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RHO archives : Topics : Older Women

Overview and Lessons Learned

Introduction

The world is in the midst of a demographic transition as the proportion of people over age 60 increases and the proportion under age 15 declines. While population aging began in developed countries, this trend now encompasses developing countries as well. Currently 8 percent of the population in developing regions is over the age of 60. As life spans increase, however, that proportion will grow to an estimated 20 percent by 2020. Already, 62 percent of the worlds older people live in developing regions.

These demographic changes will have a disproportionate impact on women, who tend to live longer than men and therefore are more likely to suffer the disabilities and illnesses associated with old age. Among people over age 60 in developing regions, there are currently 88 men for every 100 women. In years to come, that ratio probably will draw closer to levels in developed regions, where there are only 71 men for every 100 women over age 60.

As women age, they face a double burden of discrimination: both as older people and as women. Societies marginalize and discriminate against older people, who are viewed as unproductive burdens on their families and the nation. Older people are routinely excluded from decision-making and from major social programs, including those designed to improve health and alleviate poverty. They are a low priority when resources are distributed at the household, the community, and the national levels.

At the same time, aging women suffer from the lifelong effects of gender bias and low social status (see RHO's Gender and Sexual Health section). After years of poor nutrition, hard physical labor, multiple pregnancies, and limited access to health care, women often enter old age in chronic ill-health. Compared with men, older women also are more likely to be poor, widowed, and economically dependent on their families. Older women carry additional burdens associated with their role as family caregivers: they are responsible for looking after aging parents, older husbands, and orphaned grandchildren.

Population aging has important ramifications for health care. It will change the kinds of services needed as global disease patterns shift away from communicable diseases toward chronic illnesses, such as heart disease, cancer, and mental disorders. Population aging also will increase the overall burden on the health care system, as older people require more medical care.

Good health is older peoples most important asset. It enables them to continue working, function independently, and maintain a reasonable standard of living. Yet older people in developing countries must overcome stiff barriers to receive the health care they need. Poverty and transportation problems limit access to services. Once they meet with a provider, older patients often face negative attitudes, with providers considering their care to be less important than that of children and younger adults. Providers often know little about the health issues facing older people and tend to dismiss their complaints as signs of old age for which nothing can be done.

In response to demographic trends, international attention has turned to issues related to aging, most recently at the Second World Assembly on Ageing held in Madrid in 2002 (www.un.org/ageing/coverage). In Madrid, the world community identified advancing health and well-being into old age as a top priority and affirmed its commitment to provide older people with universal and equal access to health care services. At the same time, the World Health Organization has promoted the goal of active aging (www.who.int/hpr/ageing/ActiveAgeingPolicyFrame.pdf)—that is, delaying the disabilities and functional decline associated with aging so that older people can maintain their independence, quality of life, and productivity.

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Changing health needs through the life span

In many developing countries, health services for women focus on family planning and safe motherhood to the exclusion of all other health needs. Even women of childbearing age have other pressing reproductive health problems. Untreated gynecological and urinary problems, such as reproductive tract infections and urinary infections, incontinence, and uterine prolapse, affect so many women that the associated pain and other symptoms are accepted as a normal part of women's lot in life. Worst off are the young women suffering from fistulas, which result from obstructed labor and cause total loss of urinary and/or fecal control. They may be cast out by their families and communities unless the fistulas are repaired. (See the program example on Ethiopia.)

As women grow older, they also need to reconsider their contraceptive choices. Their family planning goal shifts from spacing births to preventing all further childbearing. When choosing a contraceptive method, older women also need to consider the increasing likelihood of a health condition that will contraindicate certain methods, their own declining fertility, and the potential impact of contraceptives on the symptoms and health risks associated with menopause (see RHO's Contraceptive Methods section.

As women reach menopause—generally between the ages of 45 and 55—they may need help managing symptoms associated with the menopausal transition, an approximately four-year period of hormonal and clinical changes that culminates with the end of menstruation. During this time, women may experience vasomotor symptoms (hot flushes and night sweats), urogenital problems (incontinence, urgency of urination, and painful intercourse), and psychological symptoms. The nature and frequency of these symptoms, however, vary widely from one region of the world to another. In some cultures, women view menopause positively, focusing on freedom from menstruation and the relaxation of social restrictions that comes with old age. Following the lead of physicians, however, women in developing regions are increasingly viewing menopause as a medical problem that requires intervention.

After menopause, women face new long-term health risks. Hormonal changes contribute to an increased risk of cardiovascular disease and to osteoporosis, which affects about 10 percent of women worldwide and can cause disabling hip and vertebral fractures. As they age, women also face the increasing likelihood of other reproductive health disorders, including genital prolapse, urinary tract infections and incontinence, breast cancer, and cervical cancer (see RHO's Cervical Cancer Prevention section). Mental health problems, including depression, dementia, and Alzheimers disease, also pose a threat to womens quality of life.

Gender exacerbates some other health problems suffered by older women. Elder abuse is a substantial, but little admitted, problem worldwide. Older women are vulnerable to violence and abuse from family members as well as from the larger society. Womens role as caretaker of the sick and elderly also has been extended due to the HIV/AIDS epidemic. Older women increasingly are taking on the emotional and economic burden of nursing their dying children and caring for orphaned grandchildren (see program example from Thailand).

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Designing health services for older women

Women in developing countries often accept the physical discomforts associated with gynecological problems, menopause, and aging as natural and do not seek health care. With appropriate training, however, health care providers can treat many of their immediate health problems, reduce long-term disease risks, and improve the quality of life of women as they age. Reproductive health programs, which already serve women during their childbearing years, are well placed to continue caring for women as they reach menopause and beyond (see the Program Example from the NIS and Eastern Europe).

Depending on the resources available, appropriate services for older women may include:

  • Counseling on diet, exercise, and other elements of a healthy lifestyle to prevent cardiovascular disease and osteoporosis.
  • Treatment of reproductive tract and urinary infections, uterine prolapse, fistulas, and other gynecological disorders.
  • Screening and treatment for cervical cancer and breast cancer (see RHO's Cervical Cancer Prevention section and the program example from Ukraine).
  • Counseling on menopause and alleviation of symptoms (see the program example from Malaysia).
  • Medical management of women at high risk for fractures, cardiovascular disease, and breast cancer.
  • Support services for older women caring for family members infected with HIV and for grandchildren orphaned by the disease (see RHO's HIV/AIDS section).

Before deciding which interventions to add, reproductive health managers must consider both the extent of the problem and the ability of their programs to address it. Some services, such as counseling on menopause, diet, and exercise, are inexpensive and relatively easy to integrate into existing services. Others require significant training for providers and special supplies and equipment. Routine screening for breast cancer, for example, is not cost-effective unless the incidence of the disease is high and there are diagnostic and treatment centers to which women can be referred (PATH/Outlook 2002).

Ongoing medical research also changes our understanding of which services to offer. For example, results from recent clinical trials have challenged the practice of giving older women long-term hormone replacement therapy to prevent chronic diseases (Writing Group 2002; NHLBI 2002). Research into complementary and alternative medicine therapies, such as soy and black cohosh, may reveal new options for older women based on traditional medicine.

No matter which interventions are selected, expanding services for older women will make new demands on reproductive health providers, who generally know little about the physical, psychological, and social problems of aging. Pre-service and refresher training can teach providers how to counsel these women and treat common health problems. Equally important is changing providers attitudes so that they value older clients.

To attract older women to reproductive health clinics, program managers also must address a wide variety of barriers to access. Many older women are reluctant to complain and, in any case, are not aware that treatments are available to alleviate their health problems. They also may not appreciate some of the risks they face, for example, from osteoporosis and breast cancer. When older women do decide to seek services, their physical and financial limitations may make it difficult for them to travel to the clinic and pay for services. By educating women about common health problems and the services that are available, public awareness campaigns can overcome some of these barriers, while also promoting the kind of active and healthy lifestyle that reduces health risks in old age.

Outreach programs also are a valuable supplement to clinic-based services for older women. Community-based activities, including support groups and volunteer health promoters, hold special promise since they can tap into the energies and resources of the elderly themselves as well as those of the wider community. With training and support, relatives, neighbors, and other volunteers can supply the affordable health care, social and emotional support, and help with everyday chores that older people need.

By educating women about common health problems and services available, public awareness campaigns can overcome some of these barriers, while also promoting the kind of active and healthy lifestyle that reduces health risks in old age. Outreach programs also are a valuable supplement to clinic-based services for older women. Community-based activities, including support groups and volunteer health promoters, hold special promise since they can tap into the energies and resources of the elderly themselves as well as the wider community.

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