Old age is a life stage characterized by a high degree of diversity between individuals. A growing body of literature has been dedicated to understanding this heterogeneity in aging. Special focus has been placed on the positive end of the aging spectrum. At the moment, there exists no universally-accepted definition for what constitutes this “positive end of the aging spectrum”. The “successful aging” (SA) construct, which is often used in research to examine positive aging research questions, is currently defined and operationalized in more than 100 different ways (Cosco, Prina, Perales, Stephan, & Brayne, 2014). However, despite the current lack of a commonly-accepted definition, experts in the field generally agree that the SA construct should consist of several different dimensions, including a (mental and physiological) health facet, a (subjective) well-being facet, as well as a social (engagement) facet (Kleineidam et al., 2018). Nevertheless, despite its broad variety of operationalizations, the SA construct as a whole constitutes a meaningful and useful construct that can be applied to examine why some individuals are more likely than others to remain predominantly healthy and maintain a high level of physical functionality and social activity even into older age (Kleineidam et al., 2018).
In this regard, it is particularly useful to examine what factors can be identified in connection with more favorable aging processes and outcomes. Previous research on SA has uncovered a range of predictors, including socio-demographic factors and specific behaviors linked to SA. Socio-economic status (SES; including income and wealth), education, and health-promoting behaviors (e.g., non-smoking, healthy diet, physical activity), are among the frequently identified predictors for SA (e.g., Daskalopoulou et al., 2018; Gopinath, Kifley, Flood, & Mitchell, 2018; Kok, Aartsen, Deeg, & Huisman, 2016; Vauzour et al., 2017; Whitley, Benzeval, & Popham, 2018). Other branches of health-related research can also provide additional evidence for potential risk and protective factors that are essential in predicting SA. For instance, an important line of research on the (long-term) impact of early-life stress suggests that childhood neglect and abuse can increase the risk of future ill health and mental disorders, and may thus diminish the probability of SA (Jones, Nurius, Song, & Fleming, 2018; Nurius, Fleming, & Brindle, 2017). In fact, supporting this, a recently published large-scale longitudinal study found a meaningful link between early-life stress and SA trajectories (Kok, Aartsen, Deeg, & Huisman, 2017).
Upon closer examination of the factors that may promote or hinder SA, it appears as if SA may be a rather elitist paradigm, seemingly reserved for more advantaged and already healthy individuals. That is, those who grow up in more functional families, who were provided with the opportunity for a good education, and the necessary access to health-literacy and services, coupled with the essential assets and time required to implement health-promoting behaviors. This leaves a rather pessimistic prospect for individuals who grew up and lived in poverty or come from underprivileged educational backgrounds; as well as for those who experienced early misfortune in the form of childhood stressful life events, abuse and neglect, or those living with chronic health conditions (e.g., Bøe, Serlachius, Sivertsen, Petrie, & Hysing, 2018; Kok et al., 2017; Lê-Scherban et al., 2018). Are these individuals deprived of the opportunity to age successfully?
This scientific update aims to answer this question by providing an overview of the latest research dedicated to the investigation of SA in individuals from less advantaged backgrounds. For this, a list of 'disadvantaged' groups was first compiled and the search was then limited to articles on older adults. A search of the databases was conducted for articles published since 2017. Given the wide diversity in how the SA construct is currently defined in the scientific literature, the search was not restricted by applying a particular SA definition or operationalization.
Successful Aging Within the Context of Socio-Economic Disadvantage and Childhood Adversity
The research group of Kok and colleagues (Kok, van Nes, Deeg, Widdershoven, & Huisman, 2018) qualitatively examined SA in Dutch individuals (N = 11; Agerange = 78-93 years) who had a low lifetime socio-economic position (SEP). More specifically, the authors were interested in the identification of resilience factors that protected those individuals from the potentially negative impact of chronic socio-economic adversity. Several resilience-enhancing factors were identified, including ‘social support’, ‘generativity’, ‘pro-active management’, ‘cognitive restructuring’, ‘enduring’, and ‘surrendering’. Confirming, but also expanding the resilience conceptualization for low SEP individuals previously proposed by Chen and Miller (2012), the authors concluded that in addition to mental re-evaluation of the disadvantaged background, it also appears to be necessary to have a supportive social environment (which also requires pro-social behaviors) and the will to actively confront the external circumstances in question, i.e., by changing the adverse environment with one’s own actions (Kok et al., 2018).
Another recent study (Scelzo et al., 2018) examined a sample of very old individuals living in rural villages in the southern part of Italy (N = 29; Agerange = 90-101 years). Rural areas tend to show health-disparities due to a disproportionate lack of services in medically underserved areas, issues of access to existing services, differences in patient expectations and health-seeking behaviors, as well as the delivery of health care (Douthit, Kiv, Dwolatzky, & Biswas, 2015). While not directly assessing SA in this study, (extreme) longevity can be regarded (and has previously been used) as a proxy to assess (the consequences of) SA (see Cosco et al., 2014). The qualitative part of this mixed-method study examined themes related to (extreme) longevity. Common themes associated with SA were identified, including ‘positivity’, i.e., resilience and an optimistic outlook on life (also including self-efficacy and perseverance); being a ‘controlling’ or ‘strong’ personality; being socially active and engaged, i.e., having tight bonds with family members; religious beliefs; as well as being hard working; and having a “love of the land” (p. 33). Altogether, the above findings show some parallels to those reported by Kok et al. (2018): In addition to the importance of having mental resources, such as the capacity for acceptance/perseverance (facilitated by religious beliefs or particular personality traits), there is also the necessity of actively engaging with or changing the external environment (e.g., by being hard working), which is framed within the context of a functional and close social network.
Another example of SA despite adverse life circumstances can be seen in the case of Swiss former indentured child laborers (i.e., former Verdingkinder). Due to extreme poverty, death of a parent, divorce, or single motherhood, children were taken away from their parents and placed in foster families (mostly farmers), where they had to work for their living (Leuenberger & Seglias, 2008). Given that, in those times, the foster-care system was still poorly controlled, these children (in most cases forcefully separated from their families of origin) often experienced little to no protection. Documented by individuals who came forward publicly with their experiences, and corroborated by contemporary witnesses, these biographies are filled with reports of (extreme levels of) childhood abuse and neglect. A qualitative study (Höltge, Mc Gee, Maercker, & Thoma, 2018a) investigated SA in former Verdingkinder (N = 12; Mage = 71 years; Agerange = 59-88). SA was defined as (self-rated) good health, feelings of happiness, balance and/or calmness most of the time, and a high level of satisfaction with (social) life. The factors ‘light-heartedness’, ‘social-purpose’, and ‘self-enhancement’ were identified as predictors for SA. These individuals, after what they had endured in early-life, took on a positive perspective following conscious reflection (i.e., a proxy for a resilience resource). While striving to experience positive feelings, they nevertheless kept a realistic perspective on life by acknowledging that negative experiences are part of a normal existence (i.e., cognitive re-evaluation). In general, participants could be classified as stress-resilient, a resource that was described to be developed through active coping and by coming to terms with their difficult past. They strongly valued (harmonic) social relationships and had the altruistic desire to help others (i.e., social component). Furthermore, they developed a strong motivation for self-improvement that pushed them to work hard and to continuously engage in further education (i.e., active engagement with external environment).
Successful Aging in Racial and Ethnic Minorities
Similar to individuals from disadvantaged backgrounds or adverse childhood circumstances, individuals from minority groups often face issues of marginalization and stigma, which can influence their health and well-being into later life. One such example can be seen in racial and ethnic minorities, who, in addition to potentially higher levels of disadvantages and inequalities (Zubair & Norris, 2015), can also face problems with exclusion and discrimination, which may compound health issues and ultimately hinder SA (Ferraro, Kemp, & Williams, 2017). However, despite these additional stressors, evidence is emerging that some individuals can experience good health into older age. For example, a study of perceived discrimination and psychological well-being in African American older adults (N = 397; Agerange = 65-89) found that the characteristic of ‘self-acceptance’, an awareness and acceptance of personal strengths and weaknesses, was shown to buffer the negative effect of discrimination on depressive symptomology, an indicator of psychological well-being (Yoon, Coburn, & Spence, 2019). Another study (Klokgieters, van Tilburg, Deeg, & Huisman, 2018a) examined the potential buffering effect of various religious activities against the negative impact of disadvantage (e.g., no/low resources) in older Turkish and Moroccan immigrants (N = 455; Agerange = 55-66 years). While a positive relationship was found between well-being and private religious activities, there was no indication of a buffering effect for any of the religious activities against the experienced disadvantage.
Successful Aging in Individuals Living With HIV
Another minority group that has experienced much stigma and discrimination is that of individuals living with the human immunodeficiency virus (HIV). HIV is a chronic illness, associated with a higher risk of experiencing psychosocial challenges and physiological issues. However, with advances in medicine, individuals with HIV are living longer, better lives and research has started focusing on SA and SA-related factors in this population. A qualitative study in individuals with HIV (N = 30; Agerange = 50-73) assessed barriers to and strategies for SA (Emlet, Harris, Furlotte, Brennan, & Pierpaoli, 2017). Results showed that while stigma, prejudice, and discrimination were identified as potential SA barriers, a number of SA-related themes emerged, including resilience components, such as self-care, mastery, and spirituality; social support; and the importance of the environmental context, such as structural support, social networks, and communities. Another qualitative study on SA in individuals with HIV (N = 24; Agerange = 50-73) identified similar themes, emphasizing components over which persons had individual control (Solomon et al., 2018). These included staying positive, maintaining social support and connectedness with others, taking responsibility and being self-reliant for one’s well-being, and engaging in meaningful activities. These findings indicate that a combination of individual characteristics, such as control and mastery, and external influences, such as social and structural support, are important in fostering SA in this marginalized population.
Successful Aging in LGBT Older Adults
A population that also faces additional barriers to SA, are lesbian, gay, bisexual, and transgender (LGBT) older adults. Despite the risks of ill-health and social isolation for LGBT older adults (Wright et al., 2017), discrimination is often reported as a barrier to the utilization of health and community services (Alencar Albuquerque et al., 2016). A large-scale study of N = 2,415 LGBT older adults identified risk and resilience pathways to positive health outcomes in later life (Fredriksen-Goldsen, Kim, Bryan, Shiu, & Emlet, 2017). Results showed that marginalization was a risk factor associated with fewer social resources and poorer mental health outcomes. However, resilient pathways were identified in which psychological (e.g., positive identity appraisal) and social (e.g., social connectedness) resources were associated with health-promoting behaviors, which in turn facilitated good physical health into older age. These findings suggest that the interaction of social and psychological factors can help LGBT older adults to maintain good health and foster SA, even within an environmental context of marginalization.
The above research suggests that SA is possible for individuals from less advantaged, marginalized, and stigmatized backgrounds. However, as this is a relatively new and emerging topic, the exact mechanisms through which SA is fostered in these disadvantaged populations are not yet known. Some theories and models are presented in the next section, which may be applied to help explain the underlying mechanisms of this process of SA.
Underlying Mechanisms of Successful Aging
The ‘steeling effect’ is one theory that may explain positive health in the face of adversity (Liu, 2015; Rutter, 2006, 2012). This theory proposes that previous exposure to adversity (e.g., disadvantaged circumstances, discrimination) may have a ‘steeling’ or strengthening effect on individuals, which can increase their resistance to later stress or adversity. It further suggests that moderate adversity may be more beneficial than no or high adversity, as it is adequately challenging to facilitate the development of coping skills and the utilization of resources (for a review see Höltge, Mc Gee, Maercker, & Thoma, 2018b). However, there is a lack of research applying this model in human studies (for one such study see Höltge, Mc Gee, & Thoma, 2018), particularly with older adults, and the role of steeling for SA remains poorly understood. Furthermore, while some studies have examined aspects of adverse circumstances as part of a larger assessment, such as exposure to social and environmental stress (Seery, Holman, & Silver, 2010), future research is needed to apply this steeling model specifically to individuals from disadvantaged populations.
The above literature suggests that a combination of psychological and individual factors (e.g., mastery and control, self-efficacy) and external social factors (e.g., social engagement, connectedness with others) can contribute to resilience and SA in disadvantaged populations. However, it is also important to consider the enabling environmental and context factors, which are particularly important in this specific population due to their adverse backgrounds and circumstances. Supporting this is the social ecological model of resilience, which emphasizes the role of environmental factors in health and well-being, and suggests that resilience is facilitated by the interaction between the individual and their environment (Ungar, 2012). Specifically, this model suggests that the environment can facilitate access to resilience-promoting resources; that resilience may differ as a result of the complex and changing nature of an individual’s circumstances and the interaction with their personal traits; and that the resilience process is culturally and temporally embedded and is therefore influenced by the cultural norms of the time, which is particularly important for specific cultural groups such as minorities (Ungar, 2011). The importance of the individual-environment interaction for the well-being of disadvantaged populations can be seen in the reoccurring finding that environmental and contextual factors, such as social support and social engagement, were significant in supporting individual resilience and SA (e.g., Emlet et al., 2017; Kok et al., 2018; Scelzo et al., 2018).
Further support comes from a resilience conceptualization in the field of sociology (Schafer, Shippee, & Ferraro, 2009). Schafer and colleagues (2009) argue that in order to actively buffer or overcome disadvantage, several processes must take place: First, an individual must become aware (i.e., recognition/subjective evaluation) of one’s undesirable position, adversity, or misfortune. Second, the individual must take action (i.e., constructive adaptation) to counteract or amend the adverse situation and/or to avoid negative consequences. Third, to efficaciously face disadvantage, one must activate and apply adequate and effective resources. These resources may be located within oneself (e.g., IQ, resiliency traits) and/or within the socio-economic system, in the form of social relationships, SES, and economic resources (Schafer et al., 2009). As in the social ecological model of resilience, this conceptualization highlights the importance of both individual and social-context factors in overcoming disadvantage.
The interaction between individual and environment is also reflected in and supported by another model of resilience by Liu, Reed, and Girard (2017). This model proposes that resilience is dynamic and is formed through the interaction of factors across multiple, interconnected levels. These levels include core resilience, which are inherent, stable characteristics and traits, such as gender, race, and ethnicity; internal resilience, which are learnable and changeable factors, such as active coping, mastery, and self-acceptance; and external resilience, which are contextual and environmental factors, such as social resources and support. This model could be applied in future research to better understand the multi-level mechanisms underpinning the processes of resilience and SA.
In addition, the construct ‘Sense of Coherence-Revised’ (SOC-R) could be examined in conjunction with Liu et al.’s (2017) model. This construct may help explain how individuals can utilize these multi-level factors to facilitate resilience and SA, as it is the ability to integrate and balance positive and negative experiences in order to maintain and develop health and well-being following stress or adversity (Bachem & Maercker, 2016; Mc Gee, Höltge, Maercker, & Thoma, 2018a, 2018b28). It is based on the salutogenic theory, which views health as a continuum, and proposes that SOC-R can help individuals to utilize resources (e.g., personality traits, mastery, social support) appropriate for their current circumstances and move them towards good health on this continuum (Antonovsky, 1987). In this way, SOC-R can positively influence the aging process and foster SA (Bachem & Maercker, 2016). The above theories and models provide a theoretical basis for future research to examine the mechanisms and factors associated with resilience and SA, particularly in populations with disadvantaged backgrounds.
It should be emphasized that this article constitutes a short, current update and overview of the latest developments and publications in this particular field. As such, a systematic review of the literature was not conducted. This may have resulted in a non-comprehensive or even biased delineation of existing literature and the deduction of over-simplified conclusions. It is possible that additional mechanisms and factors exist, which were not discussed in this short update that links SA to adverse experiences and disadvantaged backgrounds. The association between SA and disadvantage is complex and underlying mechanisms are still poorly understood. Disadvantage can have multiple forms and can also hide behind alleged “advantaged” circumstances. For instance, a large-scale longitudinal study on SA (Kok et al., 2017) showed that not only low, but also high SEP, was linked to stressful life events (e.g., higher divorce rate). It is also important to note that the potential buffering impact of psychological resources may depend on the particular context, such as the cultural background (Klokgieters, van Tilburg, Deeg, & Huisman, 2018b).
Research on SA is continuously uncovering predictors for more favorable aging processes and outcomes. This scientific update and overview focused on very recent developments and trends in this area, examining SA in less advantaged populations. Findings from these studies highlight the importance of considering a combination of psychological and individual resilience factors, as well as external social and environmental components. Individual, psychological, and social factors can play a compensatory role for individuals living with negative environmental influences. For clinical psychologists, the movement towards the investigation of underlying mechanisms of SA from a psychological perspective, particularly in disadvantaged individuals, may be a critical step towards understanding the vast heterogeneity in aging.