Developing Age-friendly Cities: Policy Opportunities and Challenges

Chris Phillipson, PhD
University of Manchester
Professor of Sociology and Social Gerontology;
Co-Director, Manchester Institute for Collaborative Research on Ageing

Tine Buffel, PhD
University of Manchester
Senior Lecturer in Sociology

 

Abstract

Since the mid-2000s, the need to create age-friendly cities and communities, meaning places where older people are actively involved, valued, and supported, has emerged as a major concern for urban policy. The World Health Organization (WHO) has driven this age-friendly agenda through its Global Network for Age-friendly Cities and Communities (GNAFCC). This paper reviews some of the challenges associated with the development of this policy, given the variety of economic and social pressures facing urban communities. The discussion provides background to the development of the age-friendly model and a summary of some of the factors necessary for its successful implementation. The paper then reviews a range of key areas where age-friendly policies might be developed, with a particular focus on issues relating to the various inequalities affecting older populations. The paper also emphasises the importance of future age-friendly work being grounded in collaboration with the range of movements seeking to improve the quality of life of people living in cities. The paper concludes with a call for a more inclusive age-friendly movement, one that acknowledges the full diversity of aging experiences.

Keywords: age-friendly, urban policy, inequality, co-production

Introduction
Population aging is taking place across all countries of the world, raising major issues for the direction of public policy. By 2050, one in six people in the world will be sixty-five and over (16 percent), up from one in eleven in 2019 (9 percent). In Europe and North America, one in four persons is expected to be aged sixty-five or over by 2050 (United Nations, 2019). Of equal importance is the continuing spread of urbanization, with 55 percent of the world’s population now living in urban environments (UN, 2018). The relationship between these two major trends— aging and urbanization—is now the subject of increased academic and pol- icy analysis. The Organisation of Economic Cooperation and Development (OECD) (2015, p. 18) argues that:

Designing policies that address ageing issues requires a deep understanding of local circumstances, including communities’ economic assets, history and culture. The spatially heterogeneous nature of ageing trends makes it important to approach ageing from an urban perspective. Cities need to pay more attention to local circumstances to understand ageing and its impact. They are especially well-equipped to address the issue, given their long experience of working with local communities and profound understanding of local problems.

Cities are regarded as central to economic development, attracting migrants, professional workers, and knowledge-based industries (Burdett & Sudjic, 2016). Urban environments create many advantages for older people, for example through providing access to cultural activities, leisure facilities, and specialist medical care (Phillipson, 2010). At the same time, they may also produce feelings of insecurity, arising from the impact of urban regeneration, population turnover, and environmental problems associated with climate change, together with high levels of pollution1 (Burns, Lavoie, & Rose, 2011; Rolnik, 2019; Wallace-Wells, 2019).

The pressures associated with city living indicate challenges for policies seeking to reconcile population aging with urban development (Buffel & Phillipson, 2016). An emerging theme has concerned the need to create age-friendly cities and communities. Alley et al. (2007, p. 4) define an age-friendly community as a “place where older people are actively involved, valued, and supported with infrastructure and services that effectively accommodate their needs” (see, also, van Hoof, 2018). The period from the mid-2000s saw a substantial growth of interest in age-friendly issues. This initial period of development recorded a variety of achievements, linking aging populations to the need for changes to the built environment, transportation, housing, and neighborhood design (Moulaert & Garon, 2016; Stafford, 2019). However, a combination of widening inequalities within and between urban environments, and the impact of austerity on local government and city budgets, has raised questions about future progress in age-friendly and related activities. Age-friendly programs encompass interventions across a range of environments, from large metropolitan areas to isolated rural communities. In this paper, and reflecting the bulk of research to date, the discussion focuses on issues faced by older people living in urban neighborhoods. This article contributes to the debate on developing age-friendly programs, with particular attention to factors that might assist in extending their influence across differ- ent groups and communities. The paper does this by, first, reviewing their origins; second, outlining success factors behind their development; and third, examining new approaches to advancing age-friendly interventions.

 

The Development of Age-Friendly Cities and Communities

The relationship between population aging and urban change has become the focus of various initiatives, for example, through the American Association of Retired Persons (AARP), the International Federation on Ageing (IFA), and AGE Platform Europe. The age-friendly perspective was first developed by the World Health Organization (WHO) (2007; 2015; 2018) through a project examining the experiences of older people living in urban environments. The result of this work was a guide identifying the key characteristics of an age-friendly community in terms of service provision (e.g., health services, transportation), the built environment (e.g., housing, outdoor spaces, and buildings), and social aspects (e.g., civic and social participation) (WHO, 2007). This guide has since become one of the most frequently used tools to assess the age-friendliness of cities and communities (Plouffe, Kalache, & Voelcker, 2016). To encourage dissemination of its work, the WHO launched in 2010 the Global Network for Age-friendly Cities and Communities (GNAFCC), which by 2020 had reached a membership of around 1000 cities and communities in forty-one countries.2

The growth in popularity of the age-friendly movement has led to the development of various age-friendly frameworks and initiatives. These can be found under headings such as “age-friendly,” “elder-friendly,” “aging-friendly,” “livable,” and “lifetime neighborhoods” (see, further, Buffel, Handler, & Phillipson, 2018). The difference in terminologies reflects the variety of approaches to, and organizations involved in, creating age-friendly environments. Lui and colleagues (2009) developed a typology for categorizing these, with models ranging from an emphasis on the physical versus social environment on the one hand, and from top-down to bottom-up governance on the other. Some models focus on adapting the physical infrastructure, for example through providing access to green spaces, promoting home adaptations, and enabling mobility and walkability,3 while others pay more attention to social aspects of the environment by emphasizing inclusion, participation, and social support.

Scharlach (2016, p. 313) emphasizes the importance of combining both physical and social infrastructure in building age-friendly communities, highlighting the following elements:

  1. Adequate general physical and social infrastructures that promote health and wellbeing for the entire community;
  2. Minimal age-related barriers faced by older community members in trying to access that infrastructure;
  3. Compensatory and enabling features that respond to the particular age-related needs and sensibilities of older community members;
  4. Mechanisms for engaging older adults as valued members of community life.

What are the success factors identified in the research literature that can assist in the development of age-friendly policies? Fitzgerald and Caro (2016) identify the main ones as a large and growing concentration of older people, a strong network of social and civic organizations, the availability of health and social services, an extensive transportation network, a variety of housing options, and access to green and open spaces. Another factor cited as important in the research literature is the ex- tent to which cities and communities can mobilize a range of stakeholders, built around partnerships with public, private, and third sector organizations (Garon et al., 2014). Linked with this is the need for strong political leadership in gaining support for age-friendly policies at local and regional levels of government (Moulaert & Garon, 2015). McGarry (2018, p. 247) illustrates this from developments in Manchester, UK (an early member of the GNAFCC), commenting on the extent to which the work has “been able to secure much needed political support [by] harness- ing leadership around the ageing agenda within the local authority, and embedding age-friendliness increasingly firmly into local authority thinking.” Drawing on the example of Portland, Oregon, in the US, Neal et al. (2014, p. 96) cite “existing relationships between the university and local city planning and other government agencies” as a strength of the age-friendly program developed in the city.

Second, the ability of cities and communities to develop their own interpretation of the age-friendly model has often been described as a feature of the WHO approach. Various researchers have advocated the need for the movement to remain flexible in adapt- ing to the needs of each local context (Liddle et al., 2014; Menec et al., 2011).

The notion of flexibility has been interpreted in various ways in the age-friendly literature. Liddle and colleagues (2014), for example, stress the importance for the age-friendly movement to extend its focus beyond cities. They question the ability of the WHO’s age-friendly definition to be applied to non-city settings (e.g., rural areas and retirement communities). Flexibility will also be important in the context of new challenges facing cities, not least with the effects of climate change, the impact of pandemics (such as COVID-19), and the movement of populations arising from civil and military wars (Gatrell, 2019; Mehta, 2020).

Third, the extent to which policies for older people are integrated with the management and planning of cities, will be an important element in developing successful age-friendly policies. Social policies can promote older people’s participation in urban change in a variety of ways: for example, by ensuring greater use of the resources associated with living in cities. Urban regeneration can benefit from the skills and experience of older people and the attachments they bring to their neighborhoods (Lewis et al., 2020). However, as a group, older residents often tend to be “invisible” in the implementation of policies. Kelley, Dannefer, and Masarweh (2018, p. 56) refer to this as a process of “erasure,” whereby “certain groups are ‘unseen’ in policy, research, or institutional practice.” Making cities more age-friendly will therefore require radical interventions in terms of involving both older people and the generation approaching old age as key actors setting the agenda for future urban development (see further below).

 

New Directions for the Age-Friendly Movement

Despite the many achievements arising from age-friendly activities, a variety of problems may frustrate the growth of high-quality programs. The initial development of age-friendly work came at a time of economic growth, with an expansion in public sector programs of different kinds. However, support for these was thrown into reverse with the financial crash of 2008 and the application of neoliberal policies, which led to a scaling back of social protection for vulnerable groups (McBride & Evans, 2017; Walsh, 2015). Thus, the implementation of age-friendly programs has come during a period when cities are experiencing substantial reductions in physical infrastructure and services, including the closure of libraries, cuts to community center provisions, and the tightening of eligibility for support for home and residential care (Klinenberg, 2019; Toynbee & Walker, 2020).

Changes in the economic and social environment facing cities are raising important issues for the way that the age-friendly movement might progress over the next decade. To consider these, the next section of the paper identifies a number of areas for development, grouped under the following headings: linking age-friendly work with urban policies and movements, focusing on social inequality, acknowledging diversity around health issues, securing innovation in work within neighborhoods, and strengthening research programs on age-friendly issues.

 

Linking Age-Friendly Work with Urban Policies and Movements

A starting point for extending the scope of age-friendly activity would be to strengthen collaboration with movements that are campaigning to improve urban environments. The growth of age-friendly work has been led in Europe mainly by departments within lo- cal government; in other countries (e.g., the US), non-governmental organizations (e.g., AARP) play a more influential role. Although this has led to a significant expansion in projects, the range of partnerships with non-age-related organizations, such as property developers and the business sector more generally, has been limited. This was less an issue when economic conditions were favorable for developing age-friendly programs; however, financial pressures on cities have created a need for forging a broader range of partnerships as a means of protecting existing resources and accessing additional resources.

One response would be to establish links with groups working on initiatives such as smart cities, healthy cities, resilient, and sustainable cities (Ramaswami et al., 2016; UN-Habitat, 2016). The age-friendly movement has been weakened, it might be argued, by operating separately from other urban projects, with the division between healthy and age-friendly cities programs—both WHO-sponsored—as an example. Moreover, encouraging links between different urban programs might help expand the range of age-friendly interventions. For example, ideas from the smart and sustainable cities movement around sup- porting alternatives to cars, increasing energy efficiency, and reducing pollution, should also be a central part of making cities age-friendly. Engagement with this type of work has the potential to produce further resources for the movement and add to the sustainability of existing projects.

In addition, the concept of age-friendliness needs to be developed in a way that recognizes the complexity of the urban environment and its influence across different phases of the life course. While the trend toward urban living is worldwide, the pattern of urban growth demonstrates considerable variation: a mix of expanding and declining cities (in terms of population size) in the Global North and accelerating urbanization in Africa and Asia. Securing age-friendliness in the context of the rise of mega-cities and hyper-cities pro- vides another variation (UN, 2018). At the same time, processes for developing age-friendliness will need radical adaptation given the type of urban expansion prevalent in parts of Southern Asia and sub-Saharan Africa (UN-Habitat, 2012). Population growth in these continents has taken place largely through the rise of so-called slums, many of which are located on the periphery of capital cities (Davis, 2006; Mayne, 2017). The problem of reaching older people and migrants who are aging in place, albeit housed in temporary accommodation bereft of basic facilities, underlines the need for new models of intervention that can respond to the highly unequal contexts experienced by urban elders across the work.

 

Challenging Social Inequality

A second area for development concerns grounding age-friendly work in policies that challenge social inequality. A key task for future activity must be to ensure equal access to basic necessities for daily living and the decision-making processes underpinning urban life, explicitly addressing gender, social class, ethnic and other inequalities affecting the older population (see, further, Kelly, Dannefer & Masarweh 2018). In the Global North, the age-friendly brand has been adopted in various guises in (mainly) white communities, but is much less evident among black and minority ethnic groups (Lehning et al., 2017). However, it is precise- ly the latter that experience the most disadvantaged and least age-friendly communities. It will be difficult to take age-friendly policies seriously unless there is closer engagement with those neighborhoods and groups of older people that are abandoned in the face of urban change (Scharf & Phillipson, 2005). Acknowledging social and ethnic diversity is thus an important issue for the age-friendly movement to address (Gonyea & Hudson, 2015). The implications are wide-ranging, including responding to different cultural interpretations of what age-friendliness might mean; shaping policies around the needs of particular groups with contrasting migration histories and life course experiences; recognizing distinctive forms of inequality experienced by particular ethnic groups, notably in areas such as health, income, and housing; and understanding the impact of racism on communities and the challenge this presents for the achievement of successful age-friendly work.

As well as identifying and analyzing inequities between different groups of older people and neighbor- hoods, there is also a need to identify viable and effective strategies, interventions, and actions to tackle such disparities. The potential of age-friendly cities to reduce health and social inequalities at the local level is highlighted by Kendig and Phillipson (2014). However, systematic monitoring and evaluation are necessary to determine which strategies are most appropriate and the type of resources required that can support such work.

Developing effective responses to inequality will almost certainly require stronger linkages between different lev- els of age-friendly work: macro (e.g., government), meso (e.g., corporations, municipal authorities), and micro (e.g., neighborhood). Case studies of cities in the WHO global network (WHO, 2018) confirm that, to date, there has been considerable success in securing support at the meso and macro levels—financial and administrative—for age-friendly initiatives (notably around areas such as social isolation and loneliness). However, age-friendly work has been much less successful in attracting the interest of key government departments, e.g., in areas such as economic development, transport, and urban planning. Such attention will clearly be necessary if the movement is to avoid the danger of economic and social inequalities limiting the range and effectiveness of initiatives.

 

Acknowledging Diversity in Health Issues

The diversity of health issues experienced by older people also raises important issues for age-friendly work. A relevant question here is do age-friendly initiatives reach out to people with all types of health conditions or are they focused predominantly on the “healthy,” i.e., those involved in different forms of “active aging” (Golant, 2014)? To date, it is the latter who have dominated the development of the movement. But this raises questions about whether the goal is to create inclusive rather than exclusive communities (Gonyea & Hudson, 2015). If the former, then age-friend- ly initiatives must have the capacity to support people diagnosed as frail or with dementia and associated conditions (Grenier, 2007). This would argue against the trend of developing separate dementia-friendly communities or similar. Rather, the approach should acknowledge the variety of groups for whom age-friendly issues are relevant, and the need to build environments that support and reflect the diversity of conditions in middle and later life.


W
idening Participation

Consideration is also needed when reaching out to groups that may be disengaged from age-friendly issues. To date, the movement has—in many urban areas—drawn upon organizations already involved in campaigns on issues affecting older people, such as voluntary bodies working on behalf of older people, pensioner action groups, and carer organizations (Steels, 2015). But these may have limited connections to organizations representing black and minority ethnic groups, the LGBTQ community, women’s groups, and faith- based organizations. Each of these will be affected by age-related issues in different ways: Their involvement could make a substantial contribution to creating a more inclusive and representative age-friendly movement.

The variety of groups within the older population is likely to mean that the process of developing age-friendly communities will involve reconciling conflicting interests and concerns (Moulaert & Garon, 2015). This suggests the need for methods of community engagement that will work with the range of concerns affecting different age groups. An example of such an approach is that of coproduction (Buffel, Skyrme, & Phillipson, 2017). Coproduction builds on a partnership among older people, their families, communities, and statutory and non-statutory organizations that work together to develop research and a shared understanding and to design, develop, and deliver opportunities, projects, and solutions promoting social and political change (Sanz et al., 2015). The ultimate goal is to facilitate different forms of community empowerment and to allow individuals and groups to organize and mobilize themselves toward social action.

 

Encouraging Innovations within Neighborhoods

Attention must also be given to devising new ways of delivering age-friendly interventions at a neighborhood level. The age-friendly domains put forward by the WHO provide a valuable framework for developing ideas and initiatives. The weakness of current work, however, relates to uncertainty about the best measures to assist the implementation of projects, how best to target isolated groups, how to involve minority groups, and how to ensure the sustainability of projects. Some organizational developments (notably in the US) that emerged outside the age-friendly movement merit closer consideration: for example, the Village model and Naturally-Occurring Retirement Communities. The former is a grassroots approach that engages older community residents in developing membership associations that provide supportive services and social activities. The latter represent partnerships between statutory and voluntary bodies to enhance services for older people living in geographically defined areas with relatively high densities of older adults (Greenfield et al., 2012; Scharlach, 2012; Scharlach & Lehning, 2013). The effectiveness of these approaches needs to be tested in more detailed research than presently exists (see, for example, Graham et al., 2014); there is also the problem (notably with the Village movement) of membership being restricted to financially more secure older adults, with notable underrepresentation of minority groups. Nonetheless, testing these and similar models might be a valuable way of devising ways of translating the ideals of age-friendly work into sustainable projects within neighborhoods.

 

Strengthening Research Programs on Age-Friendly Issues

Finally, the age-friendly movement has developed at a rapid rate, notably through the stimulus of the WHO Global Network and other international organizations. But this has occurred in the absence of research regarding the effectiveness and impact of such work: whether it benefits some groups rather than others, what contribution it makes to the wellbeing of older people, whether it leads to improvements in urban design, and whether it strengthens support networks within neighborhoods. Establishing answers to these questions will be vital if local authorities and cities are to extend financial support to age-friendly programs. In addition to measuring the impact of interventions, there is also a need for building process evaluation activities into program implementation, using these to conduct continuous quality improvement (Greenfield et al., 2015). Encouraging comparative studies examining the various approaches to building age-friendly communities in different social, political, and economic contexts should also be an important element of future work (Moulaert & Garon, 2016). There is also an urgent need for research on building age-friendly communities in the Global South, recognizing the distinctive pressures arising from rapid urbanization, migration, and the impact of climate change.

Given the need for a stronger emphasis on research, a key task for the age-friendly movement will be to create stronger linkages with academic institutions and researchers from multiple disciplinary perspectives. One way forward could be through the development of an international research network, pioneering new research, technology, and solutions across a range of aging-related domains and supporting the research side of GNAFCC’s policy work. An important role for such a research network would be to bring together academics from existing research centers supporting age-friendly issues, encourage the development of early-career researchers specializing on age-friendly issues, develop work on specific themes (e.g., the impact of gentrification, issues affecting migrant groups), and develop new methodological approaches for evaluating the benefits or otherwise of age-friendly interventions. This will be especially important to justify future funding for new age-friendly initiatives in times of austerity where the ability to demonstrate social and economic impact has become ever more important.

 

Conclusion

The development of the age-friendly movement must now be considered an important dimension of public policy, reflected in the work of numerous organizations working at local, regional, national, and international levels. The movement has been able to achieve significant progress within a relatively short space of time. It has been able to develop a broad global policy response to the forces associated with urbanization and aging, encouraging and enabling cities and communities worldwide to develop and adapt age-friendly programs within their local neighborhoods. The WHO has provided a global network of support and dialogue between different cities and communities, in association with partners such as AARP and Age Platform Europe. Importantly, the WHO has developed an influential framework for action with its emphasis on areas such as the built environment, transportation, housing, and social participation.

But while the age-friendly project has made significant progress as a global movement, important issues— as highlighted in this paper—remain to be addressed. Most urgently, there is the question of how this type of activity can sustain itself within the context of austerity and budget cuts facing cities and communities, which have a direct impact on many of the services on which older people rely. Unless this issue is addressed at a global, national, and regional level, the sustainability of age-friendly work is placed in some doubt. There is, at the same time, a broader issue surrounding the inclusivity of the age-friendly project. Although the movement has placed older people at the center of various initiatives, there has been a failure (as argued in this paper) to acknowledge the full diversity of aging experiences. Examples include the marginalization of many black and minority ethnic groups and those within the lesbian, gay, bisexual, transsexual, and queer community. More generally, the social exclusion experienced by many groups in urban areas—for example, migrants, refugees, and the rapidly expanding number of people without a home—have been largely ignored within the age-friendly movement. Given the pressures associated with globalization and economic recession, addressing social exclusion will be crucial to the successful development of the age-friendly project.

One response to this point might be to argue that the debate around age-friendly cities has created an important agenda for rethinking the way we both live in and manage our urban environments. Some of the questions being raised include do older people have a “right” to a share of urban space? How can the resources of the city be best used to benefit the lives of older people? Is the idea of age-friendly caring communities compatible with modern urbanization? However, in addition to these questions, we might note some fundamental issues that the age-friendly movement is likely to face in the next phase of its development. These can be summarized in terms of whether the idea of age-friendliness will progress mainly as a form of branding for cities concerned with improving their status in comparison with other cities. Alternatively, will the movement begin to engage with the serious problems facing urban environments, such as widening inequalities, problems of homelessness, and the lack of affordable housing? These issues have the potential to undermine interventions aimed at improving the lives of older people; they will almost certainly need a stronger response than presently exists from those involved in age-friendly work.

Dawson (2017) identifies the rise of what he terms “extreme cities,” with a new precariousness to urban life given the impact of climate change-induced disasters. Evidence already exists regarding the disproportionate impact of hurricanes (Katrina in New Orleans in 2005), heat waves (Chicago in 1995, France in 2003), and tsunamis (Tōhoku, Japan in 2011) on older people. Such examples underline the need to rethink approaches to age-friendly work in the context of increasingly unequal cities facing environmental and related threats. The question arising from this can be defined as how can movements representing aging and urban interests work together to resolve some of the major issues facing society? Age-friendly initiatives could drive forward new ideas relating to improving urban environments (e.g., highlighting the impact of pollution), developing new forms of community organization and solidarity (food and energy co-operatives), and supporting intergenerational cohesion (e.g., older people working with younger people in schools and other organizations). The argument is that doing age-friendly work also means recognizing and challenging the wider inequalities and injustices that affect city life. Standing apart from these will inevitably limit the scope both of the age-friendly movement and many other campaigns working to improve the lives of those living in cities.

In conclusion, there is considerable scope for the age-friendly movement to contribute to a more equal geographical distribution of society’s wants and needs, such as access to health and social services, community support, good air quality, and inviting public spaces. Questions of accessibility, housing and transport equity, and walkability can all be seen as important dimensions of the distribution of spatial resources. However, the age-friendly approach has yet to develop policies that can prevent or reduce the inequalities associated with urban living, especially as regards their impact on neighborhoods in which people may spend the majority of their lives. Ensuring spatial justice (Soja, 2010) for different groups of old- er people should, therefore, become a crucial part of the age-friendly debate, with strategies that enable communities to increase control over the conditions that shape their lives representing a key task for public policy.

 

Notes

1 “According to WHO’s most recent survey of 4300+ cities worldwide, only 20 percent of the urban population surveyed live in areas that comply with WHO air quality guideline levels for [fine particulate matter]. Average particulate air pollution levels in many developing cities can be 4-15 times higher than WHO air quality guideline levels, putting many at risk of long-term health problems.” https://www.who.int/sustainable-development/cities/health-risks/air-pollu- tion/en/. (retrieved November 16, 2019)

2 https://extranet.who.int/agefriendlyworld/who-network/. (retrieved November 16, 2019)

3 See, for example, the Atlanta Regional Commission. https://atlantaregional.org/community- development/comprehensive-planning/local-comprehensive-planning/. (retrieved March 24, 2020)

 

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