Abstract
It is the consensus that the rapid increase of the ageing population has become a global phenomenon. In 2007, the World Health Organization (WHO) advanced a handbook called Global Age-friendly Cities: A Guide. The core concept of the age-friendly cities (AFC) movement is ‘active ageing’. Taiwan became one of the few Asian countries that initially responded to the WHO AFC movement in 2010. Following the guidance set by the WHO, Taiwan began its promotion at a national level, and with local authorities. However, during the advocacy process, the fundamental differences between Eastern and Western cultures in terms of family values and deep-rooted respect for the elderly have raised an awareness of the need for an oriental paradigm. This paper identifies three key elements for AFC promotion in East Asian countries based on an analysis of Taiwan’s experience: during needs assessment take collectivism into consideration, during action plans at the community level community leaders’ views will be more important (particularism), and when promoting AFC at the institutional level a top-down approach will be more acceptable (high power distance concept).
Introduction: the global ageing trend and the Asian context
The rapid increase in the ageing population has become a global phenomenon. According to the United Nations, this increase will be greatest and most rapid in developing countries, where the older population is expected to quadruple over the coming decades. To react to this foreseeable challenge, the Age-Friendly Cities Network (AFC) proposed by the World Health Organization (WHO) in 2007 soon became a popular global movement, with a growing numbers of cities and communities accelerating efforts to better meet the needs of the elderly. According to the latest statistics, as of September, 2015, over 280 cities and communities had officially joined the WHO Global Network of Age-friendly Cities and Communities. However, of these 280 cities and communities, only eight are Asian cities, including four from China (three from Hong Kong), one from Japan, two from South Korea and one from Turkey.
There is no doubt that the ageing trend also poses a distinct challenge for countries in Asia, and it is even more challenging in some East Asian countries with the rapid speed of population ageing. The biggest challenges usually come from longer life expectancy, lower fertility rates, and limited social welfare resources (1). Recent research has confirmed that longer life expectancy is a common trend in Japan, South Korea, Taiwan, Hong Kong, and China (2,3). The statistics also show that Taiwan became an ‘ageing society’ i in 1993, and according to the projection, by 2025 one fifth of the total population will be aged over 65, which will make Taiwan the second quickest country to reach the status of a ‘super-aged society’. Therefore, considering the lack of time for preparation when compared with that enjoyed by most Western countries, it is obvious that for some East Asian cities and communities, initiating age-friendly strategies is a relatively urgent but difficult task.
In the meantime, with an average fertility rate no higher than 1.5% in women of childbearing age in many East Asian countries, by 2040 the rapid decline of manpower in production will pose an enormous threat to the productivity and competitiveness of most countries ii (4). Hence, the need to promote AFC initiatives in some East Asia countries might be more urgent from national security perspectives than from a public health perspective. Therefore, in terms of interpreting active ageing, the core concept of AFC by the WHO iii (5) in most East Asian countries, the word ‘active’ might refer to an individual’s continuing participation in all types of affairs including economic, cultural, and civil activities to the active role of the older cohort as a whole in the city and country.
Accordingly, the distinct cultural characteristics of East Asian societies, including the deep-rooted culture of respect for the elderly and the emphasis on family values, should lead to further interpretation of the contexts of the WHO AFC schemes to East Asian cities. Many culture-comparative studies have confirmed several major cultural differences between the West – mostly Europe and the US – and East Asia, and these include individualism versus collectivism, universalism versus particularism, and low power distance versus high power distance (6–9). The viewpoint of what an age-friendly environment represents in the West may be very different from that in East Asia from both individual and institutional perspectives. Therefore, in this paper it is argued that when the WHO laid out the framework for Age-friendly Cities and Communities (5), although it identified through a two-year study most key ingredients for AFC that could be universally adapted for both Easterners and Westerners, the fundamental cultural differences between the East and West and the role of the family were underestimated.
Individualism and collectivism
The emphasis on individualism in Western culture has a strong influence on the contexts in the AFC guide and how issues for ‘older individuals’ should be taken into account. Most East Asian countries are culturally steeped in collectivism and would be more concerned about how older people interact with their families in an age-friendly environment. The traditional virtues of filial piety and family values embedded in East Asian culture have stressed the importance of prioritizing the elderly over youngsters in society (10). Derived from Confucianism, filial piety can be considered as a form of normative guidance on issues related to reproductive fitness, relationships to immediate and extended family, status-seeking behaviour, relationship to government authorities, and other issues regarding the relationships between generations (10–12). Because of this deep-rooted culture, the elderly in East Asian countries usually place more emphasis on family values and devote themselves to their families, while in Western society the elderly emphasize individual independence.
Universalism and particularism
Because the essence of community values in East Asian communities is rooted in family values, it is very natural to have different interpretations of certain universal rules. ‘Particularism’ applies to different levels of relationships. The emphasis on ‘orthodox human relationships’ iv (‘Qing-Li-Fa’ system v ) affects community residents’ decision making based on their interpersonal relationships rather than rational reasons. The strong particularism values exhibited in the cultures of East Asia would have obvious effects on how the AFC schemes could apply in communities where ‘subjective relationships’ always outweigh ‘objective rules’ (7).
Differences in power distance
‘Power distance’ is one of the six cultural dimensions of the Hofstede Model in his long-term psychology and culture research. It can be defined as the extent to which the less powerful members accept how power is distributed in institutions (13). Most Western societies are low power distanced, which emphasizes equality and democracy, due to the effects of individualism. Communities and bureaucratic systems in East Asian societies are much more high power distanced, meaning that they more readily accept top-down authority (13). This could affect the promotion strategies and decision-making processes of how and what to highlight in AFC projects in East Asian communities. Thus, the empowerment of the elderly will have very different meanings in Eastern and Western societies.
The WHO AFC Model and Taiwan’s experience: what works and what does not
East Asian cultural characteristics clearly stood out during promotion of the AFC project in Taiwan and Hong Kong. Both countries conducted surveys of older people’s satisfaction level for age-friendly domains, and the domain of ‘respect and social inclusion’ was ranked the highest in both survey reports (14,15). Hence, we further examined the WHO AFC model based on the above cultural differences between the East and West and took the Taiwan experience as an example. The WHO AFC initiative includes four important elements, including the establishment of a needs assessment checklist, action plans, a promotion mechanism, and monitoring tools (5).
Needs assessment – individual level
According to the WHO guide, it is essential to investigate the needs of older individuals in communities; hence, focus groups are usually conducted in most cases in the West. However, in Taiwan, due to the strong influence of collectivism in East Asian culture, most survey respondents tend to shy away from expressing their individual demands due to peer pressure. They usually provide neutral answers to avoid any potential embarrassment. Meanwhile, the emphasis on filial piety in Taiwanese society also has an influence on older people’s projections of their image to society. It would be considered shameful to admit that their needs cannot be met by their own family or offspring. Hence, it is more difficult to collect direct information about the true feelings of East Asian older people through focus groups or interview surveys. Information from government census and family members would be more informative in most cases.
Action plan execution – community level
As in most ageing communities of Taiwan, elderly residents are lifetime residents with strong emotional commitments to their communities, and consider ageing-in-place a virtue (16). The strong attachments to the community usually result in a unique social structure which combines traditional Confucianism and the formation of ‘Qing-Li-Fa’ system. When it comes to proposing AFC action plans, the social structure and community leaders will have an essential influence on how well action plans can be decided and executed. This means that particularism rules the decision-making process at the local level in Taiwan. Community leaders usually make decisions based on creating greater good for the community as a whole instead of benefits to individuals. For instance, the Ding Juang community in Chiayi City initiated an urban farm, the aim of which was to establish a stronger connection between senior community members and to create successful local food businesses. Although it was well executed, the urban farming decision was not based on the needs assessment but on the community leader’s opinion.
The promotion mechanism – institutional level
The ‘high power distanced society’ concept applies at the institutional level of promoting AFC in Taiwan. As in most East Asian countries, the commitment of the government and the level of involvement of the higher levels of bureaucracy have a significant influence on public impressions of certain policies. Two successful AFC cases in the West – New York City in the US and a remote Manitoba community in Canada – demonstrated the flexibility of both top-down and bottom-up approaches (17). On the contrary, Taiwan decided to adopt a top-down approach rather than a bottom-up approach from the beginning, in order to leverage the traditional East Asian culture of obedience to authority and higher trust in the government (18). It was confirmed atthe promoting stage that community leaders are easier to motivate only when governments express determination and commitment (19). Also, an empowerment survey result of 997 older residents in a reputable community in Tainan confirmed that most elderly adults in Taiwan were neither comfortable in challenging the authorities (e.g. community leaders) nor aware of their rights to challenge such figures (20). Having said that, the positive contribution that older people can make to society has been gradually recognized in Taiwan’s experience, as have the efforts they have made, both within their own families and in the wider society, through volunteering and caring in the community.
Discussion and conclusion
The AFC implementation in Taiwan has entered its fifth year, and is approaching the end of the first promotional cycle indicated by the WHO. This paper argues that there is a need for an oriental paradigm which could better appreciate the cultural characteristics of East Asia and thereby establish integrated delivery approaches. Three important elements of the oriental paradigm are proposed, based on the major cultural differences between the East and West. We further examined AFC implementation in Taiwan and identified how these three elements might affect the project at individual, community, and institutional levels.
We believe that this oriental paradigm is fundamental to Asian societies and that it has implications for the healthy settings movement in general. It would not only assist the project promoters to obtain better insights of the local society from an Asian cultural perspective, but also facilitate the efficiency of the project communication and decision making. Although other Asian countries may adopt the health promotion framework as proposed by the WHO, based on Taiwan’s experience, we suggest that further research is necessary to explore the effectiveness and fitness of using an oriental paradigm in other East Asian AFC promoting cities and healthy settings in the future.
Footnotes
Declaration of conflicting interests
None declared.
Funding
This research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors.