1. A Primer on Environmental Gerontology
Alan DeLaTorre, PhD
Institute on Aging
Portland State University

2. 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

3. 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

4. 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)

5. Ecological Model (NIH, 2005)

6. 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).

7. Lawton’s Ecological Model

8. 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).

9. 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

10. 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

11. 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,

12. 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.

13. 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.

14. 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) 14

15. 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

16. 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: 16

17. “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 17

18. 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

19. 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 19

20. Source: University of Buffalo20

21. 21

22. 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 22

23. Age-friendly Cities and Communities

24. 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

25. 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 →

26. 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

27. 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

28. 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”

29. 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

30. An Age-Friendly City: Eight Domains
Source: Suzanne Garon,
University of Sherbrooke

31. 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

32. 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

33. 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

34. 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 → →

35. 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

36. 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

37. 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

38. 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

39. 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.

40. 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

41. 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

42. 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

43. 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

44. 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

45. “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

46. 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

47. 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)

48. 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.

49. 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.

50. Portland State University
For more information:
Alan DeLaTorre, Ph.D.
Institute on Aging
Portland State University
Thank you! Questions?