religious activities important to their well-being. The absence of affordable, accessible, timely transportation forces many elders to become isolated and at risk of marginalisation. Concern for safety measures to reduce accidents has increased as the incidence and prevalence of injuries due to accidents has increased. 

Research

While the number of serious studies about transport is increasing, complex and simple societies need innovative and effective strategies to increase the mobility of older people without placing them at risk of falls, accidents, and home and work related injuries.

Education

The skills and knowledge of occupational therapists need to be shared with community people, housing specialists, transportation managers and others who interact with older people facing threats associated with transport.

Policy and Practice

• Modifications in transport require engineers, planners, community people and older people to discuss the transport needs of older people—and the entire community—and to devise strategies to develop a sustainable transport system. 
• Counsellors, coordinators, social workers and others engaged in working with older people need to be aware of transport needs of older people, services available in the community, and provide the coordination people need to access transport.
• Those professionals and others who are aware of the severity of transport problems in the community need to become advocates for transport systems that work for older people and their families. 

Environmental issues, such as pollution, unclean water and untreated sewage, affect people of all ages. For older persons, living environments must be barrier free and accessible for people of all ages. Policies must be integrated so that the design of facilities, transport and homes will be easily accessed and appropriately used. Policies to remove hazards, such as increasing the safety of streets, will help older people as well as other age groups.

3.2 Issue 2: Care, and support for caregivers

3.2.1 Research, Practice and Education Implications 

Substantial research is needed concerning all aspects of caring in relation to ageing. This research needs to be conceptual, practical and applied and must range over the full scope of medical, psychosocial, economic, environmental and care provider dimensions of caring. Education in all aspects of care assessment and provision is essential in gerontology and geriatrics and must include consideration of both formal and informal modes of care. Care needs and provision are at the heart of gerontological and geriatric practice including primary and specialist care.

3.2.2 Key Messages from the Valencia Forum

Research

In addition to the important work being done about the roles and functions of care providers, more attention must be paid to economic aspects of the caring enterprise. The value of informal care providers to our systems is enormous; the cost of relying on public sector resources to pay for care is clearly out of reach for nearly all societies. Research into ways to support the informal caring networks to ensure that this vital part of a civil society is maintained requires careful attention by researchers and policy makers.

Education

• Education in the assessment of needs, setting objectives for care, and provision of formal and informal care are essential in gerontological and geriatric education. Relevant management and ethical issues should be included.
• Knowledge about the needs of elders, their requirements and preferences must continue to grow to support the rapidly expanding populations of very old people.

• Caring needs to be supported so that families can continue in their caring roles. It needs to be emphasised that public support does not lessen the amount of informal care, but that for those without the benefit of informal, family care providers, government has an obligation to provider for their care.
• New forms of caregiving need to be carefully researched and, where found to work effectively, supported and disseminated. Policies should recognise the importance of caring as an integral part of the life course; for example it should be featured in school curricula.
• Traditionally women have provided the bulk of informal care to older people, especially frail or dementing spouses, disabled children or friends.
• As women’s participation in the workforce continues to rise, this pool of carers is shrinking and the inclination of women to take on these roles is lessening. This puts at considerable risk the informal care system. 
• The important role of men as carers or potential carers needs to be recognised and supported. 

3.3.1 Research, Practice and Education Implications 

Causation, outcomes and prevention of abuse and violence against older persons needs extensive research. Those working with older persons who may be the subject of abuse in its many forms need training to detect abuse, and be aware of the referral and support mechanisms available. Practitioners in ageing and aged care need to be fully conversant with the root causes, manifestations and outcomes of neglect and abuse of older persons.

3.3.2 Key Messages from the Valencia Forum

Research

Research across a broad spectrum of issues is essential. There are no uniformly accepted definitions of elder abuse and neglect. Some would suggest that mandatory retirement is a form of abuse for those facing lost income and or psychological abuse due to lost self-esteem among those forced to retire against their will. 

Recognizing that neglect is a form of abuse, and that in home and institutional settings both actions and inactions can be abusive, the following is offered as a starting point for workable definition of elder abuse and neglect: Abuse may be defined as physical or psychological behaviors, or a lack thereof, that lead to risk of increased harm or reduced well-being of the individual.

Once standard definitions have been developed by consensus, rigorous scientific studies need to be conducted to establish scientifically the existing prevalence rates of elder abuse and neglect in developed and developing countries; these studies should allow for the scientific investigation of subgroups at increased risk for elder abuse and neglect. Some research has demonstrated that both poverty and excessive stress among caregivers are risk factors for abuse and neglect.

The world community should initiate interventions at the community and the individual level to reduce the incidence of elder abuse and neglect. Interventions that provide additional or enhanced coping strategies for those at risk of abuse and neglect should have a high priority. Community interventions should be rigorously evaluated so that successful interventions may be promoted as examples of best practice. It serves no useful purpose to lead others to infer that some interventions are effective when they have not been evaluated.

Research

• Research to iidentify factors that place people at risk and those which prevent abuse and neglect need to be undertaken.
• Research to identify programs that can prevent and intervene among people at risk for abuse and neglect should be promoted as best practices and the dynamics of effective programs need to be analysed for replication.
• Facilitating participation and contributions to family and community by older persons may increase their perceived value to society and reduce risk of abuse. Across the life span, positive attitudes of ageing need to be emphasized.
• Older persons perceive elder abuse as neglect resulting in isolation, abandonment and social exclusion; violation of human, legal and medical rights, and deprivation of choices, decisions, status, finances and respect.
• Assessment procedures establishing indirect and direct indicators should be developed with multi-informant and triangulation strategies. 

• Geriatrics and gerontological training should include recognition of all forms of abuse.
• Educate and train primary providers, family members and institutional caregivers to recognize those factors likely to increase the probability of abuse and neglect.
• Develop programs and train providers to actively initiate safeguards such as respite care, home health aids, day care, institutional personnel rotations to minimize abuse and neglect, recognize penalty for abuse and neglect

• Fund proactive programs that identify family providers and address specific problems that family members and elders face. Helpful institutions should be identified and efforts to establish safeguards to abuse must be undertaken. Law enforcement agencies must be prepared to take appropriate action and the community needs to provide alternative shelter for abused or neglected elders.
• Supportive agencies need to create international resources such as websites to inform and educate communities and concerned individuals. NGOs have an important role to play inn this development.

• Older people have the right to self determination and to live free from abuse, neglect, exploitation and discrimination.

• Governments should develop and fund a national and comprehensive strategy and action agenda to prevent, detect and intervene in elder abuse. This should include: 
• public and professional education and awareness campaigns – including the media.
• participation of older people and promoting their empowerment
• evaluation and research programs
• family, community, institutional and long-term care within a supportive legal framework
• The Office of the Commission of Human Rights should establish a task force to report on how best to promote action on the issue of abuse of older people.

3.4.1 Research, Practice and Education Implications 

Understanding of how images, including stereotypes and negative language, of older persons influence and are influenced by attitudes and understanding of ageing is needed. All educational efforts in ageing should incorporate understanding of images of ageing and how they are formed and the impacts they have on older persons, care providers and the community generally. The extent to which negative stereotypes of ageing can influence care provision and design of policies and programs must be recognised and combated at all levels. More positive images of successful ageing need to be promoted in practice settings.

3.4.2 Key Messages from the Valencia Forum

Research

• Evaluation of strategies that are efficient in changing prejudice, ageism, stereotypes and negative attitudes about older persons is needed.
• Research into various media in which inappropriate images of ageing are displayed needs to be done to raise awareness and to apply fair and accurate language and images to older people.

• Constructive views of old age and ageing should be encouraged through public media as well as in medical and other professional training programs.
• Education of realistic view of age and ageing should be done at several levels.

• Governments should develop national and comprehensive strategies to stop abuse of older people. This should include a supportive legal framework, public information and awareness campaigns, involvement of older people to promote their empowerment, and incorporating programs to deal with causes and effects of abuse and neglect in the community’s long-term care system.

• The Office of the Commission of Human Rights should establish a task force to report on how best to promote action to prevent abuse and neglect at regional levels. 

International Steering (advisory) Committee

International Association of Gerontology (IAG) Executive and Regional Chairs: Gloria Gutman, John Gray, Andrew Wister, Norton Sayeg, Gary Andrews, Sung-Jae Choi, Mario Passeri, Francisco Guillen-Llera Manuel, Osvaldo Prieto Ramos, Enrique Vega Garcia, James T. Sykes.

Spanish Society for Geriatrics and Gerontology (SEGG): Isidoro Ruipérez Cantera, Gonzalo Bravo Fernández de Araoz, Jose Ribera Casade, Rocio Fernández-Ballesteros.

UN program on ageing: Alexandre Sidorenko.

UNFPA: Richard Leete and Ann Pawliczko.

WHO: Alexandre Kalache, Irene Hoskins and John Cai.

Novartis Foundation for Gerontology: Charles Studer, Hannes Staehelin.

HelpAge International: Mark Gorman,Todd Petersen.

Others: Mary.Luszcz (Australia), Miguel Acanfora (Argentina), Astrid Stuckelberger (Switzerland) Mary Ann Tsao (Singapore), Urs Peter Gauchat (USA).

Local Program, Planning and Support Committee

Bienstar Social, Valencia Generalitat (Esther Franco Aliaga and associates), SEGG, (Rocio Fernández-Ballesteros and Pedro Gil Gregorio) IMSERSO (Jesús Norberto Fernández), Valencia (José J. Botella and Lillo Garay), UN Second World Assembly on Ageing (Aurelio Fernández )

Secretariat

Gary Andrews, Convenor

Melinda Andrews, Executive Officer

Kate Burns, Executive Assistant

It is impossible for this Report from Valencia to capture all the knowledge and insights contributed through over 470 presentations in various forms on science, education, policy and practice issues in gerontology at the Valencia Forum. Nor is it possible to individually thank all the people who provided significant contributions through presentations and discussion of key issues. All participants at the Forum deserve a special vote of thanks for their input to this document.

Drafting teams provided direct input into the drafting process by attending presentations on related topics and synthesizing the information presented and discussions around the major themes used in the World Assembly on Ageing draft document. The drafting teams included: Rocio Fernández-Ballesteros and John Grimley-Evans, Gopal Acharya and James Lubben, Toni Antonucci and Larry Branch, Janet Ashkam and Mary Luszcz, Miguel Acanfora and Irene Hoskins, Isabell Aboderin and Mark Gorman, James Sykes and Anthea Tinker, Kevin Kinsella and Andrew Wister.

The work and presentations of the eminent keynote speakers were particularly helpful in the development of ideas for the Report from Valencia. Keynote speakers included: Paul Baltes, (Bill) Piu Chan, John Grimley-Evans, Santiago Grísolia, Betty Havens, Alexandre Kalache, Yuji Kawaguchi, Ed Lakatta, Richard Leete, Daisaku Maeda, Victor Marshal, Jay Olshansky, Christopher Phillipson, Jean-Marie Robine, Alexandre Sidorenko, Lois Verbrugge, Alan Walker

Not only will the work of those at the Valencia Forum be helpful in formulating ideas for the World Assembly on Ageing, their presentations, including the keynote addresses, will be available to assist in the implementation and monitoring of emerging strategies and programs, on the World Wide Web at www.valenciaforum.com.