Abstract
Review question/objective: The objective of this systematic review is to identify policies related to age-friendly cities, and to establish the impact of age-friendly policies on psychosocial wellbeing and quality of life for older adults living in inner city environs.
Background: Going forward in the 21stcentury, one of the issues associated with rapid urbanization is the growth in the percentage of aged people living in inner city environments, and their health and wellbeing needs. These changing demographics are accompanied by both opportunities and needs, and society must redefine the concept of what it means to grow older within an inner city context. According to a 2007 World Health Organization (WHO) report on age-friendly cities, the number of people aged over 60 will double (from 11% to 22%) between 2006 and 2050. By then, there will be more elderly people than children (aged 0-14 years) in the population for the first time in human history. The number of people aged 60 and over as a proportion of the North American population will increase from 17% in 2006 to 27% by 2050. The proportion of the population aged 60 and over will increase to 9% in 2006, and 24% in 2050 in Latin America and the Caribbean. In Europe, the number of people aged 60 and over will increase from 21% in 2006 to 34% by 2050. The number of people aged 60 and over as a proportion of the Oceania population will increase from 14% in 2006 to 25% by 2050. The proportion of the population aged 60 and over will increase to 9% in 2006 and 10% in 2050 in Africa. In Asia, the number of people aged 60 and over will increase from 9% in 2006 to 24% by 2050.1 Within five decades, just over 80% of the world's older people will be living in developing countries, as compared with 60% in 2005.2,3 There is emerging evidence that urban environments may place older people at a heightened risk of isolation and loneliness, and this evidence highlights the importance of understanding what policy attributes promote aged friendly cities.4
Healthy aged people are valued as the family's social and national resources. Establishing appropriate living environments for aged people, promoting social engagement and maintaining their physical and psychosocial well-being and quality of life is becoming increasingly important. Furthermore, social engagement is an opportunity for healthy aged people to transfer their wisdom, knowledge, and experience to society.5,6 Thus, building an accessible environment for aged people, promoting humanistic medical services, and developing age-centered medical techniques to enhance aged care are important global health tasks. Many city authorities around the world are enhancing infrastructures and services to make their cities more age-friendly, a process that aims to make city services and facilities more accessible to an ageing population and increase opportunities available to older residents.1,5,7-9
In 2002, the WHO proposed an active ageing concept. The WHO suggests optimizing opportunities for health, participation, and security in order to enhance quality of life as people age. The realization of active aging is determined by multiple personal, social, economic, and environmental factors affecting individuals over their life course, such that functional capacities in older adulthood vary widely as a result of the combined and cumulative effects of all these factors.10 In 2005, the WHO started the global age-friendly cities project. The International Day of Older Persons (October 1), as proposed by the Global Age-Friendly Cities: A Guide,1 was established from an international survey, which included 22 countries and 33 cities. The purpose of this Guide is to engage cities to become more age-friendly in order to tap into the potential that older people have. In practical terms, an age-friendly city adapts its structures and services to be accessible to and inclusive of older people with varying needs and capacities. The Global Age-Friendly Cities Project highlighted the issues and concerns voiced by older people, and those who serve older people, in each of the eight areas of urban living; 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.1,10,11 The project is a start point to promote the aged-friendly city perspective. Many cities, communities, and countries have adapted this project into their health policies. Thus, it is important to understand those countries, communities, and cities' experiences in regards to their philosophy, objectives, and strategies in the promotion of becoming an aged-friendly city.
In the fall of 2007, Mayor Bloomberg, Council Speaker Quinn, and the New York Academy of Medicine launched Age-friendly NYC. The goals of Age-friendly NYC are to assess the city's responsiveness to the needs of older New Yorkers, to develop recommendations, and to implement strategies that will allow New York to sustain and enhance its status as an "age-friendly" city. While the initiatives are grouped into four main areas - community and civic participation, housing, public spaces and transportation, and health and social services - they span all domains and will benefit New Yorkers of all ages. They range from public issues such as the movement of traffic and the design of public seating, to private issues such as managing personal health concerns and living one's final years with grace and dignity.12,13 In 2010, Manchester was the first UK city to be accepted into WHO's Global Network of Age-Friendly Cities in recognition of the work carried out by the Valuing Older People partnership. The UK city's aim was to tackle the city's health and other inequalities and address specific challenges of growing older in deprived urban areas.14,15
In Asia, Shanghai City is one of the 35 most age-friendly pilot cities in the world. The main focuses of the project in Shanghai are to propose the policies and regulations which are beneficial to the elderly in order to increase public financial input.1,16 This elderly need-oriented project aims to deepen the services for the elderly, increase the professional level of services, comprehensively develop various services and activities for the elderly, expand the benefit for the elderly, enhance the scientific study and research on the elderly, implement the Elder Law and the Shanghai City Ordinance on Protection of Rights and Interests of the Elderly, protect the legitimate rights and interests of the elderly, enhance the substantial construction for the elderly, fulfill the objectives of an age-friendly city, fully put into practice the development and planning of elderly business in Shanghai, complete the cooperation system for senior commissioners at all levels, fully implement the function of the platform, and promote the constant development of elderly business.1,16 Moreover, in 2012, based on the concepts of "respect for the elderly, elderly-friendly, barrier-free, accessibility, safe housing, transportation, health and agelessness", Taichung City Government in Taiwan promoted an age-friendly city project related to three main issues: "ageing in place," "healthy ageing" and "active ageing".17(p.7)The cultural literacy and local action plans for an age-friendly city were jointly developed through cross-departmental and industry-government partnership to create the "integrated and barrier-free urban environment, which may promote active ageing".17(p.9) The specific schemes implemented for an age-friendly city in Taichung City included health-friendly approved projects such as listening to the elderly - action train, age-friendly comics and record plans; nursing homes' active ageing project; community age-friendly visiting project; elderly care talents training project; and a community elderly life demonstration project. These projects put emphasis on the development of local culture and the ethical relationship of multiple generations and intend to involve individuals, families and society in the changes.17
To help the elderly feel more comfortable to step out of their homes and to promote active ageing, it is necessary to strengthen two aspects of age-friendly environment: infrastructure services and quality of the social environment. The objective of infrastructure services is not only to develop barrier-free architecture, but also to develop barrier-free public spaces and transport facilities. The focus on quality of social environment indicates that the age-friendly city project goes beyond health care. It includes the design of the neighborhood. Urban planners should consider the multifaceted compositions of ageing. However, they should also emphasize the preservation of differences in communities.18 Creating a barrier-free atmosphere that encourages the interaction of people is also quite important. If more importance is attached to social quality and the elderly are provided with opportunities to integrate, participate in and develop social relational quality, improve the friendly cultural environment and create intergenerational interactions, more elderly or disabled people will be willing to step out of their homes.17,19 An age-friendly city needs to make an organizational transformation to respond to the needs of aged people. An age-friendly city integrates the internal personnel, facilities, culture, abilities, decision-making and operating procedures with external services and outcome of quality of care. Governments need to take the lead to promote the awareness of age-friendly cities in administration and establish partner networks with diversified groups to increase emphasis on the development of local cultural and ethical relationships of multiple generations. Governments also jointly construct an environment where the elderly are able to create opportunities for active ageing on their own, in order to enable the elderly to create the lifestyle and life process of active ageing.5,7,17
The literature reflects the increased focus internationally on age-friendly cities, particularly in Europe and the United States.7,13-15 The experiences of such projects in New York and Manchester City provide key insights into the establishment of age-friendly cities. The examples of Shanghai in Asia and Taichung City in Taiwan provide specific guidelines for implementation of establishing age-friendly cities.17
At present, many counties are in the preliminary stages of developing age-friendly cities, but there is still much to learn. It is hoped that this systematic literature review can help integrate the developmental experiences of age-friendly cities of various countries to summarize how they achieve success, to combine academic professionals with practice, to provide reference for various countries to establish age-friendly cities.
Article Content
Inclusion criteria
Types of participants
The participants of interest will be older adults as defined by the WHO criteria ageing, and who live in an inner city context.1
Phenomena of interest
The phenomena of interest are the experiences that impact quality of life and psychosocial wellbeing attributable to policies that initiate, promote or enhance an 'age-friendly' city living for older adults. Phenomena associated with impact on the lives of older adults, or impact on the perspectives of the wider local community will also be included where available.
Context
The context is focused on establishing what policy imperatives are associated with an age-friendly city plan. This includes both western and eastern perspectives, and all geographic/cultural regions provided there are accessible policy documents that relate to inner city living. The context may be expressed through changes in policy, in design or development, changes in cultural policy or perspectives on being aged and living in an inner city environment, and empowerment of older adults living in an inner city environment.
Types of Studies
This review will consider policy documents, and related green or white papers, from state, federal or lobby group sources that relate to age-friendly city initiatives from any jurisdiction that has a governance role over the development or implementation/evaluation of age-friendly initiatives. This systematic review will therefore consider opinion papers, discussion papers, position papers and other reports that examine policy formulation and promoting an age-friendly city. Papers must have been published in either English or Chinese to be included in this review as resources to translate other languages are not available.
Search strategy
The aim of the search strategy is to obtain all publically available policy documents in English or Chinese relevant to the systematic review. These include: active or age or ageing or elder or older or communities or community or cities or city The articles will be limited to papers published in Chinese or in English. A three-step approach will be adopted. First, the electronic bibliographic databases will be searched to identify relevant key words, index terms and matched subject headings. Second, an extensive search of the databases will be performed using developed search strategies to identify potential papers for inclusion. Finally the reference lists of retrieved articles, relevant conference proceedings, postgraduate and doctoral dissertations, journals, online databases and websites will be sought to identify additional studies not located through the search strategies by searching. The databases to be searched will include MEDLINE, CINAHL, Google Scholar and CEPS. The search will be limited to English or Chinese language papers, and will span from inception of each database to the present date.
Assessment of methodological quality
Textual and opinion papers selected for retrieval will be assessed by two independent reviewers for authenticity prior to inclusion in the review using standardized critical appraisal instruments from the Joanna Briggs Institute Narrative, Opinion and Text Assessment and Review Instrument (JBI-NOTARI). (Appendix I) Any disagreements that arise between the reviewers will be resolved through discussion, or with a third reviewer.
Data collection
Data extraction tools developed by the Joanna Briggs Institute will be used to extract all required and relevant information from the included papers. Textual and opinion data will be extracted from papers included in the review using the standardized data extraction tool from JBI-NOTARI. The data extracted will include specific details about the interventions, populations, study methods and outcomes of significance to the review question and specific objectives.20
Data synthesis
Textual and opinion papers will, where possible. be pooled using JBI-NOTARI. This will involve the aggregation or synthesis of conclusions to generate a set of statements that represent that aggregation, through assembling and categorizing these conclusions on the basis of similarity in meaning. These categories are then subjected to a meta-synthesis in order to produce a single comprehensive set of synthesized findings that can be used as a basis for evidence-based practice. Where textual pooling is not possible the conclusions will be presented in narrative form.20
Conflicts of interest
None
Acknowledgements
We would like to acknowledge the support of the Health Bureau of Taichung City Government, R.O.C. for this project.
Study Design Contributions: CYH, SFT, BHY, PFM
Data Collection and Analysis: CYH, SFT, BHY, PFM
Manuscript Preparation: CYH, SFT, BHY, PFM
References
1. World Health Organization [WHO]. Global age-friendly cities: a guide. Geneva, Switzerland: WHO; 2007. [Context Link]
2. United Nations Department of Economic and Social Affairs. Population ageing 2006. New York: United Nations Department of Economic and Social Affairs; 2009. [Context Link]
3. United Nations Population Fund. Population issues: meeting development goals. New York: United Nations Population Fund; 2007. [Context Link]
4. Linda G, Duncan B. Social isolation and loneliness among older people: issues and future challenges in community and residential settings. Aust Health Rev. 2008;32(3):468-78. [Context Link]
6. World Health Organization [WHO]. Towards age-friendly primary health care. France: WHO; 2004. [Context Link]
7. Lui CW, Everingham JA, Warburton J, Cuthill M, Bartlett H. What makes a community age-friendly: a review of international literature. Australas J Ageing. 2009;28(3):116-21. [Context Link]
8. Kennedy C. The city of 2050 - an age-friendly, vibrant, intergenerational community. Generations. 2010;34(3):70-5. [Context Link]
9. Austin C, McClelland R, Perrault E, Sieppert J. The elder-friendly communities program. Generations. 2009;33(2):87-90. [Context Link]
10. World Health Organization [WHO]. Active ageing: a policy framework. Madrid, Spain: Ageing and Life Course Program, Second United Nations World Assembly on Ageing Press; 2002. [Context Link]
11. World Health Organization [WHO]. What makes a city age-friendly? London: World Health Organization; 2007. [Context Link]
12. Plouffe L, Kalache A. Towards global age-friendly cities determining urban features that promote active aging. J Urban Health. 2010;87(5):733-9. [Context Link]
13. Marilynn L. Transforming New York into an 'age-friendly' city: a model program. Journal on Active Aging Nov Dec 2009:26-35. [Context Link]
14. Geoff G. Age-friendly cities of Europe. J Urban Health. 2013; 90 (Spl. 1): s116-s128. [Context Link]
15. Paul M, Jane M. A great place to grow older: a case study of how Manchester is developing an age-friendly city. Working with Older People. 2011;15(1):38-46. [Context Link]
17. Hu J, Tsai PK, Huang MN, Tsay SF. Age-friendly cities, ideals and practice: the experience of Taichung city (Chinese). J N. 2012;59(6):5-11. [Context Link]
18. Charles AE, Joane TM. The importance of social connectedness in building age-friendly communities. J Aging Res. 2012;Nov(24):1-9. [Context Link]
19. Edwards P, Tsouros A. Promoting physical activity and active living in urban environments: The role of local governments: Madrid, Spain: WHO.; 2006. [Context Link]
20. The Joanna Briggs Institute. Synthesizing evidence from narrative, text and opinion. South Australia: JBI; 2011. [Context Link]