Health Equity Requires Healthy Living, Not Healthy Ageing

Abstract

Healthy ageing is a popular term widely used throughout research and practice by gerontological nurses, other scholars and news and social media. Synonyms for healthy ageing abound. Super ageing. Active ageing. Positive ageing. Graceful ageing. Productive ageing. The classic synonym is successful ageing which dates back decades (Rowe and Kahn 1997). As gerontological nurses, these phrases are part of our professional vocabulary. We all have a favourite among them that we likely use frequently. But, with the prevalence of structural ageism well established, healthy ageing needs scrutiny (World Health Organization 2021). Consider what is left unspoken but strongly implied by the phrase health ageing. By emphasising the word healthy in relation to ageing, the phrase healthy ageing implies that ageing is a fundamentally unhealthy process. When we use the word healthy as an adjective to describe ageing, we share the implication that ageing is not healthy. With our use of healthy ageing, we are unwittingly reinforcing negative understandings of ageing and expectations about growing older.

Much of the lay discussion around healthy ageing is medicalised, especially in high-income societies. Efforts to quantify precise amounts of exercise, nutrient intake and activities with purported preventative value to promote brain health and guard against frailty abound. To a certain extent, lay people may benefit from such information and form healthier habits as a result. Nonetheless, those changes may come later in life than is desirable. This lag occurs simply because the term healthy ageing implies relevance only to people who see themselves as older or are thinking about getting older. The implicit message that their health is at risk because they are getting older, stemming from the notion that ageing is unhealthy, presents an underlying threat to population and individual health. Internalised negative understandings of ageing and later life, called negative age-related self-stereotyping, can significantly damage both health and well-being.

Nurses and other health professionals generally understand ageing as an essentially unhealthy process. Nurses and other health professionals express the structurally ageist beliefs and attitudes within their professions and healthcare with every clinical judgement or action that is predicated on chronological age. This professional perspective is as damaging as the lay phenomenon of negative age-related self-stereotyping. Health professionals are taught early in their foundational education to believe that older people—defined as 60 and older internationally or as 65 and older in many societies—are at risk of ill health merely by virtue of their age. Relying on a flawed classification of normative and non-normative—usual or successful—ageing jeopardises health and healthcare for people of all ages. Nurses and other clinicians typically look for specific diseases and dysfunction in relation to a person's chronological age and disregard that which does not fit the stereotype. This practice often defies true epidemiology and counters person-centeredness. For example, contemporary stories about delayed or missed diagnoses of malignancies thought to be diseases of later life when they occur in younger people offer a sobering reminder of the extent to which ageism threatens everyone's health.

Two realities shape consideration of the ageist consequences of healthy ageing. First, despite popular understandings and media messages to the contrary, ageing does not begin at some arbitrary age like 65 for which no one can now recall the precise rationale (Roebuck 1979). Rather, ageing begins in what we term human development and extends across the arc of each life through death. Critically, ageing is not simply a biological phenomenon. It encompasses psychological, social and spiritual experiences and processes, many of which expand and create strength over the course of a lifetime. The manifold nature of human ageing defies prosaic dichotomous categorisation as a journey of decline or growth. Second, ageing presents opportunities for individuals, populations and societies. Opportunities result from the complex development of human beings across the life span. The possibilities that older people and communities can manifest in daily life when ageist expectations are overcome are currently only the stuff of hyperbolic news and social media. While stories about so-called super agers might be exciting to read, they typically serve only to widen the distance between what most consider usual ageing and mythical ideas about those who appear to be ageing successfully. Fully realising the opportunities of ageing requires undoing ageism.

My assertions about the ageism behind healthy ageing, ageing as a lifelong process and late life opportunities are often met with scepticism. Recently, an older person asked if I was just overemphasising ageism and simply disregarding normal ageing. I replied that fully knowing normal ageing is impossible. Afterall, human beings cannot ethically or practically be placed in artificially controlled environments from birth to death to study their biological, psychological and social development. The science of epigenetics reminds us that what many would like to categorise as normal ageing is indeed epigenetic change and not a consequence of chronological age. Epigenetics is the interaction between an individual's genome and cumulative environmental exposures. These exposures occur over decades and result in differential phenotypic expressions within and across groups of individuals. The consequence is a hugely heterogenous expression of function, behaviour and disease ranging across the later decades of the human lifespan. Popularly, of course, we nurses see this reality in the remarkable heterogeneity of any birth cohort of older people.

Health living offers an anti-ageist alternative to healthy ageing well suited to our nursing discipline. It also provides us with a means to mitigate anxiety about needing to change lifestyle and behaviour when crossing a threshold into socially defined later life. Healthy living in its scholarly application incorporates consideration of behavioural, social, environmental and commercial forces that positively or negatively influence health and well-being across the lifespan. In an era of multiple threats to planetary health and thus to human health, healthy living is a necessity for all. The enormity of the current crises in climate, air pollution, plastic pollution and biodiversity requires vast science and ongoing interpretation of resulting evidence for effective responses. People of all ages, not just those who are chronologically older, need our nursing intervention for healthy living. They need our guidance to help avoid, adapt to and mitigate all classes of negative determinants of health. Moreover, individuals, families and communities will benefit from our advice on how to maximise positive determinants of health to develop and grow older with health, function and well-being.

Usefully, healthy living—though it has biomedical links and implications—is tied to an array of academic disciplines like social psychology and other behavioural science and with community planning and other social science. Such disciplinary connections allow for clear alignment of healthy living with nursing's metaparadigm. Our traditions have long highlighted social connections inherent in healthy living, including that between the nurse and the person, and the importance of the environment. As nurses, we know that individual and community health and well-being rely on strong social networks and on healthful environments. Today, we commonly call out the classes of social and environmental determinants of health when speaking about health equity. Healthy living is essential to health equity. Equally, health equity requires achieving health, function, and well-being assure optimal longevity for all.

Many academics, clinicians and public health specialists around the world outline the lack of health equity for older people. Ageism in all its forms, whether expressed individually or structurally, undermines health equity for people of all ages. We must then be cautious about the artifice of gilding ageism with the popular lustre of healthy ageing or any of its synonyms. Doing so does not erase the manifold harms of ageism. Creating the us–them divide of younger and older may hold the allure of a false reassurance that the us in that dichotomy are protected from the supposed scourge of ageing. But that false comfort is inherently ageist as much for those who would class themselves as young as for those who are labelled old. Ageing is not a biological threshold nor is it a game in which some will succeed while others fail. It is a universal human experience. Human beings naturally hope to exceed the averages of life expectancy to attain longevity and with it, health, function, and well-being. Health equity in later life mandates that we do our utmost to ensure that the very human hope of longevity with health, function and well-being is attainable for all.

Unfortunately, the anticipation of long lives marked by health, function and well-being is currently far out of reach for huge swaths of the world's population. Nursing's distinctive appreciation of the biological, behavioural, social, environmental and commercial determinants of health gives us as gerontological nurse researchers an advantage in helping to redress this absent equity. Reshaping our understanding of how ageing is related to all classes of the determinants of health is more critical than ever before. Doing so will allow us to reframe our science and to redesign our care to support health, function and well-being in service of longer, more meaningful lives. Going forward, we can achieve greater justice and equitability in our science, education, and practice by changing our language from healthy ageing to healthy living. Replacing ageing with living in this term of reference is far more than a small change in language. It shifts the standard from age discrimination to age inclusion, helping to dismantle implicit structural ageism to help achieve health equity.

The synonyms of healthy ageing each hold specific connotations, drawing proponents from nursing and other disciplines. Those connotations, like that of active ageing with activity and social participation, are valuable. Nonetheless, they cannot outweigh the ageist implication that ageing alone is unhealthy, inactive and isolating. An age inclusive future direction is to embrace healthy living and to then highlight the specific determinants of health connoted by the synonym of healthy ageing in application of healthy living going forward in our research. Further, mapping our research onto specific biological, behavioural, social, environmental and commercial determinants of health helps tie our science to the broader realm of public health and uncover potential collaborations with colleagues in disciplines outside of the health sciences.

Making healthy living the age inclusive term for achieving health equity across the life span and especially in later life requires that we tear down structural and individual discrimination. Ageism intersects and escalates corollary social discrimination including ableism and climate change denial. Ageism must be replaced with age inclusiveness and age friendliness across our societies and our systems of social and health care. The literal intent of age friendliness as encompassing people of all ages aligns well with the anti-ageist intent of adopting healthy living. Consequently, effectively investigating healthy living requires coupling it with anti-discrimination activism in our research, education, practice and advocacy.

Moving our research from healthy ageing to healthy living amplifies our potential impact on health equity for older populations. Focusing on living enables us to emphasise activity, education, meaning and life purpose with and among individuals, families and communities. Pairing the focus on healthy living with anti-ageist actions to overcome negative age-related self-stereotyping at both individual and structural levels augments the power of this approach to create further impact. Healthy living thus offers each of us, as gerontological nurse researchers, fresh possibilities to integrate our metaparadigm and pro-ageing perspectives to advance our science, improve public health and more fully realise the positive influence of nursing science, education and practice.

Here at the International Journal of Older People Nursing (IJOPN), we hope you will share the development of your healthy living and age inclusive studies with us via social media. We are excited at the prospect that you will consider submitting your research reports disseminating your findings when they are ready. We look forward to learning how you are using healthy living to advance health equity for today's and tomorrow's older people. As a reminder, you can find IJOPN on LinkedIn at https://uk.linkedin.com/in/international-journal-of-older-people-nursing-ijopn-10bb6674 and on Blue Sky at https://bsky.app/profile/intjnlopn.bsky.social. Please use the hashtag #GeroNurses and tag us on LinkedIn and Blue Sky when you post about healthy living and age inclusiveness!

The author declares no conflicts of interest.