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: Behavior both affects, and is affected by, multiple levels of influence Individual behavior both shapes, and is shaped by, the social environment (i.e., reciprocal causation)

Ecological Model (NIH, 2005)

Ecologic Model of Environment 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: Individual factors Social factors Aggregated population characteristics Physical environments Institutional and service environments Economic factors 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: Family availability and family/client preferences for care settings An acute change in health status leading to hospitalization or short-term rehabilitation Limits on services available in a home care program Mental health, legal issues, and falls Robison, 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 Communities Across 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 14

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? 15

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/ 16

“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/ 17

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 18

Making the case for the broad application of accessible design *Access is cost-effective if planned in advance New Construction Retrofitting Zero-Step Entrance $200 $3,300 Widen Interior Doors $50 $700 Source (2012): Concrete Change http://www.concretechange.org 19

Source: University of Buffalo 20

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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 22

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 27 27

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 AMERICAS Argentina, La Plata Brazil, Rio de Janeiro Canada, Halifax Canada, Portage La Prairie Canada, Saanich Canada, Sherbrooke Costa Rica, San Jose Jamaica, Kingston Jamaica, Montego Bay Mexico, Cancun Mexico, Mexico City Puerto Rico, Mayaguez Puerto Rico, Ponce USA, Portland USA, New York AFRICA Kenya, Nairobi EUROPE Germany, Ruhr Ireland, Dundalk Italy, Udine Russia, Moscow Russia, Tuymazy Switzerland, Geneva Turkey, Istanbul UK, Edinburgh UK, London EASTERN MEDITERRANEAN Jordan, Amman Lebanon, Tripoli Pakistan, Islamabad SOUTH-EAST ASIA India, New Delhi India, Udaipur WESTERN PACIFIC Australia, Melbourne Australia, Melville China, Shanghai Japan, Himeji Japan, Tokyo Image Credit: BC Ministry of Health 32 32

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 → → 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 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© Years 1-2 Years 3-5 3. Evaluate progress and continual improvement Measure progress Identify success and remaining gaps Develop new action plan 1. Joining the network Involve older people Baseline assessment of age-friendliness Develop action plan Identify indicators 2. Implementation Implement action plan Monitor indicators The aims and activities of the WHO Global Age-Friendly Cities Network are in close alignment with those of the emerging Portland Plan. City’s application to the WHO indicated a formal commitment by the City of Portland to partner with the IOA to meet the Network’s requirements: Establishment of mechanisms to involve older people in all stages of the Age-Friendly Cities (AFC) process. Development of a baseline assessment of the age-friendliness of the city. Development of a 3-year city-wide action plan based on the assessment’s findings. Identification of indicators to monitor progress against this plan. Ongoing 5-year cycles 38

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 Explain the reasons why Portland was selected – Dr. Martha Pelaez suggested Portland and researchers at the IOA/PSU 40 40

Outdoor Spaces & Buildings Select Findings Housing More affordable & accessible housing was suggested (e.g., infill development such as below seen as inadequate) Outdoor Spaces & Buildings Even more natural features & green spaces were desired, with attention toward accessibility “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

Select Findings (cont.) Transportation Regional transportation options were considered age-friendly, but improvements were suggested Social Participation Many educational and social opportunities were noted, but additional options were desired www.pdx.edu

Select Findings (cont.) Respect & Social Inclusion Language 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

Communication & Information Community Support & Health Services 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

“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 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. 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. Value culture, wisdom, and other assets that exist throughout the life course. 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. 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.) Provide appropriate community and health services that focus on enhancing independence and well-being in an affordable and efficient manner. 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. 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. Foster the creation of accessible and useful places for social interaction and civic activities within and in close proximity to housing for older adults. 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.

Portland State University For more information: Alan DeLaTorre, Ph.D. Institute on Aging Portland State University 503.725.5236 aland@pdx.edu Thank you! Questions?