Survey of international experts on research priorities to improve care for healthy ageing

Introduction

The United Nations (UN) Decade of Healthy Ageing (2021–2030), coordinated by the World Health Organization (WHO),¹ is a global collaborative initiative aimed at improving the lives of older people, their families and the communities.^{2 3} The Action Areas 3 (ie, ‘deliver person-centred, integrated care and primary health services responsive to older people’) and 4 (ie, ‘provide access to long-term care (LTC) for older people who need it’) of the Decade’s work programme focus on reorienting health and care systems to promote ‘ageing in place’ and the delivery of personalised interventions in a seamless continuum of care.⁴

Specific research activities are needed to capture older people’s health and care needs and guide the advocated paradigm shift from a disease-oriented to a more holistic approach.⁵ Interestingly, one of the enablers included in the Plan of Action of the UN Decade of Healthy Ageing points to strengthen data, research and innovation to accelerate innovation.⁶ Unfortunately, several research issues affect the improvement of care for healthy ageing, and the risk of dispersing resources and generating redundancies is high. To advance in the field, it is crucial to develop a research agenda that identifies and organises current knowledge gaps for prioritising efforts.

This work reports the results of a survey conducted among a group of international experts. Positioned as a preliminary evaluation, the survey aimed to identify the most significant and urgent research gaps to be addressed for improving care for older persons.

Methods

The survey was conducted among participants of the Clinical Consortium on Healthy Ageing and the Global Network on Long-Term Care, which are two WHO collaborating platforms on ageing. The invitation to participate was also extended to the WHO technical staff working on ageing. Participants were asked to complete an anonymous online questionnaire and indicate 3–5 research priorities that could help advance in accomplishing Action Areas 3 and 4. The open-ended question read as follows:

‘Think at how care is usually provided to older people. Which are the topics, themes, or areas requiring prioritisation and development of specific research to improve it?’

Sociodemographic information about the participants and where they conducted clinical/research activities were also recorded.

Two researchers independently reviewed the free-text data provided by the participants. Using a conventional content analysis approach,⁷ each researcher identified the knowledge gaps potentially included in each entry. Please note that a single priority (eg, ‘How to implement integrated care for older persons with HIV in low-resource settings’) could nest multiple topics (ie, research on ‘integrated care’, ‘older persons with HIV’ and ‘low-resource settings’). Each researcher then prepared a mind map to thematically cluster and organise the identified priorities. The two mind maps were compared and discussed, with reassessment against the original entries in case of disagreement. A final consensual mind map was generated.

Results

A total of 123 invitations were sent out; 91 (74.0%) responses were received between 28 June 2023 and 14 July 2023. Online supplemental table 1 describes the participants’ main characteristics and the countries where they conducted their professional activities, respectively. A total of 396 research priorities were recorded, with an average of 4.4 per participant. A simplified mind map of the research priorities is presented in figure 1 (see online supplemental figure 1 for a more detailed version). Online supplemental table 2 presents examples of research gaps identified by participants.

Figure 1. Simplified mind map reporting the research priorities to improve care for healthy ageing. Only entries reported by five or more participants are indicated here. CGA, Comprehensive Geriatric Assessment; LTC, long-term care; NCD, non-communicable disease.

Nine clusters of research priorities were identified.

1. Care delivery: A total of 51 entries focused on the definition, components, effectiveness and organisational models of integrated care. 11 entries referred to palliative care, suggesting research on identifying needs, decision-making processes and end-of-life interventions. 61 entries highlighted the need to define and organise LTC.

2. Health economics: These entries (n=33) requested more research on the cost-effectiveness of care models. Cost analyses were advocated to measure the impact of shortage and inadequate training of the health workers on older persons. Also, more work was requested to explain why investing in care for healthy ageing is beneficial.

3. Low-resource settings: Research in settings characterised by a lack of material or human resources and an inability to provide basic care defined this cluster (n=28). Several participants recommended research activities on community-based interventions, service coverage, primary healthcare, LTC and older persons living with HIV in these settings.

4. Research methodology: 25 entries required improvement of research methodologies. It was indicated that older individuals should be more involved in the design of research activities. Furthermore, patient-reported measures (eg, patient-reported experience measures (PREM), patient-reported outomes meassures (PROM)) should be used more frequently. The conduct of stratified analyses for age, gender and functional status was also identified as essential.

5. Technologies: More research on technologies (n=24) could improve care for healthy ageing. The acceptability of novel technologies by older persons, the evaluation of possible risks and benefits, and the role played by artificial intelligence in care should be explored.

6. Capacity building: Several entries pointed to the need for more research to enhance the competencies of those involved in older people’s care (n=23). This included activities to train caregivers and care workers, including on multidisciplinarity.

7. Understanding the older person: 21 entries highlighted the importance of more research to understand the older person’s needs, preferences and priorities. This cluster also included requests for more research on human rights and the decision-making process.

8. Concepts: Another cluster pointed to conceptual ambiguities in the healthy ageing framework (n=11) and some related constructs (eg, functional ability, n=8; intrinsic capacity, n=15).

9. Clinical conditions: Multiple entries referred to specific conditions of older persons, in particular mental health (n=14), frailty (n=11), polypharmacy (n=8) and multimorbidity (n=6).

Discussion

To our knowledge, this is the first attempt to identify and organise the research gaps and priorities challenging the improvement of care for healthy ageing. Aligned with Action Areas 3 and 4 of the UN Decade of Healthy Ageing,³ most research priorities were related to integrated care and LTC. Consistently, the centrality of the primary healthcare setting was fully recognised, requesting more action to improve its connections with other care settings, develop supporting infrastructures and build the necessary capacity of health workers and caregivers.

By 2050, more than 80% of older persons will live in low-income and middle-income countries.⁸ Therefore, it becomes essential to prioritise research in low-resource settings and explain how research evidence, still largely coming from high-income countries, can be translated into practice worldwide. In this context, supporting research findings with economic data is necessary to demonstrate the long-term sustainability of different initiatives and efficiently allocate available resources.

The survey shows the need for a better understanding of the older person’s priorities, values and preferences. Traditional care methods often fail on this critical aspect, especially in front of social and clinical complexity. To provide comprehensive, person-centred care, it is essential first to understand the older person’s perspectives on life and health, potentially reconsidering the standard outcomes of care.

Accelerating towards personalisation of care requires innovation in the research methodology and the nature of data collected. Besides addressing the barriers to developing evidence-based medicine in older persons,⁹ research should better consider critical determinants of health (eg, age, gender, function, education, wealth) to support better-tailored interventions. At the same time, qualitative studies and a broader use of patient-reported measures are recommended to bring research results closer to the real needs of the older person.

A research prioritisation agenda to support the development of evidence, inform programmes and policies and promote stronger connections between the health and social care systems is essential. It will have to consider the following factors:

1. The heterogeneous development stage and organisation of the health and care systems worldwide.

2. The involvement of multiple stakeholders.

3. The complexity of the older population’s needs.

4. The different contexts and values across countries and societies that impact health and social care systems.

This survey represents a preliminary step in a longer-term project that will generate a research prioritisation agenda through a Delphi methodology and wider stakeholder involvement.³ Critically, the present work provides the necessary input to initiate the process and stimulate the subsequent discussion.

This study includes limitations worth mentioning. Although no predefined framework was adopted, the survey was conducted among experts familiar with the UN Decade of Healthy Ageing framework and its Action Areas. Despite the geographical distribution across continents, we observed an over-representation of participants from high-income countries with limited feedback from stakeholders in low-income countries. While we cannot exclude possible misinterpretations in defining and clustering research priorities, the independent analysis conducted by the researchers and the iterative discussion of their results likely mitigated this risk.

In conclusion, more research is needed to improve care for healthy ageing. Due to the lack of evidence in multiple areas and the urgency to reorient care systems in response to global ageing, identifying priorities and consistently proceeding with research activities is essential.