Age-Friendly Cities: The Elder Congress

The World Health Organization (WHO) and, in the U.S., its national affiliate AARP, are engaged in an initiative to promote age-friendliness in cities and communities.  As recommended by experts and as practiced by communities that have commenced such initiatives, older residents should be involved from the start of the planning and implementation phases of the age-friendly process.  Fitzgerald and Mair (2012, p. 20) recommend that the people commencing an age-friendly initiative “[e]stablish mechanisms to involve older people throughout the process,” and AARP expects communities to “establish an advisory citizens’ committee that includes the active engagement of older adults.”

That AARP formulation raises a variety of questions.  Who should establish such a committee?  The organizers of the age-friendly initiative, presumably, but in that case how can one be sure that the committee is broadly representative of the interests of the community’s older people, as distinct from the interests of the organizers or of some other group of insiders?  Or should the committee indeed be representative of the community’s older people – should it rather merely “include” older adults along with other, younger people (e.g., experts, politicians, other community or nonprofit leaders) who take an interest in age-friendliness?  Does the “active engagement” of older adults require direct activity out in the community, or is it enough if the older adults are merely active committee members (e.g., attending regularly, participating in discussions)?

In answering such questions, it may be helpful to distinguish two sorts of entities:  executive and representative.  To some extent, the Advisory Committee sounds like the former – a decisionmaking entity, comprised of community leaders and other interested people (not all of whom may be 55+), that considers but may not reliably solicit and champion the wide variety of perspectives and needs occurring among a community’s older residents.

Against that sort of Advisory Committee, one might contrast the concept of an Elder Congress, a representative and deliberative body run by and for the community’s older residents for the purpose of finding and discussing their perspectives.  Such a Congress might adopt an ethic that welcomes older people who might hesitate to inject their personal concerns into what could become a fast-paced, insider-oriented, or otherwise intimidating Advisory Committee.  The distinction between these two concepts, executive and representative, may facilitate a clearer sense of the mission of each.

The concept of an Elder Congress may not ever become a reality.  For instance, it may not be feasible to grow an Elder Congress in communities whose older residents are few or uninterested.  To work toward such a Congress, the people behind the age-friendly initiative may opt to use (or at least to begin with) a placeholder – an Elder Congress Committee (ECC) – consisting of a few motivated older residents who actively seek out what other older residents think and experience.  The ECC may be able to inform the community’s Advisory Committee, much as a Congress would.  The work of the ECC could, but would not have to, grow eventually into an actual Elder Congress.

Without an Elder Congress, an ECC, or some other entity deliberately focused upon representing the community’s older residents, the Advisory Committee could proceed by guesswork and anecdote to determine what those residents need.  Alternately, the Advisory Committee could draw upon consultants who would advise on what is best for a community’s older residents.  These approaches may not provide the best response to AARP’s call for active engagement by older adults.  For example, this post is written by an AARP member; but that fact hardly guarantees that the views expressed here will reliably reflect the great variety of older individuals’ situations and concerns.  One could hope that a professional researcher, cast as a consultant, would manage to present consistently neutral and broadly informed perspectives.  But that may simply not happen.  Everyone has biases.  Moreover, good research is difficult, and it can be expensive.  Hired experts do not generally provide an appropriate substitute for the breadth and intensity of views and concerns aired in a representative entity.

It seems, then, that a community’s age-friendly initiative might benefit from the development of two separate bodies.  As conceived here, one – the Advisory Committee sought by AARP – appears to be an executive entity whose members may include politicians, academics, civil engineers, lawyers practicing in elder law, nursing home administrators, and other old and young adults who can contribute time and knowledge to the effort to make the community more age-friendly.  It is unlikely that the Advisory Committee will impress AARP (or anyone else) if its elder members are few and powerless.  But it is also unlikely that attainment of advanced age would be a practical criterion of membership for an effective Advisory Committee.  Some of a community’s most motivated age-friendly people may be in their 30s and 40s.

In this sketch, the key difference between an Elder Congress (or the ECC) and the Advisory Committee is that the former might be oriented toward finding and communicating what older people need, while the latter is apt to try to mesh such needs with its perceptions of political and fiscal realities.  An Elder Congress might incidentally afford continuity through successive political administrations, as different mayors manifest different attitudes toward age-friendliness.

It seems advisable to address the subject of the Elder Congress early in an age-friendly effort.  Early steps often set a pattern for what comes after.  To illustrate, there may be considerable differences between an age-friendly initiative commenced and essentially owned by older people, and one that starts out as a marketing effort advocated by real estate developers.  It would not be surprising if the latter displayed a lack of enthusiasm for improvements that would primarily benefit lower-income communities; and once a skewed perspective is ensconced, it can be difficult to reframe it.

A community’s age-friendly effort may be initiated by City Hall, by gerontologists, or by other interested experts or professionals.  Regardless, this post suggests that the best practice for such initiators (themselves forming a de facto Advisory Committee) may be to begin by creating the ECC.

There is always a risk that the ECC, or the resulting Elder Congress, would be stillborn or dysfunctional.  That short-term outcome, in itself, could provide valuable information, leading to potential improvements in the recruitment and facilitation of elder participation in the age-friendly effort.  The possibility that an elder-led entity does not spring into existence perfectly formed would probably not provide an excuse for cutting such an entity out of the picture.  It may take more than one try to get the project off the ground.  Even so, it would probably be better to make the effort, to discover difficulties, and to correct significant problems early in the game, than to let them become institutionalized within the multiyear age-friendly process.

An Elder Congress might be deemed to come into existence when its members are chosen or nominated by the groups they represent (e.g., the very old, residents of the warehouse district, older people with disabilities).  But even if that never happens – if the community’s older residents are left only with the Elder Congress Committee – there would presumably continue to be an expectation that the members of such a Committee would earnestly seek to understand and represent the community’s spectrum of older people.  Without that, the ECC might lack a raison d’être:  it would presumably contribute little that the Advisory Committee could not accomplish by itself.

The concepts of the Advisory Committee, the Elder Congress, and the Elder Congress Committee seem useful, even if they are ultimately not implemented in exactly these forms.  They express, in relatively concrete terms, the likely (and perhaps sometimes large) differences between the preferences of older people and of those who would govern, advise, study, treat, or otherwise work with them, for them, or on them.  The Elder Congress concept is especially important for purposes of highlighting those differences.  Hence, the next post looks at several factors that may deter cities from incorporating an Elder Congress Committee into their age-friendly efforts from the very start.

The Age-Friendly Community: Approaching the Baseline Assessment

As discussed in a prior post, the World Health Organization (WHO) and AARP list a community (e.g., city, county) as “age-friendly” when its mayor (or other chief administrator) commits it to an age-friendly improvement process.  That process begins with a Planning phase, in which the community conducts a baseline assessment of its current age-friendliness and then uses that assessment to inform an action plan for improvement.  As shown in that prior post’s discussion of materials from Edmonton and New York City, an action plan may identify issues of concern to older people that emerge from the assessment, and may indicate how the community intends to address those issues.  With that general concept of the action plan in place, this post turns to examine baseline assessments used by several cities.

Concept of the Baseline Assessment

A “baseline” typically provides a starting point for comparison.  What is required here, according to AARP, is “a comprehensive and inclusive baseline assessment of the age-friendliness of the community.”  WHO indicates that the assessment “can be flexible to take into account the diversity of cities and communities, however at a minimum, it needs to consider each of the eight domains identified in the WHO Age-friendly Cities Guide.”  Those eight domains are Outdoor Spaces and Buildings, Transportation, Housing, Social Participation, Respect and Social Inclusion, Civic Participation and Employment, Communication and Information, and Community Support and Health Services.

That WHO quote does not indicate that every aspect of the Guide’s detailed discussion needs to be elaborated at length in the written baseline assessment.  As noted in the previous post, the prototypical Vancouver Protocol itself failed to anticipate all of the subtopics that have since been incorporated into the Guide.  The Guide reflects WHO’s 2007 effort, which evidently sought to identify the gamut of concerns voiced by majorities in 158 focus groups from around the world.  It is unlikely that every one of those concerns will be relevant and important in every community.

It does not appear that a baseline assessment must be an extravagant affair.  Fitzgerald and Mair (2012, p. 20) suggest that it “could range from a review of current policies to a more detailed activity such as developing a survey to ask older people what they think would make their city age-friendly.”  Consistent with that mild interpretation, to cite one example, the application apparently submitted to WHO in September 2011 by Los Altos, CA – which is one of the WHO network member cities identified in an earlier post – reported the results of a questionnaire (22 close-ended questions; two open-ended questions) mailed to 4,530 addresses on a purchased mailing list (targeted to people within two specified zip codes aged 55+).  The Los Altos document summarized the results of the 1,032 questionnaires returned (23% response rate) in approximately four single-spaced pages.  That summary was divided into eight sections corresponding to WHO’s eight domains (above).  Each such section typically provided a paragraph discussing issues identified in the completed questionnaires, followed by several bullet points presenting the city’s suggestions for responsive improvements.

The Los Altos document includes reports of amounts spent and grant monies sought to defray costs.  Such materials provide a reminder that many communities (especially but not only in developing nations) may encounter budgetary and other constraints on their efforts to commence the age-friendly process – which, as noted in a previous post, should be understood as emphasizing improvement from the baseline, not as a certification effort in which each community must demonstrate performance meeting or exceeding specified thresholds.  Continued membership in WHO’s network evidently requires only the pursuit of cyclical age-improvement:  assessing areas needing improvement, implementing a plan designed to achieve improvements in those areas, monitoring the process, evaluating the outcomes, and repeating the process.  In other words, the WHO process evidently seeks to welcome and encourage communities to join and participate, not to eliminate communities that underperform.

That said, there may also be factors encouraging some diligence and completeness in the baseline assessment.  Although the situation is not clear, as described in a previous post, it appears that AARP, WHO’s national affiliate for the U.S., may soon take over the role of corresponding with age-friendly aspiring cities in the U.S. (and possibly elsewhere).  As noted in the post just cited, it appears that AARP may take at least a mildly critical look at action plans submitted by American communities.  Given the plan’s dependence upon the assessment, it would be prudent in any event to do at least a moderately defensible job of assessing what the plan needs to fix.  Moreover, the several action plans I have reviewed bespeak sincere efforts toward age-improvement.  It is likely that such efforts will make some difference over time, and that such efforts will be increasingly noticed by present and would-be residents as the nation’s population continues to age.  Governments that appear to have made no convincing, fruitful efforts toward age-friendliness may eventually confront older voters who will have become irate at the contrasts between their cities and others that were more foresightful.

Obtaining Baseline Information

As noted in the immediately preceding post, WHO’s Guide evidently sought to present, in simplified terms, the key emphases emerging from steered group discussions of a preexisting list of concerns supplied by researchers.  The Guide does appear to have noted many, possibly most, of the general concerns that would occur to most older people in most communities.  One might suggest, then, that a competent inquiry into a given community’s age-friendliness will risk being incomplete if it does not devote some attention to each of the eight WHO domains listed above.

That preceding post also offers some criticisms of the Guide, and of the 2007 WHO research underlying it.  A good assessment would presumably want to take account of those criticisms, so as to supplement or supersede that research approach with additional or alternate measures designed to yield a better picture.  That is, the Guide may serve as a useful guide to areas deserving investigation, but it could be a mistake to treat it as a definitive statement of parameters for future research into a given community’s age-friendliness.  There are competing alternatives.  It is noteworthy that, for example, Laying the Foundation for an Age-friendly Philadelphia: A Progress Report (June 2011) bases that city’s effort on the U.S. Environmental Protection Agency’s Building Healthy Communities for Active Aging (BHCAA) program.  Specifically, Philadelphia’s model seeks to combine concepts of active aging and smart urban growth in an emphasis on social capital, flexible and accessible housing, mobility, and healthy eating (p. 11).  Admittedly, EPA concepts may not be directly helpful in an effort to be listed as a WHO age-friendly city; but awareness of other constructs may foster inquiry into topics potentially neglected in the Guide.  For instance, the just-mentioned topic of social capital (summarized, in the Philadelphia document, as “a measure of trust and connectedness among neighbors and to what extent they feel part of the community in which they live”) has drawn considerable scholarly attention, and yet the Guide makes no specific reference to it.

On a methodological level, to summarize criticisms presented in the preceding post, one problem with WHO’s research is that it relied solely on focus groups, without seeking to confirm or deny the focus group conclusions via other research methods.  WHO also appears to have used focus groups to present a representative general picture, when the focus group method is not suited for that purpose – especially but not only when the groups are composed of whoever happened to show up.  The focus groups may have naturally tended (and seem to have been administered in a manner intended) to stifle individual voices in favor of enduring or perhaps temporary group consensus, whereas one might expect that many of the older people who experience hardships in age-unfriendly communities may display some variance from consensus.  The voluminous data produced by the project’s inordinately large number of focus groups seem to have been analyzed in a context not open to scrutiny, even though such floods of information are especially likely to encourage hasty and otherwise inferior data analysis – when, much to the contrary, experts recommend painstaking attention to focus group outputs.  The results were reported anecdotally, in the Guide, as illustrations of certain main points; those points were largely preconceived from prior research, not arising from any effort to elicit, from scratch, the priorities and concerns of any distinct community’s older residents.  The purpose of such criticisms is not to deny the service provided by the WHO research, and by the age-friendly movement it has helped to set in motion; it is, rather, to emphasize that communities should use appropriate research methods and should be open to their own residents’ views, taking account of but not confining themselves to the methods used and the findings reported in the Guide.  The Vancouver Protocol (pp. 11-15) does illustrate questions that one might ask, but it should not be treated as definitive.

For purposes of comparison, it may be useful to consider methods used in a closely scrutinized city – specifically, the methodology section (pp. 6-9) of New York’s baseline assessment, appearing in Toward an Age-Friendly New York City:  A Findings Report.  As reported there, New York sought “to determine the existing age-friendliness of the city and identify ways in which it can become more age friendly” (p. 6).  Methods used were as follows:

• Community Forums:  14 town-hall meetings across all five boroughs, attended by nearly 1,500 people, of whom the vast majority were older people and their caregivers.  Meetings lasted 90 to 180 minutes and featured largely participant-driven discussions (two formally translated into Spanish, one into Cantonese and Mandarin, and others translated informally into other languages).
• Focus Groups:  six groups, each lasting about 90 minutes, “to capture the views of older adults often underrepresented in other research, such as immigrants, isolated older adults, and those living in poverty” (p. 7), comprised of 19 men and 27 women altogether, for an average of less than eight persons per group.
• Interviews:  24 one-on-one interviews with older immigrants from 12 countries, primarily in Spanish.  Most had incomes below $10,000.
• Questionnaires:  available at the forums (above) and also online.  More than 600 completed, about 83% by people indicating ages of 65+.
• Expert Roundtables:  seven discussions, each focused on a particular topic (e.g., housing development, tenant rights).
• Data Mapping:  provided as appendices to the Findings Report.  These maps of New York City showed, among other things, the points of geographical concentration of older people generally, those with disabilities, those living in poverty, those with rent deemed unaffordable, those in walk-up (i.e., multistory, no elevator) residential buildings, their average distances from the closest bus stop, sidewalk cleanliness, and walkability.
• Request for Information:  18 responses, mostly from reputable nonprofits, addressing policy and regulatory changes needed to make the city more age-friendly.
• Self-Assessment of City Agencies:  assessments by commissioners of 22 city agencies regarding their agencies’ age-friendliness.
• Secondary Research:  literature review regarding characteristics of New York City’s older population and local, national, and international trends.
• Website:  more than 1,000 page views as of August 2008, when the Findings Report was in process.

Most of these measures could have been used more intensively.  For example, those pages of New York’s Findings Report acknowledge a lack of resources to reach all affected groups, including immigrants and homebound and institutionalized older people, as well as an absence of quantitative measures capable of assessing numbers of affected people overall or within specific groups.  The Findings Report also implicitly recognizes a potential need for more insightful qualitative research and/or further literature reviews to develop better understandings of elder life in diverse big-city communities:  it reports encounters with older people who, despite low incomes, felt safe, contented, and connected, thanks to their familiarity with the communities in which they had spent many years (p. 17).

Perhaps in response to the immediately preceding sentence, New York has since departed from the focus on cities as a whole that WHO’s Guide adopts (notwithstanding Vancouver Protocol p. 3), through a devolution of efforts to more immediate contexts “where older adults said they most wanted to see change:  age-friendly business; age-friendly schools, colleges, and universities; and Aging Improvement Districts, local efforts to transform neighborhoods.”  That quote comes from Creating an Age-Friendly NYC One Neighborhood at a Time (p. 10).  In other words, it can be inordinately complex – it may be unrealistic and inappropriate – to treat the welfare of older people in a place like New York as though it were capable of being addressed comprehensively through broad-sweep, high-level governmental efforts.  Without denying the advantages of the grand view for some purposes, and of the power of efforts made at such levels, it may make more sense in some settings to break the issue down into smaller or more precisely identifiable communities or populations.  For example, a questionnaire mailed to older New Yorkers generally would probably not be able to home in on issues of relevance to older Puerto Rican New Yorkers specifically, and one might say the same when using interviews, focus groups, and other methods.

New York appears to provide the broadest and most open display of information regarding research methods used in the construction of a baseline assessment.  Some other cities’ assessments provide little to no information about methods.  Others use one or more of the methods listed above.  For various aspects of its study, Philadelphia, for example, used a survey (p. 11), meetings among organizations (p. 16), and focus groups and nonprofit feedback (p. 21).  Perth (pp. 17-22) reviewed governmental publications; developed a reference group comprised of city and provincial agency heads, nonprofits, and an external consultant; conducted focus groups (including two for residents of Asian communities within the city, and one for deaf residents); made direct personal contact with relevant service providers; and mailed a survey to senior citizens.  People contacted and invited into focus groups included not only local residents but also a substantial number of visitors, possibly indicating an effort to engage older tourists but apparently also directed toward Aboriginal visitors.  Canberra (p. 7) used a pilot-tested 58-item questionnaire conducted under university auspices.  The survey was sent to all local households listed as members of the Australian Council on the Ageing, was also distributed through several dozen organizations providing services to older Canberra residents, and in addition was made generally available via SurveyMonkey.  Researchers received 1,652 completed questionnaires by mail and 320 online.  Early in the WHO process, Portland and Saanich used focus group members selected by convenience.  A number of cities also used academic literature and secondary (e.g., previously published governmental) data.  Cities promoted awareness of their efforts through various means, including posters and postcards sent to older residents and to relevant organizations; and advertisements in publications and broadcast media.  As noted in the Perth document (p. 21), outreach efforts were especially likely to reach those older people who were already involved in their communities and those of relatively high socioeconomic status.

These remarks provide a variety of thoughts about methods that age-friendly cities have used to gather the data supporting baseline assessments of their age-friendliness.  As suggested especially by the Canberra example, the task of conducting an assessment has been studied in some detail.  The next post examines some characteristics that experts have identified as important.

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.

Becoming an Age-Friendly City: The Planning Phase

Elements of the Planning Phase

The prior post in this series examined the process of obtaining World Health Organization (WHO) designation as an age-friendly city.  Having thus accounted for preliminary contact between AARP (as WHO’s nation-level affiliate) and the mayor or other administrative head (referred to here as simply the “mayor”) of the interested city, county, or other entity (the “community”), this post focuses on the crucial first phase in the work needed to earn and keep the age-friendly designation.

That first phase, named in WHO materials as the Planning phase, is to consist of four steps.  Those steps are listed in a variety of materials, including WHO’s webpage, providing an application form to join the Global Network of Age-friendly Cities and Communities (GNAFCC), and an article by Fitzgerald and Mair (2012, p. 20), as follows:

1.  Establish mechanisms to involve older people throughout the process.

2.  Develop a baseline assessment of the community’s age-friendliness, taking account of eight domains discussed in WHO’s Global Age-friendly Cities Guide.

3.  Develop a three-year community-wide action plan.

4.  Identify indicators to monitor progress against that plan.

It is worth noting, however, that at this point AARP provides a variant characterization of the process in its Network of Age-Friendly Communities booklet, as follows:

Once admitted, the communities must, within 24 months of entry, do the following:

• establish an advisory citizens’ committee that includes the active engagement of older adults;

• secure a local municipal council resolution to actively support, promote and work towards becoming age-friendly;

• establish a robust and concrete plan of action that responds to the needs identified by older adults in the community;

• demonstrate commitment to action by publicly posting [an] action plan;

• commit to measuring activities, reviewing action plan outcomes, and reporting on them publicly.

At the end of the first two years, the communities will agree to an assessment and evaluation of the action plan.

The community will commit to implementing the approved action plan during the next three-year period and will submit a progress report to AARP at the end of the five years that outlines progress against the indicators developed in the action plan. Membership would be automatically renewed following a positive assessment and submission of a revised action plan.

Interpretation of Planning Phase Elements

Both of those characterizations, by WHO and AARP, contemplate an initial two-year planning phase, following entry of the community’s name into the list of network member communities.  In the phrasing used by Fitzgerald and Mair, both also anticipate that the second phase – Implementation, in the WHO’s nomenclature – will begin “no later than two years after joining the Network” (pp. 20-21).  WHO and AARP agree, here, that the Planning phase has to include an action plan.

There is some divergence between WHO and AARP in other regards.  What Fitzgerald and Mair call an effort to “involve the user” (p. 20) is operationalized, in AARP’s version, by a specific requirement for an advisory citizens’ committee that actively engages older adults.  AARP’s requirement raises questions.  For example, which would be better:  a committee run by twentysomethings that scrupulously seeks out and facilitates the wishes of the spectrum of old people in a community, or a committee dominated by a few octogenarians who rigidly refuse to take account of anyone else’s opinion?  (In case anyone wonders about such questions, please note that I am an AARP member and often have new experiences with older people.)  In other words, what counts as active engagement of older adults, and how flexible will (and should) AARP be on that?

AARP’s second requirement, for a municipal council resolution, does not appear in the WHO formulation.  This difference seems appropriate; not every country to which WHO spoke would have an American-style system of city governance.  AARP’s concern in this regard seems to be that the community must commit to the age-friendly process, not only in the sense of involving older people, but also in the sense of insuring that governmental systems are in sync with and supportive of the process.  One wonders why WHO did not similarly anticipate this concern.  The contrast appears to be between a process driven by a non-governmental organization (NGO), in the WHO version, and a process conceived and shaped by the NGO but at least partly implemented by local government, in AARP’s approach.  This difference, too, may reflect an American difference in terms of the relative strengths and weaknesses of government and of NGOs.

Regarding the plan of action, the WHO objective is to develop what Fitzgerald and Mair call “a three-year city-wide plan” (p. 20) that is “based on the findings of the assessment.”  The AARP formulation quoted above makes no explicit reference to an assessment, instead merely stating that the plan must be robust, concrete, responsive to needs identified by older adults, and publicly posted.  It seems advisable to make clear the difference between an assessment and a plan.  According to Fitzgerald and Mair (p. 20), an assessment is intended “to determine the current age-friendliness of the city” and could entail, for example, “a review of current policies” or “a survey to ask older people what they think would make their city age-friendly.”  That latter example of assessment could be confusing, insofar as it seems to verge into the notion of a plan.  It appears that Fitzgerald and Mair suggested that kind of survey as an oblique indicator of what is presently wrong with the community (i.e., what would need to be fixed in order to make it more age-friendly).

It seems, in other words, that when AARP calls for attention to “needs identified by older adults,” it means to imply that older adults will be given an opportunity to express needs.  A survey is an example of one such approach; a series of open-ended interviews would be another.  The suggestion of “a review of current policies” would not necessarily entail a dry academic exercise if, for example, there have already been considerable efforts to identify needs within a particular city, and what seems to be most needed is a reconciliation of conflicting visions.  In short, the focus of the assessment is not upon going through the motions of a survey, especially not if a survey is not the best instrument for a particular situation.  The objective here is to identify, by whatever means, the range and concentration(s) of age-friendly needs.

Once needs have been identified, there must be a plan to address them.  This plan of action will be implemented in, of course, the Implementation phase.  Notwithstanding AARP’s adjectives (“robust and concrete”), it seems that Fitzgerald and Mair capture the gist of the plan in their remarks that such plans will vary from one community to the next and may incorporate simple steps (e.g., installing more park benches) as well as more detailed moves (e.g., describing ways in which social service programs can be better coordinated).

It would apparently be possible for a community to adopt a faux plan, easily achieved, so as to put on the appearance of becoming age-friendly without making crucial improvements.  The counterweight against such an inclination would presumably be the desire of old people in a community to experience genuine age-friendliness.  Ideally, one might speculate, the WHO’s initiative would have reached old people directly or by proxy, so as to empower them to coalesce in their own self-formed committee structures to lobby their local governments as needed.  AARP’s approach likewise does not contemplate any such grassroots effort, commencing instead with communications with mayors and such.  There may be, in this regard, a lack of conviction that older people could and would effectively organize themselves, with or without NGO assistance, or perhaps some awareness that WHO and/or AARP lack the means or inclination to begin by contacting the affected individuals directly.

In other words, the scheme generally proceeds in a top-down fashion.  This may make it seem most efficient and also most logical to bureaucrats, academics, and others involved with such processes.  At the same time, it may convey a sense that older people are not only the clientele but also, potentially, the problem, especially if they do not enthusiastically cooperate in and support what the organizers want to do.  The WHO/AARP scenario does seem to accept the reasonable proposition that a committee of twentysomethings could bring about superior results for old people in today’s world.  The responsive challenge in such a proposition seems to be not merely to trust the organizers but to facilitate independent critique of the assessment.

One might say that “age-friendly” is something of a misnomer.  “Age-friendly” usually seems to be taken as an indicator of achievement of a level of quality or service.  This interpretation emerges in, for example, the claims that various communities have been “declared” or “recognized” as age-friendly.  There are surely purposes for which it could be helpful to certify achievement of an age-friendly standard of living.  For instance, retirees contemplating the offers of real estate developers could find it helpful to know that all curbs in a community have been appropriately cut to facilitate wheelchair access, or that there exists a bus or van service offering at least a specified minimum level of service.  A bundle of such standards could be incorporated into an “age-friendly” certification.  That, however, is not the nature of the WHO effort.  That effort is oriented toward improvement over the past, not toward achievement of specified standards.  The age-friendly concept advanced by WHO and AARP is just that communities with become more age-friendly.  To answer the question posed in a previous post, then, the point is not that Kolkata and Austin will be comparably age-friendly; it is just that both will be at least somewhat more age-friendly than they were before they entered the GNAFCC.  It would be more accurate to replace the WHO “age-friendly” terminology with an indication that a community has evinced at least a preliminary commitment to “age-improvement” or “age-positivity.”  Such terms do not resonate as well as “age-friendly” – and that is fitting, given the actual limitations of the age-friendly program.

Such observations call into question the idea of basing age-friendliness upon the needs identified by community members.  No doubt residents tend to be aware of obvious problems in their locale.  But it is quite possible that only a small minority of the aged residents of an impoverished city in a developing nation have ever heard of curb cuts, or would even dream of a reliable van service.  Under such circumstances, one could expect sharply divergent findings from different forms of assessment.  Suppose, at one extreme, that such residents are simply allowed to volunteer the idea of a van service, should it happen to come to mind.  Such an assessment might conclude there is little immediate interest in van service.  Suppose, on the other extreme, that such residents are given a half-hour presentation on what life is like for aged residents of a privileged community in a developed nation where such transportation is the norm, and are then interviewed at length, so that researchers may develop a clear understanding of their thoughts on what they need, could use, and are entitled to.  It would not be surprising if the people in the latter group evince considerably greater interest in van service.  That is, people in one community, or at one socioeconomic level, may or may not be aware of and inclined toward aspects of age-friendly life that may be taken for granted elsewhere.  One wonders, then, to what extent the identification of age-friendly needs must be spontaneously generated at the grassroots level, when the age-friendly scheme itself is not of a grassroots nature.  It would seem that here is where the insights of education – of what is possible, what is being tried in various places – could provide a salutary enhancement to what older people themselves already know.

Perhaps the response to those thoughts is that, if one is seeking mere age-improvement as distinct from age-friendliness, old people who suffer from insensitivity to the plight of age may be best positioned to identify their community’s most pressing age-related needs.  It is, in other words, not a question of what is needed to put a community’s senior citizens on a par with those of some other community; it is just a practical matter of attempting whatever the community can do to improve things somewhat.  A pie-in-the-sky ideal could be unhelpful if not counterproductive.

To synthesize the conflicting thoughts expressed in the two preceding paragraphs, it seems that what is needed may be some of each:  age-improvement, on the ground, for purposes of making concrete differences in specific lives in the relatively short term; and also age-friendliness, in the sense of an appraisal of what it would take for such a community to meet specified standards (involving e.g., van service) deemed necessary to facilitate a reasonably good late life, for purposes of longer-term planning and visualization.  Relying solely upon the current awareness of old people runs the risk of impoverishing their concept of what is practically achievable in the near to medium term – that is, a good assessment might educate them regarding the possibilities – but relying solely upon an unrealistic concept of certifiable age-friendliness risks irrelevance to a particular community’s near-term situation.

Questions of feasibility seem crucial to the concept of the action plan.  Fitzgerald and Mair (p. 20) say that “cities must develop a three-year city-wide plan of action.”  Their examples (above) ranging from park benches to social service coordination illustrate some difficulties in this idea.  Park benches may be a matter of budgeting – simple, and yet politically difficult if they require a cutback in some other area of expenditure.  Social service coordination could involve no additional net expenditure, but may require exploration into the unknown, as one sets forth on the path of changing how bureaucracies act and interact.  Notwithstanding the claim that “cities” must do this sort of thing, the range of actors implicated in such efforts could well include NGOs (e.g., those interested in parks or social services), state governments, and academics.

It appears, then, that older residents may have a clear concept of immediate needs, and may offer some input into more distant possibilities, but may not be key players in terms of what the city will actually decide.  After all, the city will already have its WHO age-friendly designation; its mayor may have few incentives to alienate powerful constituencies for the sake of significant, politically unsupported shifts in spending priorities.  One might expect a tendency toward visible yet cosmetic changes, as distinct from costly and unglamorous (e.g., infrastructure) alterations, except where the population of older persons does form a voting bloc that perceives significant potential benefits.  The impetus for age-improvement may thus be strongest in those communities that combine substantial aging populations with ambitious plans of action – stimulating a substantial political consensus that offers considerable benefits to a spectrum of older residents.  It will not be surprising if communities in the vanguard of that movement eventually devise forms of certification or endorsement that distinguish them from other communicates whose smaller aged populations and/or weaker plans yield scant enthusiasm for meaningful improvement.  (There could be a question as to whether communities should consider taking account of older people who plan to move away upon retirement, or of those who would consider staying in or moving to the community if it were to offer certain age-related amenities.)

Although WHO and AARP present the identification of indicators as a separate part of the Planning phase, it seems likely that the indicators will be decided during development of the plan.  Fitzgerald and Mair (p. 20) offer, as an example of an indicator, a statement that 20 new park benches will be installed by a certain date.  That may amount simply to a budgetary decision that the community can afford to purchase and install 20 benches by that date.  AARP seems closer to the mark, here, in its statement that the community must “commit to measuring activities, reviewing action plan outcomes, and reporting on them publicly.”  The point is that there may not be a separate step of deciding upon indicators of progress.  The more likely separate step will be the tracking and evaluation of progress, or lack thereof, toward achievement of plan elements.  While some aspects of the age-friendly scheme seem governmentally oriented, this tracking dimension could evoke a more citizen-based watchdog orientation.  It appears, in other words, that the Planning phase may include not merely the development of a plan, with specific indications of what needs to be achieved (e.g., how many park benches need to be installed, and by what date), but also the conceptualization of a tracking mechanism whereby various stakeholders can learn about, and provide input on, what is actually happening during implementation.

It is not clear what AARP intended in its statement (above) that, “At the end of the first two years, the communities will agree to an assessment and evaluation of the action plan” (Network of Age-Friendly Communities, p. 11).  There is to be a progress report, “outlining progress against indicators,” at the end of year 5 (Fitzgerald & Mair, p. 21).  That fifth-year report makes sense, coming at the conclusion of the three-year Implementation phase.  But what would be assessed or evaluated at the end of year two?  In light of the following statement that the community will then commit to implementing “the approved action plan” (emphasis added), the explanation seems to be that AARP will assess and evaluate the action plan and may then approve it for implementation.  In this interpretation, “assess and evaluate” just mean “review,” and the statement that communities “will agree to” such review just means that they will send their plan to AARP.  One would hope, though, that communities would be in touch with AARP throughout the Planning phase (although the summary wording does not invite that), so as to insure that they are not somehow departing from the unspecified standards by which AARP will evidently be critiquing their potentially hard-won action plans.

Conclusion

The Planning phase appears to be both crucial and first in the WHO/AARP age-friendly process.  Within the Planning phase, the foregoing remarks suggest that, in WHO terms, the key elements are the baseline assessment and the action plan.  As AARP seems to anticipate, those two elements seem likely to require an understanding of the types of input needed or desired for the process, and of the types and roles of various players and stakeholders seeking, providing, using, and affected by that input.

The action plan will presumably sketch out a path to achieve relevant objectives identified in the baseline assessment.  That plan will coalesce within certain constraints.  For instance, as noted above, it would be possible to pursue unrealistic objectives or to depart from what WHO or AARP intend.  The baseline assessment does not unfold within a vacuum; it examines matters that could conceivably be addressed in the action plan.

It seems, in other words, that the concept of the action plan is the first local item to be developed in the age-friendly process.  The specifics of the action plan must await the outcomes of the baseline assessment, but the parameters restricting that assessment are determined by the question of what kind of plan one is aiming for.  Whatever the details, the type of plan that would be appropriate for Shanghai is likely to be substantially different from the type of plan one might use in Ann Arbor.  Basically, you have to know what you are looking for, before you start to look:  the data-gathering aspects of the assessment depend upon a prior sense of why we are gathering those particular data.  Another post examines action plans in more detail.

Becoming an Age-Friendly City: The AARP/WHO Process

In two previous posts, this blog introduced the World Health Organization’s (WHO) “age-friendly city” concept and explored certain background matters, so as to identify some key players.

As described in the second of those posts, it developed that WHO had listed approximately 140 cities as members of its Global Network of Age-friendly Cities and Communities (GNAFCC).  It also appeared that WHO had worked out agreements with eleven national-level associates – including, in the U.S., AARP’s Network of Age-Friendly Communities (NAFC).  The cities listed as U.S. members of GNAFCC did not closely match those listed on NAFC.  The latter seemed to be in a pilot phase; my guess was that GNAFCC and NAFC would conform their lists of U.S. network member cities when NAFC emerged from that pilot phase.

The purpose of those two preceding posts was to work toward the question of how a city might become age-friendly.  Although my preliminary browsing had not yielded an entirely clear understanding, eventually it appeared that AARP did intend to implement the WHO approach, as distinct from pursuing its own concept of age-friendliness.  This impression emerged from two aspects of an AARP webpage discussing the NAFC.  First, that AARP webpage listed “Eight Domains of Livability,” involving items like housing and translation, and that list matched the eight items listed by WHO, as shown in the introductory post in this blog.  Second, that AARP webpage stated that communities would contact AARP, and AARP would then notify WHO.  It seemed, in other words, that communities did not have to worry about trying to work with WHO and AARP simultaneously; the latter was evidently supposed to be the community’s point of contact.

That AARP webpage further provided a step-by-step outline of the process of becoming age-friendly.  That is, after showing the “Eight Domains of Livability,” the webpage stated certain criteria and then briefly presented a three-phase process.  Taken together, these sections of the webpage indicated that the process would begin when AARP notified a community (i.e., “cities, towns, and counties”) that it found them potentially capable of committing to a continuous effort toward improved age-friendliness.  It was not clear whether communities not contacted by AARP would have the option of initiating an age-friendly effort, nor was there any indication, on that webpage, of the criteria AARP would apply to make such determinations.

According to the AARP webpage, such notification would apparently occur when AARP “informs municipal officials” of its age-friendly program and “ascertains the community’s interest.”  The latter apparently meant that AARP would find out whether the mayor or municipal (or, presumably county) administrator (collectively referred to here, in short, as simply the mayor) was interested.  The AARP webpage did not say what would happen if both a city’s mayor and the administrator of the county containing that city expressed an interest, or if some cities within an interested county diverged in their age-friendly interests and capabilities.

The AARP webpage indicated that, if the mayor did provide written confirmation of the community’s commitment, AARP would list the community as a member of NAFC and would notify WHO (above), which would presumably list the community on GNAFCC as well.  As noted in the background post, communities might describe themselves as having been “designated” or “declared” or “recognized” as age-friendly by WHO, but such terms evidently meant just that the mayor had written that letter to AARP, committing the community to the age-friendliness improvement process.  Being listed as age-friendly thus did not appear to imply that any actual improvement had already occurred, although this was not entirely clear:  a WHO webpage providing an application form to join GNAFCC did claim that applicants were required to “commence” actual work.

It seemed that the mayor’s commitment to the age-friendliness improvement process would oblige the community to undertake a three-phase, multi-year effort.  On the AARP webpage, those three phases, each projected to last two or more years, were characterized as Planning, Implementation, and Continual Improvements.  This varied, again, from the WHO webpage just cited:  it named four steps rather than three phases in the “Network cycle.”  My impression, consistent with Fitzgerald and Mair (2012, p. 20), was that those four steps might just be elements within the Planning phase, which would typically be the only phase of immediate concern to people looking at WHO’s application webpage.  (In this and other regards, the AARP webpage substantially mirrored WHO’s GNAFCC brochure and AARP’s Network of Age-Friendly Communities booklet.)

AARP’s Implementation and Continual Improvements phases seemed self-explanatory; the latter would yield automatic renewal of NAFC membership “following a positive assessment and the submission of a revised action plan.”  It seemed, in other words, that success in the second and third phases would depend upon the work and thought required for the Planning phase.  The details of the Planning phase are the subject of a separate post.

The WHO’s Age-Friendly Cities Concept

I heard of the World Health Organization’s (WHO) “Age-Friendly Cities” concept.  I wanted to learn more about it.  This post summarizes what I found and, at the end, it links to the next post in a series on this topic.

A search led to a number of WHO webpages and materials.  Among these was Global Age-friendly Cities:  A Guide.  That document appeared to prioritize certain characteristics of what its introduction called “supportive and enabling living environments” (p. 1).  Another WHO document, “Checklist of Essential Features of Age-friendly Cities,” echoed that list of prioritized characteristics in a more boiled down form.  According to the latter, the features that would determine an Age-friendly City (AFC) were:

• Outdoor spaces and buildings
• Transportation
• Housing
• Social participation
• Respect and social inclusion
• Civic participation and employment
• Communication and information
• Community and health services

In those two documents, each of these points received detailed treatment.  For example, within the topic of Housing, the Checklist provided seven bullet points, each consisting of one expectation or aspiration (e.g., “Sufficient, affordable housing is available in areas that are safe and close to services and the rest of the community”), whereas the Guide identified nine criteria (e.g., “Affordability”), each elaborated in several paragraphs.  The two documents referred to each other.  It thus appeared that I had arrived at at least a preliminary entry into the AFC concept.

The Guide (p. 1) indicated that the WHO came up with this list of essential features by conducting focus-group investigations in which older people described “the advantages and barriers they experience in eight areas of city living.”  In particular, the materials provided under each topic heading (e.g., Housing) within the Guide were said to “highlight the issues and concerns voiced by older people in each of eight areas of urban living.”  These eight topics “had been identified in previous research with older people on the characteristics of elderly-friendly communities” (p. 8).

In those remarks, I noticed a potential contrast between “urban living” and “communities.”  The Guide provided a list of “age-friendly partner cities” (p. 8) of varying size (p. 7).  The two from the U.S. were New York City and Portland, OR.  Most of the others were similarly recognizable cities (e.g., New Delhi, Shanghai, Tokyo, Nairobi, London).  A look at a few Canadian cities that I did not recognize suggested that most of those that were not large cities in their own right might be suburbs or districts within larger cities, or might otherwise be exotic or atypical (e.g., Cancun, Mexico).  It also seemed unlikely that older people in very different cultures (in e.g., Islamabad, as compared to Geneva) would necessarily value the same things.

I was not confident, in other words, that factors identified as crucial in the WHO’s age-friendly partner cities would all be equally crucial to older residents in smaller or divergent American places (e.g., Salt Lake City, Plano, Lansing).  It was not that the WHO’s list of factors sounded bad.  Intuitively, one would expect almost everyone to applaud good housing, decent transportation, and so forth.  The question, encountered by anyone who has ever played with one of the myriad guides to selecting a “best place to live,” was how one should weight those factors.  Are housing and transportation of equal importance?  Will Brooklynites and Boulderites agree on the priority of outdoor spaces?

In that allusion to “previous research,” the Guide cited materials from AARP and the Visiting Nurse Service of New York (VNSNY).  Both such sources dated from 2007.  Since then, within the topic area of “livable communities,” AARP’s Public Policy Institute (PPI) had evidently identified a shift toward mixed-use development, highlighting walkability (which would not necessarily be the same as a focus on transportation or outdoor spaces).  At this writing, AARP’s livable communities webpage also expressed an interest in the concept of “aging in place.”  Among the AARP PPI webpages addressing that topic, I viewed a brief AARP article from December 2011 indicating that “The vast majority of older adults want to age in place, so they can continue to live in their own homes or communities.”  That article summarized an 84-page State Survey of Liveability Policies and Practices whose major findings were reportedly as follows:

• Land Use:  Certain land use policies can help older adults live closer to or within walking distance of the services they need.
• Transportation:  Increased mobility options can reduce reliance on transportation by personal car.
• Housing:  Affordable, accessible housing can decrease institutionalization and meet consumer demand.

I was not certain whether that AARP survey sought to address all of the concerns underlying the WHO’s AFC concept.  It tentatively appeared, rather, that AARP was seizing upon aging in place as a preeminent concern, perhaps deserving priority over others cited in the WHO’s Guide (e.g., employment, information).

VNSNY, the other source of research cited by the Guide, seemed to emphasize a concept of “AdvantAge.”  VNSNY indicated that this construct derived from focus groups “with older people and community leaders in various parts of the country.”  As such, it preliminarily appeared that VNSNY might have managed to come closer than WHO to identifying preferences specific to aging Americans.  It was not clear that VNSNY’s approach would overcome the concern about differences among regions and sizes of cities, but they claimed that responses were similar regardless of respondent location.  The common concerns emerging from the VNSNY research were that an elder-friendly community would:

• Address basic needs
• Optimize physical health and well-being
• Maximize independence for the frail and disabled
• Promote social and civic engagement

Pending closer investigation into the WHO criteria, one could ask whether these VNSNY criteria might be more oriented toward actual elder experience.  It would be possible, that is, to develop a transportation system that looked fantastic and yet somehow failed to produce actual benefits for older people.  A drawback of this VNSNY research was that it dated from 2003, and might thus miss the possibility of a pullback from suburbia, in the wake of the Great Recession, that might be evidenced in AARP’s more recent “walkability” emphasis.

The WHO’s Guide did cite other sources of research.  But none were newer than 2007, some were some years older, and many adopted an international perspective, unsurprising for the WHO but not necessarily suited for current conditions in the U.S.  A search for more recent research provoked a variety of questions:  Would a recent flurry of interest in companion robots prove to overcome difficulties that might otherwise have made a certain kind of domicile undesirable?  Would other technology (in e.g., monitoring or communication) likewise overcome erstwhile constraints?  Would developments in neighborhood design likewise overturn previous concepts of the ideal independent living scenario?

I did not attempt to investigate these questions at this point.  It seemed that, whatever its inevitable imperfections, the WHO framework had advantages of relative comprehensiveness and universality.  In other words, one might seek to implement it in ways appropriate to a particular location.  It thus appeared advisable to begin with the WHO framework as a guide, and to develop one’s own age-friendly community in terms that would appropriately complement and/or amend the WHO’s original expectations.  Doing so seemed to call for exploration of related background issues.