Institute of Public Health in Ireland (IPH) – Written evidence (INQ0048)
1. The Institute of Public Health in Ireland (IPH) is an all-island body that works to provide evidence and advice to promote health and wellbeing, and to reduce health inequalities on the island of Ireland, North and South. It is core-funded by the Departments of Health in both Northern Ireland and the Republic of Ireland, and works with partners at national and international level to provide evidence-based public health intelligence that can help shape effective policies and interventions. Key areas it works on include ageing and older people, obesity, physical activity, loneliness, chronic conditions, tobacco control, alcohol harm reduction and healthy workplaces. In this submission we address a number of the questions posed by the Committee.
Question 2. How firm is the scientific basis for public health advice about healthy lifestyles as a way to increase health span, including physical health and mental health?
Question 2b. Are there examples of good practice in the UK/devolved nations or elsewhere?
3. In Northern Ireland there are promising approaches that aim to support healthy ageing – covering areas such as transport, diet, physical activity, men’s health, social inclusion, arts and creativity which are a mixture of foundation services, interventions and gateway services. For example, researchers at Queen’s University Belfast are looking at the Mediterranean Diet and its association with healthy ageing, and have provided cooking advice to older people on lifestyle changes. The promotion of intergenerational practice by the charity Linking Generations, provides spaces and opportunities for people of different ages to learn, support, meet and enjoy each other’s company. ‘Walk with Me’ was a peer-led walking programme that aimed to increase physical activity in inactive older adults. This cross sectoral partnership was funded by the National Institute for Health Research. Arts Care NI, with support from the Public Health Agency focuses on using arts to have a positive impact on the health and wellbeing of older people. PLACE-EE, led by Ulster University, is a transnational partnership of public health agencies, local authorities, academics and ICT experts dedicated to improving the quality of life for older people by developing and implementing locally-derived sustainable solutions. Men’s Sheds is an international model aimed at improving wellbeing among men. In Ireland, north and south, it developed a dedicated men’s health website called Malehealth.ie that uses the analogy of car maintenance for personal care and wellbeing. To inform policy and programmes in the area of healthy ageing, we need to build the evidence base on examples of good practice (both nationally and internationally) to provide an assessment of the public health impact and to assess effectiveness, adoption, implementation, maintenance and transferability.
Question 4. How complete is the understanding of behavioural determinants and social determinants of health in old age and of demographic differences?
4. Our understanding of behavioural and social determinants of health in later life is still developing and has benefited in recent years from research in this area. To ensure people can age healthily and maintain independence in old age requires a life-course approach to address the social, economic and environmental factors that determine individual and population health. Factors include: income and social status; employment and working conditions; education and literacy; childhood experiences; physical environments; social supports and coping skills; health behaviours; access to health services etc.
5. The latest data from Northern Ireland shows men from the most deprived areas die on average 7.1 years younger than those in the most affluent areas while for women the gap in life expectancy is 4.5 years. Cancer, circulatory diseases and suicide are the largest contributors to this deprivation gap in men, while for women, cancer (primarily lung cancer), is the biggest contributor followed by circulatory and respiratory diseases (NI DOH, 2019a). Harmful behaviours such as smoking are three times more prevalent in the most deprived areas compared to the least deprived areas (32% v 11%) (HSNI, 2018) showing how behavioural determinants of health are heavily influenced by social environment.
6. The data for disability-free life expectancy is even more stark as it shows a large and widening gap in the number of years people in Northern Ireland can expect to live disability-free – in the most disadvantaged areas men enjoy 14.3 fewer disability-free years than the least disadvantaged areas in Northern Ireland, while for women the gap is 13 years (DOH NI, 2019b). These gaps in healthy life expectancy have widened since 2010-12. There is also evidence that the number of older people living with alcohol and drug-related harms is rising (IPH, 2019).
7. The data above highlights how crucial it is to address the root causes and to set in place targeted interventions. In particular, promoting and facilitating tobacco cessation, physical activity and measures to support and improve mental health in disadvantaged areas could make a vital contribution to reducing the gap in life expectancy and morbidity.
Question 6. What technologies will be needed to help people to live independently for longer with better health and wellbeing?
8. It is recognised that technologies have the potential to help people age well, but the reoccurring message is that technology must not replace human support but can supplement it. Technology is changing the ways we access goods and services and health information. There is an increasing separation between those who have the skills, knowledge and economic resources to do so with those who do not (Hardil and O’Sullivan, 2018).
9. Technologies which can help people remain in their own homes for longer, whether through monitoring and assisting health needs, helping with household or personal chores or accessing timely assistance or necessary services such as healthcare appointments and transport are all extremely important to maintaining health and independence as people age. Developing technologies must be user-focused, equitable and tailored towards supporting older people and their families.
Question 7. How can technology be used to improve mental health and reduce loneliness for older people?
10. There is a need for more robust evidence in the area of technology and mental health and whether it can address loneliness for older people and improve mental health. At present, evidence points to it potentially increasing loneliness for some groups. A recent review concluded that the evidence so far on the effect of the computer and of social networking sites on improving loneliness in older people living at home was inconclusive but that some technology-based interventions could reinforce a sense of social isolation if participants did not have the requisite physical or mental capacity or confidence to use the equipment (Victor et al, 2018). Longitudinal research in the USA found that greater use of the Internet was associated with declines in participants' communication with family members in the household, a decline in the size of social circles, and increases in depression and loneliness (Kraut et al, 1998). On the other hand, there is some indication that intergenerational programmes have been successful in using technology as a tool to increase contact between and within generations.
Question 8. What are the barriers to the development and implementation of these various technologies?
11. While many new technologies are being trialled or becoming available there can be huge information gaps between who gets access to them, and the implications for inequalities (educational attainment, gender, income and age) remain under-considered. The latest ONS data shows one in 10 people throughout the UK are non-users of the Internet and that Northern Ireland continues to have the highest proportion of non-users of any UK region (14%). It also shows that digital exclusion increases sharply with age and that over half of non-users were over the age of 75 in 2018, while three quarters of those with zero basic digital skills are aged over 65. It is crucial that older cohorts without basic internet skills are not excluded from new technological services and products being developed which could benefit them and that the most vulnerable groups in society are not disadvantaged further by any widening digital divide.
12. Given the socioeconomic divide in healthcare outcomes it is particularly important that assistive technologies are tailored very specifically at those who may not be computer-literate and that special efforts are made to find effective interventions for these cohorts to enable them access the benefits of technological advances. The increased reliance on Internet-provided information or access to services seen in both public and private sector services may isolate those who could benefit most from schemes or initiatives, so provision of information from a range of sources including traditional media or by actively facilitating older people to access digital services developed especially to meet their needs should always be the forefront of product and service design. It is also important that technological solutions do not replace interactions with healthcare professionals which for some older people can be a very important source of human interaction.
13. An example of a tailored IT solution to facilitate older people in Ireland is the Acorn age-friendly smart tablet which has been specifically designed and developed for older people with their input and feedback at every stage of the design process to facilitate their ability to communicate and access crucial services such as hospital transport online as well as fostering greater social engagement. This has been trialled through the Age Friendly Ireland initiative and with the assistance of local authorities, highlighting the way in which existing networks and partnerships can be tapped into to facilitate the rollout of assistive technology.
Question 11: How feasible is the government’s aim to provide five more years of health and independence in old age by 2035?
14. Population ageing can be seen as one of the greatest successes of public health. However, a key challenge is not only the extension of life expectancy but to ensure those extra years are healthy and disability-free for as long as possible. All countries face major challenges to ensure that their health and social systems are ready to make the most of this demographic shift.
15. In the UK, in the 20th Century, there was a steady improvement in life expectancy, attributed to healthier lifestyles, reduction in smoking and improvements in treatment of infectious conditions and disease. However, in recent years, the gains in life expectancy have slowed and come to a half in 2015-17. In Northern Ireland disability-free life expectancy has actually reduced over the last decade. Recent international data also suggests gains in life expectancy may have plateaued (Raleigh, 2019). This is a concerning pattern that has not received the attention that it deserves and we need to understand what is driving the trend.
16. Looking at international data it is clear that some countries have managed to achieve gains over recent years not enjoyed in the UK – for example Eurostat figures for 2016 show that in Sweden disability-free life expectancy at age 65 is over 16 years for women and 15 for men, compared with UK figures of 11 years for women and 10 for men. Lessons should be learned wherever possible from countries which have been successful in increasing the portion of life spent in good health.
Question 12: To what extent are inequalities in healthy ageing, as well as differences in acceptance of technologies a barrier to achieving the aims of the Government’s Ageing Society Grand Challenge?
17. As evidenced in this submission, it is crucial to address the inequalities that lead to unequal experiences of ageing and that all groups reap the benefit of the longevity dividend. To do this it will be vital that technology does not increase or compound inequalities that are evident in the digital divide which allows only those who have the resources and are already digitally-literate to benefit. It is important that alternatives to Internet-driven services and products are also made available to those who are unable to participate in a digital world.
20 September 2019
Department of Health Northern Ireland 2018. Health Survey Northern Ireland. 2017/18 https://www.health-ni.gov.uk/publications/health-survey-northern-ireland-first-results-201718
Department of Health Northern Ireland (2019a). Health Inequalities, Life Expectancy Decomposition 2019. https://www.health-ni.gov.uk/publications/health-inequalities-life-expectancy-decomposition-2019
Department of Health Northern Ireland (2019b): Making Life Better Indicator Summary: Progress Report and Tables. 2019. https://www.health-ni.gov.uk/publications/making-life-better-key-indicators-progress-update-2019
Eurostat. (2016) Healthy life years tables (also called Disability Free Life Expectancy). https://ec.europa.eu/eurostat/web/products-datasets/-/TEPSR_SP320
Hardil I. and O’Sullivan, R. (2018) “E-government: Accessing public services online: Implications for citizenship” Local Economy. Volume: 33 issue: 1, page(s): 3-9. https://journals.sagepub.com/doi/full/10.1177/0269094217753090
Institute of Public Health. (2019). Northern Ireland’s New Strategic Direction for Alcohol and Drugs – Phase 2. Focus on Health Inequalities. https://www.publichealth.ie/index.php/news/iph-press-release/northern-irelands-new-strategic-direction-alcohol-and-drugs-phase-2-focus
Kraut R, Patterson M, Lundmark V, Kiesler S, Mukopadhyay T, Scherlis W. (1998) Internet Paradox. A social technology that reduces social involvement and psychological well-being? American Psychologist. 53(9): 1017-31. https://www.ncbi.nlm.nih.gov/pubmed/9841579
Office of National Statistics. (2019). Exploring the UK’s digital divide. https://www.ons.gov.uk/releases/exploringtheuksdigitaldivide
Raleigh, V. (2019) Trends in life expectancy in EU and other OECD countries: Why are improvements slowing? OECD Health Working Papers, No 108, OECD Publishing, Paris. https://www.oecd-ilibrary.org/social-issues-migration-health/trends-in-life-expectancy-in-eu-and-other-oecd-countries_223159ab-en
Victor C et al. (2018). An overview of reviews: the effectiveness of interventions to address loneliness at all stages of the life-course. https://whatworkswellbeing.org/wp/wp-content/uploads/woocommerce_uploads/2018/10/Full-report-Tackling-loneliness-Oct-2018.pdf