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Knowledge Translation on Ageing and Health

A framework for policy development

2012

A framework for policy development 2012

Contents

Acknowledgments

1. Introduction 1

2. Knowledge translation on ageing and health: the concept and rationale 2

3. The WHO Framework on Knowledge Translation on Ageing and Health 3

3.1 Climate and context for research use 4

3.2 Linkage and exchange efforts 6

3.3 Creation of new knowledge 7

3.4 Push efforts 8

3.5 Facilitating pull efforts 9

3.6 Pull efforts 10

3.7 Evaluation of efforts to link research to action 12

4. Conclusion 13

5. Case studies 14


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ACknowledgements

The framework was prepared for the Department of Ageing and Life-Course, World Health Organization by Dr Moriah Ellen, McMaster Health Forum, McMaster University. Overall direction and finalization was provided by Islene Araujo de Carvalho, John Beard, James Goodwin and Ulysses Panisset.

In addition, the following members of the WHO Technical working group on knowledge translation on ageing and health substantially reviewed the document :

Isabella Aboderin , African Population and Health Research Centre, KenyaJulie Byles, The University of Newcastle, AustraliaDejana Cecez, Permanent Mission of Sweden in Geneva, SwitzerlandMoriah Ellen, McMaster University, CanadaJames Goodwin, Age UK, United Kingdom of Great Britain and Northern IrelandGloria Gutman, Simon Fraser University, CanadaNejma Macklai, Centre Hospitalier Universitaire Vaudois, SwitzerlandMyra Nimmo, Loughborough University, United Kingdom of Great Britain and Northern IrelandCinthya Ramirez, Global Coalition of Ageing Abla Sibai, American University of Beirut, LebanonWHO Staff: Islene Araujo de Carvalho, Kunal Bagchi, John Beard, Somnath Chatterji, Francis Moussy, and Ulysses Panisset

We gratefully acknowledge the funding and in-kind support provided by Age UK, which was crucial for implementing the review, establishing the Technical working group and publishing this document.


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1. IntroduCtIon

Knowledge derived from research and experience may be of little value unless it is put into practice. As a way of thinking about this challenge and how to start closing the “know-do” gap, the process of knowledge translation has emerged. It is defined as “the synthesis, exchange, and application of knowledge by relevant stakeholders to accelerate the benefits of global and local innovation in strengthening health systems and improving people’s health.” Given the broad scope of this challenge, both in general and specifically in regard to ageing and health, the World Health Organization’s Department of Ageing and Life Course has developed a guiding framework for the application of knowledge translation to ageing and health.

The objective of this framework is to assist policy- and decision -makers in integrating evidence-based approaches to ageing in national health policy development processes, specific policies or programmes addressing older population needs and other health programmes concerned with such issues as HIV, reproductive health, chronicle diseases etc.

The framework provide guidance through all the elements necessary for the transfer of knowledge and evidence into the policy development process. It can be used as a checklist in a situation analysis or in the planning process; and it may also serve as as a background document to inform decisions about existing conditions for knowledge transfer.


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2. knowledge trAnslAtIon on AgeIng And heAlth: the ConCept And rAtIonAle

Populations around the world are rapidly ageing, with the fastest demographic changes now occurring in low and middle income countries. These demographic changes have significant impacts on the health, social, and economic sectors of all countries. Understanding how to make use of evidence to develop a national approach will be essential to maintaining active ageing societies, dealing with growing chronic diseases and responding to the housing, community and social elements of ageing. Nevertheless, research evidence on ageing and health is not always communicated effectively and quickly. Moreover, health system policy and decision-makers do not always have the skills, tools and capacity to find and use available evidence.

Knowledge translation has emerged as a process to overcome many of the challenges impeding the use of research evidence in policy-making. The initiatives and activities that make up this process are also referred to as knowledge transfer, research utilization/transfer, evidence-informed or evidence-based decision-making, knowledge/research uptake, and research implementation. In this report we use the term knowledge translation to encompass all the aforementioned terms.

Little work has been done to apply the approaches of knowledge translation in the field of ageing. Given the importance of ensuring that responses to population ageing are built on the available evidence, WHO commissioned a study with three aims:

• provide an overview of selected perspectives on knowledge translation

• review and assess current theories and frameworks discussed in the literature

• develop a guiding framework for the application of knowledge translation in the field of ageing and health.

This report presents the resulting framework for implementing knowledge translation in the field of ageing and health. This framework is designed for use in low, middle and high income countries and is intended to be used at the health system or policy-making level; however it can be adapted to the organizational level as well.

The literature review identified numerous studies examining the barriers and facilitators to the use of research to inform health policy-making. The framework that best addressed all of the factors that influence research use as identified in the literature, provided associated tools for the different components, and reflected the complexity of evidence informed policy-making across many contexts and countries was one developed by Lavis et al1. This formed the basis for the ‘WHO Framework on Knowledge Translation on Ageing and Health’ outlined in this document.

1 Lavis JN, Lomas J, Hamid M, Sewankambo NK. Assessing country-level efforts to link research to action. Bulletin of the World Health Organization 2006; 84(8):620-628.


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3. the who FrAmework on knowledge trAnslAtIon on AgeIng And heAlth

This framework addresses the main elements required to formulate evidence informed policies and decisions in the field of ageing and health. It provides guidance on how policy-makers, practitioners, nongovernmental organizations and civil society can develop options to improve the health and well-being of ageing populations. A full review of the tools, frameworks and references will be available in a longer report entitled Knowledge Translation framework on ageing and health at http://www.who.int/ageing/publications

This proposed framework (Figure 1) has 7 main elements:

• Context looks at whether ageing is included in current policy agendas and if the health system values the use of research to inform policy-making

• Linkage and Exchange Efforts examine the relationships needed to enable the use of evidence

• Knowledge Creation looks at the opportunities and existing capacity to conduct relevant research in the local context

• Push Efforts assesses whether the information is pushed to different user groups in appropriate formats

• Pull Efforts are the efforts of policy-makers to seek and use research on ageing and health

• Facilitating Pull Efforts relates to systems that enable access to relevant research in ageing and health: for example, technical infrastructure, ‘one-stop websites’ and unrestricted access to online resources and journals providing research evidence on ageing and health.

• Evaluation Efforts assess whether health systems allocate resources and funding to monitor implementation and evaluate the impact of evidence informed decision making in ageing and health.


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Figure 1: The seven key elements for knowledge transfer on ageing and health

KT is most effective when all the elements are present and integrated.

3.1 Context for research use

Context ensures the use of research in policy-making and is often used interchangeably with the term climate in the literature2. Context can refer to the broad range of characteristics, circumstances, and conditions surrounding the use of research in management and policy-making3. Implementing change and instituting findings from research evidence in health care involve many complex interactions, some of which can be classified within the context. While research evidence should be considered in policy-making, it is only one input into the policy-making process. Other factors, such as the role of institutions, ideas, and interests as well as economic conditions, political environments, overall policy processes, local actors in the policy process and conditions of conflict should also be considered when examining the context.

The local context, understood to mean the localized manifestation of the larger overarching culture, also needs to be considered. Political will and the overall desire of knowledge users to want to use research evidence are essential components in fostering a positive climate for research use. A context that is conducive to linking research to action and that permits consideration of the effects of the local context on the use of research is therefore a foundational building block, for it will permit the other components to be implemented. Accordingly, it is essential to understand and assess the local context in order to determine feasibility of and possible challenges to using research evidence to inform policy-making.

Table 1 provides a list of questions and considerations to assist countries in assessing the current context with respect to ageing and health initiatives as well as the climate related to knowledge translation activities. These questions assist in establishing the current context.

2 Estabrooks CA, Thompson DS, Lovely JJE, Hofmeyer A. A guide to knowledge translation theory. Journal of Continuing Education in the Health Professions 2006; 26(1):25-36.

3 Damschroder LJ, Aron DC, Keith RE, Kirsh SR, Alexander JA, Lowery JC. Fostering implementation of health services research findings into practice: a consolidated framework for advancing implementation science. Implementation Science 2009; 4(50).

Evaluation

Efforts

Pull Efforts

Facilitating

Pull Efforts

Push Efforts

Knowledge

Creation

Linkage & Exchange

Efforts

Context for

Research

Use

KT for

Ageing in Health


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Table 1: Context for Research Use

Element Questions to ask to assess context

Context for research use

Is ageing and health on the policy agenda? Does the health system value the use of research to inform policy-making?

Context for Ageing and Health• Is there an awareness of the impacts of population ageing? • Is ageing considered a health and development issue? • Is ageing seen positively, not just as a problem? • Are there policies related to ageing and health (e.g. policies related to

non-communicable diseases)? Is the country implementing the Madrid International Plan of Action on Ageing?

• Is there a position or department in the government that responds to ageing concerns in general and/or ageing and health (e.g. Minister of State for Seniors)?

• Are there existing intermediary organizations acting on ageing and health (e.g. gerontology/geriatrics/gerontological nurses societies)?

• What priority is afforded to ageing and health and the needs of older people in the resource allocation?

• What are the competing priorities? Can the ageing and health agenda build on these other priorities?

• Is there a national repository of policy documents? Can it be easily accessed?

• Are there country teams that can facilitate the use of research in policy-making in ageing and health?

• Does the health system evaluate the local context with respect to ageing and health and determine its effect on research use and application?

• Are consumer groups interested in ageing and health?

Context for Knowledge Translation• Is there an interest in using evidence to inform policy? • Do the governments, leaders, health systems, intermediary groups and

research users emphasize the value of research in setting policy?• Is there a formal infrastructure or are there positions responsible for

encouraging and coordinating the use of research in health policy-making?

• Do clear points of contact exist in the health system that broker or facilitate the acquisition, assessment, adaptation and application of research evidence in decision making processes (e.g., networks, knowledge brokers, library resources, opinion leaders)?

• Do funders support efforts to link research to action, such as by requiring a knowledge translation component in each funded proposal?

• Are there recognition programs in the health system that acknowledge and reward organizations and institutions that use research evidence in decision making?


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3.2 Linkage and exchange efforts

Strong links between policy-makers, stakeholders, and researchers can enhance the transfer of research to practice. Researchers and knowledge users need to have open relationships, where dialogues enable the necessary flow of information. Linkage and exchange efforts occur when there are positive relationships between research producers or purveyors and knowledge users.

The ‘two communities theory’4 states that the reason research has a limited impact on policy-making is that researchers and policy-makers live in two different communities with different values, reward systems, and languages. In the past decade many have argued that this lack of a shared understanding needs to be addressed by increasing interaction between the two groups. Linkage and exchange can take many forms, such as working relationships, communities of practice, or formalized networks. Linkage and exchange efforts are most likely to be beneficial when the parties involved are committed to working together, asking, analyzing, and answering policy-relevant questions; when relationships are personal and ongoing; when a team-based approach is used; and where there are meaningful partnerships respecting the role and expertise of all members. Examples of initiatives that health systems can have categorized here as linkage and exchange are given in Table 2.

Table 2: Linkage and Exchange Efforts

Element Examples of linkage and exchange efforts

Linkage and Exchange Efforts

Relationships and opportunities for researchers, policymakers, and other intermediaries that enable the use of evidence informed policy-making.

• Researchers on ageing and health, knowledge users (i.e. policy-makers, advocacy groups, older community, care provider), funders (i.e. governments, national institutes, private, NGO/civil society), consumer groups, and professional bodies have open and positive relationships that support the use of evidence informed policy-making.

• Formal and informal networks of researchers and research users in ageing and health exist.

• Health systems have inter-sectoral (i.e. cross-ministry) committees that can facilitate the use of research in policy-making on ageing and health.

• Consumer groups promote/facilitate the use of knowledge in ageing and health in the health system.

• Relationships with professional bodies and learned societies exist that address ageing and health in this context.

• Public media activities (e.g. TV programs, newspaper columns) specifically address ageing and health. Alternatively, media efforts specific to health exist and collaboration initiatives can be pursued.

• Health systems currently have a policy dialogue on ageing and health, or alternatively on non communicable diseases.

• Health systems establish formal and informal ties to researchers and brokers who can assist in acquiring, assessing, adapting or applying research evidence in decision making.

• Health systems establish and fund regular meetings/public forums where research presentations on ageing and health issues are made to relevant groups.

• Health systems convene interactive workshops that bring together researchers and research users in ageing and health.

• Health systems organize ‘‘deliberative dialogues’’ during which the knowledge arising from systematic reviews can be combined with tacit (i.e., how to) knowledge and other types of knowledge brought forward by stakeholders.

4 Caplan N. The two communities theory and knowledge utilization. American Behavioral Scientist 1979; 22:459-470.


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3.3 Creation of new knowledge:

Research and knowledge creation that is relevant and timely is an essential component within this element. When we discuss the use of evidence in policy-making, we refer not only to pure research, but also to various types of knowledge, such as research evidence, local data, published research, and experiential evidence. The type of knowledge, evidence or research that is appropriate for integration in health systems interventions needs to be determined at the local level and will depend on the local context.

The quality of the research, the topic relevance, the operational usefulness, the recommendations associated with the research and the credibility of the source are all important factors in the use of research in policy-making.

Health systems need to ensure that they have the capacity to conduct research and fund the creation of new knowledge. There is often a lack of needs-driven research, particularly in developing countries. Local stakeholders, such as policy-makers and civil society, need to have an influence in determining the nature and applicability of the research being conducted. Examples of initiatives that health systems can have that focus on the creation of new knowledge are given in Table 3.

Table 3: Knowledge Creation

Element Examples of knowledge creation

Knowledge Creation

Opportunities, capacity and activities to conduct relevant research on ageing and health of use to this policy context are available.

• Researchers, intermediary groups or knowledge users ensure that there are accessible knowledge translation platforms dedicated to ageing and health or to other health issues.

• Research groups address ageing and health issues (e.g. seniors, access to/financing of health services).

• Funders support scoping reviews in ageing and health to identify the state of research in priority areas before undertaking efforts to support systematic reviews or additional research on a topic.

• University or hospital-based research centres in the country focus on ageing and health.

• University departments or schools of gerontology/geriatrics focus on building ageing and health research capacity.

• A national funding program for ageing and health research exists (e.g. US-based National Institute on Aging; Canadian Institutes of Health Research - Institute of Aging).

• Health systems collect data on older people that can be disaggregated by age so that differences between subgroups can be determined (e.g. between young vs. old-old; between groups with particular disabilities/health conditions).

• Health systems have linkages with national statistics bureaus, regional and national health information systems.

• Health systems regularly participate in priority-setting processes related to research on ageing and health to ensure that systematic reviews, primary research and efforts to link research to action are highly relevant to their and other knowledge users’ needs.

• Health systems provide and researchers participate in skill development workshops directed to ensuring the relevance, timeliness and generalizability of their research on ageing and health.


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3.4 Push efforts

The activities undertaken by researchers and intermediary groups can be termed ‘push efforts’ as they push the knowledge out to the necessary groups in appropriate formats. ‘Push’ efforts highlight research evidence on an issue, where it can inform the policy process. The type of messengers, style of communication and packaging of research all play a significant role in the push process.

Traditionally, researchers disseminate their findings via publications or conferences, both of which are important initiatives but tend to confine the research findings within academic circles. Pushing the knowledge out to users requires re-packaging information and highlighting actionable, jargon-free messages. To have an impact, research findings must be translated and adapted to specific contexts and situations and be communicated in user-friendly formats. Examples of push efforts, such as identifying actionable messages arising from research, working with credible messengers for each group, and more, are listed in Table 4.

Table 4: Push Efforts

Element Examples of push efforts

Push Efforts

Researchers or intermediary organizations push information on ageing to different user groups in appropriate formats.

• Researchers or intermediary organizations specifically package information on ageing and health for dissemination to different user groups.

• Researchers or intermediary organizations publish regional or national professional journals, newsletters, and bulletins on ageing and health.

• Researchers or intermediary groups develop media releases and use the mass media to disseminate research on ageing and health.

• Researchers or intermediary groups actively engage in encouraging uptake of their research findings (e.g. by identifying actionable messages, fine tuning messages for different user groups, working with credible messengers and using strategies to encourage and support action).

• Health systems or intermediary organizations provide support services for researchers and policy-makers to socially market their messages in ageing and health (i.e. providing access to PR and marketing departments).

• Health systems and funders provide, and researchers participate in skill development programs to strengthen researchers’ capacity to develop and execute research-informed push efforts.


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3.5 Pull efforts

Activities undertaken by the knowledge users within a health system to access evidence can be classified as ‘pull efforts’. Pull efforts by policy-makers usually require a change in structures and processes to improve the health system’s ability to acquire, assess, adapt, and apply research evidence. Pull efforts are utilized in situations where knowledge users value the use of research and recognize the need to address an information gap. Health systems that are strong in ‘pull efforts’ may have revised their decision-making process to include explicit consideration of research, conducted or participated in training programs to enhance skills related to accessing, assessing, acquiring and adapting research, created a rapid response unit that provides information about the best research in a timely manner; or they may engage knowledge brokers or opinion leaders to assist in obtaining and applying the appropriate evidence. Examples of pull efforts are presented in Table 5.

Table 5: Pull Efforts

Element Examples of pull efforts

Pull Efforts

Policy-makers seek research evidence on ageing and health and implement efforts to assist in pulling the necessary information.

• Existence of a national policy to encourage the use of evidence in decision- and policy-making.

• Rapid response units composed of experts on ageing and health, who can provide primary research, written summaries, consultation, and information about the best research in a timely manner.

• Policy-makers are skilled in asking relevant research questions, and in accessing and appraising research efforts; if not, the appropriate training is provided.

• Health systems provide and participate in programs and training that will enable decision-makers to facilitate user pull and assist in acquiring, assessing, adapting and applying research evidence in decision making.

• Knowledge brokers or opinion leaders in ageing and health are engaged to assist in acquiring, assessing, adapting and applying research in decision making.

• Health systems facilitate open communication between users and the research community in ageing and health.


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3.6 Facilitating pull efforts

Efforts to facilitate “user pull” are usually aimed at making it easier for policy-makers to identify relevant research evidence when needed. Typically, researchers and intermediary groups lead these initiatives. The ‘facilitating pull’ efforts try to support knowledge users in obtaining the evidence when necessary, whereas ‘push’ efforts focus on pushing out actionable messages. Many of the frameworks analyzed discussed different initiatives that researchers can take to increase the uptake of their research findings. Furthermore, health systems can address some of the barriers associated with facilitating pull, such as limited access to information, journals and technology.

Interactive knowledge-sharing mechanisms may facilitate pull. They can include online discussion forums, webinars, training workshops, and personalized briefings. Health systems with institutional mechanisms that facilitate pull can provide technical infrastructures with easy access to online resources and websites that provide “one-stop shopping.” Developing summaries of systematic reviews with local implications is another tool that can be used to facilitate the pull of research.

Examples of facilitating pull efforts are in Table 6.

Table 6: Facilitating Pull Efforts

Element Examples of facilitating pull efforts

Facilitating Pull Efforts

Systems that assist policy-makers getting access to and using relevant research in ageing and health exist.

• Access to a regional, national, or global network of ageing and health experts is available.

• Opportunities (i.e. websites, forums…) for posting ageing and health information exist.

• Technical infrastructure or other support, so that researchers can access online journals and other resources that may contain relevant research on ageing and health, is provided.

• Websites exist that provide ‘one-stop shopping’ for systematic reviews on ageing and health that are optimally packaged and of high relevance.

• Organizations within the health systems implement accessible and efficient systems to support the use of research in decision-making (e.g. documentation and reporting tools, communication tools, and decision support tools).

• Websites or repositories of tools exist that support the use of research in decision-making (e.g. documentation and reporting tools, communication tools, and decision support tools.


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3.7 Evaluation of efforts to link research to action

The final element in supporting the efforts of health systems to use research evidence in policy-making is the monitoring and evaluation of such efforts. Rigorous evaluation of the various activities that support the process of linking research to action is necessary to assure that the best research evidence and knowledge translation mechanisms are developed and used to improve and protect the health of ageing populations, and in this way, promoting benefits and minimizing risks of health systems initiatives. Health systems that support evaluation efforts should not only fund rigorous evaluations but also ensure that researchers and knowledge users participate in these evaluations. Examples of evaluation efforts are in Table 7.

Table 7: Evaluation Efforts

Element Examples of evaluation efforts

Evaluation Efforts

The use and impact of evidence for policy on ageing and health is evaluated

• Health systems develop structures and allocate resources to monitor implementation and evaluate the impact of evidence-informed decision making in ageing and health.

• Funders, research and intermediary groups partner and participate in identifying criteria for success and methods for determining whether knowledge translation has been effective in improving policy for ageing and health.

• Health systems promote/facilitate outcome as well as process evaluations of knowledge translation.

• Funders, researchers, and intermediary organizations promote/facilitate the application of knowledge to specific subgroups as defined by age, gender, income, living arrangements, dementia, other disabilities, ethnicity and culture.


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4. ConClusIon

This document presents a framework for incorporating evidence into policy-making for ageing and health by integrating the advances of various knowledge translation frameworks developed in the past decade. Making use of this proposed framework may significantly advance the possibilities of building evidence-informed policies to respond to the health needs of an ageing population. By minimizing risks and focusing on potential benefits, evidence-informed policies benefit citizens and governments as well as social and health care systems. Case studies help demonstrate the importance of the different elements within the proposed framework. Policy development is both complex and very context-specific, and while knowledge translation strategies and processes have been developed and continue to be proposed, more research is needed to determine what works better and in what contexts.


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This case study demonstrates the effects that linkage and exchange between researchers, interests groups and knowledge users can have on the use of research to inform policy. This influenced the knowledge creation and ensured that it was timely and relevant. This case study also provides examples of concerted push efforts, such as developing policy briefs, as well as some pull efforts, such as working groups instituted by the Ministry of Health to pull in the necessary information.

5. CAse studIes

Inclusion of Older Persons’ Health Issues into National Health Frameworks by the Uganda Reach the Aged Association

An interest group made up of civil society, academic, and policy role players was formed to work towards the inclusion of older persons. The group collected qualitative data on older persons’ experiences and perspectives through focus group discussions and key informant interviews. They also undertook a systematic review to identify old age related gaps in all relevant policy documents. Members of the interest group negotiated participation in and, based on the collected evidence, contributed to the deliberations of technical working groups instituted by the Ministry of Health to inform a process of health sector review, including a revision of several national policies and guidelines. In addition, the interest group built relationships with key decision-makers, developed policy briefs with key messages and participated in other official policy review processes.

Chapters on older persons were included in the Nutritional Handbook for Uganda and National Policy/Guidelines. “Medicines for Non-Communicable Diseases” was incorporated in the National Essential Drugs List 2006.


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Inclusion of Data on Older Persons’ HIV/AIDS Prevalence in National Datasets in Kenya

The two first National AIDS Strategic Plans in Kenya made no provision for testing and prevention services for persons over the age of 49 years.

For the development of the next AIDs Strategic Plan (2009/10-2012/13) the Kenya National AIDS Council undertook a new survey drawing explicitly on a previous Kenya AIDS Indicator Survey (KAIS) in 2007. In contrast to other national surveys that only provided data on HIV prevalence and impacts for the population aged 15-49 years, the new survey was expanded to include persons aged 50-64 years in its sample. The results of the survey showed a significant prevalence of HIV infection among adults aged 50-64 years.

As a direct result of the findings, the national guidelines regarding the provision of testing, counseling and prevention services explicitly expanded the target group to include persons aged 50-64 years.

This case study demonstrates the need to focus on the current climate, take advantage of windows of opportunity, and consider the local context. There are also elements in this case study that demonstrate the need for effective linkage and exchange between researchers and knowledge users, as well as ensuring that knowledge creation activities are relevant and can inform policy.


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This case study demonstrates the importance of linkage and exchange between research and knowledge users as they worked together to define the needs and develop the necessary research. The knowledge creation was specific to the users needs and relevant and applicable. Examples of push efforts (i.e. presentations) and pull efforts (i.e. commissioning the research and conducting policy forums) are also evident in this case study.

Preventive Assessments for people aged 75 years and over

In the 1990’s the Australian government was interested in understanding the potential for preventive assessment programs to improve health outcomes for community-dwelling older people. Initial interest in these programs came from the Department of Veterans Affairs, which commissioned a literature review, a feasibility study and a randomized controlled trial of health assessments. The Department of Human Services and Health was also interested in different approaches to the prevention and management of chronic and complex health needs affecting older Australians. The Enhanced Primary Care (EPC) Medicare Benefits Schedule items were introduced in 1999-2000 to improve the health and quality of life of older Australians, people with chronic conditions and those with multi-disciplinary care needs.

Researchers worked with policy-makers and providers to review existing literature, develop tools and undertake the assessment. Other agents were also engaged in preparation for the introduction of the assessments, with particular emphasis on the role of the general practitioner. Reports were presented to the government’s high level officials, at national and international conferences and published in peer reviewed journals.

A national evaluation of the uptake of the Medicare health assessment items was undertaken. The uptake of the Medicare health assessment item was initially limited but has since become more widely used.

Photos credits:

Cover - Frederic Courbet/ HelpAge International 2012 Page 1 - Chris Leslie/Help the Aged 2006Page 11 - Kate Holt/HelpAge International 2009Page 13 - Kate Holt/HelpAge International 2007

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