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.
Social Work Interventions 