COMMENTARYMinority Group Status and Healthful AgingSoci

COMMENTARY
Minority Group Status and Healthful Aging:
Social Structure Still Matters
During the last 4 decades,
a rapid increase has oc-
curred in the number of sur-
vey-based and epidemio-
logical studies of the health
profiles of adults in general
and of the causes of dispar-
ities between majority and
minority Americans in par-
ticular. According to these
studies, healthful aging con-
sists of the absence of dis-
ease, or at least of the most
serious preventable diseases
and their consequences, and
findings consistently reveal
serious African American
and Hispanic disadvantages
in terms of healthful aging.
We (1) briefly review con-
ceptual and operational def-
initions of race and Hispanic
ethnicity, (2) summarize how
ethnicity-based differentials
in health are related to social
structures, and (3) empha-

size the importance of atten-
tion to the economic, politi-
cal, and institutional factors
that perpetuate poverty and
undermine healthful aging
among certain groups. {Am
J Public Health. 2006;96:
1152-1159. doi:10.2105/AJPH.
2006.085530)
Jacqueline L Angel, PhD, and Ronald J. Angel. PhD
ALTHOUGH THE SUPREME
Courl outlawed the principle of
sepajate but equal in 1954 with
its famous Brown versus Bom-d
of Education decision, many mi-
nority y^mericans luul that they
are still separate and unequal.
Despite a century of impressive
innovations in medical science
and improvements in public
health, poverty continues to un-
dermine the pliysical and emo-
tional health of a large number
of Americans, and serious ra-
cial/ethnic health disparities
persist'"^ Low-income families
have inadequate healtli care
coverage,"'^ and individuals who
lack adequate insurance are
more likely to die from cancer
and other serious diseases be-
cause of late diagnoses and defi-
cient care.^"" Perhaps the most

basic question is wliether health
disadvantages among minority
Americans are the direct and
almost complete resuit of pov-
erty and its correlates. Well-
documented correlates include
low educationai levels, labor
force disadvantages, and resi-
dential segregation iii ghettos
and barrios, where individuals
are exposed to environmental
and social health risks such as
drugs. 'io!ence. and fainily
disruption.'"^" ̂ ''
Radal/ethnic disparities in mor-
bidity and mortality are so glaring
that the federal govemment has
been forced to respond, and a
large body of research has exam-
ined tlie role socioeconomic status
(SES) and ailture play in these
disparities.'̂ The ultimate goal Ls
to identiiy the sodal stuictural
causes of inequities in health so
that genera] population health can
be impn)ved. We will present ap-
proaches to studying radal/etlinic
health disparities hy (1) reviewing
operational definitions of race and
ethnicity and tlie research tools
tliat estimate difierential disease
burdens and health au'e use,
(2) assessing jast how far the field
has come in understanding healtli.

and (3) |iro]X)sing a future re-
search agenda that examines the
sodal, economic, and [xilidcal
foires tliat peipetuatc health
vulnerabilities.
GROUP CLASSIFICATION
Duriiig the past 2 decades, we
have witnessed an increasing
appreciation for the conceptual
complexity of gi-oup dassification
and its potential for intiTxiudng
bias into studies of comparative
health levels.'̂ Individuals can be
of mixed race/ethnidt>', tliey can
intermarry and identify with an
adopted group, and they can even
ivject a group clas.sification. pai-
ticularly if that identity is imposed
by others. Individuals who strug-
gle e^aiiist the sodal stigma asso-
dated with group dassification
often embrace that identity as a
political statement and a sign of
defiance. Standard classifications
of race/ethiiidty do not overlap
with spedfic genetic profiles or at-
tributes.'^ To a large extent, sudi
classifications are political cate-
gories defined by history ajid the
sodal vulnerabilities imposed on
minority gi-oups by the dominant
majority.'" A political basis of
gi-oup classification does not

translate directly into useful sden-
tific or intellectual classification.''''
We no longer differentiate among
non-llispanic White nationality
groups, because distinguishing
whidi nation an individual's an-
cestors came from is no longer
relevant. According lo Richard
Alba, Americans of all European
ancestries have come to be viewed
and to view themselves as ethni-
cally American."" Therefore, tlie
radal/ethnic disdndions that re-
main reflect enduring sodoeco-
nomic viilnerabiiitiGs.
Because of the compiex social
basis of radal/ethnic classifica-
tions and identities, David Wil-
liams proposed that Hispanic be
included with African American
and the various .̂ sian nati<inali-
ties as a radal rather tlian an
ethnic categorization.'" His justifi-
cation is that the nmjority of His-
panics self-identify as "Hispanic."
and although tlie actual percent-
age varies among studies, a
large proportion do not further
self-identify as either Black or
White,"''^^ Subjectively, there-
fore, what many consider to be
an ethnicity is as basic as race
in teiTOS of identity. What is sub-
stantively important in such radal/
ethnic classification is the identi-

fication of sociai and structural
vulnerabilities assodated with
group classification. Immigration
adds another diinension of com-
plexity to ethnic categories and
identities. Immigrants who ar-
rived from tlie state of Guererro
in Mexico yesterday are very dif-
ferent culturally and sodaily
from ininiigi-ants of tlie same
Mexican-origin census category
1152 I Commentary | Peer Reviewed I Angel and Angel
American Journal of Public Health I July 2006, Vol 96. No. 7
COMMENTARY
whose ancestors arrived with the
Conquest.* '̂
Census categories, even as
they become more detailed aiid
provide more choices, gloss over
a great deal of heterogeneity
ihat is of immediate importance
Lo health and heaiUi service
use?'' The reali^ is most health
survey and census data use re-
spondents' seli-ieported race, but
only provide a limited number
of choices. Biracial individuals or
individuals who consider tliem-
selves to be something other
ihan White. Afiican American,

Hispanic, or any of the other
available categories answer
questions about radal/ethnic
j{i-oup classification in ways that
are not yet understood.
Some data systems, such as
the National Vital Statistics Sys-
tem, do not even collect informa-
tion on the race/ethnicity of the
decedent, and data on mortality
r-isks come from different and po-
lentially contradictory sources.
Data on the number of deaths.
lor example, come from death
certificates completed by fiineral
directors or medical personnel
on the basis of information from
;m infonnant, usually a family
member.'̂ "' In other systems, such
as those in which data are de-
rived from hospital/patient care
records, it is often unclear who
made the racial/ethnic determi-
nation. The different sources of
radal/ethnic classification create
a potential confounding factor
when recording deaths." '̂' Infor-
mation about the population at
risk comes from survey data.^'
!-;ach of these data sources intro-
duces different possibilities for
undercoujiLs or racial/ethnic mis-
classification.
Additional reporting problems,

such as the census undercount
of minority group membei-s, af-
fect population estimates. As a
consequence of the combined ef-
fect of numerator and denomina-
tor biases, it has been estimated
that death rates are overstated by
about 1 "/o for the White popula-
tion and by about 5% for tlie Af-
rican American popuiation. Such
biases lead to underestimates of
mortality for other groups, per-
haps up to 21 % for the Ameri-
can Indian or Alaska Native pop-
ulations, up to 11% for Asian/
Pacific Islanders, up to 2% for
Hispanics as a group,^'' and up to
6% for Mexican Americans.^''
In addition to gaining a better
understanding of problems with
administrative classification, re-
seai'chei:s have become more
aware of tlie potentially serious
measurement biases that are in-
hereiit when self-reported healUi
data are used. Understanding the
effect of these SES, cultural, and
linguistic factors on the interpre-
tation and response to questions
about health is imperative if in-
vestigators want to reduce poten-
tial bias in the collection of data
from survey and clinical respon-
dents.'*" The group differences

in cognitive schemas and world
views that ethnographic studies
of local and culturally based be-
lief systems—including those that
address disease and its causes-
take as their objects of investiga-
tion are methodological nui-
sances for siurey reseai-chers
and epidemiologists who want
to deveiop valid and universal
[jrobes that can be translated
from one language to another for
comparative use," Unfortunately.
the figurative and impredse na-
ture of language makes such an
objective elusive.'^
Although researchers are
aware of the potential confound-
ijig of outcomes and predictors in
comparative studies of the health
of different groups, this potential
confounding presents serious
pi'oblems to researchers who are
only working with 1 cultural
group. Individuals who have
chronic conditions (e.g., diabetes)
that have never been diagnosed
by a doctor wiU answer nega-
tively to a question about
whetlier a doctor has ever told
them they had the disease."
Such confounding means that
prevalence estimates for groups
that have very different health

care experiences, such as African
Americans and non-Hispanic
Whites, may vary gi^atly in their
validity. In the absence of some
objective criterion or other inde-
pendent data about a respon-
dent's actual condition, survey-
based prevalence estimates must
be inteipreted cautiously.
The ways in which individuals
structure their responses to gen-
eral health questions or to ques-
tions about symptoms are poorly
undei-stood." To make progress
in measurement, researchers
must have a much more sophisti-
cated understanding of the im-
pact of culture, language, SES,
and other group-related factors
on the complex response task. It
is clear that reference group fac-
tors affect how individuals evalu-
ate their own healtli. Otlier cul-
tui'ally based appraisals and
valuations also may affect re-
sponses. For example, it is possi-
ble that in some cultures the fear
of appearing arrogant leads indi-
viduals to report their health as
fair ratlier tlian as very good or
excellent."''' One useful character-
istic of comparative research is
that it does not allow researehers
to ignore the problems of compa-
rability that probably affe(-t all

data collecLJon efforts, even
within the same cultural group.
We believe traditional epi-
demiological approaches a:id re-
search instruments, particularly
those that elidt self-reports of
subjective states, should be com-
plemented whenever possible by
other techniques and should in-
clude qualitative assessments of
how respondents inteipret ques-
tions and structuix' responses.^^
A multimethod approach may
lead to a more sophisticated im-
derstanding of subjective re-
sponses spedficaily and the in-
terview response task more
generally.
Understanding social struc-
tures and theii- impact on health
requires an emphasis on both the
cognitive aspects of culture and
the social and material resources
tliat individuals have at their dis-
posal. '̂ The combination of tra-
ditional epidemiological methods
and ethnographic tecliniqiies is
more effective for assessing the
terminology that individuals use
to talk about disease and the
meaning it has for them. Com-
bining qualitative techniques
with surveys and even more ob-

jective physiological data and
[performance assessments will
gi-eatly improve our knowledge
of real comparative health levels
among different populations and
subgroups.
A CULTURE OF POVERTY?
The existence of minority
group disadvantages in health
indicators have led many to
speculate about how poverly
might cieate and |ierpetuate
health disparities. Some theorists
have suggested variations of the
culture of poverty explanation
(i.e., that chronic poverty leads
individuals to develop a set of
orientations and behaviors that
are incompatible with sodal mo-
bility and economic success or
effective Involvement with social
organizations) forwarded by
Oscar Lewis several decades
ago.*'' Susan Mayer, for example.
July 2006, Vol 96. No. 7 | American Journal of Public Health
Angel and Angel Peer Reviewed I Commentary I 1153
COMMENTARY
argiied that poverty is a product
of the loanied present orienta-

tion ol" tliose who grow up in
poverty."" Individuals who never
witness a payofT to effective
long-term pianning do not leam
the niiddle-dass ability to delay
gratific:ation and thus do not
leam to plan lor their own fu-
tures. From this perspective, tlie
social environmenls in which
such individuals grow up do not
foster a strong work ethic, nor
do Ihey encourage the resistance
of immediate gî atification. Indi-
viduals who have been social-
ized in tliis way are unlikely to
respond to educational opportu-
nities or interventions for chang-
ing their hehavior or reducing
their health risks.
Blocked Opportunities
More structural explanations
focus on the limited opportuni-
ties available to individuals be-
cause of their racial/ethnic chai'-
acteinstics. From this perspective.
Ihe deleterious heaith conse-
quences of poverty are the result
of exploitation and structural vul-
nerabilities. Piven and Qoward,
fttr example, explained higli rates
of poverty among African Ameri-
cans as Ihe result of institutional
racism, which refers to the sys-
tematic differential allocation of

rewards (jn the basis of race. '**
Institutional racism and discrimi-
nation perpetuate poverty and its
resultant individual-level healtli
damage through unsafe and
unhealtlifijl envii-onmenls, low
educational levels, inadequate
medical care, and feelings of
helplessness and hopelessness." ~
Our reseairh and that of otiiers
show that the fundamental nature
of the laboi' market that places
African /Xmericans and Ilispanics
at a disadvantage in terms of
health insurance also under-
mines heath and well-being.' '*'
Historically, African Americans
and Hispanics have been dispro-
portionately confined to the low-
wage service sector or to casual
and informal jobs, where pay-
ment is made in casli and where
their ability to accumulate wealth
is impaired. Discriminatory prac-
tices iji the real estate market
have confined many members of
these groups to unsafe neighbor-
hoods that liave few local em-
ployment opportunities or com-
munity rcsf)urces and inferior
schools." Such confinement, and
the inescapable poverty associ-
ated with it. create chronically
high levels of physical and social

stress that increase the risk for
poor health and vitality.""̂ Indi-
viduals who live in tliese situa-
tions lack adequate social capital
and thus have few resources that
might improve their lots.
Poverty and deprivation can
undermine a people's sense of
control and roh them of the opti-
mism needed for a healthy life.
Individuals who experience pov-
erty, relative deprivation, and
stress early in life become vul-
nei-able to a variety of stressors
throughout adulthood, which
increases their risk for demoral-
ization and depression late in
life."" '̂ Older poor women, for
example, are exposed to more
social disruption in their lives
compared with more af^uent in-
dividuals, and these women's
lives are often punctuated by a
series of negative life events that
are difficult to manage. At the
same time, they are exposed to
elevated levels of stress and have
fewer resources for coping with
life's hardships.''^
Disparities in Health Care
Access
Among tbe reasons for the
large differentials in health be-

tween majority and minority
Americans ai'e the large differ-
ences in adequacy of health care
coverage, amount and quality of
care, and access to long-tenn
care.'"'~"^ Institutional racism
that is rooted in ailturally insen-
sitive and discriminatoiy prac-
tices may explain the tendency
for older minorities to receive
fewer and lower-quality acute
and chronic health care services.^
Those who sjiend their lives in
low-wage service sector jobs are
unable to save for retirement
and the employers for whom
they work rarely offer healtli or
retirement benefits.̂ '̂ '
Even after contixil for SES dif-
ferences, older African Ameri-
cans perceive more discrimina-
tion, personal rejection, and
unfair treatment compared with
non-Hispanic Wliites. and self-
reported discrimination has been
shown to inci"ease reports of de-
pressive symptoms.^' In other
cases, older minorities are sys-
tematically excluded from pub-
licly limded programs. Medicaid,
for example, potentially penalizes
poor elderly Mexican Americans
and others who have lai"ge and
complex families and want to

care for frail parents. Under Med-
icaid waiver programs, some
states restrict eligibility to indi-
viduals who have serious disabili-
ties and are unable to function
and who do not have access to
other community-based services
or family support. Although thii
exclusion limits participation to
those who have no other alterna-
tives, it clearly discriminates
against those who aie most de-
pendent on their families. Rather
than aiding family caregivers of
elderly parents, this program may
discourage their involvement^^
Immigration and Health Levels
In addition to SES. nativity has
an important impact on health
outcomes. Studies on racial/
ethnic change in the United
States have shown the increas-
ingly important role nativity
plays in determining the position
of immigrants within the social
structure.^' A generation of so-
cial stratification has drawn atten-
tion to ttie serious disadvantages
immigrants may face in Ameri-
can society. ̂ ''~ '̂' Although a se-
lection effect may me-dn that im-
migrants are healthier than those
who remain behind or even indi-

viduals who were bom in the
United States,"" immigrants often
suffer economic hardships and
experience other strains as pail
of the migration experience itself,
which can undemiine their men-
tal health and impede their social
As a result of inadequate health
care in their aiuntry of origin,
many immigrants may not be in
optimal health when they arrive
in the United States. In addition
to the system-level barriers that
may place the health of immi-
grants at risk, disadvantages im-
migrants face in the labor market
also may place their health at
risk. Many HLspanic elderly im-
migrants have spent the majority
of their lives outside the United
States toiling in often harsh and
dangerous conditions for very
low pay. Many have been ex-
posed to dangerous materials
and have had inadequate preven-
tive health care. Dangerous or
difficult work and tlie lack of
regular health care can result in
serious health problems later in
life, and a lifetime of low pay
means that the financial re-
sources necessary for maintain-
ing a liealtliy independence can-
not be accumulated.^" When
these individuals become ill or

incapacitated, they often have
no recourse but to rely on family
members for support.*''
1 1 5 4 j Commentary J Peer Reviewed | Anget and Angel
American Joumai of Public Health i July 2006, Vol 96, No. 7
One reason why individuals
kick health insuraiice is the em-
ployment-based system of group
health care coverage in the
Uniled States. Few service sector
jobs offer health insurance, and
when they do, the premium that
the employee is required to pay-
particularly for family coverage-
is prohibitive. Needless to say,
jote that do not ofTer group cov-
erage are unlikely to provide
wages that allow employees to
purchase private insurance. In
the absence of a universal
health care system in the United
States, minority groups and re-
i:ent immigrants are often con-
fined to working in the low-wage
service sector, which makes it
difficult to obtain the care neces-
.sary for maintaining optimal
healtli with dignity.
Linguistic and Cultural
arriers to Care

Racial/ethnic classifications
say little about an individual s
biological or genetic makeup. In
Llie same vein, although such
classifications indicate an individ-
ual's origin, they say little about
the individual's level of accultur-
ation or cultural orientation.
Broad census categories, such
as Asian or Hispanic, combine
various groups that have differ-
ent cultures, belief systems, and
histories. Specific nation-of origin
groups also have very different
immigration histories: they
came to the United States at dif-
ferent times in history, and they
came for different reasons {e.g.,
economic opportunities vs polit-
ical asylum).
Immigrants also have dilTer-
ent levels of English proficiency
and social competency, because
of the age at which they immi-
grated and other individual,
family, and community factors.^''
Although immigrant children
quickly leam the language and
customs nf the host society,
older individuals and those who
migrate to the United States late
in life face particular problems
in becoming fluent or proficient
with the English language,''^

and many never do. Individuals
who migi-ate during midlife or
later often find the experience
to be traumatic, because they
are uprooted from familiar sur-
roundings and are thrust into a
new culture where they must
leam a new language, new cus-
toms, and a new set of social
institutions. This can lead to
mental health problems, such
as depression.*"'
Cultural and Neighborhood
Protective Factors
Although poverty and a lack
of assets increase health risks
among older minorities, other
factors associated with culture
potentially neutralize tliese
health lisk factors and act in a
protective manner. Cultural iden-
tity and social Incorporation into
a group that provides positive
social involvement can improve
health in and of itself, and group
involvement can foster or en-
courage positive health behav-
iors.'""* Therefore, cultural factors
that reduce the risk for social
isolation are potentially health
protective or enhancing.
Strong social institutions, such
as family and church, can pro-

vide similar support that pro-
motes health and well-being.'"^'^
Hvidence suggests tliat religious
involvement protects health gen-
erally and plays an important
role in minimizing the negative
consequences of chronic condi-
tions.''' Older Mexican American
Catholics benefit fi-om frequent
church attendance and report
that it provides them with com-
fort during times of trouble.''^
Church members can assist older
inlinn members with daily tasks,
which allows the older membei-s
to remain in the community.*''*
Recent findings showed that
residents who lived in high-
density Mexican American and
Cuban American neighborhoods
were in better health than those
who lived in lower-density neigh-
borhoods.^" Although the data
show a strong con-elation be-
tween ghetto or barrio residence
and poverty, other aspects of
racial/ethnic enclaves may well
protect health, possibly because
of an enhanced sense of belong-
ing, positive social interactions
where the native language is spo-
ken, and the availability of instru-
mental social support.

DOES THE
EPIDEMIOLOGICAL
APPROACH MINIMIZE
STRUCTURED
INEQUALITIES?
Much progress in understand-
ing health risks for individuals of
all ages has been made in recent
decades. Yet, it is dear that much
remains to be understood if dis-
parities in health are to be elimi-
nated or even reduced and if
everyone in the population is to
enjoy optimal healtb at every age.
To that end. we s u r e s t future re-
search should improve our un-
derstanding of how social policy
and organizational structures and
practices affect the opportunities
available to minority Americans
in ways that directly and iiidi-
rectly affect group health levels.
The structured and institu-
tional inequalities that have im-
peded minority Americans' eco-
nomic and social progress in tlie
past and that continue to operate
today—often in subtle ways-
have their basis m a history of
racism and systematic exclusion
from opportunities for economic
and social advancement. Among
African Americans and Hispan-

ics. almost every aspect of social
service delivery, educational op-
portimities. and employment op-
portunities have been infiucnced
by race/ethnicity."''^ Data show
that the health levels of entire
groups are directly influenced by
the fact that political and eco-
nomic power are determined by
both hi.story and the specific so-
cial policies that perpetuate the
social exclusion of specific groups
of people.
Afiican Americans and His-
panics lag far behind non4-lis-
panic Whites in personal and col-
lective wealth and political
power. Lack of resources limits
their ability to help their children
and grandchildren buy houses
and continue their education, and
it translates into diminished eco-
nomic and political power for the
community' as a wbole. Although
income and wealth do not guar-
antee a good and virtuous life,
poverty certainly does not guar-
antee it either. Tbe intentional or
unintentional exclusion of groups
from sources of economic and
political power is a major public
health problem. We must develop
a better understanding of the
pathways to disadvantage and
how health vulnerabilities are

perpetuated Irom one generation
to tlie next as the result of fonnal
policies and institutional barriers
to social mobili^.
Individuals choose to take ad-
vantage of opportunities for
economic and social advance-
ment, and they make pei'sonal
choices that affect their health.
If opportunities for pei-sonal ad-
vancement do not exist, or if
they are blocked on the basis
of group classification, members
of that group find it difficult or
impossible to avail themselves
July 2006, Vol 96, No. 7 American Journaf of Public Health
Angel and Angel Peer Reviewed Commentary ' 1155
of potential avenues for social
and economic advancement.
Tliese blocked opportunities
may result in frustrated hopes,
demoralization, and deleterious
health behaviors.
The complex association be-
tween race/ethnicity and health
has heen well doaunented at the
individual level. African Ameri-
cans suffer from more and more
serious illnesses and die at
higher rates compared witb non-

Hispanic Whites. Although sur-
vey-based studies tbat examine
individuals and their vulnerabili-
ties continue to provide useful
information about health risks,
Lheir failure to directly focus on
the problems of institutionalized
racism and exclusion is a serious
sbortcoming. Studies tJiat ob-
serve and analyze the individual
have, for the most pail, not been
accompanied by significant at-
tempts to understand the role
lai-ger social stmctures play in
perpetuating racial/ethnic strati-
fication and contributing to less
favorable individual family, and
community health profiles.
There are many reasons for
Ihis i-elative neglect of structural
and political factors. After World
War II. the rapid development
of survey researdi and the intro-
duction of sophisticated analytic
techniques pushed researchers in
the direction of survey-based epi-
demiological and health studies.
Funding agencies, including the
federal government tended to
shy away from politically sensi-
tive topics and instead focused on
individual risk profiles. Tliis locus
promised to inform public policy
with educational and individual-
level public health interventions.

The power of individual-level
biological approaches has mani-
fested itself in the recent impe-
tus to fund researdi projects that
examine genetics and biology,'^
Yet the heath profiles of com-
munities and groups are influ-
enced by factors well above the
level of the cell or the individual.
Tliey are alTected by the ade-
quacy of public healtti initiatives.
federai and state health cai-e poli-
cies, and other sodal policies. Be-
yond that, bealtli levels are af-
fected directly and indirectly by
education, poverty, housing,
physical and social environmen-
tal stressors, and social exclusion
and discrimination. These are
emergent phenomena that can-
not be undei-stood solely on the
basis of individual-level studies.
New Directions in Research
Future investigations should
build upon and add to the bio-
medical mode! of disease and
illness and should include a
broader definition of health.̂ *' A
more comprehensive and useful
conceptual model of healthful
aging might well hegin with a
definition that includes not only
the absence of disease and physi-

cal infirmity at ils coi-e hut also
tlie institutional and structural
components and factors—such as
educational opportunities, good
housing, and sale neighborhoods—
that have been shewn to affect
health. The health of poor and
minority Americans is under-
mined by what has been termed
tiie new morbidity. i.e.. threats to
health from domestic violence,
drug abuse, crime, and the perva-
sive sense of inferiority that is the
result of discrimination.
New studies on healthfiil aging
should examine the underlying
determinajits of illness within the
community and develop better
conceptual motiels and methods
for assessing the stiiictured and in-
stitutionalized stresses that minor-
ity- Americans experience.̂ ^ We
need to understand how these
stresses affect individual-level
behaviors, patterns of sodal
interaction, risk for 'idimization,
aime. poverty, and other factors
tliat inlluence health and func-
tioning at all ages. Again, this
approach should avoid purely
individual- or family-level attribu-
tions and should seaidi for the
lai^er contextual factors that re-
sult in structui'ed inequalities and

disadvantage.
Ironically, the "diseases of af-
fluence" in the United States-
obesity, heart disease, cancer,
and diabetes—take tiieir greatest
toll on the least allluent, Tlie
prevalence of these chronic dis-
eases is affected by diet and
other lifestyle factors and thus is
influenced by SES. Almost one
half (49.6%) of all African Amer-
ican women anti more tliaii one
third (38.9%) of Mexican Ameri-
can women are obese.'*' To im-
prove the health status of minor-
ity women, newer and more
aggressive efforts that educate
medical care providers, extend
community outreach, and im-
prove compliajice with treatment
regimens are necessary. Because
ofthe pervasiveness of the struc-
tui-al disadvantages minority
.Vnericans face in the labor
force, the entrenched poverty
characteristic of urban ghettos
and barrios and continuing dis-
crimination efforts focused solely
on individual health-related be-
haviors aî e unlikely to be suc-
cessful in improving population
health levels.
In current practice, institu-
tional and structural factors enter

individual-level statistical models
indirectly through controls for
health insurance (private, Medic-
aid. Medicare, or other coverage)
and controls for income and edu-
cation. Certain hierarchical tedi-
niques indude ecological and
larger geographical chai-acteris-
tics. but these do not address
how institutionalized discrimina-
tion, specific organizational
structures, or fonnal aspects of
public polides influence the
health of spedfic groups. Because
level of education, income, and
wealth are determined by boUi
opportunity structures and per-
sonal choice, understanding how
those structtires are maintained
and how they operate to influ-
ence health risks is necessary for
understanding radal/etlinic
health disparities.
The ina-easing awareness of
tlie need to target research specif-
ically at the unique health ml-
nerabilides of poor and minority
Americans is a welcome develop-
ment Poverty, low educational
levels, and other social disadvan-
tages are the underlying causes
of poor health generally, but
these economic ajid .sodal disati-
vantages are not randomly dis-

tributed throughout the popula-
tion and are greatest among
Alrican Americans and 1 lispan-
ics. Both groups will comprise a
large proportion of the working-
age population of the future, and
they will comprise a growing pro-
portion of the retired population.
The capadty of tJie young to be
productive and the general health
levels and quality of life of Oie el-
derly are both affected by factoi's
closely associated with race, His-
panic ethnicity, and inequality.
The Data Archive
Attempting to better under-
stand tliese social vulnerabilities
is an important research agenda.
This effort will require the imagi-
native use of existing data sets
and an enhancement of san^)Ies
to include larger oversamples of
minority ,'mericans. New data
collection initiatives will be diffi-
ailt during what is likely to be a
period of retrenchment for majoi"
funding agendes. Nonetheless,
1156 Commentafy F^er Reviewed Angel and Angel American
Joumai of Public Health i Juiy 2006. Vol 96. No, 7
COMMENTARY

new and specialized data that
examine spedfic vulnerabilities
among groups that live and work
in specific ecological and social
niches will be necessary if we are
to make progi'ess. During the
past decade, the National Insti-
tutes of Health have recognized
the need for specially focused
surveys that show the health sta-
tus and functioning of minority
elderly groups. ITie National
Center for Health Stadstic's sup-
plement to the National Health
Interview Survey—the Longitu*
dinal Study of Aging (LSOA)-
presented new opportunities for
documenting trends and cohort
changes in the health and fiinc-
tioning of a representative sam-
ple of aging African Americans.'^
Data from several sources en-
riched the LSOA data set and
made the analysis of age-graded
sodal processes possible.
Other existing and ongoing
data sets include the National
Health Interview Survey, the
1984 Health Insurance Supple-
ment, the 1984 baseline Survey
on Aging, the follow-up LSOA in-
terviews. Medicare records, tlie
National Death Index, and multi-
ple cause-of-death files. Research-

ers are usijig these data sets to
examine patterns of health ser-
vice access and use, including the
impact of medical insurance, fam-
ily dructure. housing, fomial and
informal sources of care, employ-
ment history, transpoi-tation, and
sodal networks. There ai'e many
unexplored possibilities for the in-
novative and informative use of
these data. The availability of lon-
gitudinal data makes it possible to
examine (1) the sequence and
the consequences of morbidity
and health care access on func-
tional independence and
dependence, as well tis death,
within the community, and
(2) the risk for institutionalization.
The possibility of new mod-
ules in ongoing efforts provides
new opportunities for under-
standing the needs of spedfic
groups. For example, although
most survey questions were iden-
tical in the first 2 waves in ttie
LSOA series, new infomiation
was gathered on individual risk
behaviors, induding health opin-
ions, during the third wave. In
addition to interviews with sur-
vivors, additional information
was collected about decedents'
hospitalization and nursing fadl-
ity admission from their named

next-of-kin contact. As part of the
series, the Family Resources Sup-
plement replaced the Health In-
surance Supplement and pro-
vided in-depth infonnation about
caregiving, care receiver needs,
unmet care needs, and reasons
that needs were not met.
The Third Health and Nutri-
tion Examination Survey
(1988-1994) is a particularly
useful source of information
about the incidence and the
prevalence of type 2 diabetes
among the elderly. The sample
had no preset upper-age limit
and included individuals older
than 85 years. This study in-
cluded a medical examination of
respondents and is one of the
few data sets that provides both
objective clinical observations
and infonnation about the sub-
jective experience of having dia-
betes.'^ The life spans of older
African Americans and Hispan-
ics who have chronic conditions
will prohably increase in the fu-
ture as disease management im-
proves. Yet, without substantial
improvement to the economic
and social situations of these
groups, they will continue to
fare worse than non-Hispanic
Whites. Understanding all

aspects of the assodation be-
tween sodal factors, genetics.
and chronic illness is a higb-
priority research objective.
The Hispanic Established
Populations for the Epidemiologi-
cal Stiidies of the Elderly is an
important example of a spedal-
ized study that is focused on a
single group. This 10-year longi-
tudinal study is ongoing and is
sponsored by the National Insti-
tute on Aging. It examines Mexi-
can-origin individuals who tive in
the Southwest and who were
aged 65 years and older at the
beginning of the study, its results
are providing much needed infor-
mation about tlie dynamics of
aging throughout the life course.
Studies of this sort are expensive
and may gamer little political
support if they focus on power-
less groups. However, without
such focused efforts, our tmder-
standing of the physical and
mental health and the health care
needs of the minority elderly will
remain superficial. National Insti-
tute on Aging initiatives that are
aimed at understanding and re-
dudng health disparities among
older persons and populations
will foster these efforts.

In addition to important re-
search on the health of older mi-
nority Americans, special data
makes it possible to investigate
the impact of individuals' pre-
retirement economic situations
on welfare and healtli during
their postretirement years. The
Health and Retirement Study
and the Study of Assets and
Health Dynamics among the
Oldest Old. for example, provide
a better understanding ofthe
complex interactions of race/
ethnicity, health, economics, and
other social factors on aging
processes for different groups.
These data show serious income
and aSxSet deficits among African
Americans and Hispanics as
they approach retirement, when
many of these individuals will
lack resources for needed pre-
ventive, acute, or long-term
care and resources for living
the most fulfilling life possible,
including the possibility of help-
ing their children.
Conclusions
As we progress into the 21st
century, new and important med-
ical innovations will increase life

spans and will improve the qual-
ity of those additional years.
Much of that progress will no
doubt result from a better under-
standing of the genetic contribu-
tion to disease. However, social
structural factors that place cer-
tain groups at a liigh risk for ill-
ness and that impede their access
to the highest quality health care
continue to plague our sodety. As
documented by the Institute of
Medicine, institutionalized disad-
vantages that manifest themselves
most obviously as occupational,
ijicome, and asset disadvantages
across the life coui-se translate di-
rectly into impaired health care
access and poorer healtli among
minority Americans.̂ ^ This fact
makes it imperative that we con-
tinue to examine sodal factors in
health service, epideniiological,
and health poficy research. The
necessities of a healthful living
and healthful aging are dear, but
they ai'e out of tlie reach ol" many
minority Americans. •
About the Authors
]acquelme L Angel is with ttie Schoot of
Puhtic Affairs ami Depurtment ofSodot-
Hgy. and Ronald J. Anget ts icith the De-
partmettt of Sodotogy. Vmversity of Texas,
Austin. Both authors are with the Popula-
tion Hesearch Center. University of Texas,

.'histin.
Requests for reprints should he sent to
Jacqueline L. Angel. LBJ School of Public
.•Iffairs. University of Texas at Austin. PO
Box Y. Austin. TX 78713-8925 (e-mait:
[email protected] utexas.edu).
This articte was accepted February 19.
2006.
July 2006, Vol 96. No. 7 | American Journal of Public Health
Angel and Angel ' Peer Reviewed | Commentary | 1157
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Angel and Angel i Peer Revievred | Commentary ' 1159
Indian Journal of Gerontology
2015, Vol. 29, No. 3, pp. 259–282
Promoting Active Ageing Through the Use of
ICT: From Global and Indian Perspective
Soumyadeep Chakrabarti, Sohom Karmakar and
*Somprakash Bandyopadhyay
Department of Electronics and Telecom Jadavpur University.
*Management Information Systems, Indian Institute of
Management,
Calcutta
ABSTRACT
With the advent of science especially in the areas of medicine
and
physiology the average life expectancy has been on the rise
since the
past few decades. This, along with decreasing infant mortality
rate,
has led to an increase in the elderly population all over the
globe.
With a thriving elderly population the concept of active ageing

has
gained traction in the last few years and modern society has
found
widespread application in this area. Not surprisingly, active
ageing
has benefitted largely from use of Information and Communi -
cation Technologies (ICT). It has profound implications in
educational institutions, labour markets, social justice, medical
care, long term care and relationship between generations. With
the ever growing popularity of nuclear families, the condition of
the elderly population seems to have taken a backseat in recent
years. With children moving away for the sake of careers the
older
generation finds itself under the care of professional agencies
which
provide a kind of social security but do not really provide any
sense
of “activity” to nourish the mind. To address this problem, the
theory of active ageing aims to include better opportunities for
people to continue working as they grow old and contribute to
society in some way or the other. Active ageing has found many
advocates whose policies tend to improve individual quality of
life.
This paper presents the current situation of market in Europe
and
United States where active ageing through ICT is already an
estab-
lished concept. Further, a brief overview of the market situation
in
India has been discussed along with further scope of implication
in
this sector.

Key words: Active Ageing, Quality of Life, Telecare
From its very inception, studies on ageing have not only
provided
description and mechanisms of ageing phenomenon, but have
also
enhanced the reservoir of existing knowledge required for the
change
in living situation of the old which would positively affect their
ageing
process. They have influenced policy decisions of both the
private as
well as the government sectors since the first world assembly on
ageing
in 1982 to the first global consensus on providing dignified care
of the
elderly in the form of the Madrid International Plan of Action
on
Ageing (United Nations, 2008) in 2002. The concept of “active
ageing”
refers to the method of ageing by which people maintain a high
quality
of life as they age, ensuring that they not only receive passive
help
from the society but can also engage in its activities. One of the
basic
challenges of research on ageing concerns the question whether
active
ageing (Tesch-Roeme, 2012), is possible and if so, which
factors enable
individuals, social groups, and societies to grow older healthily
and
actively. Three highly important domains on quality of life need
to be
considered regarding any discussion on active ageing: health,
social

integration, and participation. Active ageing is normally
synonymous
to successful ageing. Successful ageing in general includes
three main
components: low probability of disease and disease-related
disability,
high cognitive and physical functional capacity, and active
engagement
with life. For successful implementation of active ageing the
following
basic requirements have to be fulfilled.
Early Awareness of Active Ageing
Active ageing should incorporate diverse aspects of life (even
before seniority is attained) such as volunteering in childhood
and
adolescence and education and healthy behaviour. Of these,
education
has the greatest effect visible in old age.
260 Indian Journal of Gerontology
Offer Opportunities for Active Ageing Also Later in the Life
Course
Lack of energising social integrand and stimulating volunteer
activities are prime examples of vanishing active ageing
investment
even in middle and late adulthood. Even though studies show
that
changes in health and participation are possible up to late
adulthood,
the changes are practically growing obsolete. Moreover,

efficiency of
interventions decreases as one grows older. It is therefore the
responsi-
bility of the respective authorities to provide life-long health
education
for the aged along with sustainable environment for everyone,
irrespective of their age.
Improve Societal Frameworks for Active Ageing
Active ageing needs a secure base. Health and participation in
late
life can be fostered by societal frameworks. Results from
comparative
surveys (United Nations, 2005), show that the extent of welfare
state
support – through social security systems like unemployment
allowance, pension and prolonged elderly and medical care
system –
seems to be connected to opportunities for active ageing.
Although the
instruments for building social security differ between societies,
governments may provide regulation for the combined effects of
different stakeholders. Highly relevant is the prevention of
poverty, as
poverty bears the high risk of social exclusion. Combing
poverty will
also help to reduce health inequalities and increase the chances
to take
an active part in society.
Pay Attention to Images of Ageing
Societal and individual conceptions of ageing influence
develop-
mental trajectories over the life span. The societal images of

ageing
have a profound impact on proper utilization of the potentials of
active ageing dealing with the restrictions of frailty and
dependency in
old age. Inflicting new “images of ageing” into the
consciousness of the
general public might show that older people are a potential
societal
resource. It should be noted, however, that purely positive
images of
ageing do not do justice to frail, old people in need of care.
Hence,
images of ageing should be inclusive and embrace both
potentials and
risks of old age.
Promoting Active Ageing Through the Use of ICT 261
With the recent developments and breakthroughs in portable
communication technology and computing systems, Information
and
Communication Technologies (ICT) has been given a central
role to
play in the advancement of active ageing. Due to varying levels
of
importance attached to the development of these new
technologies by
the policy-making bodies of different countries, ICT has faced
different challenges and achieved different levels of penetration
as we
will see in the following section.
Situation of the Market in Europe and Beyond

The general background to this study was derived from the trend
towards an ever increasing ageing population (United Nations,
2012)
and this has been observed across Europe and beyond for some
time
already. For Europe and many other countries around the world,
the
on-going demographic development has significant socio-
economic
implications: in the future, there will be more older people both
in
numbers as well as in percentage of the population. The very-
old
section will particularly experience a boom, there will be a
decrease in
their family support system, and there will be a smaller
productive
workforce to contribute to the creation of economic wealth as
well as
to the financing of health and social services in particul ar.
During recent years, the social and economic challenges
connected to these developments have received increasing
policy
attention. In this regard, the potential offered by Information
and
Communication Technologies (ICT) is of paramount importance
in
order to cope with them in an efficient manner. Recently, the
European Commission has adopted an Action Plan on
Information
and Communications Technology for Ageing where it is
highlighted
that better utilization of the potential provided by ICT for
independent living in an ageing society represents both a social
necessity and an economic opportunity. More specifically, it is

emphasised that ICT holds the key for more efficient
management and
delivery of health and social care for the aged population
thereby facil-
itating active ageing (Organisation for Economic Cooperation
Development, 2007).
Advancement in Telecare
This section focuses on telecare services, one of the most
important examples of ICT. Telecare is defined for current
purposes
mainly in the form of ICT-supported remote social care
services. It is
the “continuous, automatic and remote monitoring of real time
emergencies and lifestyle changes over time in order to manage
the
risks associated with independent living” as defined by
Tunstall, the
leading telecare developer in the world.
Telecare systems essentially perform two basic functions:
1. Detect and Record Emergencies: These systems control
processors
which process the signals from sensors and detect events such
as
major falls or heart-attacks, in which case, carers are
immediately
notified. These systems can also compute the time variation of
minor events monitored over a long time and this data in the
form of graphs, etc. is useful for caregivers to determine any

change necessary in the course of treatment.
2. Reduce chances of an emergency: As an illustration we can
consider
a sound-producing device attached to asthma inhalers for the
elderly which can be remotely activated in order to aid in
finding
them easily in case of an impending asthma attack.
Telecare includes social alarm services, also known as first
gener-
ation telecare, and more advanced telecare services involving
additional sensors and other variants. Figure 1 represents the
use of
Figure 1
Age -related utilisation of social alarms among the 50+
population in five
EU countries with the age groups listed on the vertical axis
(Kubitschke and Cullen, 2010)
social alarms among 50+ populations in the four European
countries
mentioned below. United States of America is the only non-
European
example included in the following list.
Germany

Social alarm services have been provided in Germany for more
than 25 years and are available throughout the country. Nearly
90 per
cent of the social alarm services are provided by six large social
welfare
organisations. The rest of the market is made up by commercial
providers, such as Recontrol, Tunstall, Vitaphone, HausNotruf
Service GmbH and Bosch (Kubitschke and Cullen, 2010). In
addition,
an increasing number of housing organisations are providing
social
alarm services, e.g. the housing societies in Wuppertal or in
Gelsenkirchen within the framework of SOPHIA. Some of the
service
providers also offer mobile alarms alongwith GPS localisation.
Mobile
alarms are not widely used, nor is, since reimbursement in these
types
of services within the existing framework of the long term care
insurance possible yet. The social welfare organisations that are
providing the social alarm services often have their own call
centres.
There are around 180 call centres run by welfare as well as
commercial
organisations in Germany. While some forms of telecare are
widely
available in the form of enhancements to basic social alarms
(e.g.
smoke detectors, gas detectors, fall detectors or movement
detectors),
in practice there is rather little usage of anything other than
basic
alarms. Some social alarm providers offer additional services
such as
organisation of home- and outpatient services, and reminder
calls

(partly automated), although the latter appear not to be much in
use.
Apart from social-alarm based telecare, there are only a few
other
telecare services up-and-running in the marketplace. One
example is
the SOPHIA service which is a commercial picture-based care
and
communication service for old people, operated as a regional
franchise
company which seeks to extend operations nationwide. The
service
model is for a new standard for safety and security,
communication,
comfort, telemedicine, multimedia and facility management. It
is
currently the only picture communication service. Several other
efforts to establish comparable services on the German senior
market
failed. Telecare devices and services are yet not listed in the
eligibility
catalogues of insurers, which means that costs are not
reimbursed
under the insurance systems and have to be paid for out of
pocket. The
government here has also helped in setting up the research
programme
on Ambient Assisted Living (AAL), jointly organised by
different
countries across Europe.

France
Social alarm services are widely available throughout the
country
and are provided at the level of counties and municipalities.
Service
operation may include various players such as local fire
departments,
commercial organisations and insurance companies. Uptake of
social
alarms is estimated at about 3 per cent of the population aged
65 and
above. Existence of considerable variation in end user charges
across
the country has been reported. It is estimated that the average
monthly
service charge ranged between 25 and 35 Euro (Kubitschke and
Cullen,
2010). Beyond this, sometimes an initial installation charge may
be
imposed on the end user, which may amount to about 50 Euro.
Social
funding is estimated to range between 30 per cent and 50 per
cent of
monthly costs, while in some parts of the country the service
has been
reported to be provided free of charge. Users who are eligible to
receive support under the social benefit scheme can receive full
cost
reimbursement.
United Kingdom
The UK has a well-developed infrastructure of community alarm
services provided by local housing authorities, social service
organiza-

tions and voluntary and private sectors. Social alarm services
are
provided to both section of people, those who are living in
sheltered
housing and those in ordinary housing in the community. There
is
also a significant private subscriber market. Overall, there are
an
estimated 1.5–1.6 million people using some form of social
alarm in
the UK, representing about 15 per cent of those aged 65 years or
older
(Ibid). Most local authorities run an alarm scheme, either
directly
provided by themselves or with outsourcing to a private
supplier. In
general, it seems that outside the sheltered housing context,
family
carers are typically the main responders once the call centre has
been
alerted, although in some areas the social care services also
provide a
mobile response team in addition to the nominated informal
carer
response. The charging/reimbursement situation varies across
local
authorities. As a general rule, it seems that equipment is
provided free
of charge to those with an assessed need and users pay a
monthly usage
charge unless they are eligible for a waiver on the basis of low

income.
User costs may vary from 10 to 25 euro per month, depending
on
location and provider. In recent years, social care authorities
have been
putting into place telecare sensor services (e.g. smoke, heat,
flood
detectors) and the UK is on the verge of taking telecare into the
mainstream. This has been driven by policy and funding,
including the
Preventative Technology Grant in England and other
programmes on
telecare in Scotland, Wales and Northern Ireland. It has been
reported
there were nearly 1,50,000 new telecare users in England in
2006/7,
and a further 1,61,000 in 2007/8. This approximately amounts to
about 3 per cent of the population aged 65 years or older who
are
receiving ‘telecare’. Provision and charging approaches vary
consid-
erably across local authorities. In general, the most common
approach
of telecare sensor services seems to be similar to that of social
alarms
although sometimes at a higher level because of the additional
extras
provided. Preventative Technology Grant funding is given to
councils
in England with expectation that they will work with volunteers
and
government authorities in housing to establish new services.
Some
local authorities/primary care trusts have recently claimed to be
providing mainstream telecare services. It would appear that
telecare is

now embedded in government health and social care policy but
it is
yet to be fully embedded in mainstream services. The Scottish
government have been promoting telecare service provision
through a
Telecare Development Programme since 2006. Regional care
providers have started providing practical and implementable
solutions tailored to the local environment. The Welsh Telecare
strategy which was launched in 2005 gives grants to local
authorities.
A Telecare capital grant of £9 million has been made available
(with a
policy target of providing 10,000 homes with telecare
equipment),
together with additional money to support the development of
telecare strategies. All 22 Welsh local authorities have now
produced
telecare strategies, which in many cases are very ambitious.
Based on
monitoring reports it is expected that by the end of the grant
period
some 45,000 people will be using a telecare service other than a
community alarm (this would be about 7 per cent of the
population
aged 65 years and older). The Minister for Health, Social
Services and
Public Safety in Northern Ireland announced a grant of £1.5
million in
January 2008 for pilot projects to promote the development of
new
technologies to assist people to live at home over the next two

years.
The European Centre for Connected Health was established at
the
same time to promote improvements in patient care through the
use of
technology and to fast track new products and innovation in
health
and social services. Substantial investment was planned to use
remote
tele-monitoring to improve care for people with chronic
conditions.
Italy
Social alarm services are widely available, although many local
service offerings seem to have emerged only during recent
years.
Today, the major municipalities in Italy seem to have initiated
social
alarm schemes and in some cases such schemes have been
initiated by
the Provinces. Uptake is estimated between 1 per cent and 2 per
cent
of the overall population aged 65 years and above (Kubitschke
and
Cullen, 2010). In many cases the technical infrastructure,
notably
alarm centres, and the service itself are operated by commercial
service
providers or third sector organisations. This accords with the
general
situation in Italy where social and welfare service frameworks
are
determined on local or regional administrative levels and are
often
complemented by services provided by commercial and/or

voluntary
organisations. There seems to be no general charging model that
applies across the whole country. Individual examples suggest
that
users tend to be charged a monthly service fee of about 20–40
Euros.
Figure 2
Sector-wise utilisation for social alarms in the European
countries
(Kubitschke and Cullen, 2010)
Under certain circumstances users may be eligible to use the
service
free of charge.
Figure 2 illustrates the utilisation rate of telecare in different
countries of Europe.
United States
Social alarms are known and used as personal emergency
response
systems (PERS) throughout USA. There are both national and
local
providers, including private companies, hospitals and social
service
agencies. It has been estimated that about 2.3 per cent of the
population aged 65 years and older use social alarms (Ibid). The
main

forms of provision are either linked to healthcare facilities or
private
companies. In the former case, the response may often be
provided by
staff employed by the healthcare facility; in the latter case,
response
would normally be by local, user-nominated contacts.
Historically,
the focus seems to have been especially on provision by
hospitals or
other healthcare facilities with a view to reducing bed-
occupancy and
other costs. There also has been provision by religious/charities
as a
more social welfare oriented service, and by manufacturers and
security companies. Most PERS are purchased out of pocket by
the
individual or their family members. Purchase prices range from
$200
to more than $1,500. There are additional charges for
installation and
monthly monitoring ranging from $10–$30.
In America, there has been an overall increase in interest in
telecare, with the emphasis apparently more on healthcare than
social
care in a wider sense. Such ‘telecare’ services are provided by a
range of
providers including medical practice sites, hospitals and social
service
providers, both public and private. The availability of services
varies
from state to state with little or no coherence in application or
utili-
zation. The extent of take-up varies hugely across the country
and

there is no data available on the extent of take-up. To date, the
Veterans Administration healthcare system seems to be the main
provider of telecare services with an independent living focus,
even
though the main focus of its remote support monitoring is
telehealth.
Some of the services have been mainstreamed. In Florida, for
example,
the Low ADL Monitoring Program (LAMP) is a Community
Care
Coordination Service (CCCS) program designed to address the
needs
of veterans with activities of daily living (ADL).
Summary of Benefits Obtained and Preliminary
Identification of Barriers
A successful telecare application is seen to have certain
established
benefits:
1. The most important benefit is the improvement in patient
prognosis, including both the number of emergency hospital
admissions and mortality rate.
2. The old will also be able to live a more independent life,
taking
care of themselves with their dignity intact.
3. Also, the respective governments benefit from the decrease in
monetary benefits (given to people with disability) and higher

tax
returns which in turn leads to more spendable income.
4. Finally, ICT in the form of telecare has been a boon to unpaid
caregivers as it allows them to pursue paid employment in
addition to the care-giving job and also gives further assurance
about the security and well-being of the elders.
The extent of mainstreaming of home telehealth is very limited
to
date and in many countries no major drivers can yet be
discerned. In
general, increased attention being given to more effective
management
of chronic diseases and increase in importance of this with
population
of ageing provides the most important underlying driver, even if
this is
not leading to a lot of mainstream telehealth yet (Figueras, et
al., 2008).
In relation to first generation telecare, the key factors of
influence
seem to vary considerably across countries. In fact, some
countries
may already be at ‘saturation’ point to a certain degree (Solow,
1956)
and thus have no concrete barriers, as such, to the achievement
of
higher penetration levels. Underlying this may be some
important
variability in perceptions of the role of social alarms in social
care, and
of where it fits in the spectrum of human and other services that
are
needed. More generally, where they exist, the main barriers

appear to
be limited public provision and lack of public funding and
disparities
in geographical availability in some countries. It also seems that
technology and, especially, technological change may be a
limiting
factor in some countries, for example upgrading old systems to
work
with new digital telecommunications networks and providing
services
to IP telephony user.
Role of ICT In Ageing: An Overview of the Situation in India
Ageing of population is a major aspect of the process of
demographic transition. The developed regions of the world
being
ahead of the developing countries with respect to demographic
transition have already experienced its consequences and the
devel-
oping world is currently facing the consequences. Even though
the
relative number of elderly in some developed countries seems to
be on
the lower side, the sheer population size of these countries
signifi-
cantly increases the absolute numbers (Chen, 1998). There has
been a
spurt in the studies focused on developing countries’ elderly
population: this can be understood to be the result of the
deteriorating

living conditions of the elderly in these countries. Natural
demographic change account for the increasing numbers while
the
shift in traditional family structure due to modernisation and
migration of younger family members is to blame for the
socio-economic degradation of the elderly.
Projected increases in both the absolute and the relative sizes of
the elderly population in many third world countries are a
subject of
growing concern for public policy. Such increases in the elderly
population are the result of changing fertility and mortality
regimes
over the past 40 to 50 years. The combination of high fertility
and
declining mortality during the twentieth century has resulted in
large
and rapid increases in elderly populations as successively larger
cohorts
step into old age. Further, the sharp decline in fertility
experienced in
recent times is bound to lead to an increase in the population of
the
elderly in the future. Besides, given that these demographic
changes
have been accompanied by rapid and profound socio-economic
changes, cohorts might differ in their experience as they join
the ranks
of the elderly. Against this backdrop, we may now preface our
discussion with an account of the structure and size of the
elderly
population. The number of elderly in the developing countries
has
been growing at a phenomenal rate; in 1990 the population of
persons
aged 60 years and above in the developing countries exceeded

that of
the developed countries. According to present indications, most
of this
trend of growth would take place in developing countries and
over
half of this would be in Asia. Obviously, the two major
population
giants of Asia, namely India and China would contribute a
significant
proportion to the growth of the elderly.
In India, the 2011 census has shown that the elderly population
consisting of 28 states and 7 Union Territories accounted for 97
million. In 1961, the elderly population had been only 24
million; it
increased to 43 million in 1981 and to 57 million in 1991. The
proportion of elderly persons in India has increased from 5.63
per cent
in 1961 to 6.58 per cent in 1991 and to 8 per cent in 2011.
Within the
elderly population, persons aged 70 and above have also grown
rapidly; from a mere 8 million in 1961 to 21 million in 1991 and
to 40
million in 2001. The growth rates among the different groups of
the
elderly, namely 60 years plus, 70 years plus and 80 years plus
during
the decade 1991–2001, were much higher than that of the
general
population growth rate of 2 per cent per annum (Bose and
Shankardass, 2004), a trend continuing to this day. Available

findings
on ageing suggest that fertility as compared to mortality has
played a
predominant role in the ageing process. As far as India is
concerned,
there has been a substantial reduction in mortality compared to
fertility since 1950. For instance, while the crude birth rate
declined by
52 per cent from 47.3 during 1951–61 to 22.8 in 1999, the crude
death
rate fell more steeply by 70 per cent from 28.5 to 8.4 during the
same
period (Chakraborti, et al., 2004). Logically, therefore, India is
expected to undergo a more rapid decline in fertility in the
immediate
future than mortality because mortality has already fallen to an
extremely low level. The ageing process in India is expected to
be,
therefore, faster in the years to come than in other developing
countries. Moreover, the transition from high to low levels of
fertility
is expected to narrow down the age structure at its base and
broaden it
at the top (D’Souza, 1989). In addition, improvement in life
expec-
tancy at all ages would allow more old people to survive thus
intensifying the ageing process. In this context, an examination
of the
rising trends in life expectancy indicates that the gain is going
to be
shared more and more by elderly people, a process which would
make
them live even longer (Clark, et al., 1997). The size of India’s
elderly

population aged 60 and above is expected to increase from 77
million
in 2001 to 179 million in 2031 and further to 301 million in
2051. The
proportion is likely to reach 12 per cent of the population in
2031 and
17 per cent in 2051. The number of elderly persons above 70
years of
age (old-old) is likely to increase more sharply than those of 60
years
and above. The old-old are projected to increase five-fold
during
2001–2051 – from 29 million in 2001 to 132 million in 2051
(Bordia
and Bhardwaj, 2003). Their proportion is expected to rise from
2.9 per
cent to 7.6 per cent.
Health Concerns of the Old in India
Health care of the elderly is a major concern of a society as old
people are more prone to morbidity than young age groups.
Ageing is
invariably accompanied by multiple physical ailments, but the
less
publicly acknowledged fact is that the aged are more prone to
mental
ailments as well, which arises from nervous system disorders,
old-age
and perceived quality of life including comfort and
independence.

Figure 3
Dependency Status among the Elderly (Irudaya Rajan, et al.,
2003)
Preliminary studies by government and private organisations
point to
the deplorable health status of the Indian elderly population.
The proportion of the sick and the bedridden among the elderly
is found to increase with age; the major physical disability
consists of
blindness and deafness. A study of urban elderly in Gujarat
found
deteriorating physical conditions among two-thirds of the
elderly,
such as poor vision, impairment of hearing, arthritis and loss of
memory. An interesting observation made in this study relates
to the
sick elderly’s preference for treatment by private doctors.
Besides
physical ailments, psychiatric morbidity is also prevalent among
a
large proportion of the elderly. An enquiry in this direction
provides
evidence of psychiatric morbidity (Darshan, et al., 1987) among
the
elderly. A sharp distinction between the functional and organic
aspects
of ailments is suggested by a large number of studies.
Functional
disorder strikes first and gradually develops into organic
disorders

around the age of seventy. Another rural survey reported that
around
5 per cent of the elderly were bedridden and another 18.5 per
cent had
only limited mobility. Given the prevalence of ill health and
disability
among the elderly, it was also found that dissatisfaction existed
among
the elderly with regard to the provision of medical aid. The sick
elderly lacked proper familial care and that public health
services were
Figure 4
Health Service by Elderly (Irudaya Rajan, et al., 2003)
insufficient to meet the health care needs of the elderly. The
uptake of
healthcare from different sources is illustrated in Figure 4.
Among the elderly, 80 per cent died at home and only 17 per
cent
died in hospitals (9 per cent in government hospitals compared
to 8 per
cent in private hospitals). Similarly, close to 30 per cent of the
elderly
had not received any medical attention before death (D’Souza,
1989).
A few had been examined by medical practitioners. One in three
was
reported to have died of old age. More than 5 per cent of the
elderly

died due to causes such as disorders related to the lungs, blood
circu-
lation and digestion.
Approximately 50 per cent of all elderly Indians are under
lifelong medication for at least one chronic disease and this
trend is
stronger among the urban population. The Eastern region led all
the
other regions in India in the matter. The percentage of elderly
(two
out of three) suffering from at least one chronic disease was the
highest
in this region. It was followed by the South; the lowest
proportions
were in the North and North-Western regions of India.
Similarly, one
out of every five elderly reported suffering from two chronic
diseases
canvassed in the NSS; from Figure 5, we can see that close to
three per
cent suffered from three chronic diseases.
Figure 5
Reported Chronic Diseases in Old Age (Irudaya Rajan, et al.,
2003)
Five types of disabilities of the elderly were probed by the NSS:
visual impairment, hearing problem, difficulty in walking
(locomotor
problem), problems in speech and senility. The prevailing

disability
demography in India (Ibid) is illustrated in Figure 6 and Figure
7.
Figure 6
Number of Disabled per 1 Lakh Elderly Persons for Different
Types of
Disability (Irudaya Rajan, et al., 2003)
Figure 7
Percentage of Differently Abled Old Age Population
(Irudaya Rajan, et al., 2003)
Twenty-five per cent of the elderly in India suffered from visual
impairment, followed by hearing difficulties (14%) and
locomotor
disability and senility (each 11%). The prevalence rates of all
the five
disabilities were higher in rural than in urban areas (James,
1994).
Except in respect of visual impairment, women were ahead of
males in
respect of the disabilities. Though the elderly in India tend to
suffer
from many ailments, particularly the old-old and the oldest old,
they

Figure 8
Percentage Distribution of Elderly Men of Various Age Group
by State of
Physical Mobility (Ibid)
Figure 9
Per cent of Elderly Women of Various Age Groups by State of
Physical
Mobility (Irudaya Rajan, et al., 2003)
do not undergo proper medical treatment due to absence of a
compre-
hensive health insurance scheme; this is particularly true in the
case of
the poorer elderly (Gulati and Irudaya Rajan, 1999). One such
disability is the lack of physical mobility which affects a large
population of India as can be seen from Figure 8 and Figure 9.
Dependency among the elderly population in India is illustrated
in Figure 3 which shows high degree of dependence across the
rural-urban divide. This dependence is not only of economic
origin
but is also associated with first-hand care, as can be seen from
the
demographically differentiated graph in Figure 10.
Daily Life Assistance: An Illustration
Consider a retired octogenarian who is living all by his own in

the outskirts of the city. In spite of his age related physical
limitations
he seems perfectly at ease largely due to a well organised and
holistic
ICT network which caters to his everyday needs. A system
installed in
his house provides a proactive environment with a range of
intercon-
nected sensors, devices and smart appliances working together
to
provide a safe and secure place to live. These appliances are
easy to use
due to their customized interfaces and are connected to the
neigh-
bourhood care centre. This allows, when necessary, remote
operation
by authorized personnel. As part of the system infrastructure,
the
smart phones of his children also interact with his home during
times
Figure 10
Percentage of Elderly Persons by State of Economic
Independence
(Irudaya Rajan, et al., 2003)
of emergency. Several video cameras distributed along the
house allow
observing his daily routines (by authorized people) and, at the
same
time, maintain his privacy. The system analyses the situation

from the
captured images and decides on the best course of assistance,
which
varies from helping in cooking to interacting with the care-
providers.
The installed system is also able to react to the most common
domestic
accidents that are recurrent to people living alone. If it sees him
suffering a potential injury, like falling on the floor or cutting
himself,
the system inquires him to make sure he is well. This
interaction is
done via spoken natural language. If there is no reply, an alert
is
immediately sent to his children and the care centre.
Thus with proper application of ICT technology these short-
comings which are largely prevalent among the aged community
at
present, can be successfully curtailed and an overall upliftment
is
definitely possible.
Existent Organizations In India Supporting Active Ageing
In India, HelpAge and Agewell are organizations working
towards
creating awareness of the problems and needs of older persons
in
society and government. But, they do not provide any specific
platform for interaction between volunteers or emergency
assistance
to older people. Heritage Health Care, which is based out of
Hyderabad and has 18 years of experience in treating senior
citizens
has diversified from a geriatric hospital to providing care at

home and
personalized old age home. But unlike the European and
American
counterparts, there has been no such noticeable progress in the
field of
application of ICT for helping the aged population (Knodel and
Debavalya, 1997). As a result, there are several areas in the
healthcare
services which can be developed by using ICT, so as to include
old
people within the perimeter of advanced telehealth and telecare
programmes (as in developed countries), for improved and
prompt
medicare.
India being a developing country, specific case of telecare may
actually work to her advantage. India can use the scientific
knowledge
and intellectual resources already available due to the extensive
R&D
investments done by developed countries. In fact, a joint survey
by
Georgia State University and Apollo Telenet working
Foundation
shows that Indians are quickly becoming conversant w ith the
concept
of telecare: 55 per cent of rural and 72 per cent of urban
population is
aware about and open to using telecare services. In fact the
Indian
government has recently planned to install 1,00,000 computer

centres
in rural areas, which will further increase awareness about
telecare.
Moreover the “Smart City” plan of the Government of India also
includes provisions for use of telecare to create a holistic
automated
environment. Rs 7,060 crore has already been provisioned as
seed
money for this project, which is to be utilised for information
technology to provide the most efficient and comfortable living
standard for the bulging neo-middle class in the Indian society.
Fields of Improvement
Old people value their independence, and thus there is a need of
an effective proactive environment which will function remotely
and
will consist of a group of professionally trained and dedicated
volun-
teers, who can be available to old people as and when needed
during
emergency situation. A large section of the aged community of
our
country is in need of assistance but the present market fails to
cater to
their needs. Some of the NGOs, in spite of aiming to work for
the
upliftment of the aged population, largely fail to deliver as per
the
requirement. Figure 11 and Figure 12 depict the current
scenario of
Kolkata, one of the major metro cities of our country (Liebig, et
al.,
2003). So various functioning units of public healthcare need to
be

Figure 11
Need for Support (Liebig, et al., 2003)
integrated to form an efficient network to function effectively in
tandem.
One serious problem is obviously, lack of professional
caregivers
which often proves to be detrimental in this respect.
On the other hand, a user friendly technology is required, in the
form of radio-alarms and effective social networking so that old
people
can connect to the health-centres when they feel the need of any
sort
of medical assistance. This also helps older people overcome
isolation
and loneliness, and increases possibilities for keeping in contact
with
friends and also extending their social involvement
(Subrahmanya and
Jhabvala, 2000). Thus, a person with movement disability can
use an
alarm if (s)he has any difficulty in movement, so that a trained
caregiver is available for immediate assistance. Obviously it
requires
prompt service, so efficient management and monitoring of the
entire
telehealth facility is of immense importance. Technology can
assist in

normal daily life activities, like tasks at home, mobility, safety,
etc.
Main developments under this perspective are focused on
assistance at
home, namely for elderly people living alone, which can be
further
expanded into developing smart homes. It includes services
such as
living status monitoring, with connection to care providers in
case of
any emergency, companion and service robots, integration of
intel-
ligent home appliances, etc. Support outside home, namely in
terms of
mobility assistance, shopping assistance, and other daily life
activities,
is also considered (Schafer, 1999).
Figure 12
Effectiveness of NGOs (Liebig, et al., 2003)
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