A PRIMER ON ENVIRONMENTAL GERONTOLOGY

Alan DeLaTorre, PhD

Institute on Aging

Portland State University

aland@pdx.edu

Active Ageing: A Policy Framework

(World Health Organization, 2002) Health and Social Services Behavioral Determinants Personal Determinants Physical Determinants Physical Environment Social Determinants Economic Determinants Gender Culture

One lens for thinking about living arrangements for older adults is the Ecologic Model This framework can be applied to many

topics and in a variety of ways and incorporated several levels:

Micro – The home and immediate surroundings, including personal relationships

Meso – The neighborhood and community

Macro – Larger connections such as policies, laws, systems, and societal relationships

Ecological Perspective (Theory at a Glance: A Guide for Health

Promotion Practice: NIH, 2005) The ecological perspective emphasizes the interaction

between, and interdependence of, factors within and across all levels of a health problem.

It highlights people’s interactions with their physical and social environments.

Two key concepts of the ecological perspective help to identify intervention points for promoting health:

1. Behavior both affects, and is affected by, multiple levels of influence

2. Individual behavior both shapes, and is shaped by, the social environment (i.e., reciprocal causation)

Ecological Model (NIH, 2005)

Ecologic Model ofEnvironment and Aging

Lawton and Nahemow’s (1973) described interdependence of the various elements in a system and stressed the fact that there is a continual process of adaptation, from both older people and their environments.

The field of public health has also utilized an ecologic model for building healthy communities; myriad factors influence healthy behaviors: biological, behavioral, social, and environmental variables (Satariano & McAuley, 2003).

Lawton’s Ecological Model

Gerontology and Public Health Ecological Models

Both the gerontology and public health ecological models focus on attributes of the individual (e.g., the aging body, disease and disability, individual behavior) and the environment (e.g., accessibility and usability, social connections and interaction, healthy housing).

From Theory to Practice An ecologic model is useful in framing research

and moving toward implementation efforts (Sallis, 2003).

Moving beyond basic research and has been identified as an important next step for broadening the effectiveness of the ecologic model (Cunningham and Michael, 2004)

The result would be action-based research that considers the social, biological, behavioral and environmental factors while understanding the dynamic interplay over time that occurs between older people and their environments

Factors that Contribute to the Health and Well-being of Older Adults in Cities and

Communities The following factors were identified by combining the

core aspects of the social ecological models in public health and gerontology with the WHO’s active ageing framework and domains of age-friendly cities and communities: 1. Individual factors

2. Social factors

3. Aggregated population characteristics

4. Physical environments

5. Institutional and service environments

6. Economic factors

7. Public policy

Factors Leading to Nursing Home Transition from HCBS Programs

Based on a review of case notes, four general factors were shown to contribute to ending home health and moving to long-term care settings:

1. Family availability and family/client preferences for care settings

2. An acute change in health status leading to hospitalization or short-term rehabilitation

3. Limits on services available in a home care program

4. Mental health, legal issues, and fallsRobison, Shugrue, Porter, Fortinsky, & Curry (2012). Journal of Aging and Social Policy, 24, 251-270

Nursing Home Transition from HCBS (cont.)

Based on focus group research with clients who transitioned, several additional system-level factors were identified:

Staffing: lack of home care providers on nights and weekends, limits on covered services, high turnover rates, uneven quality, low pay, language barriers, and the need for home care workers who could provide a wide range of service (from hands-on to homemaker)

Lack appropriate housing features, inadequate adult ay programs and respite care, and the need to educate family members about participant needs

Robison et al., (2012), Journal of Aging and Social Policy.

Nursing Home Transition from HCBS (cont.)

Several recommendations were given for moving from research findings to policy and practice

More structured coordination with hospital and nursing home discharge planners

Family and caregiver support is needed (e.g., caregiver support, respite programs, adult day programs)

Employer recommendation: flexible work schedules, telecommuting, paid time off, in-person and online support for eldercare providers, and wellness program that include exercise and stress reduction

Innovative transportation solutions (e.g., cooperative models and/or nonprofit agencies providing services)

Mental health/substance abuse services for older adults

Robison et al., (2012), Journal of Aging and Social Policy.

Housing and CommunitiesAcross the Life Course There is an urgent call for

planners and policymakers to prepare for the rapidly aging society, including addressing the specific need for planning and developing affordable housing for an aging population that is well designed, connected to essential services and infrastructure, and fosters social and community integration

Farber, Shinkle, Lynott, Fox-Grage, & Harrell (2011)

www.joblo.com

What is Aging in Place? Not having to move from one’s present

residence in order to secure necessary support services in response to changing needs (Journal of Housing for the Elderly)

Or, more simply out, growing older in the location that one desires

An interesting questions emerges:

Should we facilitate aging in place or aging in community?

Universal Design► “Universal design is the design of

products and environments to be usable by all people, to the greatest extent possible, without the need for adaptation or specialized design”

–Ron Mace

► Universal design benefits people of all ages and abilities

The Center for Universal Design (CUD) – North Carolina State University: http://www.design.ncsu.edu/cud/

“Visit-ability” or “Visitability”

► “Visit-ability” or “Visitability” is an affordable, sustainable and inclusive design approach for integrating basic accessibility features into all newly built homes and housing

► Refers to single-family or owner-occupied housing designed in such a way that it can be lived in or visited by people who have trouble with steps or who use wheelchairs or walkers

► The inflexible features are: Wide passage doors At least a half bath/powder room on the main floor At least one zero-step entrance

http://www.visitability.org/

The Details of Visitability

► An entrance without a step or threshold that is on an accessible path of travel from the street, sidewalk or driveway An accessible path of travel has no steps, is at least 36 inches wide and

is not steeper than 1:20 (5% grade) for walkways or 1:12 for ramps.

► Throughout the ground floor: doorways designed to provide 32 inches of clear space hallways that have at least 36 inches of clear width

► Basic access to a half bath or full bath on the ground floor As defined here, basic access simply denotes sufficient depth within the

bathroom for a person in a wheelchair to enter, and close the door

-Rehabilitation Engineering Research Center on Universal Design at Buffalo

New Construction Retrofitting

Zero-Step Entrance $200 $3,300

Widen Interior Doors $50 $700

Source (2012): Concrete Change http://www.concretechange.org

*Access is cost-effective if planned in advance

Making the case for the broad application of accessible design

Source: University of Buffalo

Flexible housing design► Flexible housing is a way of easing the shortage of

affordable housing by designing new and rehabilitated single family residences so that accessory apartments are easily and cost-effectively created or removed.

►Howe, 1990

► Important elements: Placing studs that will allow for grab bars in

the future Being able to convert part of the house

into an accessory dwelling unit in the future Adjustable countertops and cupboards Zero-step entrance Bathroom and bedroom on main level Outlets at waist-level

http://savoirfair.org

Age-friendly Cities and Communities

Origins of Age-Friendly Cities Project

2005 – Original Age-Friendly Cities project conceived at the International Association of Gerontology and Geriatrics in Rio de Janeiro, Brazil Immediately attracted enthusiastic interest

WHO advisory group guided project development Included WHO staff and international

representatives from public, non-governmental, university, and advocacy groups

Funding and in-kind support from the Public Health Agency of Canada helped in developing and implementing the project and publishing the final report: Global Age-Friendly Cities: A Guide

The Age-Friendly City Model WHO’s focus on “age-

friendly” cities emerged from its “active aging” model

Active aging: Involves optimizing

opportunities for health, participation, & security

Is determined by various factors that are cumulative over the life course

→

Development of the WHO’s

Age-Friendly Cities research project

2006 – Initial meeting of advisers in Vancouver, Canada Experts in policy, community action, and qualitative research

convened Attendees were familiar with the social context of both

developing and developed countries

“Vancouver protocol” was created to: Guide collaborating groups to use a

standardized method to assess their community’s age-friendliness

Identify areas for remedial action Contribute to WHO’s objective of

identifying the essential features of an age-friendly city

Study Objectives

For WHO: to identify concrete indicators of an age-friendly city and produce a practical guide to stimulate and guide advocacy, community development and policy change to make urban communities age-friendly

For participating cities: to increase awareness of local needs, gaps and good ideas for improvement in order to stimulate development of more age-friendly urban settings

An “Age-Friendly” City:

Is a World Health Organization designation

Is defined as a city that:is “an inclusive and accessible

urban environment that promotes active ageing”

“emphasizes enablement rather than disablement”

“is friendly for all ages, not just age-friendly”

Implementing the WHO’s Age-Friendly Cities Protocol

Eight features of urban life were identified for examination in the Vancouver protocol

Semi-structured focus groups were required where participants were asked to identify positive and negative features of the city and to offer suggestions for improvement

Informed consent/ethics review was mandatory

An Age-Friendly City: Eight Domains

Source: Suzanne Garon,University of Sherbrooke

Implementation (cont.) Project sites were recruited through informal networks of

WHO project leaders, connections to municipal or state governments, and promotion of the project at professional conferences

Focus groups were conducted in 33 cities in 22 countries 158 focus groups with people aged 60+ (n = 1,485) Some sites conducted caregiver focus groups (n = 250) Some sites conducted focus groups with service providers in

public, voluntary & commercial sectors (n = 515)

Participating cities were diverse: 19 developing and 14 industrialized countries Areas within 7 mega cities (10 million +) were included: Mexico

City, Moscow, New Delhi, Rio de Janeiro, Istanbul, Shanghai, and Tokyo

Smaller cities/communities/neighborhoods also were involved

Original Age-Friendly Collaborating Cities AMERICASArgentina, La PlataBrazil, Rio de JaneiroCanada, HalifaxCanada, Portage La PrairieCanada, SaanichCanada, Sherbrooke Costa Rica, San JoseJamaica, KingstonJamaica, Montego BayMexico, CancunMexico, Mexico CityPuerto Rico, MayaguezPuerto Rico, PonceUSA, PortlandUSA, New York

AFRICAKenya, Nairobi

EUROPEGermany, RuhrIreland, DundalkItaly, UdineRussia, MoscowRussia, TuymazySwitzerland, GenevaTurkey, IstanbulUK, EdinburghUK, London

EASTERN MEDITERRANEANJordan, AmmanLebanon, TripoliPakistan, Islamabad

SOUTH-EAST ASIAIndia, New DelhiIndia, Udaipur

WESTERN PACIFICAustralia, MelbourneAustralia, MelvilleChina, ShanghaiJapan, HimejiJapan, Tokyo

Image Credit:BC Ministry of Health

Implementation: Assistance for Developing Countries Public Health Agency of Canada allowed WHO to

award small research contracts to NGOs & research centers in developing world:

Jamaica, Mexico, Costa Rica, Brazil, Argentina, Libya, Kenya

Help the Aged UK contracted with HelpAge India to conduct the research in two cities in India

The Guide & Checklist The recurring themes and

variations among communities were reported in detail in the WHO main report: Global Age-friendly Cities: A Guide

A set of core features of an age-friendly city was identified in the Guide and in a four-page Checklist of Essential Features of Age-friendly Cities The Guide and Checklist are intended to

serve as a reference for other communities to assess their strengths and gaps, advocate for and plan change, and monitor progress

→

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http://www.who.int/ageing/age_friendly_cities_guide/en/

The Launch of Findings: 2007 The United Nations

recognizes October 1st as International Day of Older Persons

WHO launched the Global Guide on October 1st, 2007 in London (English) and Geneva (French)

Cities around the world were encouraged to have special events to launch their findings For example, in Portland we

presented findings to government leaders and media at City Hall

Alexandre Kalache, former Director of WHO's Life Course and Aging Programme,

speaks about age-friendly cities

Canadian Health Minister Tony Clement (right) accepts an international award from Help the

Aged UK as part of the launch of findings

The WHO Global Network of Age-Friendly Cities (and Communities)

After the initial Age-Friendly Cities project, the WHO was overwhelmed by positive responses, and new cities around the world wished to join this global movement

To support cities wanting to follow the approach, and to ensure the quality of the tools and interventions they use, the WHO established the WHO Global Network of Age-friendly Cities

Recently, the WHO has added “Communities” to the program name based on requests from non-urban areas

Goals and Requirements of the Network Goals:

To provide technical support and training To link cities and communities to WHO and each other To facilitate the exchange of information and best practices To ensure that interventions taken to improve the lives of

older people are appropriate, sustainable and cost-effective

Membership requirements: City must commit to undertaking a process of continually

assessing and improving its age-friendliness Older residents must be involved in a meaningful way

throughout the process City must complete an online application form and submit a

letter from the mayor/municipal administration indicating commitment

WHO Proposed Cycle for Members of the Global Network of Age-

friendly Cities©

1. Joining the network• Involve older people• Baseline assessment of age-friendliness

• Develop action plan• Identify indicators

2. Implementation• Implement

action plan• Monitor indicators

3. Evaluate progress and continual improvement

• Measure progress• Identify success and remaining gaps

• Develop new action plan

Years 1-2 Years 3-5

Ongoing 5-year cycles

Current WHO Global Network of Age-friendly Cities and Communities As of March, 2013 there were 138 cities in 21

countries across the world There were 10 affiliated programs

coordinating municipal efforts worldwide (e.g., AARP in the U.S., Pan Canadian Initiative, Ageing Well Network in Ireland)

Current countries in the network: Andorra, Argentina, Australia, Belgium, Canada, China, Finland, France, Ireland, Israel, India, Japan, Mexico, Portugal, Russian Federation, Slovenia, Spain, Sri Lanka, Switzerland, UK, & U.S.

WHO Age-Friendly Cities Project

in Portland, Oregon

Select FindingsOutdoor Spaces &

BuildingsEven more natural features & green spaces were desired, with attention toward accessibility

HousingMore affordable & accessible housing was suggested (e.g., infill development such as below seen as inadequate)

“A reporter [called] me and [told] me he was writing an article about new homes in the Portland area, brand new construction built to be accessible, and I laughed and said it would be a very short article.” – Design Expert

TransportationRegional transportation options were considered age-friendly, but improvements were suggested

Social ParticipationMany educational and social opportunities were noted, but additional options were desired

www.pdx.edu

Select Findings (cont.)

Respect & Social InclusionLanguage and inclusion matter! Terms such as “honored citizen” and “long-term living” were preferred, and organizations were encouraged to consult and listen to the advice of older adults

Civic Participation & Employment

Employment and volunteer opportunities for older adults, especially those with lower incomes and less education, were advocated

www.trimet.org

Select Findings (cont.)

Communication & Information

Opportunities to learn how to use technology were seen as important, but services should not assume access and proficiency by all

Community Support & Health Services

Connecting necessary services to people was seen as critical to making Portland age friendly

Select Findings (cont.)

“Portland [will be] a Place for All Generations”

Draft Plan released March, 2012 Written comments were

submitted that specifically addressed needed improvements to the Plan

BPS requested a meeting with aging and disability representatives to discuss written comments

March 19, 2012 – We were asked to present to Portland’s Planning Commission

Final result: Portland Plan now specifically addresses how Portland can become a more age-friendly city

Portland Plan Action Items Develop an age-friendly city action plan

Prioritize expansion and availability of accessible housing

Concentrate on age-friendly, accessible community hubs

Foster safe and accessible civic corridors (e.g., infrastructure and transit)

Increase access to and services within medical institutions

Increase inter-generational mentoring opportunities

Bolster framework for equity, including integration with newly forming City of Portland Office of Equity

Proposed (revised) definition of Sustainable Development

Sustainable development seeks to meet human needs while cultivating opportunities for human development across the life course, cultures, and geographies. Such development must address the current generations’ ability to sustain their quality of life and well-being while maintaining the ability for future generations to do the same. Furthermore, human development must be integrated into evolving ecological systems by balancing aspects of the natural, built, and social environments. Growth patterns, services, and underlying economic systems must foster social equity in a manner that leads to the health of people, places and systems, both now and in the future.DeLaTorre, A., 2013 (Dissertation findings)

Proposed Guiding Principles of Sustainable Development for an Aging Population

1. Share best practices among municipalities that pertain to sustainable housing and

communities for an aging society and adopt or adapt those in an effort to best serve local

and regional needs and abilities.

2. Enable meaningful processes, participation, and partnerships across sectors,

organizations, and community stakeholders in an attempt to achieve informed decision

making and to bolster community development efforts.

3. Value culture, wisdom, and other assets that exist throughout the life course.

4. Consider social equity implications when creating and/or refining policies and

programs in order to provide an appropriate collective response that addresses the

identified needs of vulnerable populations and protected classes of people.

5. Create viable and sustainable economic resources that utilize the assets of people of all

ages and abilities.

Proposed Guiding Principles of Sustainable Development for an Aging Population (cont.)

6. Provide appropriate community and health services that focus on enhancing independence

and well-being in an affordable and efficient manner.

7. Expand environmental sustainability and green building principles to better address the

planning and development of healthy housing and communities that are appropriately and

accessibly designed.

8. Refine codes, regulations, plans, and strategies to better align the proximity of and

connections between accessible housing, transportation, and land uses in order to create

efficient infrastructure systems and appropriate levels of density for an aging society.

9. Foster the creation of accessible and useful places for social interaction and civic activities

within and in close proximity to housing for older adults.

10. Integrate research efforts in gerontology, urban planning, public health, and related fields

in an attempt to inform practice and improve the implementation of housing and community

development policies and programs.

For more information:

Alan DeLaTorre, Ph.D.Institute on Aging

Portland State University 503.725.5236

aland@pdx.edu

Thank you! Questions?