Age-friendly Cities and Communities: A Review of Empirical Evidence and Interventions

Improving living conditions for older people remains among the priorities and programmes of the World Health Organization (WHO), from the first International Plan of Action on Ageing adopted in Vienna in 1982 (UN, 1982), till the most recent report conformed through several workshops and webinars held during 2019-2020: The Decade of Healthy Ageing: Baseline report (WHO, 2020), that sets the stage for the decade of healthy ageing 2021-2030. Healthy ageing is a dynamic process and this baseline report points out that the tree components of healthy ageing are: functional ability (people’s abilities to meet basic needs, make decisions, complete daily activities, maintain relationships and contribute to society), intrinsic capacity (individual’s physical and mental capacities) and environments (physical, social and policy environments) (WHO, 2020, p. 10-13) and the interactions among them, aimed at improving age-friendly environments.

Related to the ageing and environments, the global Age-Friendly Cities and Communities (AFCC) project was developed by Kalache and Plouffe (WHO, 2007a), as part of the Active Ageing framework (WHO, 2002; Fernández-Mayoralas et al., 2018; Pérez Díaz y Abellán García, 2021; Rojo-Pérez et al., 2021a; Rojo-Pérez et al., 2021b). An age-friendly city can be defined as an “inclusive and accessible urban environment that promotes active ageing” (Buffel et al., 2016) through the eight domains: outdoor spaces and buildings; housing; transportation; social participation; respect and social inclusion; civil participation and employment; communication and information; community support and health services (WHO, 2007a). Under the ecological model, Menec (2017) pointed out that AFCC create bidirectional connections between older persons and their environments highlighting the role of different levels (individual, organization and community).

Within the AFCC project, the “age-friendly” construct has expanded beyond cities to include communities, states, businesses, universities, healthcare systems and public health systems, in a kind of synergy between the AFCC initiatives, under the umbrella of the global age-friendly ecosystem (Fulmer et al., 2020). Multiple sectors (older people and their family and caregivers, policy-makers, stakeholders, services providers) have an important participatory role in the implementation and the assessment of the age-friendliness of a neighbourhood or district and the requirements for a community action (WHO, 2007b).

Since the seminal AFCC project, a wide body of scientific literature, as well as other reports and grey literature, has been published on this topic of interest and across diverse disciplines, being the last 10 years the most prolific period, specially carried out in the developed countries. In this line, this post is a summary of a recent research into the systematic review of AFCC (Sánchez-González et al., 2020). This article belongs to the special issue on Active/Healthy Ageing and Quality of Life.

This paper aiming at identifying the empirical evidence related interventions in AFCC model for promoting active and healthy ageing. Among the scientific literature reviews (Dellamora et al., 2015; Hwang, 2017; Luciano et al., 2020; Lui et al., 2009; Menec & Brown, 2018 first online; Neville et al., 2016; Neville et al., 2018; Rogelj & Bogataj, 2019; Ronzi et al., 2018; Rudnicka et al., 2020; Steels, 2015; Syed et al., 2017; Torku et al., 2019 first online; Williams-Roberts et al., 2016) none covered the objective of our paper, the intervention or experimental design of age-friendly environments for older population. There is no consensus to define intervention, but it has a social utility with the purpose of mitigating or preventing risk situations through the implementation of actions intended to resolve specific problems at different levels (individuals, groups and communities).

Selected electronic databases (Web of Science and Scopus) were searched, by following a systematic review based on the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines (Moher et al., 2009), to obtain scientific documents published between 2007 and mid-2020. This procedure pointed out us the way in the process of study selection, quality assessment and the eligibility criteria. Tools for assessing quality and type and degree of risk bias were supported by the PRISMA statement and the Cochrane handbook (Higgins et al., 2011). At the end of this assessment process, 11 documents were retained in the review. A diagram reporting information through the different phases of the systematic review can be seen in the paper, as well as several tables charting the date of the included studies (Sánchez-González et al., 2020).

The paper explored the empirical evidence of the academic literature related to the characteristics, content and effectiveness of interventions designed for improving environmental and psychosocial risk factors for older persons based on the AFCC paradigm. Environmental interventions were focused on reducing risk and adapting the everyday environmental setting, while psychosocial ones prioritised social strategies (behavioural changes, promotion of participation) and training. Likewise, the authors and expertise fields were dominated by multidisciplinary profiles, based on the paradigms of AFCC or Active Ageing or Healthy Ageing, and focusing on the physical and social environments and healthy ageing theoretical approaches. However, one in two studies ignored such approaches.

The average age of the older participants was 76.1 years, with women represented 7 out of 10, and 6 out of 10 interventions were performed in Asia and Australia, with no studies of Latin America and the Caribbean and Africa. All of the studies were non-pharmacological interventions with a predominance of multicomponent followed by environmental and psychological types, and almost a half were individually-based. From a geographical point of view, most of the interventions were carried out mainly in an urban and metropolitan scales. Mixed methodology were followed in almost 6 out of 10 studies, and in a lesser extent quantitative or qualitative approaches were applied.

The study design was based primarily on uncontrolled interventions, followed by non-random and random controlled approaches. Also, a high proportion of studies of low methodological quality and high risk of bias were observed. In fact, only two studies achieved high quality in their description of the methods and instruments underpinning their results.

The relevant findings showed that interventions were more effective in certain domains of AFCC such as transportation and housing, followed by increased participation as a lifestyle-related behavioural change. The inferred changes were associated with providing information and enhancing skills; modifying access, barriers, exposures, and opportunities; enhancing services and support; continuity and effectiveness of changes over time; and modifying policies based on the bottom-up approach of AFCC. Also, interventions focused on personal and organisational aspects might have positive effects in the longer term. However, fewer changes would be observed in interventions revolving around changing lifestyles owing to the impact of complex multi-causal factors.

The relative effectiveness in terms of health calls into question the design of interventions and the supposed “friendliness” of certain communities. There is a need to encourage sound longitudinal research aimed at providing key knowledge for the implementation and evaluation of public policies and to encourage AFCC programmes. This systematic review evidenced the need to design and apply interventions in different geographical contexts, as well as performing research to confirm their effectiveness in order to translate knowledge for the development of public policies for the promotion of active and healthy ageing.

References (Only the complete references of the publications that cannot be correctly linked from the text have been included here, as well as the references of international organizations and the original publication from which this post has been summarized).

- Pérez Díaz, J., & Abellán García, A. (2021 forthcoming). “Active Ageing”: Its Relevance from an Historical Perspective. In F. Rojo-Pérez & G. Fernández-Mayoralas (Eds.), Handbook of Active Ageing and Quality of Life. From concepts to applications (pp. 171-184). Cham: Springer, series International Handbooks of Quality of Life. https://doi.org/10.1007/978-3-030-58031-5_10

- Rojo-Pérez, F., Fernández-Mayoralas, G., & Rodríguez-Rodríguez, V. (2021, forthcoming prensa). Active Ageing and Quality of Life. A Systematized Literature Review. En F. Rojo-Pérez & G. Fernández-Mayoralas (Eds.), Handbook of Active Ageing and Quality of Life. From Concepts to Applications (pp. 63-96). Cham: Springer, International Handbooks of Quality-of-Life series. https://doi.org/10.1007/978-3-030-58031-5_4

- Rojo-Pérez, F., Gallardo-Peralta, L., Fernández-Mayoralas, G., Rodríguez-Rodríguez, V., Montes de Oca Zavala, V., Prieto-Flores, M. E., & Lardiés Bosque, R. (2021 en prensa). Envejecimiento activo y buen envejecer en Iberoamérica. Una revisión bibliográfica. En G. Fernández-Mayoralas & F. Rojo-Pérez (Eds.), Envejecimiento Activo, Calidad de Vida y Género. Las miradas académica, institucional y social (pp. 177-211). Valencia: Tirant lo Blanch.0

- Sánchez-González, D., Rojo-Pérez, F., Rodríguez-Rodríguez, V., & Fernández-Mayoralas, G. (2020). Environmental and Psychosocial Interventions in Age-Friendly Communities and Active Ageing: A Systematic Review. International Journal of Environmental Research and Public Health, 17(22), 8305. https://doi.org/10.3390/ijerph17228305

- UN- United Nations. (1982). The Vienna International Plan of Action on Aging was adopted by the World Assembly on Aging held in Vienna, Austria from 26 July to 6 August 1982. New York: United Nations. https://tinyurl.com/y3bnmugr

- WHO- World Health Organization. (2002). Active Ageing: A Policy Framework. Geneva: World Health Organization. https://tinyurl.com/y7wtbuf5

- WHO- World Health Organization. (2017). Age-friendly environments in Europe. A handbook of domains for policy action. Copenhagen: WHO Regional Office for Europe. https://tinyurl.com/y5nfpr9s

- WHO- World Health Organization. (2020). Decade of healthy ageing: baseline report. Geneva: World Health Organization. https://tinyurl.com/y5ymp474

- WHO- World Health Organization. (2007a). Global age-friendly cities: a guide. Geneva: World Health Organization. https://tinyurl.com/y482zruf

- WHO- World Health Organization. (2007b). WHO Age-Friendly Cities Project Methodology. Vancouver Protocol. Geneva: World Health Organization. https://tinyurl.com/y53yjrol

Authorship:

Fermina Rojo-Pérez (1); Diego Sánchez-González (2); Vicente Rodríguez-Rodríguez (3); Gloria Fernández-Mayoralas (4)

1. Institute of Economics, Geography and Demography (IEGD), Spanish National Research Council (CSIC). Research Group on Ageing (GIE-CSIC). Ageing Network of the Latin American Population Association (ALAP). fermina.rojo@csic.es

2. Department of Geography, National Distance Education University (UNED), 28040 Madrid, Spain. dsanchezg@geo.uned.es

3. Institute of Economics, Geography and Demography (IEGD), Spanish National Research Council (CSIC). Research Group on Ageing (GIE-CSIC). Ageing Network of the Latin American Population Association (ALAP). vicente.rodriguez@csic.es

4. Institute of Economics, Geography and Demography (IEGD), Spanish National Research Council (CSIC). Research Group on Ageing (GIE-CSIC). gloria.fernandezmayoralas@csic.es