Action Plans for Age-Friendly Cities

As observed in the previous post, communities that have been added to AARP’s Network of Age-Friendly Communities (NAFC) – and, thus, to the World Health Organization’s (WHO) Global Network of Age-friendly Cities and Communities (GNAFCC) – are expected to work through a multiyear process, beginning with a Planning phase.  That phase, not to exceed two years (evidently measured from the time when the mayor or other executive commits his/her community to the process), is especially oriented toward the development of an action plan for making the community more amenable to the needs of older people.  The specifics of the action plan depend upon the information gathered during a baseline assessment of the city’s present age-friendly circumstances.  That assessment reciprocally seeks to gather data that will be useful in the action plan.  It seems advisable, then, to begin the Planning phase by developing a general sense of what might count as an appropriate plan for a given community.

It seemed reasonable to begin with an assumption that a plan document could be conceived in terms of form and substance.  Absent a detailed user’s guide that might stipulate layout, format, and so forth, the form of the plan would perhaps be influenced by practical experience in other contexts and by exposure to the kinds of plan documents that other cities had submitted.  The substance of the plan would presumably be steered by the concept of the age-friendly community (AFC):  if such a community had to have certain kinds of transportation arrangements, for example, then it seemed likely that the plan would have to say something about that.  In some places, transportation might be in excellent condition, in which case the plan might simply state that fact.  In other places, transportation might be in dire need of improvement; presumably a good baseline assessment would document that need; and the action plan would then acknowledge what the assessment had turned up, and would indicate what was going to be done about it.

Form:  The Edmonton Example

As of March 2013, WHO listed the following U.S. members of GNAFCC:

Austin, TX
Bowling Green, KY
Brookline, MA
Chemung County, NY
Chicago, IL
Los Altos, CA
Des Moines, IA
Macon-Bibb County, GA
New York, NY
Philadelphia, PA
Portland, OR
Roseville, CA
Los Altos Hills, CA
Washington, DC
Wichita, KS

It was not clear how many of these cities had progressed beyond the initial letter of intent to the point of developing action plans.  The links associated with the cities on the foregoing list lead to distinct Google searches for those respective cities’ WHO action plans.  Quick scanning of the leading items produced in those searches yielded potentially useful links to plan-related items for Brookline, New York, Philadelphia, Portland, and Washington – and also for Edmonton, one of a number of Canadian cities on the list of GNAFCC members.  A more thorough search across the U.S. and Canada would surely have turned up additional examples, but these seemed sufficient to provide a starting point.

Action plans from those six cities varied considerably in length, detail, and structure.  For example, it appeared possible for a large city to produce a small plan, and vice versa.  A Washington, DC plan document named four general goals in as many pages, typically listing four or five bullet points under each such goal, while Brookline (a city of 58,000) produced a 28-page (single-spaced) combined assessment and planning document.  As was the case in some other listed cities, neither of those documents styled itself as being precisely an action plan; communities typically seemed to be developing hybrid materials that addressed their unique governmental structures (e.g., Washington), prior initiatives (e.g., Brookline), diversity (e.g., New York), and other situational characteristics.

For purposes of general illustration, Edmonton (pop. 817,000) seemed to provide an especially well organized model.  Its colorful, graphically appealing Vision for an Age-Friendly Edmonton Action Plan (Spring 2011) indicated (p. 3) that it was the third of three documents comprising the city’s age-friendly preparation and presentation, following the Edmonton Seniors Declaration (a one-page “call to action to all residents to commit to improving the age-friendliness of our city”) and Edmonton Seniors:  A Portrait.  The Portrait provided what appeared to be a solid assessment of the city’s older people, and the Vision sought to respond with “strategic direction to meet the needs of seniors in Edmonton and guide the direction of services for the next five years” (p. 3) – or, more accurately, for items varying in implementation from one to five years (p. 14).  After an executive summary and an introduction of those previous publications and other background information, the Vision identified nine “key strategic areas” that almost perfectly matched the eight areas identified in WHO’s Global Age-friendly Cities Guide (Edmonton saw community support and health services as two distinguishable matters).  In its treatment of each of those nine areas, the Vision typically cited related local and regional documents; listed WHO age-friendly recommendations; summarized strengths, gaps, and challenges confronting the city, according to Edmontonians (e.g., “Many seniors do not have family or friends to help provide health related support”); specified corresponding goals (e.g., “Seniors have methods of obtaining education, knowledge and skills that are critical for them to support their own health”); listed related actions to be taken (e.g., “Action 1:  Ensure senior volunteers are provided with the support and training to provide mentoring and support to their peers . . . .”); and identified the lead partner (which was often the Edmonton Seniors Coordinating Council, author of the Vision), key stakeholders, and the expected implementation timeframe.  The action-oriented section of the Vision closed with a brief statement of “Next Steps.”

Critique of the WHO Research

The following paragraphs offer several criticisms of the research methods used by WHO, and of certain resulting aspects of the WHO’s Guide and related documents.  These criticisms are not intended to negate the substantial contributions made by WHO and its research toward the advancement of the age-friendly movement and toward relevant improvements in various communities.  The purpose of these criticisms is, rather, to underscore the importance of solid research that takes account of each community’s unique circumstances, as distinct from an assumption that one should just do whatever WHO did.

Despite (or perhaps because of) the clarity of its organization, Edmonton’s Vision highlights some uncertainty as to what WHO recommended.  In the area of housing, for example, the Vision lists eight WHO recommendations, evidently summarizing nine areas of discussion provided in the Guide.  One such recommendation, according to the Vision, is that “The living environment has sufficient space and privacy” (p. 41), and that seems correct:  the Guide says that on its page 35.  But WHO’s Checklist of Essential Features of Age-friendly Cities does not list any such recommendation in the housing area, and contains no reference at all to privacy.  Although I did not explore the question, it seems probable that other seemingly worthy points in the Guide‘s relatively lengthy presentation were deemed not to be “essential” for purposes of the Checklist.  One would assume that Edmonton did not err in following the Guide, but the notion that some of its concerns were nonessential does inspire uncertainty as to the importance of the Guide‘s contents.  According to Plouffe and Kalache (2010, p. 737), the Checklist does present the core features of an age-friendly city.

A separate concern involves the weight to be placed upon those WHO recommendations.  Edmonton’s Vision is missing a strict link between the cited recommendations and the proposed action steps:  it is not generally clear that the former led to the latter.  In this regard, the writers of the Vision document seem to have concluded that WHO recommendations could be irrelevant and even inappropriate for Edmonton’s purposes.

That conclusion seems justified in light of the Vancouver Protocol (VP), describing the research methods WHO used in 2007.  Using convenience sampling (see Plouffe and Kalache (p. 736), the WHO research did not typically attempt to obtain representative groups of older adults (VP, p. 5).  The research focused only on “specific neighborhoods or districts within cities” (VP, p. 3), not upon cities as a whole; and it focused on cities, not on small towns and rural communities.  In addition, the WHO data came from very different kinds of cities (e.g., Copacabana versus Tokyo) (see Guide, p. 8, and VP, p. 3), and were reduced (in a process whose details are neither provided nor sourced in the VP or the Guide, nor by Plouffe & Kalache) to the contents of the Guide and/or the Checklist.  The WHO research differentiated participants into two different age groups and two different socioeconomic statuses, and also questioned caregivers and service providers; yet there, again, the Guide provides no indication that such divergent subsets differed in their concepts of age-friendliness.  This outcome does not necessarily mesh with other research.  For instance, Menec et al. (2011, p. 486) suggest a significant difference in preferences between “active” and “stoic” seniors.

According to the Protocol, “The Age-Friendly City project explicitly adopts a locally-driven and ‘bottom-up’ approach that starts with the lived experience of older persons regarding what is, and what is not, age-friendly” (VP, p. 4).  This appears inaccurate.  The Guide (pp. 8-9) says that the topics open to discussion in the WHO’s focus groups had been previously selected by experts.  Plouffe and Kalache (p. 735) confirm this, with an unelaborated remark that variations were made “to accommodate communities in widely varying countries.”  There is a question as to which experts were, or should have been, deemed authoritative.  For instance, Menec et al. (2011, pp. 482-484) consider WHO’s selection of eight key areas of urban living but decide, instead, that age-friendliness is better understood to involve seven key domains; Menec et al. indicate, moreover, that a proper expert analysis of such areas would call for a potentially massive review of literature across such domains (e.g., housing, security, mobility) (e.g., Lehning et al., 2012, Colangeli, 2010, p. 206).  Absent a thorough expert analysis covering the field, it is not clear that the preferences of one or more WHO-selected experts do provide a better, more locally suitable indication of key domains than might have emerged from, say, an ethnographic investigation of the lives of residents within a single community.  (With this emphasis upon involving older persons, it may also deserve mention that Menec et al. (2011, p. 487) warn against governmental attempts to use community engagement as a strategem to “offload” the entire burden of age accommodation onto communities.)

The Guide indicates that all focus groups on all continents were restricted to those same topics.  The groups were apparently rather constrained in their ability to get around to topics that the experts may have overlooked.  One such constraint arose from the “priming” included in the focus group instructions (VP, p. 10:  “An age-friendly community is a community which enables older persons to live in security, maintain their health and participate fully in society”), reinforced by the narrow scope of the questions distributed to focus group participants in advance (VP, pp. 19-22).  Another contraint appeared in the large number of preset questions to be answered (VP, pp. 11-16), within a limited amount of group time, by the ten members of the typical focus groups, given the group leaders’ instructions to keep the discussion within the specified topics (VP, p. 8).

The topic of privacy in housing, mentioned above, is not among the prescribed questions that focus group participants were asked regarding housing (VP, p. 12); indeed, the topic of privacy does not appear anywhere in the Protocol.  Although it is possible that a writer simply invented that addition to the Guide, the more charitable assumption is that focus groups recurrently raised that topic despite its apparent neglect in the previous research encapsulated into the Protocol’s list of questions.  But if groups of older people did repeatedly mention that concern, it is discouraging that the writer of the Checklist felt they could be overruled.  By itself, this instance may not be highly significant.  But I was not hunting for it; it just came out as I was browsing through the Edmonton Vision.  I do not know how many other similar questions would arise if I were to conduct a thorough analysis of the Guide and related documents, never mind what would happen if I had access to WHO’s raw data and to the process by which it was distilled into the Guide.  The privacy example does raise a question about the value that WHO’s researchers placed upon ideas that were initiated by focus group members as distinct from researchers and experts.

There were some methodological drawbacks to the WHO decision to rely solely on focus groups.  Consider, for example, these words from Rubin and Babbie (2005, pp. 455-456):

[T]he representativeness of focus group members is questionable.  Perhaps those who agree to participate or who are the most vocal are the ones with the biggest axes to grind . . . . [Group] dynamics also can create pressures for people to say things that may not accurately reflect their true feelings . . . . Controlling the dynamic within the group is a major challenge. . . . [At the same time,] you must resist overdirecting the interview and the interviewees, thus bringing your own views into play.  Another disadvantage of focus groups is that the data . . . are likely to be voluminous and less systematic than structured survey data.  Analyzing focus group data, therefore, can be more difficult, tedious, and subject to the biases of the evaluator.  And the analysis becomes more difficult to the extent that multiple focus groups yield inconsistent open-ended data.  Thus, focus groups, like any other qualitative or quantitative research method, have certain advantages and disadvantages and are best used in combination with other research methods.

It seems prudent to bear such cautions in mind, considering that the WHO research involved 1,485 participants in 158 groups, conducted in nearly three dozen cities and a variety of languages (Guide, p. 7).  A great deal of contextual and culture-specific information seems to have been lost in the process of milling all that data into the polished form shown in the Guide.  According to Hydén and Bülow (2003, p. 319),

[I]nteraction between the participants has to be taken into account in order to understand and interpret the focus group material.  Focus groups, like dyadic interviews, should be regarded as interactive and communicative events. . . . [This] makes it necessary to describe, not just the social and professional background of the participants, how they were recruited, and where the group met [citation omitted], but also how the group interacted since it is possible for participants to choose different positions for their interactions and also to shift between different modes of interacting during the conversation.

It appears that WHO may have been attempting merely to assemble a list of the concerns that focus groups, with considerable steering, were inclined to emphasize.  This would explain why there is no discussion of any such group complexities and no indication of any disagreements in, or among, any groups.  It appears that WHO data analysts were to eliminate variation by favoring what the Protocol calls “group consensus” – or “groupthink,” as Rubin and Babbie (p. 455) call it – over “individual opinions” (VP, p. 15) that might vary from the majority.

No doubt the WHO recommendations (indeed, the prior research on which it was based) do anticipate many major areas of concern for older people.  The WHO research surely provides a useful addition to the literature.  Without denying the impressiveness of doing research that was in some sense global (despite being mostly confined to a few countries), a better research design would have used focus groups in a more purposeful and exploratory manner, would have reported the findings in more nuanced terms, and would have sought a more representative impression of older people’s concerns by using surveys or other means appropriate to that end.

For such reasons, it would probably be inappropriate to prioritize the WHO recommendations above the findings obtained from good local research.  It appears, then, that Edmonton’s Vision could have provided some clarification as to what it was doing (or not doing) with the WHO recommendations, but that it was probably justified in not linking its goals directly to those recommendations.

Substance:  The New York Example

New York’s age-friendly effort appears to surpass those of all other American cities, in terms of both the swiftness of its start and the number of webpages and other works that mention it.  Like Edmonton, New York has produced several discrete, detailed, readily available documents that address its progress through stages of the age-friendly process.  These include an assessment published in 2008 (Toward an Age-Friendly New York City:  A Findings Report), an action plan in 2009 (Age Friendly NYC:  Enhancing Our City’s Livability for Older New Yorkers (AFNYC)), and other materials expanding or following upon those two (such as, intriguingly, Creating an Age-Friendly NYC One Neighborhood at a Time).  The size and complexity of the city, and of these documents, suggest that many substantive issues arising elsewhere have probably been encountered and articulated to some extent in New York’s publicly available materials.

Like other cities’ action plans, AFNYC does provide its own unique ideas related to the document’s form and structure (above).  While the Edmonton example is notably straightforward, the writer of an action plan might benefit from browsing through a collection of other cities’ plans, including AFNYC.  For example, AFNYC mentions but does not conform its areas of focus to precisely the eight topic areas addressed in WHO’s Guide.  Structurally, this frees AFNYC from the occasional awkwardness of those instances when Edmonton’s Vision finds itself recurrently obliged to state simply that “ESCC continues to seek a lead partner” (e.g., p. 21) to tackle some problem.  In other words, AFNYC asserts control of the substance it will present, and presents it in ways that it deems most suitable for its purposes.

AFNYC presents that substance in the form of initiatives designed to address various aging issues.  The bulk of AFNYC (pp. 25-116) is devoted to these initiatives, in four major sections:  Community and Civic Participation, Housing, Public Spaces and Transportation, and Health and Social Services.  The WHO topics not named in those major section headings largely appear to be treated as subsections thereof; for example, WHO’s Communication & Information topic may be substantially subsumed into the Information & Planning subsection within AFNYC’s section on Community and Civic Participation.  The converse is not always applicable, however:  topics of concern in New York do not necessarily appear in the WHO Guide, even though New York was a participant in WHO’s 2007 research.  For instance, the topic of “access to nutritious food” has its own subsection in AFNYC, whereas the word “food” is mentioned only once in WHO’s Guide.  The same is true of “palliative care.”  Assistance to homeowners and renters has a subsection in AFNYC, but “homeowner” does not appear in the Guide.  Of course, home ownership may be a concern especially in developed nations; but those are where the bulk of the cities featured in WHO’s 2007 research are located.  For a different example of dissimilarity, see the comparison of WHO’s approach against that of Manchester provided by McGarry and Morris, 2011, p. 40.  In such regards, AFNYC provides concrete illustrations in support of the relatively abstract concerns, expressed above, regarding the Vancouver Protocol:  it is highly advisable for communities seeking a solid grasp on their own age-friendliness to do good local research, making use of insights and materials developed since 2007, and to treat the Guide and the Vancouver Protocol as reference sources, not as controlling authorities.

Structurally, each of the four major sections of AFNYC (e.g., Community and Civic Participation) presents its own overview, its agenda, and then a discussion breaking down the individual bullet points (i.e., initiatives) listed in the agenda.  That discussion typically runs for perhaps the equivalent of one-half to one typed double-spaced page.  Such discussions may explain the importance of the issue, describe what New York is currently doing in that regard, and indicate additional relevant steps that the city expects to take.  So, for instance, in response to an Aging in Place issue regarding naturally occurring retirement communities (NORCs), AFNYC (p. 58) cites some advantages of NORCs and then says that the city “will partner with the United Hospital Fund to implement strategic evidence-based interventions in these communities” and will also “continue to seek funding opportunities to promote independent living and increase healthy aging behaviors.”

AFNYC Agendas

It would not be possible to provide a coherent summary of the substance contained in the 92 pages (pp. 25-116) in which AFNYC discusses its initiatives.  It may be helpful, however, to reproduce the agendas of AFNYC’s four major sections.  As just described, each agenda lists the subsections within those major sections, and the initiatives taken in response to certain issues within those subsections, as follows:

COMMUNITY & CIVIC PARTICIPATION AGENDA

Goal: Improve social inclusion, civic participation, and employment opportunities for older adults

Employment & Economic Security

• Provide job training and search assistance to older New Yorkers

• Increase number of paid job opportunities for older New Yorkers

• Assist older New Yorkers short of work histories to obtain employment allowing them to be eligible for Social Security

Volunteerism

• Promote intergenerational volunteering and learning through partnerships with schools and nonprofit organizations

• Provide new volunteer opportunities and expand resources for older New Yorkers through timebanking and other initiatives

Cultural & Recreational Activities

• Establish citywide partnership between senior centers and libraries

• Recruit artists to conduct programs in senior centers

• Provide a guide of discounted arts/cultural events for older New Yorkers

Information & Planning

• Publicize citywide opportunities for older New Yorkers through new older adult-focused NYC & Co. website

• Redesign DFTA’s website to be more user-friendly and provide great information about services

• Conduct local community assessments of neighborhoods to determine age friendliness

• Conduct cultural competency trainings on LGBT issues with the City’s senior service providers

HOUSING AGENDA

Goal: Increase availability and affordability of safe, appropriate housing

Affordable Housing Development

• Target housing funds and streamline process of building low income housing for older New Yorkers

• Examine parking requirements for affordable senior housing and amend the zoning code as necessary to facilitate construction of senior housing

• Provide loans for rehabilitation and new construction of affordable housing

Homeowner & Renter Assistance

• Provide loan assistance to older New Yorkers for home repairs

• Engage NYC home improvement contractors in best practices for the older adult market

• Improve access to SCRIE through transfer to Department of Finance

• Expand eviction prevention legal services for older New Yorkers

Aging in Place

• Provide additional supportive services to NORCs

• Target Section 8 vouchers to vulnerable older adults at risk of eviction

• Promote access to new models of housing that support aging in place

PUBLIC SPACES & TRANSPORTATION AGENDA

Goal: Provide age-friendly public spaces and a safe means for reaching them

Accessible & Affordable Transportation

• Improve elevator and escalator service and enhance accessibility of subway stations

• Improve efficiency of Access-A-Ride by equipping vehicles with GPS devices and implementing phone notification system

• Match accessible taxis with users who need them

• Develop model accessible taxi

• Develop taxi voucher program for older New Yorkers who are unable to use public transportation

Safe & Age-Friendly Public Spaces

• Increase seating in bus shelters

• Install public restrooms at key locations citywide

• Create new, pedestrian friendly public spaces while calming traffic

• Redesign street intersections at key locations citywide to improve safety for older New Yorkers

• Identify age-friendly parks and encourage older adults to utilize them

Planning for the Future

• Provide environmental stewardship workshops and engage older New Yorkers in planting trees as part of PlaNYC and MillionTreesNYC

• Conduct study to better address the mobility needs of older New Yorkers

• Promote use of Universal Design Guidelines through education and awareness efforts

HEALTH & SOCIAL SERVICES AGENDA

Goal: Ensure access to health and social services to support independent living

Wellness & Healthcare Planning

• Increase HIV awareness and health literacy among older New Yorkers

• Redesign senior centers to focus on wellness and develop health outcomes

• Establish fitness club discount for older New Yorkers

• Increase awareness about health insurance options through DFTA’s HIICAP program

Assistance to At-Risk Older Adults

• Implement citywide falls prevention initiative

• Provide free air conditioners to at-risk older New Yorkers

• Conduct outreach to older New Yorkers at risk of social isolation

• Add Silver Alert to Notify NYC

• Expand “Savvy Seniors” campaign to educate older New Yorkers about identity theft and fraud

Access to Nutritious Food

• Improve older New Yorkers’ access to food stamps by implementing telephone application process and outreach campaign

• Implement NYC Green Cart program and form supermarket commission to address needs of neighborhoods underserved by supermarkets

• Provide bus service for older New Yorkers to access grocery stores

• Increase efficiency in City’s case management and home delivered meals programs

Caregiving & Long-Term Care

• Provide counseling and support services to grandparents raising grandchildren

• Expand educational materials and supports available to family caregivers

• Explore policies that would allow more New Yorkers to take family leave when needed

• Conduct outreach and workshops on long-term care and caregiving resources for employers in NYC

• Increase access to community-based care

• Expand training opportunities and other supports for paid caregivers

• Promote awareness and education about long-term care insurance

Palliative Care & Advance Directives

• Promote palliative care

• Expand existing HHC palliative care programs

• Promote advance directives

• Advocate for State legislation authorizing family members or domestic partners to act as surrogates to make health care decisions on behalf of an incapacitated adult

Conclusion

The action plans developed by Edmonton and New York City provide general insights into how an action plan might look and what it might try to achieve.  While there have been a number of approaches, including straightforward black-and-white text documents submitted especially by smaller cities, there are obvious marketing and readability advantages to the construction of an action plan document using colorful graphics and professional layout.

Such a document may address a list of issues, framed within additional introductory and conclusory materials and remarks.  Those issues may follow the eight topic areas suggested in WHO’s Guide or may instead incorporate those eight topics, to varying extents, into a discussion of some alternate list of topics emerging from the community’s own research.  Either way, it appears that the local research, if done well, should play a dominant role – that, in other words, the research methods and underlying the Guide, and the findings reported therein, should be treated as merely advisory.

Having presented this introductory sense of the kind of plan document that a community may ultimately be trying to assemble, in its quest to become and remain age-friendly, it seems appropriate, in a separate post, to move toward developing a baseline assessment of the city’s present age-friendly circumstances.