LEE SENNOTT-MILLER
R E S E A R C H O N A G I N G IN L A T I N A M E R I C A : PRESENT STATUS AND FUTURE DIRECTIONS
ABSTRACT. This essay examines the status of aging research in Latin America. It presents a profile of the aging population in the Region in relation to societal institutions, illustrating how the aged are only marginally served by them. Most of the available information is derived from secondary sources and comes from international and national agencies, and private organizations. Data-based research includes small-sample studies of specific issues and country-specific investigations by both U.S. and Latin American researchers. Paradigms used emphasize successful/productive aging, functional ability, and, to a lesser extent, work focused on health conditions or specific situations such as poverty. The best sources of contextual information are often unpublished or not published in the mainstream literature. Future directions recommended include organizing existing data to inform policy, identifying, with Latin American researchers, the most critical research questions, formalizing collaborative relationships, and holding a working conference of those involved in Latin American aging research to develop a future agenda. Key Words: aging, Latin America, review, elderly, international
Despite the proximity of Latin America, research on aging in the Region has been limited. My challenge in this essay is to discuss the dimensions of the aging phenomenon in Latin America, identify available information and suggest data that still need to be gathered; to frame the issues and set a future agenda. One way to frame aging issues in Latin America is in terms of older people's marginal or unclear status in relation to the institutions that serve all members of a society: educational, economic, health, family, etc. This ambiguity is not intentional, but the result of social and demographic changes that have overwhelmed the countries of the Region since about 1950. Before this time, life expectancy was low, and those who survived to old age played an important role in the family and were rewarded by a reliable source of support and care when they needed it. With the rapid increase in the number of elderly, there is neither work nor services to go around, and many families are hard pressed to incorporate their aging members. Old values and prescriptions for living no longer serve, and they have not yet been replaced by new ones. To put the problem in context Latin America follows a global trend toward aging in which the total population is growing at a rate of 1.7% annually while the segment represented by persons 60 and over is growing much more rapidly at 2.5% per year. Eighty percent of this increase is in developing countries and the growth rate for those 60 and over in these countries (3.3%) is nearly three times that of those in developed countries. The percent of the over 60 population in Latin America and the Caribbean is projected to rise from 6.5 in 1980 to 12.7 in 2025 (PAHO 1990b: 37). In some parts of the Region, the pressures of the aging population on the
Journal of Cross-Cultural Gerontology 9: 87-97, 1994. 9 1994KluwerAcademic Publishers. Printed in the Netherlands.
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social and economic structure, particularly the family and social services, are already being felt. In most of the countries, however, while absolute numbers of elderly are growing alarmingly, they are still overshadowed by those in the younger age groups. For this reason, children have been the focus of most assistance programs and the 'child survival revolution' is one of the factors responsible for the recent rapid fall in infant mortality and the subsequent transition to an aging society. Two factors implicit in the 'demographic transition' in which Latin American countries are currently involved increase the potential problems in planning for larger elderly populations. First, countries with smaller current percentages of older persons have larger projected increases. The countries fitting this description are also the least developed and poorest in the Region, making those least prepared to make changes to accommodate an aging population, most likely to require them urgently (Sennott-Miller 1989). Second, countries at a point in the transition at which they combine decreases in fertility and infant morality with decreases in mortality at older ages also have large cohorts of persons in the childbearing ages of 15 to 49. This sets the stage for excesses of population at both ends of the age spectrum and makes dependency ratios of heightened concern (Kinsella 1988). Those planning for an increase in the aged population are at a disadvantage. Competition for limited resources is perceived as a zero sum game in which someone (or some groups) must lose. Children are not only more numerous, but their plight is more visible and pricks our conscience more deeply. On the other hand, the fact that the numbers of aged have not yet reached the point of crisis allows countries a period of time to plan for their integration - if they act soon. Some of the problems faced by the elderly are a direct product of the aging process; deteriorating health, unbalanced sex ratios, and widowhood are examples. In other cases, the elderly simply share the problems of other marginal groups - the poor in particular. Problems of housing, financial stability, and access to health care are exceptionally acute or take different forms for older persons, but they are suffered also by the rest of the population. Initially this discussion centers on the current situation of the elderly in Latin America. A description of the available data on aging in the Region follows. Finally, I will make some suggestions about future directions for research involving this phenomenon. CURRENT SITUATION OF ELDERLY IN LATIN AMERICA Geographic location of the elderly has a strong influence on how they fare. In most areas of the developing world, a larger proportion of the population lives in the rural areas than in the cities. In Latin America the reverse is true, and in 1990, 72% of the population lived in urban areas (PAHO 1990b). Pressure on the land as more of it went to large agribusiness concerns and opportunities in rapidly growing urban areas prompted families to send their children to the cities, the girls to domestic labor, the boys to find work in industry. This left
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parents in the rural areas with little support as they aged, and it sent several generations to urban areas where they have begun to 'age in place', contributing to the urbanization process through natural increase (Margolies 1990). Those who found employment and prospered and now wish to move their rural elderly closer to them to take advantage of better health and social services find themselves with living situations that will not accommodate an extended family. Urban housing does not lend itself to expansion by adding extra space. The female survival advantage prevails in all countries in the Region, and among those 64-75 years of age, median male deaths exceed median females deaths by 170 to 100 in urban areas and 140 to 100 in rural areas. At ages 75 and over, the sex ratio can be as low as 60 males for every I00 females (SennottMiller 1989). This differential mortality, in turn, means there will be a large proportion of older women who are widows and who must find a means to support themselves or rely on children to provide for them. The issue of financial viability for the aging is both crucial and complex. The major institutions involved are education and the formal economic system. Age cohorts born before 1950 failed to benefit from the former, making it difficult to compete in the latter. For those who are over 55, rates of primary school completion are low. Rates for men and women 60 to 74 years old range from not quite 40% in urban centers to as low as 1.7% in rural areas (Sennott-Miller 1989). Poorly educated adults do not fare well in the urban job market as work is becoming increasingly technical. They find themselves relegated to the most menial and lowest paying jobs or replaced by younger, better trained workers. Rates of formal employment fall off dramatically after midlife for both men and women. According to the International Labor Office (1986), in 1980, employment rates for women 40 to 44 were 31%, while for those over 65, they were 8%. For men at 40 to 44 years of age, rates were 95%. These dropped to 41% for men 65 and over. Official employment rates for women at any age are rarely more than about 30%. This results in one of the most difficult problems facing the elderly in Latin America. Pension and often health benefits are usually tied to employment rates. Countries in Latin America vary enormously in their pension coverage, from 100% in Cuba to about 1% in Haiti (Sennott-Miller 1989). Complicating the problem is that de jure coverage often does not necessarily translate into de facto benefits, so that even the 30% of women covered, plus those covered under their husband's pension, may not receive the assistance reflected in the official rates (Mesa-Lago 1986). It is clear that 70% of women in Latin America are not idle. On the contrary, as a result of the debt crisis that developed during the 1980s, the need to eke out an existence for the family has often fallen on the shoulders of the women. This is because, since most of the formal sector jobs were held by men, it was they who were most affected when the formal economy faltered and stagnated. Creative means of survival were necessary, and women found these in street and market selling, domestic labor, and piece and temporary work. Thus, for both
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men and women, the sources of income they will have to rely on in old age are even more meager than before. With population aging has come an increase in the chronic conditions of adulthood in the Region, including cardiovascular disease, hypertension, cancer, arthritis, and diabetes. Thus, one of the most important institutions from the aging person's perspective is the health care system. The countries in the Region differ in the quality and quantity of their health care, as well as their sensitivity to health issues of the aging. All subscribe to the WHO goal of Health For All by the year 2000 and all practice a version of Primary Health Care to reach that goal. Demand drives the care offered, and, thus far, the aging have not constituted a large enough group in all but a few countries to generate the demand that would produce changes to meet their needs. Since women are the greatest consumers of health services, and the aging population will consist predominately of women, this group may soon reach the critical mass necessary for response. Currently, however, health services are still designed more for maternity than menopause in most of the Region, and no end to this situation is in sight (Koblinsky, Campbell, and Harlow 1993; Sennott-Miller 1989). The combination of decreasing family size, increasing population, and greater life expectancy has produced a situation in which traditional family caregivers have less help from children and potentially greater numbers of elderly for whom to care. The phenomenon of mass aging is relatively new in the Region. A few elderly have not strained the system, but many will. There is a tradition in Latin culture for the family to care for its own and, with few exceptions, this value is supported. The norms for accomplishing this, however, are vague at best. There are few precedents and cultural guides for understanding and dealing with aging. How does one learn to distinguish between normal aging and disease? What help is available to learn to care for an elderly family member with a chronic disease? What level of care should a family be expected to give? A few countries are attempting to plan ahead for a time when the aged will represent a large proportion of the population. Costa Rica, for instance, is experimenting with home hospitalization as an alternate method of health care delivery. This program is the functional equivalent of the U.S. system of home health care. The pilot project is small and has not attracted much official attention, but it shows promise for adapting an existing system of care to serve a particular set of chronic conditions that need management and supervision, but not continuous or even frequent treatment in the acute setting (Chaney and Sennott-Miller 1993b). AVAILABLE INFORMATION To talk about 'available' information is perhaps misleading. Much of the information on aging in Latin America is anything but readily available. The sources used in the following section were uncovered over a period of about five years of periodic, frustrating, and painstaking detective work. The majority was
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found during 1987-1988 when I was employed by the Pan American Health Organization (PAHO) and the American Association of Retired Persons (AARP) to prepare a report on the health and socioeconomic status of midlife and older women in Latin America and the Caribbean. Funding did not permit original research or travel in Latin America. The major sources of information were international publications by the United Nations and the International Labor Office; U.S. Census Bureau, Center for International Research reports; PAHO publications; documents from Women's Studies organizations such as the International Center for Research on Women; and the 'fugitive literature', which included unpublished work such as theses, workshops and program reports, and case studies as well as limited circulation journals, ethnographic and small-sample studies that rarely find their way into the mainstream literature. To prepare the report, the published data provided the skeleton, but the fugitive literature was what allowed the women to speak and me to put flesh on their bones. Much of the fugitive literature was obtained by writing to approximately 75 persons in Latin America using mailing lists from international organizations, universities, and non-governmental organizations. In 1990, a trip to Argentina, Colombia, and Jamaica yielded sources unknown to me while I was preparing the report and introduced me to private research organizations with extensive libraries containing much relevant information, especially, the Centro de Estudios de Poblaci6n (CENEP) in Buenos Aires and the Asociaci6n Colombiana para el Estudio de la Poblaci6n (ACEP) in Bogot~i. A recent international, interdisciplinary conference on women in Costa Rica provided the occasion for acquisition of several new and useful titles, particularly Redondo's (1990) work on poverty and aging. Finally, in preparation for this article, I contacted as many of the major sources as I could to verify and seek information about any new research on aging in Latin America currently being conducted. The majority of the information currently available in the United States about aging in Latin America is derived from a relatively small number of sources. Much of it is not based on empirical research, but rather consists of a synthesis of data from a variety of government documents, program reports, conference proceedings, and commissioned papers prepared for international organizations. When empirical research is conducted, it is usually descriptive, atheoretical, cross-sectional, and retrospective - the kind of research that is characteristic of beginning investigations in a new area of interest. Among the earliest widely available information were studies of the aged around the world (Kinsella 1988; Kinsella and Taeuber 1993; Torrey, Kinsella and Taeuber 1987), conducted by the Center for International Research of the U.S. Bureau of the Census. Although they dealt with aging as a global phenomenon, the Latin American Region was included and could be compared with other developing areas. The PAHO has also been a longstanding contributor to the general knowledge of the aging in Latin America through its series of publications on Health of the
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Americas (PAHO 1986, 1990b). In addition to helpful analyses of the current overall situation in the Region, these publications contain data on the aging segment of the population that can be extracted from their comprehensive tables. Proceedings of a consulting group meeting held in Washington D.C. in 1988 in which investigators from Latin America and the Caribbean presented original research on midlife and older women were published with an unabridged version of the original report on the subject by PAHO (1989b). A recent collaboration between PAHO and the Inter-American Foundation has produced an important addition to the literature on the poor (including poor elderly) in a study of the health care and access to services in five countries in Latin America. The author, Carmelo Mesa-Lago, is an authority on social security issues in Latin America (PAHO 1992). In the past few years the U.S. trend toward a more positive view of the elderly has been seen also in Latin America. An emphasis on 'successful' or 'productive' aging that has as its most eloquent spokespersons in the U.S., Bortz (1989) and Fries(1990), is mirrored in Latin America by Helpage International (Scott 1990) and the American Association of International Aging (AAIA) (1985, 1989). These organizations promote independence among the elderly by providing funding and training for ownership or employment in micro enterprises. Likewise, a major paradigm shift in U.S. gerontology from the effects of specific chronic diseases to functional ability as a predictor of the success of the aging process has had an impact on Latin American research. During the mid1980s, comparative studies of the needs of the elderly were undertaken by PAHO in collaboration with researchers from 14 countries. A major portion of the questionnaire was devoted to evaluating the ability of the population over 60 to perform activities of daily living, both physical and instrumental. Not surprisingly, in most countries, the clearest differences were between men and women and in terms of gender-linked activities; men had more trouble with housekeeping and cooking and women with traveling outside the home. The overall pattern, however, was for those under 80 to be capable of performing most ADLs without assistance and for those over 80, particularly women, to need some help (PAHO 1989a; 1990a). 'Western' emphases are balanced by those of many Latin American researchers who use a more eclectic approach. Their data-based studies take several forms. There are small-sample studies of specific issues including: widowhood (S~inchez 1989); self-image (Dulcey-Ruiz and Segura Barrios 1989; Margolies 1991); sexuality, (Londofio Velez 1989); role change (Gutitrrez de Pifieda 1989); midlife women's employment patterns (Recchini de Lattes 1989), and poverty (Redondo 1990). Country-specific studies with limited dissemination are also quite common. Some recent examples are: a demographic and epidemiological study of the situation of the elderly in Ecuador by Castro (1990); a report of a study of the effects of change among midlife women in Colombia (Dulcey-Ruiz, Gaitan-Leyva, and Marin de Micolta 1991); and a unique longitudinal study of the elderly population of a neighborhood on the
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outskirts of San Jose, Costa Rica, which is monitoring morbidity, anthropometric measures, blood chemistries, utilization of dental and health care, psychological health, and mortality in a sample of over 700 men and women (Llanos 1990). Currently the WHO Special Program on Aging at the National Institutes of Health is beginning projects in Latin America involving osteoporosis, determinants of healthy aging and age-associated dementias. A study sponsored by the U.S. Bureau of the Census, Center for International Research has just concluded in Costa Rica. Data on hospitalization and medical consultations of the aging population were explored for information that could be used to assess cost and plan for age-appropriate services (Chaney and Sennott-Miller 1993a). In addition, PAHO and AARP are sponsoring the development and testing of a protocol to study the emotional well-being of midlife women in the Americas. The protocol has been through several iterations, and pilot tests were performed in Arizona, Puerto Rico, and Costa Rica, after which the protocol was revised. It will be used in a multicountry study in 1993-94 (Sennott-Miller 1991). FUTURE DIRECTIONS The future agenda for research on aging in Latin America could take many directions. The following are suggestions, and I hope they will stimulate discussion. - Catalog existing empirical research and program evaluations and identify gaps. One of the most frustrating problems with current secondary data is the lack of disaggregation by age and by sex. Large data sets that have been inaccessible to reserachers lacking sophisticated computer capability can now be handled successfully on microcomputers using representative samples, e.g., a one/seventh sample of hospital discharges was used to analyze patterns of morbidity among aging Costa Ricans in one of our recent studies (Chaney and Sennott-Miller 1993a). -
Organize and archive the research to make it truly available. Collect copies of documents, particularly some of the least accessible ones, from those who have been producing and using them so that those interested in aging in Latin America do not have to begin at the beginning each time, and so that those working in the area are not duplicating each other's efforts. Maintain documents and raw data in places accessible to both U.S. and Latin American researchers and establish consortia to share them.
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Begin to frame policy statements for aging services derivable from current research findings. Currently, since governments don't know what the situation of the aging is in their
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LEESENNOTT-MILLER countries, they are free to ignore them, or set policy on the basis of ideology. It is doubtful that the current body of research will lend itself to formal rnetaanalysis, but systematic observation of regularities is possible and can provide interim information for policy recommendations.
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Outline research questions that need to be answered to guide future policy recommendations. The Commission on Health Research for Development (1990) has called for each country to establish an essential national health research base to inform health policy and decision-making. The purposes are to: "understand its own problems, enhance the impact of limited resources, improve health policy and management, foster innovation and experimentation and provide the foundation of a stronger developing country voice in setting international priorities..." (p. 85). This base must include priorities for research on aging in each country. Research can be used to empower the elderly by asking questions that include them as coinvestigators (Moiler 1993). For example, an intervention could be tested that included the training of senior community health workers to disseminate health promotion and illness prevention information to the community. This could illustrate the productive capacity of the elderly and, at the same time, address multigenerational health information needs.
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Begin systematic exploration of some of the common themes appearing in the literature that are not empirically grounded. Concepts such as empowerment and productive aging keep recurring in the literature with meager empirical support. The case for their existence and importance would be strengthened immeasurably if they became the object of data-based research.
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Initiate a research network of interested co-investigators. International agreements among researchers in several countries will allow proposals for more efficient use of funding. Cooperating scientists can take advantage of strengths of all concerned, e.g., combine developed country technology with developing country insight and sensitivity. Collaborative research can foster solutions to shared problems, e.g., housing for aging refugees and migrants who move from one country to another. Training opportunities can be offered to researchers and students in collaborating countries that provide experience in both developed and developing country settings. Comparative research can help to identify universal and unique elements of the aging process to develop appropriate interventions.
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Develop a publication strategy that will get results of research into the
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mainstream scientific literature. Possibilities include special editions of peer-reviewed journals and better dissemination of research sponsored and published by national and international organizations. Approach publishers regarding a series of monographs to provide concentrated, summarized information to target audiences of researchers and service providers. Develop a plan for future research directions and methods. Experiment with other research designs that might allow for more flexibility and require less funding. Examples include: case-control studies to examine outcomes among those who have received a treatment (contact by a community health worker) and those who have not; life histories using older persons as trained interviewers to explore risk factors for chronic disease, and focus groups of older women to discover their strategies and coping methods for use in interventions. Explore greater use of applied research methods such as operations research and focus groups to speed utilization of research results. Promote funding of more population-based research on topics of urgent policy importance so that we avoid extrapolating to an entire population on the basis of small isolated studies. For example, projecting needs for future elderly from the current service use of this subgroup ignores changing lifestyles of people at midlife and younger ages which may produce a different size and distribution of chronic disease burden. Or, the tendency to study sick elderly may convey a false picture and result in overestimation of the needs for future care of those with chronic illness. It is clear that an exhaustive agenda would include many more ideas and suggestions. The final proposal, therefore, is to organize a working conference involving key organizations and persons conducting research in Latin American aging. In addition to summarizing current findings and identifying necessary collaboration and foci, the conferees would address the critical issue of how to fund research on aging in Latin America in order to move the enterprise forward. The challenge it seems, is to begin a dialogue among those interested in this phenomenon, so that we can become familiar with each other's work and begin to chart a future course. REFERENCES American Association for International Aging 1985 Aging Populations in Developing Nations: A Strategy for Development Support. Washington, D.C.: American Association for International Aging. American Association for International Aging 1989 Senior Economic and Enterprise Development Series, 10 publications. 1511 K Street, N.W. Suite 443, Washington, D.C. 20005. Tel. (202) 833-8893. Bortz, W.M. 1989 Redefining Human Aging. Journal of the American Gerontological Society XXXVII: 1092-1096.
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Castro Jaramillo, Y. 1990 Situaci6n de los Anciano en el Ecuador. (Situation of the aged in Ecuador) Quito: (mimeographed). Chaney, E.M. and Sennott-Miller, L. 1993a Case Study of the Aging Population: Costa Rica. Final Report. Contract # 50-YABC-1-66009, Bureau of the Census, Department of Commerce, Washington, D.C. Chaney, E.M. and Sennott-Miller, L. 1993b Case Study of Older Persons and the Health Care System in Costa Rica: Paper presented at the XVth Congress of the International Association of Gerontology, Budapest, Hungary, July 4-9. Commission on Health Research for Development 1990 Health Research. Essential Link to Equity in Development. New York: Oxford University Press. Dulcey-Ruiz, E. and Segura-Barrios, M. 1989 Psychosocial Perceptions of the Status of Women Over 45 in Colombia. In Midlife and Older Women in Latin America and the Caribbean. Pp.279-288. Washington DC: Pan American Health Organization and American Association of Retired Persons. Dulcey-Ruiz, E., Gaitan-Leyva, A. and Matin de Micolta, S.C. 1991 Situaciones de Carnbio en Mujeres Adultas Colombianas. (Situations of change in adult Colombian women) Santaf6 de BogotL D.C., Colombia: Centro de Psicologia Gerontologica. Fries, J.F. 1990 The Compression of Morbidity: Near or Far? Milbank Quarterly LXVII: 208-231. Gutirrrez de Pifieda, V. 1989 Role Changes in the Midlife Woman 45-60 Years of Age in Colombia. In Midlife and Older Women in Latin America and the Caribbean. Pp. 316-322. Washington DC: Pan American Health Organization and American Association of Retired Persons. Intemational Labor Office 1986 Economically Active Population, 1960-2025, Latin America (Vol. 3). Geneva: International Labor Office. Kinsella, K. 1988 Aging in the Third World. International Population Reports Series P95, No. 79. Bureau of the Census. Washington DC: U.S. Government Printing Office. Kinsella, K. and Taeuber, C.N. 1993 An Aging World II. International Population Reports P95/92-3, Washington DC: U.S. Government Printing Office. Koblinsky, M.A., Campbell, O.M.R., and Harlow, S.D. 1993 Mother and More: A Broader Perspective on Women's Health. In The Health of Women: A Global Perspective. Koblinsky, Timyan and Gay, eds. Pp. 33-62. Boulder: Westview Press. Llanos, G. (Ed.) 1990 Estudio de la Tercera Edad en Coronado. San Jose, Costa Rica: Monograffa 90-91, Serie Salud del Adulto. Londofio Velez, A. 1989 Female Sexuality and Aging in Colombia. In Midlife and Older Women in Latin America and the Caribbean. Pp.289-305. Washington, DC: Pan American Health Organization and American Association of Retired Persons. Margolies, L.M. 1990 Issues of Cross-Cultural Transferability of Model Programs for the Aged. In Coping with Social Change: Programs that Work. I. Hoskins ed. Pp. 63-69. Washington, D.C.: American Association of Retired Persons. Margolies, L.M. 1991 Ageing in Venezuela: The Greying Population in the Face of Sociocultural Change. Paper presented at November 21 meetings of the American Anthropological Association, Chicago, IL. Mesa-Lago, C. 1986 Comparative Study of Social Security in Latin America. International Social Security Review II: 127-152. Moiler, V. 1993 Research as a Tool for Empowerment in South Africa. Ageing International XX: 32-36. Pan American Health Organization 1986 Health Conditions in the Americas: 1981-1984, Vol. 1, Scientific Publication No. 500. Washington, DC: Pan American Health Organization. Pan American Health Organization 1989a A Profile of the Elderly Technical Papers 22, Trinidad and Tobago; 24 Guyana; 26 Argentina. Washington, DC: Pan American Health Organization. Pan American Health Organization 1989b Midlife and Older Women in Latin America
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and the Caribbean. Washington DC: Pan American Health Organization and American Association of Retired Persons. Pan American Health Organization 1990a A Profile of the Elderly Technical Papers 29, Costa Rica; 30 Chile. Washington, DC: Pan American Health Organization. Pan American Health Organization 1990b Health Conditions in the Americas, Vol. I. Washington, DC: Pan American Health Organization. Pan American Health Organization and Inter-American Foundation 1992 Health Care for the Poor in Latin America and the Caribbean. PAHO Scientific Publication No. 539 Washington DC: Pan American Health Organization and the Inter-American Foundation. Recchini de Lattes, Z. 1989 Role Changes in Women at Midlife in Argentina. In Midlife and Older Women in Latin America and the Caribbean. Pp. 346-353. Washington DC: Pan American Health Organization and American Association of Retired Persons. Redondo, N. 1990 Ancianidad y Pobrezo (Old Age and Poverty) Centro de Promocion y Estudio de la Vejez (CEPEV) Buenos Aires, Argentina: Editorial Humanitas. S~chez, C.D. 1989 Informal support systems of widows over 60 in Puerto Rico. In Midlife and Older Women in Latin America and the Caribbean. Pp. 265-278. Washington, DC: Pan American Health Organization and American Association of Retired Persons. Scott, G.L.N. 1990 Improving the Economic Situation of Older Persons. In Coping with Social Change: Programs that Work. I. Hoskins ed. Pp. 31-33. Washington, D.C.: American Association for Retired Persons. Sennott-Miller, L. 1989 Midlife and Older Women in Latin America and the Caribbean. Washington: American Association of Retired Persons. Sennott-Miller, L. 1991 Protocol will be Used to Study Stress on Midlife Latino Women in the Americas, Psychology International, 2(4): 1, 6. Torrey, B.B., Kinsella, K., and Taeuber, C.M. 1987 An Aging World. International Population Reports Series P-95, No. 78, Bureau of the Census, Washington, DC: U.S. Government Printing Office.
University of Arizona College of Nursing 1401 N. Martin Tucson, AZ 85721
R E S E A R C H O N A G I N G IN L A T I N A M E R I C A : PRESENT STATUS AND FUTURE DIRECTIONS
ABSTRACT. This essay examines the status of aging research in Latin America. It presents a profile of the aging population in the Region in relation to societal institutions, illustrating how the aged are only marginally served by them. Most of the available information is derived from secondary sources and comes from international and national agencies, and private organizations. Data-based research includes small-sample studies of specific issues and country-specific investigations by both U.S. and Latin American researchers. Paradigms used emphasize successful/productive aging, functional ability, and, to a lesser extent, work focused on health conditions or specific situations such as poverty. The best sources of contextual information are often unpublished or not published in the mainstream literature. Future directions recommended include organizing existing data to inform policy, identifying, with Latin American researchers, the most critical research questions, formalizing collaborative relationships, and holding a working conference of those involved in Latin American aging research to develop a future agenda. Key Words: aging, Latin America, review, elderly, international
Despite the proximity of Latin America, research on aging in the Region has been limited. My challenge in this essay is to discuss the dimensions of the aging phenomenon in Latin America, identify available information and suggest data that still need to be gathered; to frame the issues and set a future agenda. One way to frame aging issues in Latin America is in terms of older people's marginal or unclear status in relation to the institutions that serve all members of a society: educational, economic, health, family, etc. This ambiguity is not intentional, but the result of social and demographic changes that have overwhelmed the countries of the Region since about 1950. Before this time, life expectancy was low, and those who survived to old age played an important role in the family and were rewarded by a reliable source of support and care when they needed it. With the rapid increase in the number of elderly, there is neither work nor services to go around, and many families are hard pressed to incorporate their aging members. Old values and prescriptions for living no longer serve, and they have not yet been replaced by new ones. To put the problem in context Latin America follows a global trend toward aging in which the total population is growing at a rate of 1.7% annually while the segment represented by persons 60 and over is growing much more rapidly at 2.5% per year. Eighty percent of this increase is in developing countries and the growth rate for those 60 and over in these countries (3.3%) is nearly three times that of those in developed countries. The percent of the over 60 population in Latin America and the Caribbean is projected to rise from 6.5 in 1980 to 12.7 in 2025 (PAHO 1990b: 37). In some parts of the Region, the pressures of the aging population on the
Journal of Cross-Cultural Gerontology 9: 87-97, 1994. 9 1994KluwerAcademic Publishers. Printed in the Netherlands.
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social and economic structure, particularly the family and social services, are already being felt. In most of the countries, however, while absolute numbers of elderly are growing alarmingly, they are still overshadowed by those in the younger age groups. For this reason, children have been the focus of most assistance programs and the 'child survival revolution' is one of the factors responsible for the recent rapid fall in infant mortality and the subsequent transition to an aging society. Two factors implicit in the 'demographic transition' in which Latin American countries are currently involved increase the potential problems in planning for larger elderly populations. First, countries with smaller current percentages of older persons have larger projected increases. The countries fitting this description are also the least developed and poorest in the Region, making those least prepared to make changes to accommodate an aging population, most likely to require them urgently (Sennott-Miller 1989). Second, countries at a point in the transition at which they combine decreases in fertility and infant morality with decreases in mortality at older ages also have large cohorts of persons in the childbearing ages of 15 to 49. This sets the stage for excesses of population at both ends of the age spectrum and makes dependency ratios of heightened concern (Kinsella 1988). Those planning for an increase in the aged population are at a disadvantage. Competition for limited resources is perceived as a zero sum game in which someone (or some groups) must lose. Children are not only more numerous, but their plight is more visible and pricks our conscience more deeply. On the other hand, the fact that the numbers of aged have not yet reached the point of crisis allows countries a period of time to plan for their integration - if they act soon. Some of the problems faced by the elderly are a direct product of the aging process; deteriorating health, unbalanced sex ratios, and widowhood are examples. In other cases, the elderly simply share the problems of other marginal groups - the poor in particular. Problems of housing, financial stability, and access to health care are exceptionally acute or take different forms for older persons, but they are suffered also by the rest of the population. Initially this discussion centers on the current situation of the elderly in Latin America. A description of the available data on aging in the Region follows. Finally, I will make some suggestions about future directions for research involving this phenomenon. CURRENT SITUATION OF ELDERLY IN LATIN AMERICA Geographic location of the elderly has a strong influence on how they fare. In most areas of the developing world, a larger proportion of the population lives in the rural areas than in the cities. In Latin America the reverse is true, and in 1990, 72% of the population lived in urban areas (PAHO 1990b). Pressure on the land as more of it went to large agribusiness concerns and opportunities in rapidly growing urban areas prompted families to send their children to the cities, the girls to domestic labor, the boys to find work in industry. This left
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parents in the rural areas with little support as they aged, and it sent several generations to urban areas where they have begun to 'age in place', contributing to the urbanization process through natural increase (Margolies 1990). Those who found employment and prospered and now wish to move their rural elderly closer to them to take advantage of better health and social services find themselves with living situations that will not accommodate an extended family. Urban housing does not lend itself to expansion by adding extra space. The female survival advantage prevails in all countries in the Region, and among those 64-75 years of age, median male deaths exceed median females deaths by 170 to 100 in urban areas and 140 to 100 in rural areas. At ages 75 and over, the sex ratio can be as low as 60 males for every I00 females (SennottMiller 1989). This differential mortality, in turn, means there will be a large proportion of older women who are widows and who must find a means to support themselves or rely on children to provide for them. The issue of financial viability for the aging is both crucial and complex. The major institutions involved are education and the formal economic system. Age cohorts born before 1950 failed to benefit from the former, making it difficult to compete in the latter. For those who are over 55, rates of primary school completion are low. Rates for men and women 60 to 74 years old range from not quite 40% in urban centers to as low as 1.7% in rural areas (Sennott-Miller 1989). Poorly educated adults do not fare well in the urban job market as work is becoming increasingly technical. They find themselves relegated to the most menial and lowest paying jobs or replaced by younger, better trained workers. Rates of formal employment fall off dramatically after midlife for both men and women. According to the International Labor Office (1986), in 1980, employment rates for women 40 to 44 were 31%, while for those over 65, they were 8%. For men at 40 to 44 years of age, rates were 95%. These dropped to 41% for men 65 and over. Official employment rates for women at any age are rarely more than about 30%. This results in one of the most difficult problems facing the elderly in Latin America. Pension and often health benefits are usually tied to employment rates. Countries in Latin America vary enormously in their pension coverage, from 100% in Cuba to about 1% in Haiti (Sennott-Miller 1989). Complicating the problem is that de jure coverage often does not necessarily translate into de facto benefits, so that even the 30% of women covered, plus those covered under their husband's pension, may not receive the assistance reflected in the official rates (Mesa-Lago 1986). It is clear that 70% of women in Latin America are not idle. On the contrary, as a result of the debt crisis that developed during the 1980s, the need to eke out an existence for the family has often fallen on the shoulders of the women. This is because, since most of the formal sector jobs were held by men, it was they who were most affected when the formal economy faltered and stagnated. Creative means of survival were necessary, and women found these in street and market selling, domestic labor, and piece and temporary work. Thus, for both
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men and women, the sources of income they will have to rely on in old age are even more meager than before. With population aging has come an increase in the chronic conditions of adulthood in the Region, including cardiovascular disease, hypertension, cancer, arthritis, and diabetes. Thus, one of the most important institutions from the aging person's perspective is the health care system. The countries in the Region differ in the quality and quantity of their health care, as well as their sensitivity to health issues of the aging. All subscribe to the WHO goal of Health For All by the year 2000 and all practice a version of Primary Health Care to reach that goal. Demand drives the care offered, and, thus far, the aging have not constituted a large enough group in all but a few countries to generate the demand that would produce changes to meet their needs. Since women are the greatest consumers of health services, and the aging population will consist predominately of women, this group may soon reach the critical mass necessary for response. Currently, however, health services are still designed more for maternity than menopause in most of the Region, and no end to this situation is in sight (Koblinsky, Campbell, and Harlow 1993; Sennott-Miller 1989). The combination of decreasing family size, increasing population, and greater life expectancy has produced a situation in which traditional family caregivers have less help from children and potentially greater numbers of elderly for whom to care. The phenomenon of mass aging is relatively new in the Region. A few elderly have not strained the system, but many will. There is a tradition in Latin culture for the family to care for its own and, with few exceptions, this value is supported. The norms for accomplishing this, however, are vague at best. There are few precedents and cultural guides for understanding and dealing with aging. How does one learn to distinguish between normal aging and disease? What help is available to learn to care for an elderly family member with a chronic disease? What level of care should a family be expected to give? A few countries are attempting to plan ahead for a time when the aged will represent a large proportion of the population. Costa Rica, for instance, is experimenting with home hospitalization as an alternate method of health care delivery. This program is the functional equivalent of the U.S. system of home health care. The pilot project is small and has not attracted much official attention, but it shows promise for adapting an existing system of care to serve a particular set of chronic conditions that need management and supervision, but not continuous or even frequent treatment in the acute setting (Chaney and Sennott-Miller 1993b). AVAILABLE INFORMATION To talk about 'available' information is perhaps misleading. Much of the information on aging in Latin America is anything but readily available. The sources used in the following section were uncovered over a period of about five years of periodic, frustrating, and painstaking detective work. The majority was
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found during 1987-1988 when I was employed by the Pan American Health Organization (PAHO) and the American Association of Retired Persons (AARP) to prepare a report on the health and socioeconomic status of midlife and older women in Latin America and the Caribbean. Funding did not permit original research or travel in Latin America. The major sources of information were international publications by the United Nations and the International Labor Office; U.S. Census Bureau, Center for International Research reports; PAHO publications; documents from Women's Studies organizations such as the International Center for Research on Women; and the 'fugitive literature', which included unpublished work such as theses, workshops and program reports, and case studies as well as limited circulation journals, ethnographic and small-sample studies that rarely find their way into the mainstream literature. To prepare the report, the published data provided the skeleton, but the fugitive literature was what allowed the women to speak and me to put flesh on their bones. Much of the fugitive literature was obtained by writing to approximately 75 persons in Latin America using mailing lists from international organizations, universities, and non-governmental organizations. In 1990, a trip to Argentina, Colombia, and Jamaica yielded sources unknown to me while I was preparing the report and introduced me to private research organizations with extensive libraries containing much relevant information, especially, the Centro de Estudios de Poblaci6n (CENEP) in Buenos Aires and the Asociaci6n Colombiana para el Estudio de la Poblaci6n (ACEP) in Bogot~i. A recent international, interdisciplinary conference on women in Costa Rica provided the occasion for acquisition of several new and useful titles, particularly Redondo's (1990) work on poverty and aging. Finally, in preparation for this article, I contacted as many of the major sources as I could to verify and seek information about any new research on aging in Latin America currently being conducted. The majority of the information currently available in the United States about aging in Latin America is derived from a relatively small number of sources. Much of it is not based on empirical research, but rather consists of a synthesis of data from a variety of government documents, program reports, conference proceedings, and commissioned papers prepared for international organizations. When empirical research is conducted, it is usually descriptive, atheoretical, cross-sectional, and retrospective - the kind of research that is characteristic of beginning investigations in a new area of interest. Among the earliest widely available information were studies of the aged around the world (Kinsella 1988; Kinsella and Taeuber 1993; Torrey, Kinsella and Taeuber 1987), conducted by the Center for International Research of the U.S. Bureau of the Census. Although they dealt with aging as a global phenomenon, the Latin American Region was included and could be compared with other developing areas. The PAHO has also been a longstanding contributor to the general knowledge of the aging in Latin America through its series of publications on Health of the
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Americas (PAHO 1986, 1990b). In addition to helpful analyses of the current overall situation in the Region, these publications contain data on the aging segment of the population that can be extracted from their comprehensive tables. Proceedings of a consulting group meeting held in Washington D.C. in 1988 in which investigators from Latin America and the Caribbean presented original research on midlife and older women were published with an unabridged version of the original report on the subject by PAHO (1989b). A recent collaboration between PAHO and the Inter-American Foundation has produced an important addition to the literature on the poor (including poor elderly) in a study of the health care and access to services in five countries in Latin America. The author, Carmelo Mesa-Lago, is an authority on social security issues in Latin America (PAHO 1992). In the past few years the U.S. trend toward a more positive view of the elderly has been seen also in Latin America. An emphasis on 'successful' or 'productive' aging that has as its most eloquent spokespersons in the U.S., Bortz (1989) and Fries(1990), is mirrored in Latin America by Helpage International (Scott 1990) and the American Association of International Aging (AAIA) (1985, 1989). These organizations promote independence among the elderly by providing funding and training for ownership or employment in micro enterprises. Likewise, a major paradigm shift in U.S. gerontology from the effects of specific chronic diseases to functional ability as a predictor of the success of the aging process has had an impact on Latin American research. During the mid1980s, comparative studies of the needs of the elderly were undertaken by PAHO in collaboration with researchers from 14 countries. A major portion of the questionnaire was devoted to evaluating the ability of the population over 60 to perform activities of daily living, both physical and instrumental. Not surprisingly, in most countries, the clearest differences were between men and women and in terms of gender-linked activities; men had more trouble with housekeeping and cooking and women with traveling outside the home. The overall pattern, however, was for those under 80 to be capable of performing most ADLs without assistance and for those over 80, particularly women, to need some help (PAHO 1989a; 1990a). 'Western' emphases are balanced by those of many Latin American researchers who use a more eclectic approach. Their data-based studies take several forms. There are small-sample studies of specific issues including: widowhood (S~inchez 1989); self-image (Dulcey-Ruiz and Segura Barrios 1989; Margolies 1991); sexuality, (Londofio Velez 1989); role change (Gutitrrez de Pifieda 1989); midlife women's employment patterns (Recchini de Lattes 1989), and poverty (Redondo 1990). Country-specific studies with limited dissemination are also quite common. Some recent examples are: a demographic and epidemiological study of the situation of the elderly in Ecuador by Castro (1990); a report of a study of the effects of change among midlife women in Colombia (Dulcey-Ruiz, Gaitan-Leyva, and Marin de Micolta 1991); and a unique longitudinal study of the elderly population of a neighborhood on the
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outskirts of San Jose, Costa Rica, which is monitoring morbidity, anthropometric measures, blood chemistries, utilization of dental and health care, psychological health, and mortality in a sample of over 700 men and women (Llanos 1990). Currently the WHO Special Program on Aging at the National Institutes of Health is beginning projects in Latin America involving osteoporosis, determinants of healthy aging and age-associated dementias. A study sponsored by the U.S. Bureau of the Census, Center for International Research has just concluded in Costa Rica. Data on hospitalization and medical consultations of the aging population were explored for information that could be used to assess cost and plan for age-appropriate services (Chaney and Sennott-Miller 1993a). In addition, PAHO and AARP are sponsoring the development and testing of a protocol to study the emotional well-being of midlife women in the Americas. The protocol has been through several iterations, and pilot tests were performed in Arizona, Puerto Rico, and Costa Rica, after which the protocol was revised. It will be used in a multicountry study in 1993-94 (Sennott-Miller 1991). FUTURE DIRECTIONS The future agenda for research on aging in Latin America could take many directions. The following are suggestions, and I hope they will stimulate discussion. - Catalog existing empirical research and program evaluations and identify gaps. One of the most frustrating problems with current secondary data is the lack of disaggregation by age and by sex. Large data sets that have been inaccessible to reserachers lacking sophisticated computer capability can now be handled successfully on microcomputers using representative samples, e.g., a one/seventh sample of hospital discharges was used to analyze patterns of morbidity among aging Costa Ricans in one of our recent studies (Chaney and Sennott-Miller 1993a). -
Organize and archive the research to make it truly available. Collect copies of documents, particularly some of the least accessible ones, from those who have been producing and using them so that those interested in aging in Latin America do not have to begin at the beginning each time, and so that those working in the area are not duplicating each other's efforts. Maintain documents and raw data in places accessible to both U.S. and Latin American researchers and establish consortia to share them.
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Begin to frame policy statements for aging services derivable from current research findings. Currently, since governments don't know what the situation of the aging is in their
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Outline research questions that need to be answered to guide future policy recommendations. The Commission on Health Research for Development (1990) has called for each country to establish an essential national health research base to inform health policy and decision-making. The purposes are to: "understand its own problems, enhance the impact of limited resources, improve health policy and management, foster innovation and experimentation and provide the foundation of a stronger developing country voice in setting international priorities..." (p. 85). This base must include priorities for research on aging in each country. Research can be used to empower the elderly by asking questions that include them as coinvestigators (Moiler 1993). For example, an intervention could be tested that included the training of senior community health workers to disseminate health promotion and illness prevention information to the community. This could illustrate the productive capacity of the elderly and, at the same time, address multigenerational health information needs.
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Begin systematic exploration of some of the common themes appearing in the literature that are not empirically grounded. Concepts such as empowerment and productive aging keep recurring in the literature with meager empirical support. The case for their existence and importance would be strengthened immeasurably if they became the object of data-based research.
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Initiate a research network of interested co-investigators. International agreements among researchers in several countries will allow proposals for more efficient use of funding. Cooperating scientists can take advantage of strengths of all concerned, e.g., combine developed country technology with developing country insight and sensitivity. Collaborative research can foster solutions to shared problems, e.g., housing for aging refugees and migrants who move from one country to another. Training opportunities can be offered to researchers and students in collaborating countries that provide experience in both developed and developing country settings. Comparative research can help to identify universal and unique elements of the aging process to develop appropriate interventions.
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Develop a publication strategy that will get results of research into the
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mainstream scientific literature. Possibilities include special editions of peer-reviewed journals and better dissemination of research sponsored and published by national and international organizations. Approach publishers regarding a series of monographs to provide concentrated, summarized information to target audiences of researchers and service providers. Develop a plan for future research directions and methods. Experiment with other research designs that might allow for more flexibility and require less funding. Examples include: case-control studies to examine outcomes among those who have received a treatment (contact by a community health worker) and those who have not; life histories using older persons as trained interviewers to explore risk factors for chronic disease, and focus groups of older women to discover their strategies and coping methods for use in interventions. Explore greater use of applied research methods such as operations research and focus groups to speed utilization of research results. Promote funding of more population-based research on topics of urgent policy importance so that we avoid extrapolating to an entire population on the basis of small isolated studies. For example, projecting needs for future elderly from the current service use of this subgroup ignores changing lifestyles of people at midlife and younger ages which may produce a different size and distribution of chronic disease burden. Or, the tendency to study sick elderly may convey a false picture and result in overestimation of the needs for future care of those with chronic illness. It is clear that an exhaustive agenda would include many more ideas and suggestions. The final proposal, therefore, is to organize a working conference involving key organizations and persons conducting research in Latin American aging. In addition to summarizing current findings and identifying necessary collaboration and foci, the conferees would address the critical issue of how to fund research on aging in Latin America in order to move the enterprise forward. The challenge it seems, is to begin a dialogue among those interested in this phenomenon, so that we can become familiar with each other's work and begin to chart a future course. REFERENCES American Association for International Aging 1985 Aging Populations in Developing Nations: A Strategy for Development Support. Washington, D.C.: American Association for International Aging. American Association for International Aging 1989 Senior Economic and Enterprise Development Series, 10 publications. 1511 K Street, N.W. Suite 443, Washington, D.C. 20005. Tel. (202) 833-8893. Bortz, W.M. 1989 Redefining Human Aging. Journal of the American Gerontological Society XXXVII: 1092-1096.
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Castro Jaramillo, Y. 1990 Situaci6n de los Anciano en el Ecuador. (Situation of the aged in Ecuador) Quito: (mimeographed). Chaney, E.M. and Sennott-Miller, L. 1993a Case Study of the Aging Population: Costa Rica. Final Report. Contract # 50-YABC-1-66009, Bureau of the Census, Department of Commerce, Washington, D.C. Chaney, E.M. and Sennott-Miller, L. 1993b Case Study of Older Persons and the Health Care System in Costa Rica: Paper presented at the XVth Congress of the International Association of Gerontology, Budapest, Hungary, July 4-9. Commission on Health Research for Development 1990 Health Research. Essential Link to Equity in Development. New York: Oxford University Press. Dulcey-Ruiz, E. and Segura-Barrios, M. 1989 Psychosocial Perceptions of the Status of Women Over 45 in Colombia. In Midlife and Older Women in Latin America and the Caribbean. Pp.279-288. Washington DC: Pan American Health Organization and American Association of Retired Persons. Dulcey-Ruiz, E., Gaitan-Leyva, A. and Matin de Micolta, S.C. 1991 Situaciones de Carnbio en Mujeres Adultas Colombianas. (Situations of change in adult Colombian women) Santaf6 de BogotL D.C., Colombia: Centro de Psicologia Gerontologica. Fries, J.F. 1990 The Compression of Morbidity: Near or Far? Milbank Quarterly LXVII: 208-231. Gutirrrez de Pifieda, V. 1989 Role Changes in the Midlife Woman 45-60 Years of Age in Colombia. In Midlife and Older Women in Latin America and the Caribbean. Pp. 316-322. Washington DC: Pan American Health Organization and American Association of Retired Persons. Intemational Labor Office 1986 Economically Active Population, 1960-2025, Latin America (Vol. 3). Geneva: International Labor Office. Kinsella, K. 1988 Aging in the Third World. International Population Reports Series P95, No. 79. Bureau of the Census. Washington DC: U.S. Government Printing Office. Kinsella, K. and Taeuber, C.N. 1993 An Aging World II. International Population Reports P95/92-3, Washington DC: U.S. Government Printing Office. Koblinsky, M.A., Campbell, O.M.R., and Harlow, S.D. 1993 Mother and More: A Broader Perspective on Women's Health. In The Health of Women: A Global Perspective. Koblinsky, Timyan and Gay, eds. Pp. 33-62. Boulder: Westview Press. Llanos, G. (Ed.) 1990 Estudio de la Tercera Edad en Coronado. San Jose, Costa Rica: Monograffa 90-91, Serie Salud del Adulto. Londofio Velez, A. 1989 Female Sexuality and Aging in Colombia. In Midlife and Older Women in Latin America and the Caribbean. Pp.289-305. Washington, DC: Pan American Health Organization and American Association of Retired Persons. Margolies, L.M. 1990 Issues of Cross-Cultural Transferability of Model Programs for the Aged. In Coping with Social Change: Programs that Work. I. Hoskins ed. Pp. 63-69. Washington, D.C.: American Association of Retired Persons. Margolies, L.M. 1991 Ageing in Venezuela: The Greying Population in the Face of Sociocultural Change. Paper presented at November 21 meetings of the American Anthropological Association, Chicago, IL. Mesa-Lago, C. 1986 Comparative Study of Social Security in Latin America. International Social Security Review II: 127-152. Moiler, V. 1993 Research as a Tool for Empowerment in South Africa. Ageing International XX: 32-36. Pan American Health Organization 1986 Health Conditions in the Americas: 1981-1984, Vol. 1, Scientific Publication No. 500. Washington, DC: Pan American Health Organization. Pan American Health Organization 1989a A Profile of the Elderly Technical Papers 22, Trinidad and Tobago; 24 Guyana; 26 Argentina. Washington, DC: Pan American Health Organization. Pan American Health Organization 1989b Midlife and Older Women in Latin America
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and the Caribbean. Washington DC: Pan American Health Organization and American Association of Retired Persons. Pan American Health Organization 1990a A Profile of the Elderly Technical Papers 29, Costa Rica; 30 Chile. Washington, DC: Pan American Health Organization. Pan American Health Organization 1990b Health Conditions in the Americas, Vol. I. Washington, DC: Pan American Health Organization. Pan American Health Organization and Inter-American Foundation 1992 Health Care for the Poor in Latin America and the Caribbean. PAHO Scientific Publication No. 539 Washington DC: Pan American Health Organization and the Inter-American Foundation. Recchini de Lattes, Z. 1989 Role Changes in Women at Midlife in Argentina. In Midlife and Older Women in Latin America and the Caribbean. Pp. 346-353. Washington DC: Pan American Health Organization and American Association of Retired Persons. Redondo, N. 1990 Ancianidad y Pobrezo (Old Age and Poverty) Centro de Promocion y Estudio de la Vejez (CEPEV) Buenos Aires, Argentina: Editorial Humanitas. S~chez, C.D. 1989 Informal support systems of widows over 60 in Puerto Rico. In Midlife and Older Women in Latin America and the Caribbean. Pp. 265-278. Washington, DC: Pan American Health Organization and American Association of Retired Persons. Scott, G.L.N. 1990 Improving the Economic Situation of Older Persons. In Coping with Social Change: Programs that Work. I. Hoskins ed. Pp. 31-33. Washington, D.C.: American Association for Retired Persons. Sennott-Miller, L. 1989 Midlife and Older Women in Latin America and the Caribbean. Washington: American Association of Retired Persons. Sennott-Miller, L. 1991 Protocol will be Used to Study Stress on Midlife Latino Women in the Americas, Psychology International, 2(4): 1, 6. Torrey, B.B., Kinsella, K., and Taeuber, C.M. 1987 An Aging World. International Population Reports Series P-95, No. 78, Bureau of the Census, Washington, DC: U.S. Government Printing Office.
University of Arizona College of Nursing 1401 N. Martin Tucson, AZ 85721
