Age-Friendly Community Initiatives: Conceptual Issues and Key Questions

Abstract

Public policy and programs for older adults traditionally have focused on the delivery of benefits to targeted individuals. Over the past decade, age-friendly community initiatives (AFCIs) have developed as a paradigm shift in contrast to this predominant focus. AFCIs engage stakeholders from multiple sectors within a typically local geographic area to make social and/or physical environments more conducive to older adults’ health, well-being, and ability to age in place and in the community. We describe three general categories of AFCIs, including community planning approaches, support-focused approaches, and cross-sector partnership approaches. Following from this conceptual overview, we posit four key policy-relevant questions with implications for the expansion of AFCIs, including what public policy supports are necessary for the implementation of AFCIs across diverse communities, how entities outside of aging can be engaged to collaborate, to what extent advocates for various models can work together, and how the outcomes of these initiatives can be rigorously evaluated. We conclude by discussing how AFCIs are germane to the primary issues highlighted by the 2015 White House Conference on Aging.

Emerging approaches within efforts to enhance health and well-being in later life focus not so much on “when is old age” but rather “where is old age” (Stafford, 2009). Although traditional supportive services that focus on individuals are important for promoting aging in place and optimizing well-being in later life, the rapid growth of age-friendly community initiatives (AFCIs) suggests another approach: deliberately influencing social and physical environments to benefit older adults. This article aims to advance research, policy, and practice on AFCIs by (a) describing how AFCIs reflect a paradigm shift from a focus on individuals to one on communities, (b) advancing a unifying definition of AFCIs as well as a typology to identify primary categories of models, and (c) posing policy-relevant questions that have implications for the expansion of AFCIs in the United States. The article concludes with a discussion of how AFCIs relate to the themes highlighted by the 2015 White House Conference on Aging (WHCoA).

AFCIs as a Paradigm Shift

Historically, national policy on aging has focused on the delivery of services to targeted individuals. For example, President Lyndon B. Johnson’s “Great Society” legislation in the 1960s created foundational federal programs for the provision of health and social services for older adults, including Medicare, Medicaid, and the Older Americans Act (OAA) (Gelfand, 2006). More recently, the 2010 Patient Protection and Affordable Care Act has supported initiatives to better meet the needs of individuals by enhancing service delivery systems, such as patient-centered medical homes, accountable care organizations, care transition programs, and Medicaid waiver reform (Takach, 2012). Much of the national discourse on an aging population continues to focus on systems to provide benefits to individuals, such as long-term services and supports and the solvency of Social Security (Williamson, 2014).

Overall, these developments take a “downstream” approach—facilitating assistance to a particular individual with a defined need at a specific point in time. In contrast, AFCIs have shifted the focus from individuals to communities as a whole. These efforts involve a more “upstream” approach, whereby the goal is to change older adults’ broader physical and social environments to enhance their capacity to function optimally in their own homes and communities (Boufford, 2014). This approach is congruent with ecological perspectives, which address dynamic transactions among people and their environments (Bronfenbrenner & Morris, 2006; Lawton, 1989). It also fits with a public health approach to aging, suggesting the importance of benefits targeted not only to those with age-related problems already, but also of population-level efforts to prevent problems from occurring in the first place (Hunter et al., 2013). Many initiatives also reflect a growing emphasis on participatory approaches to promoting health, which involves consumers sharing in the power of decision making with other stakeholders (Rifkin, Lewando-Hundt, & Draper, 2000).

Toward a Conceptual Definition of AFCIs

Especially given the emergent nature of AFCIs, a variety of terms have been developed to refer to this area, such as age-friendly communities, livable communities, communities for all ages, and community aging initiatives. We adopt the term “age-friendly community initiatives,” or AFCIs, as this term has been used most consistently within recent publications (Ball & Lawler, 2014; GIA, 2013; Golant, 2014). It also fits with the 2015 WHCoA’s attention to fostering “communities that are age-friendly” (WHCoA, 2014).

Integrating across prior conceptual work in this area (Alley, Liebig, Pynoos, Banerjee, & Choi, 2007; Bookman, 2008; Greenfield & Giunta, in press; Lehning, Scharlach, & Wolf, 2012; Scharlach, 2012), we define AFCIs as deliberate and distinct efforts across stakeholders from multiple sectors within a defined and typically local geographic area to make social and/or physical environments more conducive to older adults’ health, well-being, and ability to age in place and in the community. AFCIs share criteria along the five dimensions of who, where, what, how, and why:

• 1. Who: AFCIs include active involvement from major systems influencing the lives of older adults. Examples include municipal governments, local service providers, faith-based organizations, transportation authorities, housing providers, and private citizens themselves.

• 2. Where: AFCIs focus on a specified geographic area, whether defined by a cluster of apartment buildings, neighborhood, zip code, municipality, or region. Whereas some initiatives have been organized on a scale as large as countries, such as Ireland (National Council on Ageing and Older People, 2005), most initiatives focus on smaller areas.

• 3. What: AFCIs are deliberate and distinct initiatives from those of single organizational entities, such as municipal offices on aging or aging services divisions within nonprofit organizations. They focus on influencing social environments (such as relationships among community members and social institutions), as well as physical environments (including the built and natural environments).

• 4. How: AFCIs, as a whole, use a variety of methods to influence local environments, such as by conducting needs assessments, forming coalitions, engaging in advocacy campaigns, developing interorganizational collaborations, and engaging community volunteers.

• 5. Why: Broadly stated, the goal of AFCIs is to enhance older adults’ health and well-being; to strengthen their capacity to live in their own homes or communities safely and comfortably; and to facilitate their engagement in meaningful community roles (Golant, 2014; Pynoos, Nishita, Cicero, & Caraviello, 2008; Scharlach & Lehning, 2013; Thomas & Blanchard, 2009).

While advancing the above definition to identify diverse efforts as AFCIs, it is also important to note meaningful differences across approaches under this umbrella term. A number of frameworks have been proposed (Bookman, 2008; Gonyea & Hudson, 2012; Greenfield, 2012; Lui, Everingham, Warburton, Cuthill, & Bartlett, 2009), with common dimensions including the type of locale in which AFCIs are implemented, their relative focus on physical versus social environments, the extent to which they encourage older adults versus local authorities as leading processes of change, and the populations and systems engaged. Drawing largely on work by Lehning, Scharlach, and Wolf (2012), we suggest a three-part typology that we believe is parsimonious yet meaningful for identifying clusters of AFCIs. The three categories differentiate initiatives in terms of the primary activities through which they intend to influence social and physical environments to promote aging in place and in the community.

• 1. Community planning approaches. As articulated by Lehning, Scharlach, and Wolf (2012), community planning approaches are based on a top–down model involving needs assessments and rational planning processes. These activities are sometimes under the auspice of local government but other times originate from universities or other research, policy, service, or advocacy organizations. Some community planning efforts have been intended to improve environments for older adults while benefitting others, too, across the age and ability spectrum (World Health Organization [WHO], 2007). Community planning approaches appear similar to cross-sector partnership approaches (described below), as they require engagement and collaboration of individuals and organizations from different fields, including older adults themselves; however, the primary focus is on the domains of action (e.g., transportation and safe mobility; housing and universal design; civic engagement and social participation; access to services and supports) more so than the process of bringing together a variety of actors to lead community-level change. Examples of community planning approaches and tools to support them include the AdvantAge Initiative (Feldman & Oberlink, 2003), the Lifelong Communities Initiative in Atlanta, Georgia (Atlanta Regional Commission, 2009), AARP Public Policy Institute’s Livable Communities Initiative (AARP, 2014), the Milken Institute’s Best Cities for Successful Aging Initiative (Chatterjee & DeVol, 2014) and the WHO’s Global Age-Friendly Cities Project (WHO, 2007). These initiatives encompass explicit frameworks to assess features of targeted geographic areas, which are intended to foster collaborative activities around aging and community that build upon existing strengths and address priorities for improvement.

• 2. Support-focused approaches. AFCIs that include an explicit focus on facilitating supports for older adults fall within the support-focused cluster (which combines the consumer-directed approaches and residence-based support services initiatives as described by Lehning, Scharlach, and Wolf [2012]). These models reflect the intersection between downstream and upstream approaches. Although they include collaboration among people and organizations to make environments more supportive of older adults at both the community and individual levels, there is particular attention to collaboration for the purpose of enhancing community-wide networks of informal and formal sources of support. Examples include convening local stakeholders to address service delivery issues within the community, or creating a pool of community volunteers that allow neighbors to more readily help their neighbors. Two nationally prominent models of this type are Villages and Naturally Occurring Retirement Community Supportive Service Programs (NORC programs). Both models share an emphasis on promoting older adults’ access to services and reducing social isolation through efforts to transform social relationships at the community level (Greenfield, Scharlach, Lehning, Davitt, & Graham, 2013). Villages are usually membership-based, neighborhood organizations (Scharlach, Lehning, & Graham, 2012), whereas NORC programs are typically part of larger multiservice, community-based organizations (Vladeck, 2004).

• 3. Cross-sector partnership approaches. As also described by Lehning, Scharlach, and Wolf (2012), cross-sector partnership approaches prioritize collaboration among different organizations and individuals to expand the range of sectors focused on aging. These initiatives in their implementation can appear similar to community planning approaches (e.g., an initiative focuses on changing zoning ordinances), as well as to support-focused approaches (e.g., an initiative seeks to enhance collaboration among service providers). However, the initiatives under this category themselves do not necessarily ascribe to a particular framework for assessing age-friendliness, nor do they primarily emphasize formal and informal sources of support. The focal mechanism of cross-sector partnership approaches is the bringing together of entities from a wide range of sectors to develop and implement locally based action plans concerning aging, which can lead to a variety of proximal objectives under this category. Examples of cross-sector partnership approaches include the Robert Wood Johnson Foundation’s Community Partnerships for Older Adults (CPFOA) program (Bolda, Saucier, Maddox, Wetle, & Lowe, 2006), and several grantees as part of Community Innovations for Aging in Place (CIAIP), an OAA demonstration program, which made cross-sector partnership the cornerstone of its initiatives (Oberlink, 2014).

Critical Questions Concerning the Expansion of AFCIs in the United States

All three categories of AFCI models described above demonstrate the promise of creating changes at the community level to benefit older adults. Nevertheless, AFCIs also share common challenges—most notably that their presence within any given community is more the exception than the rule (Ball & Lawler, 2014). At the present time, Grantmakers in Aging (GIA)—a nonprofit organization for groups making charitable grants in aging—has identified about 270 “age-friendly programs” nationwide (www.giaging.org/programs-events/community-agenda/community-agenda-database). Moreover, a U.S. national survey of local governments conducted in 2005 and again in 2010 found that most communities had not made progress toward creating “livable communities for all ages” and that many were struggling to simply maintain existing programs and services (National Association of Area Agencies on Aging [N4A], 2011). In response to these developments, we pose four key questions that (a) have implications for the expansion of AFCIs, (b) are relevant for policy-making, and (c) apply to all three categories of AFCI models, as described above.

What public policy supports are necessary for AFCIs to flourish in diverse communities throughout the United States?

A major challenge facing AFCIs’ development is the commitment of resources—including financial, political, social, and human capital—to sustain them over time. Concerning financial capital, there is a general sense that creating meaningful changes at the community level takes a considerable investment of time and resources, yet funding periods for these initiatives are oftentimes for only several years. This was the case for communities funded by the national NORCs Aging in Place demonstration program (Greenfield, 2013), the federal CIAIP (Oberlink, 2014), the Robert Wood Johnson Foundation’s CPFOA (Bolda et al., 2006), and GIA’s Community AGEnda, which was funded by the Pfizer Foundation from the outset as a three-year project (J. Feather, personal communication, October 17, 2014). Concerns regarding stable sources of support are especially salient when considering the types of communities that have adequate resources to initiate and sustain robust AFCIs, raising concern that communities with existing privileges are the ones most likely to implement, and benefit from, AFCIs (Scharlach & Lehning, 2013).

Clearly, public policy at the national level has the potential to address these concerns, at least in part, through the provision of financial and nonfinancial support. To date, however, federal leadership specific to the development of AFCIs has been limited to Title IV demonstration projects under the OAA that sunseted at the end of their demonstration periods. Advocates’ efforts to engage more local levels of government in many areas of the United States have had limited success, given pressures on municipal, county, and state governments to use public funds to address other issues (for an exception, see Pine & Pine, 2002, regarding New York City and State funding for NORC programs). Additionally, although the market for long-term support services and products is growing, there is no evidence yet that consumers express a widespread demand for physical or social infrastructure changes. Increased public education, advocacy, and evidence regarding the benefits of AFCIs might be necessary before there is sufficient political will to devote resources to their development. Moreover, additional conceptual and empirical work is necessary to (a) identify the various roles of different levels of government, as well as those of the private sector and civil society, to initiate and sustain AFCIs, and (b) determine how AFCIs might be advanced through existing legislation, programs, and services, such as Medicaid waivers, Section 8 housing vouchers, the Americans with Disabilities Act, and the QA (see Ball & Lawler, 2014, for further discussion).

How can advocates engage entities traditionally outside of the field of aging to collaborate on aging-related issues and joint agendas?

The siloed separations endemic to professional practice, academia, health care, and government bureaucracies prevent the development of a more widely shared aging agenda across public and private institutions and disciplines. These silos are maintained and reinforced by a number of factors: the disaggregation of funding streams by governments and philanthropy, a scarcity model of resources that leads to perceived intergenerational conflicts, the nearly total lack of convergent strategic planning across major institutions, and the basic cultural worldview of the life course itself that separates age groups from one another.

Despite these challenges, there are examples from the field of how community-level issues concerning older adults have been infused within entities traditionally outside of the area of aging. In Portland, Oregon, two of the city’s primary formal planning tools, the Portland Plan and the Comprehensive Plan, were up for renewal, thus providing an opportunity to highlight the population’s future aging-related issues and to create an action plan involving a range of stakeholders (Neal, DeLaTorre, & Carder, 2014). Also, New York State’s Project 2015 has required all state agencies to consider how the growth of the older population will impact the agencies and to identify strategies to assure that agencies are prepared (New York State Office for the Aging, 2005). Although not specific to aging, the Partnership for Sustainable Communities demonstrates partnerships among federal agencies—including the U.S. Department of Housing and Urban Development, Department of Transportation, and Environmental Protection Agency—to advance community-level priorities (Partnership for Sustainable Communities, 2013). These examples provide strong models for the development of greater cross-sector collaboration at both the federal and local levels on behalf of community-level issues concerning aging. They also demonstrate how government can support the development of AFCIs beyond the provision of financial resources by engendering greater collaboration across diverse sectors.

To what extent should advocates of various models identify and work with each other?

Overall, it appears that AFCIs have not evolved into a readily unifiable organizational field—a term to indicate efforts that have similar values, goals, methods of operation, and evaluation strategies (Greenwood & Hinings, 1996). Regarding goals, some initiatives focus exclusively on older adults, while others have called for changes that are good for people of all ages (WHO, 2007). Regarding methods, whereas many have emphasized ways in which AFCIs alter social and physical environments, others have framed these initiatives as enhancing person–environment transactions, including individuals’ capacity to better manage environmental challenges as they and their environments change over time (Scharlach, in press). Differences in the initiatives’ models, as well as in their implementation across diverse communities, are likely to impede the rapid development of coalition building, exchange of information, joint research agendas, and pooling of resources that could potentially benefit AFCIs as a whole.

A political economy perspective suggests yet other barriers to collaboration across AFCIs, holding that the allocation of material, social, and financial resources serves to maintain the interests of groups already in power. It also highlights the overall lack of public funding—particularly at the federal level—to benefit older adults, especially those who are most vulnerable on account of social positions that intersect with age, such as race/ethnicity and gender (Estes, 2001). From this perspective, limited funding for aging services is likely to lead to competition for resources—and even more so for AFCIs, whose federal funding has been relatively small amounts through OAA demonstration programs (Greenfield, 2013; Oberlink, 2014).

How can the individual- and community-level outcomes of these initiatives be rigorously evaluated?

A major challenge facing all community initiatives—in aging and outside of aging alike—is how to evaluate their impact on individuals and communities (see Kubisch, Auspos, Brown, & Dewar, 2010, for a discussion). In an era when policymakers and private funders are increasingly seeking evidence for programs’ effectiveness, especially in terms of costs, more rigorous outcomes research in this area is sorely needed. Although there is a growing body of research on how neighborhood conditions affect the health and well-being of community residents (see, e.g., Pruchno, Wilson-Genderson, & Cartwright, 2012), there is little systematic examination of whether deliberate efforts to change community-level conditions yield desired outcomes among individuals (for an exception, see Wilson et al., 2014). Lack of evidence regarding effectiveness likely contributes to hesitancy among policymakers to invest substantial funds in AFCIs. Many of the difficulties in evaluating AFCIs are inherent within the design of the initiatives themselves, including (a) their multifaceted nature (e.g., should observed effects be attributed to one component alone or to the initiative as a whole?), (b) the diverse ways in which individuals can benefit (e.g., would we expect benefits among people who do not directly participate in the activities organized by an AFCI?), (c) the complexity of their outcomes (e.g., how can we precisely measure aging “in place” or “in community”?), (d) their flexible design to accommodate the particular needs and strengths of the localities in which they are implemented (e.g., is comparing the effectiveness of a model in one locality to that in another sensible if the models have different emphases and/or are implemented in different ways?), and (e) the overall lack of funding available to support AFCIs, which constrains financial support for rigorous, longitudinal evaluation.

Despite these challenges, there is some promise for evaluation work in this area. With respect to cross-sector partnership models, CPFOA sites developed site-specific methods to evaluate programmatic activities, partnership processes, and local impacts (Giunta & Thomas, 2013). Regarding community planning initiatives, the New York City Age-Friendly Initiative has evaluated pilots of specific activities, such as finding reduced rates of pedestrian and non-pedestrian crashes after the introduction of improved street design (Age-Friendly NYC, 2013). WHO (2013) also is developing a set of core and recommended indicators for use in evaluating cities’ age-friendly efforts. Perhaps even more promising are examples of rigorous evaluation from fields outside of aging. Researchers in youth development have conducted longitudinal, experimental research—with randomization occurring at the level of communities—for a community-level intervention to promote adolescent health and to prevent behavioral problems (Hawkins, Oesterle, Brown, Abbott, & Catalano, 2004). These efforts suggest that more rigorous outcomes research on AFCIs might be possible.

Conclusion: Implications for the 2015 WHCoA

The 2015 WHCoA addresses AFCIs under the issue of healthy aging. As the conference website states: “Creating and supporting communities that are age-friendly can allow older adults to age in place in the community as well as assist in supporting their health and vitality. Bringing together enhanced partnerships among health care services, aging services, and housing can help support older Americans thriving in their communities as they age” (U.S. Department of Health and Human Services, n.d.).

This inclusion indicates increasing recognition of AFCIs’ potential to promote older adults’ health and well-being and to prevent or delay the onset of disease and disability. The incorporation of AFCIs under the topic of healthy aging, in particular, provides the opportunity to generate discussion around the above four questions, especially in terms of their implications for policy advocacy, analysis, and recommendations. AFCIs are further relevant to the other three issues selected for the 2015 WHCoA, including elder abuse and neglect, long-term services and supports, and economic security in later life. For example, AFCIs have the potential to reduce older adults’ social isolation, which can lower the risk for maltreatment. AFCIs can provide a vehicle for making long-term services and supports more accessible, especially at a community level. They also have the potential to engage diverse stakeholders in conversations germane to economic security, including employment in later life and affordable housing. The 2015 WHCoA presents an opportunity to discuss community-level approaches to major challenges facing a rapidly aging United States, a discussion which is likely essential for developing the broad-based supports for meaningful federal policy on AFCIs so that they can more fully achieve their intended benefits.

References

Author notes