Age-friendly environments in Europe: a handbook of domains for policy action

M U N IC IP AL S ER VI CE S PHYSICAL ENVIRONM ENT SOCIAL ENVIRONMENT AGE- FRIENDLY ENVIRON- MENTS O ut do or en vi ro nm en ts Tra ns po rt an d m ob ilit y Housing Social participation So ci al in cl us io n an d no n- di sc rim in at io n Civ ic e ng ag em en t an d e mp loy me nt Communication and information Com m unity and health services Age-friendly environments in Europe A handbook of domains for policy action

Age-friendly environments in Europe A handbook of domains for policy action Abstract Policies to create better age-friendly environments have become a forceful movement in Europe and globally in which a growing number of cities and communities, local authorities and regional governments participate. This publication provides a handbook for local policy-makers and planners on eight domains for policy action. These cover both the physical and social environment as well as community services. It builds on a WHO model of eight domains for age-friendly cities and communities that is widely used by local governments in Europe as point of reference. This handbook is based on lessons learned from existing age-friendly initiatives in Europe. It thus builds on the richness of relevant locally and regionally developed tools that are now available, as well as the latest evidence from research. This publication links actions to create more age-friendly environments to the broader context of European health and social policies for ageing populations. A focus is on the inter-connectedness and mutual syn- ergies between the eight domains and how they can work together to address common goals such as increasing social inclusion, fostering physical activity or supporting people living with dementia. Keywords URBAN HEALTH AGEING OLDER PEOPLE INTERGENERATIONAL PROGRAMMES VOLUNTEERS HEALTH POLICY EUROPE ISBN 978 92 890 5288 7 Address requests about publications of the WHO Regional Office for Europe to: Publications WHO Regional Office for Europe UN City, Marmorvej 51 DK-2100 Copenhagen Ø, Denmark Alternatively, complete an online request form for documentation, health information, or for permission to quote or translate, on the Regional Office website (http://www.euro.who.int/pubrequest). © World Health Organization 2017 All rights reserved. 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The responsibility for the con- tent of this report lies with the authors, and the views expressed herein can in no way be taken to reflect the official opinion of the European Commission; nor is the Commission responsible for any use that may be made of the information contained herein. iii Contents List of figures, boxes and tables .................................................................................................. vi Foreword ....................................................................................................................................... vii Acknowledgements ......................................................................................................................viii Introduction ..................................................................................................................................... 1 Healthy ageing: a priority for Europe .............................................................................................................2 Supportive environments: a European and global movement ........................................................................2 Aim and objectives of the AFEE project ........................................................................................................3 Target audience ............................................................................................................................................3 Methodology ................................................................................................................................................4 How age-friendly environments unlock the potential of healthy ageing ..........................................................5 How local governments create age-friendly environments .............................................................................7 Supportive physical environments .................................................................................................................7 Participatory and inclusive social environments .............................................................................................8 The role of municipal and local government services ....................................................................................8 Cross-cutting themes that link between domains .........................................................................................8 Trends of demographic ageing in Europe ....................................................................................................12 Patterns of ageing by broad geographical region in Europe ........................................................................12 Domain 1: outdoor environments ............................................................................................... 14 Introduction ................................................................................................................................................15 Strategic directions for policy interventions .................................................................................................15 Barrier-free public spaces and buildings accessible and usable by people with impairments .......................16 Support for community interaction and personal independence ..................................................................17 Places to be and to stay outdoors ..............................................................................................................19 Urban environments that support belonging, continuity and sense of self ...................................................20 Policy interventions and initiatives by action area and objective ...................................................................21 Resources and toolkits ...............................................................................................................................24 Further reading ...........................................................................................................................................24 Domain 2: transport and mobility ............................................................................................... 26 Introduction ................................................................................................................................................27 Strategic directions for policy interventions .................................................................................................27 Infrastructure for active mobility and walkability ...........................................................................................29 Public transport ..........................................................................................................................................30 On-demand services and other support to improve mobility .......................................................................31 Policy interventions and initiatives by action area and objective ...................................................................32 Resources and toolkits ...............................................................................................................................35 Further reading ...........................................................................................................................................35 Domain 3: housing ........................................................................................................................ 38 Introduction ................................................................................................................................................39 Strategic directions for policy interventions .................................................................................................39 Combating inequity through improved housing ...........................................................................................41 Support for home assessments, repair, maintenance and adaptation .........................................................42 iv Setting and enforcing standards for newly built houses ...............................................................................43 Creating broader housing choices that support independence ...................................................................44 Alternative models of living: collaboration with private and user-driven initiatives .........................................46 Support for relocation .................................................................................................................................47 Security and safety, including crime prevention ...........................................................................................47 Policy interventions and initiatives by action area and objective ...................................................................47 Resources and toolkits ...............................................................................................................................52 Further reading ...........................................................................................................................................52 Domain 4: social participation ..................................................................................................... 54 Introduction ................................................................................................................................................55 Strategic directions for policy interventions .................................................................................................56 A range of opportunities for social participation accessible for older people ................................................57 Supportive environments for social exchange in the community .................................................................59 Lifelong learning .........................................................................................................................................60 Policy interventions and initiatives by action area and objective ...................................................................62 Resources and toolkits ...............................................................................................................................66 Further reading ...........................................................................................................................................66 Domain 5: social inclusion and non-discrimination .................................................................. 68 Introduction ................................................................................................................................................69 Strategic directions for policy interventions .................................................................................................69 Respect and non-discrimination .................................................................................................................71 Combating social exclusion ........................................................................................................................73 Targeted action for individuals in vulnerable situations .................................................................................74 Social capital and neighbourhood cohesion ................................................................................................77 Intergenerational spaces and activities ........................................................................................................78 Policy interventions and initiatives by action area and objective ...................................................................79 Resources and toolkits ...............................................................................................................................81 Further reading ...........................................................................................................................................82 Domain 6: civic engagement and employment ......................................................................... 84 Introduction ................................................................................................................................................85 Strategic directions for policy interventions .................................................................................................85 Engagement in political life and decision-making ........................................................................................86 Economic life and employment ...................................................................................................................87 Engagement in public life: co-creation and volunteering ..............................................................................89 Policy interventions and initiatives by action area and objective ...................................................................91 Resources and toolkits ...............................................................................................................................93 Further reading ...........................................................................................................................................94 Domain 7: communication and information ............................................................................... 96 Introduction ................................................................................................................................................97 Strategic directions for policy interventions .................................................................................................97 Age-friendly information ..............................................................................................................................98 A clearing house for health- and ageing-related information ........................................................................99 Improving health literacy ...........................................................................................................................100 Addressing the digital gap ........................................................................................................................101 vPolicy interventions and initiatives by action area and objective .................................................................102 Resources and toolkits .............................................................................................................................105 Further reading .........................................................................................................................................106 Domain 8: community and health services .............................................................................. 108 Introduction ..............................................................................................................................................109 Strategic directions for policy interventions ...............................................................................................109 Community action for coordination and integrated care provision .............................................................110 Health services, including health promotion and prevention services .........................................................111 Home care and support for informal care ..................................................................................................111 Residential care facilities ...........................................................................................................................113 Ambient assisted living and “ICT for ageing well” services .........................................................................113 Emergency planning and disaster preparedness .......................................................................................116 Policy interventions and initiatives by action area and objective .................................................................117 Resources and toolkits .............................................................................................................................118 Further reading .........................................................................................................................................119 Glossary and references ............................................................................................................ 122 Glossary ...................................................................................................................................................123 References ...............................................................................................................................................125 vi List of figures, boxes and tables Figures Fig. 1. Framework of the AFEE project ................................................................................................................... 1 Fig. 2. Pathways to health and well-being for older people ..................................................................................... 5 Fig. 3. Public health framework for healthy ageing: opportunities for public health action across the life-course ..... 6 Fig. 4. Risk factor model for falls in older age ........................................................................................................ 10 Fig. 5. Patterns of ageing by broad geographical region in Europe ....................................................................... 13 Fig. 6. A conceptual model for ICT/AAL applications .......................................................................................... 114 Boxes Box 1. Age-friendly cities and communities ............................................................................................................. 3 Box 2. Preventing elder abuse and ensuring high-quality services in the EU ......................................................... 11 Box 3. Oslo’s common principles for universal design ........................................................................................... 17 Box 4. Case study: designing outdoor spaces to become dementia-friendly neighbourhoods for life ................... 18 Box 5. Perspectives from the public transport sector ............................................................................................ 30 Box 6. Case study: Cyclopousse, Lyon ................................................................................................................. 32 Box 7. Applying WELHOPS guidelines in the City of Gyoer, Hungary .................................................................... 43 Box 8. Health has no age – a comprehensive settings approach for health promotion in residential homes ......... 45 Box 9. No alla solit’Udine [No to loneliness]: a network of volunteering action in the city of Udine, Italy ................ 58 Box 10. The Slovenian Third Age University .......................................................................................................... 61 Box 11. Experience from existing European Commission initiatives ...................................................................... 61 Box 12. Forms of social exclusion in later life ........................................................................................................ 70 Box 13. Healthy ageing and social exclusion in rural areas .................................................................................... 74 Box 14. Dementia-friendly communities combat stereotypes about dementia ...................................................... 76 Box 15. Combating loneliness and reaching out to those people most at risk in Milan, Italy ................................. 78 Box 16. What works in facilitating older people’s ability to stay active in employment ........................................... 88 Box 17. Actively recruiting volunteers in the city of Horsens, Denmark .................................................................. 90 Box 18. Let us be active! Social inclusion of older people through volunteering in three Baltic cities ..................... 90 Box 19. Silver Line helpline for older people in the United Kingdom .................................................................... 100 Box 20. Local initiatives in Germany to implement the national action plan IN FORM ......................................... 101 Box 21. Services of early support to promote independent living in Kuopio, Finland ........................................... 112 Box 22. Telesupport at home: improving access to services and combating social isolation in Maltepe municipality, Turkey .................................................................................................................. 115 Box 23. Guidance on helping older people in emergencies ................................................................................. 117 Tables Table 1. Practice examples for outdoor environments from local age-friendly action plans and assessments ....... 22 Table 2. Practice examples for transport and mobility from local age-friendly action plans and assessments ....... 32 Table 3. Practice examples for housing from local age-friendly action plans and assessments ............................. 48 Table 4. Practice examples for social participation from local age-friendly action plans and assessments ............ 63 Table 5. Practice examples for social inclusion and non-discrimination from local age-friendly action plans and assessments ..................................................................................................................................... 79 Table 6. Practice examples for civic engagement and employment from local age-friendly action plans and assessments ..................................................................................................................................... 91 Table 7. Practice examples for communication and information from local age-friendly action plans and assessments ................................................................................................................................... 103 Table 8. Practice examples for community and health services from local age-friendly action plans and assessments ................................................................................................................................... 117 Foreword vii Foreword As people become older, the neighbourhoods and communities in which they live become more important. Age- friendly environments empower people so that they can continue to lead independent lives in good health, stay engaged in their communities and remain socially included and active in different roles: as neighbours, friends, family members, colleagues and volunteers. Many cities and communities in Europe have led the way and shown how policies at different levels of local government can make a difference to the health and well-being of our ageing populations in the WHO European Region, which has the highest median age among all WHO regions. The WHO Regional Office for Europe has a long track record of supporting this movement by providing evidence on how physical and social environments can support people to lead healthy lives, working closely with members of the European Healthy Cities Network and, more recently, with the WHO Global Network of Age-friendly Cities and Communities. Age-friendly policies contribute to the achievement of a number of Sustainable Development Goals, ensuring healthy lives and promoting well-being for all at all ages – “leaving no one behind” – and working towards sustainable cities and communities. These policy principles are also core principles of Health 2020, the WHO policy framework for health and well-being in Europe. As strategic directions, they are vital for implementing WHO’s European and global strategies and action plans on ageing and health. This handbook provides a welcome update for the framework of the WHO publication Global age-friendly cities: a guide, which is used widely in Europe and globally. It adapts the guide’s core principles and domains for action to the Europe-specific context and experience. The handbook is the outcome of a joint project between the European Commission’s Directorate-General for Employment, Social Affairs and Inclusion and the WHO Regional Office for Europe. It has greatly profited from the cooperation with WHO’s partners in the European Innovation Partnership on Active and Healthy Ageing and with members of the European Healthy Cities Network. We at the WHO Regional Office for Europe hope that this handbook will provide inspiration and guidance for politicians and practitioners to join the movement for age-friendly, healthy cities or to continue developing new innovative practice to improve the health and living situations of senior citizens in Europe. Zsuzsanna Jakab WHO Regional Director for Europe viii Many external experts and WHO staff members con- tributed to the development of this handbook and the authors are very grateful for their support and guidance. The handbook is indebted to the work of experts in member cities of the WHO European Healthy Cities Network and its Healthy Ageing Task Force. Case studies submitted for evaluation in phase V (2009– 2013) of the European Healthy Cities movement pro- vided a rich source of evidence for mapping policy actions to age-friendly domains. The authors would also like to thank the members of the WHO Global Network of Age-friendly Cities and Communities, who shared their strategies, action plans and prog- ress reports with WHO and made them available on the public “Age-friendly world” ePortal of the Global Network. The Age-friendly environments in Europe (AFEE) proj- ect was developed in close cooperation with a par- allel European Commission project called Thematic Network on Innovation for Age-Friendly Environments (AFE-INNOVNET), and we thank Christina Dziewanska-Stringer, Willeke van Staalduinen, Julia Wadoux and Anne-Sophie Parent for their coopera- tion and coordination. The AFEE project was supported by the following members of its scientific steering board: Rodd Bond, June Crown, Evelyne de Leeuw, Mireia Ferri Sanz, Harriet Finne-Soveri, Geoffrey Green, Paul McGarry, Bozidar Voljc, Asghar Zaidi and Gianna Zamarro. Very valuable comments and support were also received from members of the AFEE steering com- mittee: Susanne Iwarsson, Clive Needle, Karoline Noworyta, Hugh O’Connor, Anne-Sophie Parent, Setsuko Saya and Julia Wadoux. A special thank you is due to the following external reviewers and commenters: Alzheimer Europe, Tine Buffel, Giovanni Lamura and Kai Leichsenring. The following WHO staff members contributed to this publication by participating in project meetings and discussions and providing comments and input: John Beard, Matthias Braubach, Joao Breda, Casimiro Dias, Jo Jewell, Tina Kiaer, Alana Officer, Francesca Racioppi, Christian Schweizer, Dinesh Sethi, Agis Tsouros, Lisa Warth, Yongjie Yon and Isabel Yordi Aguirre. The following experts contributed to individual chapters: Introduction: Geoff Green; Domain 1: outdoor environments: Markus Grant; Domain 2: transport and mobility: Adrian Davis; Domain 3: housing: Matthias Braubach; Domain 4: social participation: Christine Broughan; Domain 5: social inclusion and non-discrimination: Christopher Phillipson and Thomas Scharf; Domain 8: community and health services: Rodd Bond and Kai Leichsenring. Thanks are also due to the coordinators of the AFEE pilots, whose comments and experiences were crucial to improving this handbook: • Anne Berit Rafoss (City of Oslo, Norway); • Elma Greer (Healthy Ageing Partnership, Belfast, United Kingdom) and Anne McCusker (Belfast Healthy Cities, United Kingdom); • Furio Honsell and Stefania Pascut (City of Udine, Italy); • Ikbal Polat, Kadıköy Akademi (Kadıköy Municipality, Turkey); • Judith Kurth (Stoke-on-Trent City Council, United Kingdom); • Katazyna Ziemann (Gdynia, Poland); • Nikola Tilgale-Platace (Department of Welfare, Riga City Council, Latvia). Natalie Turner supported the management of AFEE pilots and summarizing of results. Janneke T. de Wildt provided support with compiling key facts and Caroline Acknowledgements Acknowledgements ix Bergeron provided input on dementia-friendly com- munities. Special thanks also go to the contributors of case studies included in this publication: Stefania Pascut, Furio Honsell and Ursula Huebel. Finally, we thank Gauden Galea, Director of the Division of Noncommunicable Diseases and Promoting Health through the Life-Course of the WHO Regional Office for Europe, for his encouragement and support through- out the AFEE project. Josephine Jackisch and Manfred Huber were the lead authors of this handbook, supported by Casimiro Dias and Yongjie Yon, all at the WHO Regional Office for Europe. The project received financial support from the European Commission Directorate-General for Employment, Social Affairs and Inclusion, contribution agreement no. VS/2013/0260. Age-friendly environments in Europe. A handbook of domains for policy action x Introduction Introduction 1 This chapter presents an introduction and overview of the Age-friendly Environments in Europe (AFEE) handbook, created through a joint project between the European Commission’s Directorate-General for Employment, Social Affairs and Inclusion and the WHO Regional Office for Europe. The handbook expands the framework of an earlier WHO publication, Global age-friendly cities: a guide (hereafter the “WHO global guide” (WHO, 2007a)), which has been widely used to structure and inspire local government initiatives in cit- ies and communities around the world (WHO, 2015a). The original WHO global guide summarizes eight domains of age-friendly environments and their char- acteristics that older people identified as key features of an age-friendly environment. The AFEE project complemented this framework by bringing together evidence from research and an empirical analysis of community action in Europe. Its findings suggest that age-friendly environments are most supportive if policies and projects comprehen- sively cover physical accessibility, social inclusion and person-centred services. “The population in the European Region has the highest median age in the world. People in many European countries enjoy some of the highest life expectancies in the world… However, trends in longevity gains are uneven, and gaps between and within countries of the European Region continue to grow.” WHO Regional Office for Europe (2012a: 3) The AFEE project also added to the WHO global guide with a companion publication to this handbook that pro- vides guidance on the policy process and management cycle of putting in place and sustaining age-friendly action (WHO Regional Office for Europe, 2016a). A complementary paper sets out how local governments have used indicators, monitoring and assessment to support age-friendly policy initiatives (WHO Regional Office for Europe, 2017a). Age-friendly environments aim to encourage active and healthy ageing by optimizing health, stimulating inclu- sion and enabling well-being in older age. They adapt physical environments, social environments and munic- ipal services to the needs of older people with varying capacities (see also WHO, 2015b). Fig. 1 groups the eight domains for age-friendly action into these three clusters of supportive local environments. A key idea here is the “person–environment fit” coined by environmental gerontology (Iwarsson, 2005). This concept refers to the fact that a person’s ability to age well and independently depends on the relationship between his or her physical and mental capacity and the “press” (or barriers) of his or her environment. For example, an older person living independently in his or her original home may find it increasingly difficult to climb stairs due to chronic health problems or a physical disability. Rather than move, however, they may Introduction AGE FRIENDLY ENVIRON MENTS 1. O ut d oo r en vi ro n m en ts 2. Tr an sp or t an d m ob ilit y 3. Housing 4. Social participation 5. Social inclusion and non- d iscrim ination 6. C ivi c e ng ag em en t an d e mp loy me nt 7. Communication and information 8. Com m unity and health services M U N IC IP A L SE RV IC ES PHYSICAL ENVIRONM ENT SOCIAL ENVIRONMENT Fig. 1. Framework of the AFEE project Age-friendly environments in Europe. A handbook of domains for policy action 2 choose to adapt their home and reduce environmental impediments by installing a stair lift or find other ways to remove barriers. A number of approaches reviewed in this handbook are based on the person–environment fit concept – for example, universal design, walkability or liveable communities. They all seek to reduce environmental burdens so that older adults can age in place, age well and maintain independence. While all domains interact with each other, each is described in a separate chapter of this handbook that presents a synthesis of the evidence for policy action. Moreover, each chapter contains a table of practical examples that show how local governments have operationalized policy interventions and initiatives in their action plans. The glossary at the end of this handbook brings together key terms on healthy ageing, mainly adopted from the recent World report on ageing and health (WHO, 2015b). Healthy ageing: a priority for Europe WHO and the European Commission recognize active and healthy ageing as a major societal trend, provid- ing both challenges and opportunities. The European Commission’s Innovation Union initiative gives prior- ity to active and healthy ageing as part of its broader goals to achieve the Europe 2020 strategy objectives of smart, sustainable and inclusive growth for the European Union (EU). Improving the conditions for active ageing is also among the key objectives of the European Commission’s Social Investment Package (European Commission, 2014a). Age-friendly, supportive environments have been sin- gled out as one of four strategic areas for policy inter- ventions in the WHO strategy and action plan for healthy ageing in Europe, 2012–2020 (WHO Regional Office for Europe, 2012a). At a global level, evidence-based goals for investment in supportive environments are a core element addressed in WHO’s World report on ageing and health (WHO, 2015b) and subsequently endorsed as strategic priority area for action in the global strat- egy and plan of action on ageing and health (WHO, 2016a). Moreover, age-friendly environments are a pri- ority of the European Innovation Partnership on Active and Healthy Ageing (EIP on AHA), which is part of the Innovation Union initiative (EIP on AHA, 2015), and the European Commission has long played an active, sup- portive role in this field (AGE Platform Europe, 2012a; European Commission, Committee of the Regions & AGE Platform Europe, 2011). WHO’s overarching European policy framework for health and well-being, Health 2020, underlines the fact that cross-sectoral policy action is needed for promot- ing active and healthy ageing. Health 2020’s strategic objectives include reducing inequality and providing better governance (WHO Regional Office for Europe, 2013a; AARP, 2015; HelpAge International, 2016). Cities, communities and other local authorities play an important role in helping Member States achieve the targets set by Health 2020 and in aiming at more equal health and well-being outcomes for ageing populations (WHO Regional Office for Europe, 2012b). Supportive environments: a European and global movement Supportive environments for healthy ageing contrib- ute to optimizing opportunities to promote population health over the life-course and into older age. They enhance the quality of life and well-being of every senior citizen, whether in good, moderate or poor health, and free or not from disability. Over the past 10 years many cities and communities have expressed their commitment to making local communities more age-friendly; they have created what has now become a European and international movement (Age Friendly Ireland, 2013). The WHO Global Network of Age-friendly Cities and Communities is growing quickly, bringing together those who are committed to making their communities more age- friendly (Box 1; WHO, 2015a; 2015b). Moreover, a number of cities in the WHO European Healthy Cities Network have engaged in age-friendly environment initiatives (Green, 2013; Jackisch et al., 2015a). Some of these have formed the Healthy Ageing Task Force to work together to find innovative ways to support healthy ageing. The growing recognition of the rights and needs of people living with dementia has exerted a strong influence for a number of cities (Alzheimer’s Disease International, 2016). Cooperation under the EIP on AHA has added momentum to the age-friendly environments move- ment in Europe and has exerted a strong influence, creating new ways of cooperating and exchang- ing practice examples between cities, communi- ties, regional networks and other initiatives. The Thematic Network on Innovation for Age-Friendly Introduction 3 Environments (AFE-INNOVNET) has spurred this momentum by mobilizing an EU-wide community of local and regional authorities and other stakehold- ers, with the goal of scaling up innovative solutions for age-friendly environments that support active and healthy ageing across Europe. This is now also carried forward by the Covenant on Demographic Change (AFE-INNOVNET, 2015a). Moreover, age- friendly policies contribute to realizing the “Right to the City” for older people in the context of the new EU Urban Agenda (AGE Platform Europe, 2016) To support their commitment, local authorities have requested further guidance on how they can respond to the needs of older people (EIP on AHA, 2013). The AFEE project responded to this demand and pro- vided direct support to these initiatives. Aim and objectives of the AFEE project The aim of the AFEE project was to inspire poli- cy-makers to take decisive action and to create environments that are supportive of and responsive to the needs of older people. It thus had three main objectives: • to increase knowledge and awareness of the main areas of action for age-friendly environments and what is known about policy initiatives undertaken by cities, communities and other regional and local authorities; • to summarize for local and regional authorities the main steps and processes required to become a more age-friendly city or community; • to make recommendations on how to set up the information systems and indicators needed for monitoring and evaluation of age-friendly projects and communicating them to the public. The AFEE project benefited from synergies with a range of activities on age-friendly environments – in particular in cooperation with partners under the WHO European Healthy Cities Network, the Global Network of Age- friendly Cities and Communities, and the EIP on AHA (EIP on AHA, 2015) and other projects funded by the European Commission. Target audience The target audience for the AFEE handbook is primarily local politicians, regional authorities, nongovernmental Box 1. Age-friendly cities and communities An age-friendly city or community is a good place to grow old. Age-friendly cities and communities foster healthy and active ageing and thus enable well-being throughout life. They help people to remain independent for as long as possible, and provide care and protection when they are needed, respecting older people’s autonomy and dignity. Since 2010, the WHO Global Network of Age-friendly Cities and Communities has supported municipalities by: • inspiring change and showing what can be done and how it can be done; • connecting cities and communities worldwide to facilitate the exchange of information and experience; • supporting cities and communities to find solutions by providing innovative and evidence-based technical guidance. The network included more than 250 cities and communities in 28 countries by 2015. Network members commit to: • engage with older people and other stakeholders across sectors; • assess the age-friendliness of their cities and identify priorities for action; • use the assessment findings to engage in evidence-based planning and policy-making across a range of fields; • adapt their structures and services to be accessible to and inclusive of older people with varying needs and capacities. Source: WHO, 2015b: Box 6.1 (see also WHO, 2015a). Age-friendly environments in Europe. A handbook of domains for policy action 4 agencies and city networks engaged in policy develop- ment, advocacy and implementation of environments supportive of healthy ageing. Other stakeholders include citizens engaged in healthy ageing initiatives, academia, councils and representatives of older peo- ple, national and subnational governments, regional networks and private and third sector partners, such as those engaged in the EIP on AHA. Methodology The WHO age-friendly city concept was created in 2006 through a project involving 33 cities worldwide, which asked older people in focus groups to describe the advantages and barriers they experienced in eight areas of city living. This gave a voice to older people and culminated in the original WHO global guide and a checklist of characteristics that older people identi- fied as critical features within eight domains of an age- friendly city (WHO, 2007a). The global initiative pro- vided the inspiration and a framework for age-friendly cities that has now become a dynamic bottom-up movement in many countries in Europe and around the globe. The AFEE handbook adds to the methodology used to develop the WHO global guide by shifting the focus from problem identification and demands to policy action and interventions. Rather than asking older people and other stakeholders to define age-friendly features again, the AFEE project focused on how local authorities have reacted to the areas and challenges raised by older people and outlined in the WHO global guide. This handbook brings together both evidence from research behind each of the action areas and experience from local action plans and strategies on how to respond to the main points identified by older people. For the latter, the AFEE project reviewed action plans, initiatives and approaches adopted by communi- ties and local authorities from a number of sources: the WHO Global Network of Age-friendly Cities and Communities, the WHO European Healthy Cities Network, websites from other cities and communities and examples from EIP on AHA projects. The proj- ect thus adopted a “realist synthesis” methodology (de Leeuw et al., 2015; Jackisch et al., 2015a). This approach synthesizes evidence from different sources: scientific and grey literature and experiential, primary and secondary information. At the heart of the empirical analysis were existing age- friendly strategies and action plans and a wealth of reports from member cities of the European Healthy Cities Network (EHCN) that were gathered during 2009–2013, including comprehensive reports for the EHCN Phase V report: • strategies and action plans from European coun- tries, complemented with innovative examples from a number of non-European countries; • 33 structured case studies on the topic of healthy ageing, submitted by 32 member cities of EHCN; • 51 case studies presented at the EHCN’s annual business meetings, from 35 cities and 16 countries (including three non-EU countries); • annual reports of EHCN member cities; • case studies presented at meetings of the Healthy Ageing Task Force of the EHCN; • practice examples submitted by initiatives under the EIP on AHA and the AFE-INNOVNET project (European Commission & Funka Nu, 2013). Case studies and action plans were systematically analysed and coded in the Nvivo© software for qualita- tive analysis. Each planned or reported intervention or action towards age-friendly environments was mapped to one or more of the eight domains, clustered around (i) physical environment, (ii) social dimensions and (iii) municipal services. For each action intended out- comes, mechanisms of change and context were iden- tified, leading to clusters of approaches and actions under each domain. The resulting structures and lists of interventions are at the core of this AFEE handbook and are summarized in tabular form at the end of each domain chapter. In addition to the empirical analysis, insights and evi- dence from academic literature were used to com- plement and structure the information from reports and action plans from communities. External experts conducted “reviews of reviews” of published and grey literature in support of the actions and pathways identi- fied in the action plans. The literature on what is known about pathways to health and well-being for older peo- ple in various policy fields has grown exponentially in the past 15 years, but progress in this field of research has been uneven. In general, few age-friendly projects have systematically evaluated the impacts of their inter- ventions so that most evidence stems from more gen- eral studies in the respective fields. Some mechanisms (such as those concerned with how environments can Introduction 5 support physical activity) are much better researched, whereas many other fields of action currently still lack systematic evaluation. How age-friendly environments unlock the potential of healthy ageing The AFEE handbook is based on evidence of a logic pathway that begins with processes and structures of local governance and ends with the well-being of older people in cities and communities. The sequence is summarized in Fig. 2. This dynamic model fuses the insights of the original WHO global guide (WHO, 2007a) with evidence from the literature and from WHO’s recent World report on ageing and health (WHO, 2015b). The WHO global guide focuses on the attributes and qualities of an age-friendly city or community, organized into eight domains. The AFEE handbook further analyses the critical importance of these supportive environments (c) in unlocking the potential of healthy ageing (e) and promoting well-being as a final aim (f). The well-being and quality of life of older people depends on ageing in good health. Health and healthy ageing are not the absence of disease but people’s ability to do the things they value most (Nordenfelt, 2001) – what is called “functional ability” in WHO’s pub- lic health framework for healthy ageing (see Fig. 3). This functional ability depends on the level of both physical and mental health of individuals – their intrinsic capac- ity – and the support provided by the environment in which a person lives and grows older (WHO, 2015b). In order to foster functional ability by promoting healthy ageing, actions thus need to go beyond a focus on dis- ease, creating systems that promote health through- out the life-course and support continued functioning into old age. WHO identifies local environments as key entry-points for action to promote healthy ageing, next to health services and long-term care services (Fig. 3; WHO, 2015b). Supportive environments are crucial across the life- course for promoting healthy living and functioning of individuals with less than optimal capacity. Three a. Local governance structures and processes d. Influence on the proximal causes of health e. Health status b. Strategic actions c. Attributes and qualities of an age-friendly city in eight domains f. Well-being Fig. 2. Pathways to health and well-being for older people Age-friendly environments in Europe. A handbook of domains for policy action 6 principles can be drawn from the life-course approach to healthy ageing for the different phases of the life- course (WHO Regional Office for Europe, 2015a). • Maximize intrinsic capacity: start as early as possible. • Maintain the peak: it is never too late for preven- tion, rehabilitation and effectively managing chronic conditions. • Minimize loss and maximize functional ability: create and maintain supportive environments and develop integrated systems of care. Supportive environments for healthy ageing contribute by maximizing intrinsic capacity, with action that starts as early as possible. Walkable streets, for example, encourage a person to stay active and take exercise, which promotes physical activity and health. A good social environment promotes mental health and social participation. This contributes to minimizing loss of capacity and maximizing functional ability. Many of these strategies target people with relatively high or sta- ble levels of capacity and health. Healthy living is also still relevant in phases of life when health and capacity decreases in order to maintain good functional ability and independent living as long as possible. Supportive environments, moreover, assure that age-re- lated declines in intrinsic capacity do not translate into similar declines of functioning. The importance of this pathway increases when intrinsic capacity declines. Older people can continue to participate and live to the fullest of their capacities when barriers in the environ- ment are low and support is provided where capacity is lost. A life-course approach also supports action at critical transitions (such as from work life to pension) and when faced with sudden decline of intrinsic capac- ity (such as after a fall), offering opportunities for partici- pation, rehabilitation and support of lost capacity. More can be done across sectors both to improve sup- portive environments and to provide better integrated systems of services and care for more efficiently coor- dinated health and long-term care. This would ensure Fig. 3. Public health framework for healthy ageing: opportunities for public health action across the life-course Source: WHO (2015b). Introduction 7 that even those with serious limitations in functioning have opportunities for participation and a more active role in families, neighbourhoods and society more gen- erally (WHO, 2015b). To improve the health and well-being of older people and to increase their opportunities for active participa- tion in society, a challenge is to reach out to those older people most at risk. In particular, this includes those living on their own or at risk of social exclusion and loneliness; thus, a focus on equity should always be kept in mind. How local governments create age- friendly environments The bottom-up movement of age-friendly environ- ments has long realized the importance of acting on supportive environments and the potential of healthy ageing. Age-friendly communities foster healthy and active ageing at the local level by adapting structures and services to the needs of older people with varying capacities. Approaches and opportunities for intervention by local authorities are at the core of the AFEE handbook. Fig. 1 above clusters eight age-friendly domains across three overall guiding categories. For each domain, the AFEE handbook identifies areas for action, the main strategic directions and objectives that cities and local authorities have pursued with them and examples of policy inter- ventions and initiatives. These examples and evidence from the literature help communities that have started a dialogue about barriers and opportunities with their older members to consider strategies for intervention; assess and anticipate the effectiveness and impacts of their potential policies, programmes or project interven- tions; and learn from existing experience. Supportive physical environments The first three domains focus on the physical compo- nents of age-friendly environments: • domain 1: outdoor environments; • domain 2: transport and mobility; • domain 3: housing. Policy interventions and initiatives under these three domains have a critical role in reducing physical and structural barriers to lowering the disability thresh- old and enabling full participation of older people, regardless of their physical or mental abilities and functional status. In the physical dimension it is criti- cal to increase awareness of the needs of people living with limitations and ensure accessibility and safety in all areas of the physical environment, including public places, streets, public transport and housing. Supportive physical environments aim to lower the dis- ability threshold and help older people to find new ways of coping with reduced functional abilities. Moreover, physical environments are crucial to increasing health and resilience over the life-course by encouraging healthy behaviour and social interaction. Whether old age and early stages of reduced health result in experience of ill health and disability depends to a large extent on the physical environment in which the person lives; this can enable people to do or prevent them from continuing to do the things that are important to them (WHO, 2015b). It is now well established that some characteristics of the physical environment can promote health, well-being and participation (Annear et al., 2014). Research and age-friendly assessments have also identified a range of environmental barriers that limit older people’s opportunities to live and move around places like home and the neighbourhood and to pursue interests (Gilroy, 2008; Kerr, Rosenberg & Frank, 2012). An older person with slightly reduced vision and mobil- ity, for example, can feel in good health and lead an independent life if the physical environment does not create overly high demands. This means that even if feeling unsafe to drive due to impaired vision, he or she can go out to the next shop or café at walking distance, or visit friends, family or activities using public transport if it is easy to use, well signed, affordable and well con- nected to the local area. Age-friendly physical environments optimize opportu- nities for people to live healthily and actively across the life-course and encompass different needs and abilities. Among a growing number of studies and community assessments, consensus has emerged about the main components of age-friendly physical environments. These include “land use and commu- nity design that increase social integration and reduce automobile dependence, a wide range of accessi- ble and affordable housing options, multiple forms of transportation and mobility supports” (Lehning et al., 2010: 418). In terms of implementation of better physical environments for ageing, the importance of space and place for health and active ageing means Age-friendly environments in Europe. A handbook of domains for policy action 8 that urban and transport planners and city developers are key actors and need to become more age-aware (Gilroy, 2008). Participatory and inclusive social environments The second cluster of domains covers the social dimensions of age-friendly environments: • domain 4: social participation; • domain 5: social inclusion and non-discrimination; • domain 6: civic engagement and employment. The social dimensions of age-friendly environments can be highly interwoven with the domains of the phys- ical environment. Thus, age-friendly programmes usu- ally need to address both dimensions jointly; this is one of the common themes that emerged from the work that has led to the AFEE handbook (Menec et al., 2011; Buffel, Phillipson & Scharf, 2012; Liddle et al., 2014). The social dimensions of age-friendly environments are important for encouraging people to lead active and healthy lives and for lowering barriers for healthy and active ageing – barriers that are sometimes less vis- ible than elements of the physical environment like a lack of benches or obstructed pavements. The social environment is a crucial determinant of health in older ages: strengthening it can help overcome barriers to older people’s active and healthy ageing and contrib- ute to substantially improving health and well-being in the population. Social networks and support, for exam- ple, can buffer the effects of declining health on quality of life and well-being by enabling those with less than optimal health still to contribute in meaningful ways and helping them do the things that are important for them (WHO, 2015b). Social barriers and exclusion, by contrast, can lead to older people being isolated involuntarily and suf- fering from feelings of loneliness; these have a major impact on older people’s quality of life and contribute to inequalities in healthy and active ageing. Creating a better understanding of social relationships in later life and the nature of barriers for full participation, alongside developing evidence-informed interventions and evalu- ating them, is crucial to enhancing social participation and social relationships of older adults in the future. Starting from strategic interventions to promote social participation, the AFEE handbook also reviews the impacts of social exclusion and discrimination for equity in age-friendly environments and discusses the opportunities and benefits of voluntary engage- ment in the community and in political and economic life. Addressing the social determinants of health of older people requires policies across different sectors and concerted action at all levels of government. The Commission on Social Determinants of Health has confirmed that local authorities are key actors in this respect (WHO Regional Office for Europe, 2013b). The role of municipal and local government services The final cluster brings together two domains that address how municipal and local government ser- vices can contribute to age-friendly, supportive environments: • domain 7: communication and information; • domain 8: community and health services. Municipal and local government services are critical in ensuring communication and coordination across sectors. Furthermore health, care and community ser- vices that are delivered by the local authority to older people are essential for promoting healthy ageing and enabling a dignified life. Services from all different sectors and actors of the community need to be well integrated in order not to create unnecessarily high demand on older people. Cross-cutting themes that link between domains The next subsections discuss three cross-cutting aspects and links between the domains of age-friendly environments. These topics address important interim outcomes of age-friendly community design and action, which have been identified as protective fac- tors for active and healthy ageing, supporting people to stay physically active and preventing falls and elder maltreatment. Evidence is growing about the specific challenges and what works in terms of interventions for each topic, although much more is currently known about com- munity action on physical activity and falls preven- tion than about what works for preventing elder mal- treatment. All three topics have a range of resources and tools that support their implementation. All have received specific policy recognition as priority Introduction 9 interventions in the WHO strategy and action plan for healthy ageing in Europe, 2012–2020 (WHO Regional Office for Europe, 2012a) and they are also priorities in the EIP on AHA and in the WHO global strategy and plan of action on ageing and health (WHO, 2016a). Promotion of physical activity The physical and social environment of a community can support increased physical activity of older people in many ways (Van Holle et al., 2012; Olanrewaju et al., 2016). Level of physical activity is a key enabling factor and strong predictor of healthy ageing for all groups of older people (WHO Regional Office for Europe, 1996; Council of the European Union, 2013). Staying physically active, however, is especially crucial for the oldest of old age groups and for those at risk of functional decline and frailty (Cavill, Kahlmeier & Racioppi, 2006). For the adult population, physical inactivity is very high and is one of the major risk factors for mortality. It ranked fourth highest as a risk factor after high blood pressure, tobacco use and high blood sugar. Over the life-course, a lack of physical activity is linked to morbidity and many noncommunicable diseases (NCDs) including cardio- vascular disease, type 2 diabetes, depression and some cancers (WHO, 2010; 2017b). Increasing physical activity can result in extending healthy life expectancy for older adults, while reduc- ing the impact of morbidity on public expenditure (McPhee et al., 2016). Studies have shown that phys- ical activity among older adults is associated with an overall improvement in their quality of life, with bene- fits including cardiorespiratory and muscular fitness, bone and functional health and reductions in the risk of NCDs, depression, cognitive decline (Chodzko- Zajko & Schwingel, 2009) and falls (Cavill, Kahlmeier & Racioppi, 2006). Physical activity interventions play an important role in preventing or reducing frailty levels among older adults (Puts et al., 2017). Despite evidence of the risks posed by physical inactiv- ity for poor health, older adults engage in less physical activity than younger adults (Hallal et al., 2012). This gap seems to increase with age, making the promotion of physical activity an important policy intervention for healthy ageing. Data from a 2013 Eurobarometer sur- vey show that inactivity levels are particularly high for women and men aged 55 years and older (European Commission, 2014b). Physical activity for older adults can include recreational or leisure-time activity (such as gardening and hiking), aspects of daily mobility (such as walking and cycling), household chores, games, sports or exercise organized in the context of daily, family and community activities (WHO, 2016b). The physical and social environments can promote physical activity and healthy ageing in many ways. Economic benefits are detailed in a WHO health eco- nomic assessment tool (HEAT) (WHO Regional Office for Europe, 2014). The physical activity strategy for the WHO European Region 2016–2025 sets out three objectives to improve physical activity among older people: improving the quality of advice on physical activity by health professionals; providing infrastruc- ture and appropriate environment; and involving older people in social physical activity (WHO Regional Office for Europe, 2015b). Physical activity is connected to many interventions under a number of age-friendly policy domains: • domain 1: outdoor environments and domain 2: transport and mobility: - creating barrier-free public spaces and buildings to improve walkability among older adults; - strengthening infrastructure for active mobility and walkability, including creating accessible walking paths with resting points, increasing road safety, supporting safe cycling and devel- oping accessibility standards in public transport; - installing exercise equipment and areas in public places and parks, as well as making parks more accessible and safe by installing benches and lighting; • domain 3: housing and domain 4: social participation: - setting and enforcing standards for newly built houses, such as creating “20-minute neighbour- hoods” with key facilities within reach of older people’s housing within a limited time of walking or public transportation; - providing a range of opportunities for social par- ticipation and physical activities that are acces- sible for older people such as day and field trips for older people; - creating supportive environments for social exchange and places to meet, and providing opportunities for social contact in the commu- nity, while combining the promotion of physical activity with social and cognitive activity; • domain 5: social inclusion and non-discrimination and domain 6: civic engagement and employment: Age-friendly environments in Europe. A handbook of domains for policy action 10 - creating targeted action for individuals in vul- nerable situations, such as reaching out to excluded and isolated individuals and promot- ing social inclusion of older people through vol- untary work; - encouraging interaction between neighbours by providing community-based initiatives to promote health and well-being. Prevention of falls Falls are the second leading cause of accidental or unintentional injury deaths worldwide (WHO, 2012a; 2007b). The consequences of falls among older peo- ple are often severe; injuries sustained from falls are responsible for a large share of the burden of disease. In many cases, injuries from falls mark the onset of frailty (Chodzko-Zajko & Schwingel, 2009). Falls pre- vention is therefore a priority intervention in the WHO strategy and action plan for healthy ageing in Europe, 2012–2020 (WHO Regional Office for Europe, 2012a). Falls are a common problem affecting many older adults, as the risk and prevalence of falls increases steeply for higher age groups (Campbell et al., 1990; Rubenstein, 2006). Such injuries are costly, especially if falls result in femur fracture that requires hospitaliza- tion and rehabilitation (Peel, Bartlett & McClure, 2007). Moreover, the risk of falls is even higher for those living in institutions. Falls are the results of a complex inter- action of risk factors relating to biological, behavioural, environmental and socioeconomic factors (see Fig. 4). An age-friendly environment can address these in a holistic way by removing potential barriers that might cause falls while promoting physical activity to improve fitness as a protective factor against falls. Prevention of falls is an important component of active ageing, and research has shown that many falls are preventable (Goodwin et al., 2014; Gillespie et al., 2012). Preventive measures have been shown to be cost-effective and even cost-saving in a number of studies (Todd & Skelton, 2004). The many relevant policy interventions within each AFEE domain include: • domain 3: housing and domain 2: transport and mobility: Environmental risk factors Poor building design Slippery floors and stairs Loose rugs Insufficient lighting Cracked or uneven sidewalks Socioeconomic risk factors Low income and education levels Inadequate housing Lack of social interactions Limited access to health and social services Lack of community resources Behavioural risk factors Multiple medication use Excess alcohol intake Lack of excercise Inappropriate footwear Biological risk factors Age, gender and race Chronic illnesses (e.g. Parkinson’s dis- ease, arthritis, osteoporosis) Physical, cognitive and affective capacities decline Falls and fall-related injuries Source: WHO (2007b). Fig. 4. Risk factor model for falls in older age Introduction 11 - supporting home assessments and modifica- tions, including providing home hazard assess- ments and professionally supported evaluations of fall risks; - informing and helping older people to plan for ageing in place, including offering counselling and information on grants to solve older people’s housing problems and help to apply for support; - providing visiting services from specialists to find solutions and offer training on how to overcome functional limitations; - creating infrastructure for active mobility and walkability, including building accessible walk- ing paths with resting points, water points and points of interest along the path, as well as pedestrian streets with good lighting; • domain 1: outdoor environments and domain 4: social participation: - retrofitting public spaces and infrastructures to create barrier-free access to public places, routes, buildings and transport; - using multilevel interventions, including combin- ing promotion of physical activity with social and cognitive activity. Prevention of elder abuse Elder abuse is a common problem. It is defined as “a single or repeated act or lack of appropriate action, occurring within any relationship in which there is an expectation of trust, that causes harm or distress to older people” (WHO, 2002a). Like violence, elder abuse can occur at home, in the community and in institutions in the form of psychological, physical, sexual and finan- cial abuse and neglect. It can cause injury, illness and despair, and can have serious consequences for the victims, their family members and the wider commu- nity. Community action to prevent elder maltreatment has to act on all the instances where people may be maltreated: in their home by family members and care- givers, or in institutions by professional staff or visitors. But elder abuse is not inevitable and can be prevented (WHO, 2014c). The WHO global strategy and plan of action on ageing and health (WHO, 2016a) and the strategy and action plan for healthy ageing in Europe, 2012–2020 (WHO Regional Office for Europe, 2012a) call for urgent action for multisectoral collaboration and supportive environments to address elder abuse. Abuse and neglect of older people is a gross violation of fundamental human rights; thus, addressing this problem is a crucial prerequisite for an inclusive society. This may include addressing fear of crime and victimiza- tion in the neighbourhood and tackling the problem of ageism through education, public awareness, engaging older adults in community participation and training and support of carers. Community settings offer opportuni- ties to raise awareness about elder maltreatment and to improve the quality of services in the community and in institutions, to adapt them better to the special needs of older people with functional limitations and to ensure that high-quality guidelines are in place for preventing elder maltreatment (Sethi et al., 2011). This has become a priority area for European countries, as addressed by a number of activities (Box 2). Several of the age-friendly domains can contribute to elder abuse prevention: • domain 1: outdoor environment and domain 3: housing: - creating barrier-free environments and boosting environmental confidence using techniques such as “design out crime” and “passive surveillance”, in collaboration with local police to reduce fear of crime; - ensuring security and safety of older adults through crime prevention activities, such as Box 2. Preventing elder abuse and ensuring high-quality services in the EU Preventing elder abuse by ensuring high-quality care services across the EU is a priority action for the European Commission. The European Charter of the rights and responsibilities of older people in need of long-term care and assistance was developed to set out the fundamental principles and rights for those dependent on others for support and care due to age, illness or disability. The accompanying guide provides examples of experiences and initiatives relating to the Charter. The European Quality Framework for long-term care services contributes to preventing and fighting elder abuse. The Framework aims to improve the quality of life for older adults in need of care and assistance with a set of 11 quality principles and seven areas of action, recommendations for policy-makers and a methodology on how to implement them. Sources: AGE Platform Europe (2012b; 2012c). Age-friendly environments in Europe. A handbook of domains for policy action 12 collaborating with police on crime prevention programmes and organizing ambassador and policing initiatives in neighbourhoods that are per- ceived as unsafe; - fostering the feeling of safety at home and in the neighbourhood by setting up neighbourhood watch or friendly call initiatives to reach out to older people at risk of isolation and abuse; • domain 4: social participation and domain 5: social inclusion and non-discrimination: - empowering older people to participate in activ- ities by creating local meeting places to inform older people of their rights and to provide resources to recognize and report abuse; - combating ageism by raising awareness and education campaigns to challenge the represen- tation of ageing, while striving to promote positive representations of older people in the public; - creating intergenerational spaces and activities to promote intergenerational contact, mutual understanding and exchange of values, skills and experiences; - collaborating with the police force to enforce prosecution of suspected perpetrators of elder abuse and safeguard older people from further victimization; • domain 8: community and health services: - supporting carers and families with dependent older people, including providing psychosocial counselling, capacity-building programmes and training for carers; - developing strong quality control of health care providers, including establishing a health worker registry of those terminated for reasons of abuse and fraud to help prevent abuse at home or institutions. Trends of demographic ageing in Europe The population of the WHO European Region had the highest median age (42 years) among all WHO regions in 2015, according to United Nations Department of Economic and Social Affairs (UN DESA) Population Division estimates (UN DESA, 2015a). This has mainly been the result of decreasing fertility rates and growing life expectancy. From 2000 to 2015, female life expec- tancy at birth increased by 3.7 years in the European Region, to 80.2 years. During the same period, men gained 5.1 years of life expectancy and can now expect to live to 73.2 years; thus, the gender gap in life expectancy has decreased by 1.4 years. As life expec- tancy increases, more people live past 65 years of age, many of them into very old age, greatly increasing the numbers of older people in the population. Meanwhile, the cohorts of younger people are shrinking. As women outlive men, Europe has the lowest ratio of men to women (both current and projected) among all world regions, although the ratio is improving. In gen- eral, increasing sex ratios among very old people reflect the fact that improvements in life expectancy at age 80 are occurring at a faster pace among males than among females (UN DESA, 2015b). The proportion of people aged 65 years and older in the population is projected to continue to increase rapidly. According to UN DESA population projections, in 2010 only two countries in the WHO European Region had more than one in five inhabitants aged 65 years and older (Germany and Italy). By 2015 this was the case for six countries. By 2030 the number is expected to grow to around 30 countries, which is more than half of the 53 Member States in the Region. This is projected to include all but three of the current 28 Member States of the EU (Cyprus, Ireland and Luxembourg). Moreover, the older population is itself ageing: the UN DESA European region currently has the highest proportion of people aged 80 years and older among those 60 years and older, and this situation is projected to continue until around 2030 (UN DESA 2015a). While many people in Europe are living not only lon- ger but also healthier lives, there are important uncer- tainties about future trends in the health and functional status of ageing populations (WHO Regional Office for Europe, 2012a; WHO, 2015b). For the WHO European Region as a whole, healthy life expectancy increased by almost four years between 2000 and 2015 (from 61 to 65.5 for men and from 67.3 to 70.5 years for women), according to data from the WHO Global Health Observatory (WHO, 2017a). Results from differ- ent data sources that use differing methodology, how- ever, are not always consistent. Patterns of ageing by broad geographical region in Europe In 2000–2015, population ageing was an almost univer- sal trend in the 53 Member States in the WHO European Region. Fig. 5 compares the changes in population of all ages with the growth in numbers of people aged 65 years and older for broad geographical groups that Introduction 13 follow definitions from UN DESA (2014; 2015a; 2015c). For each geographical group, population trends are shown separately for people living in predominantly urban versus predominantly rural regions. With the exceptions of both urban and rural areas in those countries in central and western Asia that are Member States in the WHO European Region, the numbers of older people have grown faster in all parts of the Region compared to the total global population (depicted as lying above the line of equal growth for total versus older populations in Fig. 5). From 2000 to 2015, population ageing was strongest for both urban and rural areas in western Europe, with the total rural population in western Europe declining by around 11% – a greater decline than for any other regional cluster – while the number of older people in predominantly rural areas in western Europe grew by 13%. Fig. 5 also provides a snapshot of where older people live in Europe: the size of each bubble corresponds to the estimated number of people aged 65 and over in the year 2015. Of the 140 million older people in Europe, around 99 million live in predominantly urban areas – more than twice as many as live in predomi- nantly rural areas (41 million). The combination of population decline and ageing is a common trend for all the predominantly urban regional clusters, with the exception of central and western Asian countries. Population decline and age- ing also coincided in rural areas of eastern Europe, whereas all other urban clusters experienced popu- lation growth and ageing – again, with the exception of central and western Asian countries. Besides the urban and rural western European clusters, popula- tion ageing was strongest in urban areas of eastern Europe. On average, population ageing was stronger in urban than rural areas. The older population will therefore be increasingly concentrated in urban areas, and more so in Europe than in other world regions (UN DESA, 2014). This combination of ageing and shrink- ing populations will pose special challenges for rural and remote areas. Central and western Asia Eastern Europe Southern Europe Eastern Europe Northern Europe Northern EuropeSouthernEurope Western Europe Western Europe -20% 0% 20% 40% 60% 20% -10% 0% 10% 20% 30% 40% Ch an ge o f p op ula tio n ag ed 6 5 ye ar s a nd o ve r, 20 00 –2 01 5 Change of population, all ages, 2000–2015 Urban Rural Fig. 5. Patterns of ageing by broad geographical region in Europe Note: countries included in each category are as follows: central and western Asia: Armenia, Azerbaijan, Cyprus, Georgia, Israel, Kazakhstan, Kyrgyzstan, Tajikistan, Turkey, Turkmenistan, Uzbekistan; eastern Europe: Belarus, Bulgaria, Czechia, Hungary, Poland, Republic of Moldova, Romania, Russian Federation, Slovakia, Ukraine; northern Europe: Denmark, Estonia, Finland, Iceland, Ireland, Latvia, Lithuania, Norway, Sweden, United Kingdom; southern Europe: Albania, Andorra, Bosnia and Herzegovina, Croatia, Greece, Italy, Malta, Montenegro, Portugal, San Marino, Serbia, Slovenia, Spain, the former Yugoslav Republic of Macedonia; western Europe: Austria, Belgium, France, Germany, Luxembourg, Monaco, Netherlands, Switzerland. Source: calculation based on UN DESA population estimates. Age-friendly environments in Europe. A handbook of domains for policy action 14 Domain 1: outdoor environments Outdoor environments 15 Introduction The importance of adapted outdoor spaces and build- ings for active and healthy ageing is confirmed by growing evidence from research (Sugiyama & Ward Thompson, 2007a; Sugiyama & Ward Thompson, 2007b; Curl et al., 2012). The links between the design and features of public space and intermediary goals such as promoting physical activity and preventing falls are now well documented (Van Cauwenberg et al., 2011). Land use patterns, urban design and transportation systems are three dimensions of the physical environ- ment that can affect functional limitations and disability in positive and negative ways (Rosso, Auchincloss & Michael, 2011). The key issues to be addressed may be particular to a local context, like steeply sloping neighbourhoods or a specific target group of people living with dementia or in precarious economic circum- stances. The term “environment” is used in the AFEE handbook in a broader sense than the classic policy field of environmental protection. There is, however, ample evidence that older people can be especially vulnerable and negatively affected by environmental degradation (see e.g. Simoni et al., 2015) for adverse effects of air pollution). This chapter presents the first domain – outdoor envi- ronments – of the AFEE framework. This is the first of three domains that address the physical dimension of age-friendly communities. It corresponds to the “out- door spaces and buildings” domain in the original WHO global guide (WHO, 2007a). Strategic directions for policy interventions The goal of interventions in this domain is to plan and design the built environment and pub- lic spaces with awareness of the needs of – and in consultation with – older people, recognizing their diversity. To support ageing in place, initia- tives to create age-friendly outdoor environments focus on retrofitting existing neighbourhoods in addition to following good practice in the design of new neighbourhoods. In most cases, age-friendly city initiatives that address the outdoor environment do not start from scratch: existing buildings and infrastructures, regulations, cul- ture and history of places already shape the experience of ageing in any specific neighbourhood. In order to make cities more age-friendly it is crucial to under- stand the barriers, constraints and strengths of exist- ing outdoor environments in order to retrofit them and to reduce barriers, while preserving what is valued by building on community assets. Older women and men themselves are frequently an excellent source for monitoring and evaluating the quality of their own urban environments, including those living with dementia (WHO, 2012b). Their voice is critical for evaluation of and planning for change, for both shorter- and longer-term action plans. Although changing basic urban design may require long-term vision, many interventions in outdoor environments implemented as part of community action plans can Domain 1: outdoor environments Age-friendly environments in Europe. A handbook of domains for policy action 16 yield benefits in the short term (Kerr, Rosenberg & Frank, 2012; Annear et al., 2014). The following sections bring together main features and initiatives that practitioners, age-friendly action planners and researchers have identified as relevant age-friendly practices for neighbourhood development. Recent research has provided evidence supporting many elements of the urban initiatives for healthy age- ing that have been undertaken in a growing number of cities and communities. A table at the end of the chap- ter provides practical examples that show how local governments have operationalized areas for action into their action plans. Barrier-free public spaces and buildings accessible and usable by people with impairments As people get older they often experience a greater sensitivity to seemingly small physical features that might be obstructive or decrease their feeling of safety and confidence in outdoor spaces, and are thereby discouraged or inhibited from going outdoors and moving around. A number of studies, however, have shown promising results from interventions in the out- door environment that address these concerns. There is evidence that some interventions have the poten- tial to increase walking and participation, both in the short term and over the longer term (Hallgrimsdottir, Svensson & Ståhl, 2015). For example, a lack or insufficient density of facilities such as benches, public toilets or elevators has been reported to discourage independent movement out- doors for older age groups (Moran et al., 2014; Yen et al., 2014). Planners and policy-makers increasingly recognize the need to pay more attention to the corre- sponding quality-of-life issues that older people have raised and to include them in all planning decisions. Moreover, some of the actions listed below can create synergies with the broader planning agendas of sus- tainability, cohesion and liveability, to create places that promote well-being for all age groups (Gilroy, 2008). “An impairment becomes a disability only when the built environment does not compensate for impairments.” Utton (2009: 380) Supportive and barrier-free environments can make the biggest difference to people at greater risk of disability and poor health. With increasing age the likelihood of living with one or more functional limitations or disabilities grows. This may not automatically lead to dependence and frailty but needs special attention from city planners and transport planners. Studies suggest that the built envi- ronment may have more limited effects among those with mild or no impairment, but as soon as some impairment occurs, potential barriers of the built envi- ronment can become a more important factor (Clarke & Nieuwenhuijsen, 2009). Having a number of chronic conditions or living with dementia can undermine the confidence of older people to navigate and master the outdoor environment and hence put them at risk of social exclusion (see also the chapter on domain 5: social inclusion and non-discrimination). Key facts • In the WHO European Region each year 46 000 people aged over 70 years die as a result of falls (WHO, 2014a). WHO estimates that 26% of these falls can be attributed to the environment, such as housing environments, access to building sites and recreational environments (WHO, 2006). Improved design of outdoor environments can help reduce the risk of accidental falls. • Survey results for the EU indicate for 2012 that 13% of people aged over 65 years perceive crime, violence or vandalism in their area as a problem (Eurostat, 2015a). • Many older people face barriers getting outdoors; for example, 52% of respondents in the United Kingdom said that a lack of public toilets in their area prevented them from going out as often as they would like (Hogg & Godfrey, 2007). • People living close to open and green spaces are more likely to go out and walk (Saelens & Handy, 2008; Sugiyama & Ward Thompson, 2008). Outdoor environments 17 Adapting or designing public environments in a way that is accessible for all, regardless of age and level of ability, benefits not only older people but also the wider community. Accessibility has been promoted by concepts such as “inclusive design” and “universal design” prin- ciples, which have become part of national legis- lations in some countries (including in the Nordic countries). These principles are also enshrined in the United Nations Convention on the Rights of People with Disabilities, to which the EU and European countries are signatories. Local action plans should assess the level of accessibility in neighbourhoods and make sure that it is promoted. Guidelines on accessibility standards and universal design have increasingly become available at national and subnational levels (see Box 3); these help plan- ners to identify gaps in communities, in consultation with older people, their organizations and other rele- vant stakeholders (see the section on resources and toolkits). Safe and well signalled pedestrian crossings are a major concern for people with any kind of impairment, frequently identified in focus groups and surveys. Special buttons have been installed at important crossings in some cities that grant people with disabil- ities more time to cross the street. A more refined way to request longer crossing time has been introduced in the form of an electronic card for disabled people. More details on crossings can be found in the chapter on domain 2: transport and mobility. Special solutions can support people with sensory impairments or with reduced vision or hearing. Audio signals at traffic lights and specially designed curbs that provide better visibility are among the examples that have been implemented in many cities. The right of access to the city includes people with dementia as well as people with mobility limitations. Research has shown that the majority of older people with dementia live at home – many on their own (WHO, 2012b). Unless outdoor environments are designed to help older people who live with dementia to con- tinue to use their local neighbourhoods, many of them may become effectively housebound (Mitchell, Burton & Raman, 2004). Designing urban areas that are easy to understand and have landmarks and high legibility, including clear signage and layout, is critical for people with dementia but also relevant to other members of society (Box 4). This includes not only outdoor environ- ments but also buildings and public meeting places. For instance, shopping centres can be challenging environments for people with dementia as they can be disorienting (Blackman et al., 2003). Support for community interaction and personal independence When there are places to rest, interesting street-life and a perception of safety an older person is likely to venture outdoors more often, to walk and meet peo- ple and participate in everyday life. Conversely, a busy street right in front of the house – especially without traffic lights or with short crossing times – can create frightening situations, thus discouraging some older people from going out into the community. A direct neighbourhood and residential context that invites older people to go out and about, to take care of daily activities independently and to interact with others is of great importance. This is particularly true Box 3. Oslo’s common principles for universal design In 2014 Oslo City Council adopted common prin- ciples for its local implementation of the Norwegian national action plan on universal design. The prin- ciples provide guidelines for each city department and agency, which are required to develop individ- ual plans for universal design. The city’s Agency for Social and Welfare Services is in charge of coordi- nating these initiatives across the municipality. The principles of universal design cover three main areas: • transport and communication • planning of construction, property and outdoor areas • information and communication technology (ICT). The common principles are based on the govern- ment’s vision that universal design is to be imple- mented in Norway by 2025. Source: City of Oslo (2014), WHO (2015c). Age-friendly environments in Europe. A handbook of domains for policy action 18 for people who live in residential care and those who through various life events (such as the death of a loved one or relocation) or characteristics like health, gender, ethnicity or income have become more iso- lated (Clarke & Nieuwenhuijsen, 2009; Atkinson et al., 2014). It is important for older people that neighbourhoods have access to core destinations such as local shops, services and amenities. Access to and density of nearby open spaces, ser- vices and amenities and interesting street frontages have been shown to be among the most important factors influencing older people’s walking and ability to take care of their daily activities (Kerr, Rosenberg & Frank, 2012). Decisions of how and where to locate health services and integrated service providers, including housing and residential choices for older people in the community, need to be considered in this context. Consideration is especially required for peo- ple with dementia, who – it has been shown – usually feel more comfortable in a familiar environment, hence with amenities close to home. Efforts to support personal independence include improved access to buildings and to the local transport network. An environment that supports social contact and access to public transport adds to quality of life and fosters physical ability in older people (Elmståhl & Ekström, 2012; De Donder et al., 2013). Relevant Box 4. Case study: designing outdoor spaces to become dementia-friendly neighbourhoods for life A three-year research project from the Oxford Institute of Sustainable Development examined how outdoor environments can be made more dementia-friendly. People with dementia have more difficulty using outdoor spaces independently: studying the way they perceive, experience and use the outdoor environment enabled the researchers to identify design factors and criteria that influence their ability to use and negotiate their local neighbourhoods successfully. While the majority of participants with dementia said that they enjoyed going out, many could no longer drive or use public transport when unaccompanied, often limiting their choice of destinations to places within walking distance. Older people with dementia tend to prefer: • mixed-use, compact local neighbourhoods; • short, gently winding streets with wide pavements and good visual access; • varied urban forms and architectural features and aesthetic environmental features; • historic, civic or distinctive landmarks; • quiet, pedestrianized streets and welcoming open spaces; • places, spaces and buildings whose functions and entrances are obvious; • simple, explicit signs with large, dark unambiguous graphics and a light background; • easy-to-use street furniture in styles familiar to them; • smooth, plain, non-slip, non-reflective paving. These findings were translated into preliminary guidance for designers – at all scales from urban design to street furniture – on the criteria to consider when developing dementia-friendly urban environments. In summary, this research identifies the six major requirements for outdoor environments to be demen- tia-friendly: they need to be familiar, legible, distinctive, accessible, comfortable and safe. All criteria are very closely related to the topics in this chapter. Environments that are easy for people with dementia to access, understand, use and enjoy are likely also to be age-friendly and to benefit other people with or without limita- tions; this gave rise to the concept of “neighbourhoods for life”. Source: Mitchell & Burton (2006). Outdoor environments 19 neighbourhood infrastructure includes not only local commercial centres but also meeting places for older residents; both should be designed in inclusive ways. Amenities close to home may, however, be absent in rural and remote communities, which underlines the need for combined planning and transport strategies, and special solutions to bring services to people, such as mobile shops (Keating, Eales & Phillips, 2013). Physical environments can be co-created with older people and older people’s associations. Involving older people in consultation processes for newly planned urban developments can ensure that their needs are respected in urban planning. Many cit- ies have set up “senior councils” that advise the local authority on issues affecting the lives of older peo- ple (see also the chapter on domain 6: civic engage- ment and employment). To support these planning processes, municipalities have developed a range of methods for street audits and public consultations (Buffel et al., 2014). Older people’s associations and other organized or informal groups of older people are important stake- holders with an interest in promoting local activity and healthier physical environments. Co-creating public, residential and open spaces with older people has two benefits: first identifying and avoiding barriers for older people with special needs (Gilroy, 2008; Beard & Petitot, 2010) and second increasing subsequent use by organized and informal groups through creating a feeling of ownership. Places to be and to stay outdoors Going out is not only an act of getting things done or getting from A to B. Being in public and open spaces also gives people the broader feeling of tak- ing part in the life of their community and of having social encounters. Physical environments that enable life and participation need to plan with people in mind and define relevant and measurable targets for what they want to achieve (Gehl, 2011). Public benches and other opportunities to rest, as well as adequate access to toilets, are essential for older people with some functional limitation to feel confident in public spaces. This also concerns privately owned extensions of public spaces: shops, supermarkets and com- mercial shopping malls. Where “age-friendly” or “generation-friendly” business labels have been intro- duced, their checklists usually address these issues, sometimes with a special focus on the needs of peo- ple living with dementia. Insufficiently safe or clean environments are frequently stated concerns by older people when asked about rating their neighbourhood. Uncleanliness, litter and graffiti can be perceived as evidence for decline and degradation of the neigh- bourhood (De Donder et al., 2013). This can lead to the subjective feeling among older people of a lack of safety. Feeling secure in one’s living environment is a major factor in older people’s choices to leave their homes and engage in their communities (Broekhuizen, de Vries & Pierik, 2013; Yen et al., 2014). The feeling of safety can depend on a number of fac- tors. These include negative factors such as objective or subjectively perceived risk of violence, observed antisocial behaviour and reported crime, but also pos- itive factors such as adequate street lighting or having emergency phones around public transport hubs. In addition to perceived disorder and litter, experienc- ing road safety problems adds to feelings of unsafety, as do poor conditions of pavements and insufficient recreational infrastructure or heavy traffic (De Donder et al., 2013). An infrastructure of local shops, on the other hand, might lead to the perception of increased safety. Some longitudinal research has shown that fear of crime or street design that favours motorized transportation and neighbourhood degradation may adversely influence health outcomes among older people (Beard & Petitot, 2010). Neighbourhoods need to be created where older people have a choice of places for recreation, physically activity and other leisure activities. Some evidence exists that seeing other people being active in one’s neighbourhood can increase the per- ception of trustworthy and responsible residents, motivating older people to participate more (Annear et al., 2014). An increasingly popular intervention in age-friendly cit- ies is the creation of accessible walking paths, infra- structures for physical activity and cycle paths that older people can use for recreational purposes. The health benefit goes beyond physical activity to addi- tional social interaction and mental health benefits. Age-friendly environments in Europe. A handbook of domains for policy action 20 These infrastructure investments should be consid- ered in disadvantaged neighbourhoods, in combina- tion with other measures to increase perceived safety and attractiveness. Walking groups invite older people to leave their houses and foster recreational walking, while promoting social engagement. Case studies indicate some positive effects from phys- ical structures in the community, such as intergenera- tional playgrounds where grandparents can play with their grandchildren and special equipment from the recent “adult playground” movement. All of these can make the use of open spaces more attractive for older people and provide possibilities for social interaction. (More details on participation and recreational activi- ties can be found in the chapter on domain 4: social participation.) Natural environments, parks and green spaces can promote well-being and health through increased activity levels. Access to a green living environment is positively linked to better perceived health, less disease and longer lives in people aged 60 years and over (Broekhuizen, de Vries & Pierik, 2013). One possible explanation of this effect is illustrated by research sug- gesting that older people who live close to parks and other open spaces walk more and leave their homes more frequently (Saelens & Handy, 2008; Sugiyama & Ward Thompson, 2008). Design, attractiveness and the perceived safety of green places are all critical to their effect on increased activity levels (Michael, Green & Farquhar, 2006). Some beneficial effects of green spaces studied were stronger among older people than in the general population; for example, in improv- ing quality of sleep (WHO Regional Office for Europe, 2016b). Nature and green spaces have additional effects on well-being and mental health. Research indicates that older people have a preference for green environments, like tree-lined streets, plants and things to watch in the park (Ward Thompson, 2013). Distribution of trees within the neighbourhood and exposure to green open spaces appear to be correlated to older people’s subjective well-being and subjective health (Kweon, Sullivan & Wiley, 1998; Van Dillen et al., 2011). Engaging with nature has been shown to have a pos- itive effect on mental health, alleviate stress, restore energy and enhance mood – effects that have been described as “therapeutic landscapes” or “restorative environments” (Kaplan and Kaplan, 2003; Hansen- Ketchum et al., 2011). Moreover, allotments and community gardening can be beneficial to the mental health and well-being of older people (Milligan, Gatrell & Bingley, 2004; Van den Berg et al., 2010). By inter- acting and working in the garden older people get a sense of achievement, satisfaction and aesthetic pleasure (Milligan, Gatrell & Bingley, 2004). In urban action plans communal gardening or allot- ment sites often appear in intergenerational and inter- cultural strategies for social integration, but they have clear links to age-friendly policies. Community gar- dens can have the double benefit of simultaneously helping to combat social isolation and contributing to social networks and skills. People with dementia also value a connection to nature and participation in nature-based activities, rating them as highly enjoy- able – for those living either in the community or in sheltered housing (Gibson et al., 2007). Urban environments that support belonging, continuity and sense of self The space around the home is more than just a geo- graphical unit and physical quality: it also has char- acter, history, meaning and value for residents. The wish of older people to age in place is connected with a feeling of continuity and being familiar with a place. Rapid changes in a neighbourhood, however, may make it feel new and unfamiliar and threaten the continuity and attachment that older people have with it. This may be particularly relevant for people with dementia, but limited research has been done so far into how rapid urban changes affect older people in this regard. Attachment and a sense of belonging are shaped through experiences of accessibility, social bonds, feelings, memories, thoughts and routines in the neighbourhood over the life-course. It is important to recognize the ways in which people have and build connections to places, and more research needs to be done in this field. The experience of a place can affect older people’s subjective judgement of it and Outdoor environments 21 their ability to participate in the built environment (Phillips, Walford & Hockey, 2011). “Public and shared spaces are critical environments shaping the conduct of everyday life. Our use of and identification with public spaces is an essential component of an overall sense of being in place. There are public places in which we feel safe, welcomed, and within which we can experience a sense of belonging and identification. Other public spaces are dangerous, hostile and alienating. The design and ambiance of these spaces is a critical element in determining our ability or willingness to venture forth from the relative security of our residence.” Rowles & Bernard (2013: 4) Perceptions and feelings about a place can have an important impact on actual use and participation. Aesthetic buildings, streetscapes and scenery are highly valued and are associated with increased par- ticipation by older people (Moran et al., 2014). Thus, a subjective reading of the security or attractiveness of a neighbourhood is linked to whether older people are actually leaving their houses. Research has shown that aesthetics, usability and shared memories help older people to develop a sense of place and attach- ment, even in unfamiliar places (Phillips et al., 2013). Urban planners and city developers increasingly recognize that older people have not only technical and material needs but also emotional demands from their neighbourhoods. People develop ties of belonging and agency with their neighbourhoods over the life-course (Wahl, Iwarsson & Oswald, 2012). These lead to place attachment and create memories and meaning. Considering that people in their older years have often lived for a long time in the same neighbourhood, such processes of belonging explain subjective evaluations of neigh- bourhoods. Understanding these dynamics is crucial to creating environments that enable ageing in place; it may also help to assist older people in adapting to new places should they need or wish to relocate to more fitting environments. Finding ways to preserve and recall meanings, values and collective lective memories of places could help to preserve a feeling of continuity and support a sense of belonging to the neighbourhood. Research is only at an early stage of understanding how such emotional levels influence the health and well-being of older people, particularly in contexts of rapid urban change and regeneration. People trans- form the spaces of their lives by imbuing these pat- terns of use and the habituation of their everyday activities with meaning. Community integration and continuing engagement with the environment are criti- cal to enhancing quality of life for older adults (Rowles & Bernard, 2013). It is important for urban planners and policy- makers to recognize how place affects older people’s confidence of going outdoors. Unsupportive environments may lead to a loss of self-efficacy and self-esteem. For instance, not being able to find a toilet or having to ask for help to access a building as a wheelchair user can evoke feelings of being dependent. Supportive outdoor environments can benefit from an understanding of people’s sub- jective experiences and aspirations in terms of use of space and quality of life. People-centred environments respect the subjective values and meanings of the peo- ple inhabiting a place; support the diversity and needs of older people; and focus on physically and emotion- ally inclusive design of spaces. Listening to the voices of older people is crucial throughout the design and planning process. Policy interventions and initiatives by action area and objective Table 1 follows the structure of this chapter’s proposed directions for interventions and objectives and adds examples from existing age-friendly strategies, action plans and case studies. Interventions and initiatives mentioned may be projects already implemented in local contexts or those designed for implementation in an age-friendly action plan. Age-friendly environments in Europe. A handbook of domains for policy action 22 Table 1. Practice examples for outdoor environments from local age-friendly action plans and assessments Action area Objective Examples of policy interventions and initiatives Barrier-free public spaces and build- ings that are acces- sible and usable for people with impairments (cross-cutting with domain 4: social participation) Support to peo- ple at risk • Neighbourhood regeneration programmes for the development and improvement of infrastructures in socially disadvantaged neighbourhoods (including social development) • Urban audit-informed improvements in specific disadvantaged areas or with specific target groups • Planting of greenery and planning for the provision of urban amenities in disadvantaged areas Accessible/ inclusive design • Retrofitting public spaces and infrastructures to create barri- er-free access to public places, routes, buildings and transport (even with mobility aids) • Following accessibility principles for newly built infrastructures • Age-friendly and accessible design workshops with city plan- ners and urban designers • Participatory mapping of accessibility and targeted retrofitting of outdoor environments and buildings (developing walkability, accessibility and street audit tools) Crossings and traffic lights • Street audits including people living with impairments • Adjustable timing of traffic lights to allow safe crossing of mobil- ity-impaired people • Sonar signals on traffic lights Sensory impairments • Universal design initiatives • Consideration of safety and accessibility for vision-impaired users in the planning of public infrastructure, recreational zones and walking/sport facilities • Information and signage in braille and audio versions Dementia-friendly • Dementia strategies for the public realm and civic buildings • Involvement of people with dementia in neighbourhood audits • Familiar design of benches, traffic lights • Other dementia-friendly design principles, e.g. legibility, distinc- tiveness, good lighting • Walking groups for people with dementia Support for com- munity interaction and personal independence (cross-cutting with domain 8: community and health services) Access to amenities • Co-location of amenities and local services, especially in places close to care institutions and age-friendly buildings • Regulated distribution of pharmacies and health services in line with locations for older populations • Providing decentralized social services in the neighbourhood (offices proportional to number of inhabitants) • Service providers and businesses consulting with senior coun- cils in relation to development of buildings and outdoor spaces • Promotion of urban planning concepts such as the 20-minute neighbourhood and the city of short distances • Promoting access to, and viability of, healthy food, markets and local stores in the neighbourhood Outdoor environments 23 Action area Objective Examples of policy interventions and initiatives Access to buildings and local transport • Mapping accessibility of buildings (heavy doors, steps without handrails or wheelchair access) • Building ramps to public buildings and housing • Analysing distribution and density of bus stops and their dis- tance to residential areas of older people (using geographical information system mapping) Places to be and stay outdoors (cross-cutting with domain 4: social participation) Benches and toilets • Online bench request forms • Improvement of signage for public toilets • Mapping of toilets and ensuring maintenance • Accessible toilet initiatives and labelling with local shop owners and gastronomy Safe and clean environments • Working with private landlords to control noise and litter issues from their premises • Removal of litter and graffiti • Urban renewal and regeneration initiatives Places for recreation and leisure • Installing exercise equipment and areas in public places and parks • Supporting swimming pools and leisure centres • Creating culture and walking tracks Parks and green spaces • Creating new parks • Making existing parks more accessible, inviting and safe by installing benches and lighting and increasing maintenance • Providing dog fouling collection bags Resilient and therapeutic places • Improving accessibility and connection to forests and natural places • Allotment gardens • Community gardens • Assessing resilience to extreme climates: climate evaluation and adaptation of city centres Belonging and sense of self (cross-cutting with domain 2: transport and mobility and domain 4: social participation) Agency • Supporting local citizen initiatives to improve the urban environment Aesthetics and usability • Recognizable design of outdoor furniture • Neighbourhood beautification campaigns designed with inhabitants Understanding belonging • Focus groups with older residents • Asset mapping of neighbourhoods Preserve memories and continuity • Using participatory planning approaches to urban renewal and regeneration • Preservation of historical urban landscape Table 1 contd Age-friendly environments in Europe. A handbook of domains for policy action 24 Action area Objective Examples of policy interventions and initiatives Environmental confidence • Clear signage and legible layout • Focusing on fear of crime as well as crime itself, using tech- niques such as “design out crime” and “passive surveillance” in collaboration with local police • Developing and promoting use of impact assessment tools for older people Resources and toolkits Australian Local Government Association (2006). Age-friendly built environments: opportunities for local government. Canberra: Australian Local Government Association (http://www.beactive.wa.gov.au/index. php?id=1117, accessed 2 July 2015). Center for Active Design. Active design guidelines. New York: Center for Active Design (http://center- foractivedesign.org/guidelines/, accessed 25 May 2016). Handler S (2014.) Age-friendly handbook. Manchester: University of Manchester Library (http:// www.micra.manchester.ac.uk/connect/news/head- line-431019-en.htm, accessed 25 May 2016). Inclusive Design for Getting Outdoors [website] (2013). Edinburgh: Inclusive Design for Getting Outdoors (www.idgo.ac.uk, accessed 25 May 2016). Integrated age-friendly planning toolkit for local gov- ernment in NSW (2016) Sydney: Local Government in NSW (http://www.lgnsw.org.au/policy/integrat- ed-age-fr iendly-planning-toolkit- local-govern- ment-nsw, accessed 25 May 2016). Further reading AARP (2007). A great city for older adults: an AARP survey on the strengths and challenges of growing in Old Burlington. Washington DC: AARP (http://www. aarp.org/livable-communities/learn/research-trends/ info-12-2012/survey-growing-old-Burlington-2007. html, accessed 25 May 2016). Buffel T, Phillipson C, Scharf T (2012). Ageing in urban environments: developing “age-friendly” cities. Crit Soc Policy. 32(4):597–617. Burton E (2012). Streets ahead? The role of the built environment in healthy ageing. Perspect Public Health. 132(4):161–2. Curl A, Ward Thompson C, Aspinall P (2015). The effectiveness of “shared space” residential street interventions on self-reported activity levels and quality of life for older people. Landscape Urban Plan. 139: 117–25. Garin N, Olaya B, Miret M, Ayuso-Mateos JL, Power M, Bucciarelli P et al. (2014). Built environment and elderly population health: a comprehensive lit- erature review. Clin Pract Epidemiol Ment Health. 10(1):103–15. Hanson HM, Ashe M, McKay HA, Winters M (2012). Intersection between the built and social environments and older adults’ mobility: an evidence review. Vancouver: National Collaborating Centre For Environmental Health. Hartig T, Mitchell R, De Vries S, Frumkin H (2014). Nature and health. Annu Rev Public Health. 35:207–28. Hovbrandt P, Ståhl A, Iwarsson VH, Carlsson G (2007). Very old people’s use of the pedestrian environment: functional limitations, frequency of activity and environ- mental demands. Eur J Ageing. 4(4):201–11. McGarry P (2012). Good places to grow old: age-friendly cities in Europe. J Intergener Relatsh. 10(2):201–4. McGarry P, Morris J (2011). A great place to grow older: a case study of how Manchester is developing an age- friendly city. Working with Older People. 15(1):38–46. Michael YL, Yen IH (2014). Aging and place – neigh- borhoods and health in a world growing older. J Aging Health. 26(8):1251–60. Table 1 contd Outdoor environments 25 Newton R, Ormerod M, Burton E, Mitchell L, Ward Thompson C (2010). Increasing independence for older people through good street design. J Integrated Care. 18(3):24–9. Norgate S (2012). Accessibility of urban spaces for visually impaired pedestrians. Municipal Engineer. 165(4):231–7. Nyman SR, Ballinger C, Phillips JE, Newton R (2013). Characteristics of outdoor falls among older peo- ple: a qualitative study. BMC Geriatr.13:125. doi: 10.1186/1471-2318-13-125. Plouffe L, Kalache A (2010). Towards global age-friendly cities: determining urban features that promote active aging. J Urban Health. 87(5):733–9. Puhakka R, Karisto A, Poikolainen J (2015). Spatial practises and preferences of older and younger peo- ple: findings from the Finnish studies. J Soc Work Pract. 29(1):69–83. Saelens BE, Papadopoulos C (2008). The impor- tance of the built environment in older adults’ physical activity: a review of the literature. Wash State J Public Health Pract. 1(1):13–21. Sheehan B, Burton E, Mitchell L (2006). Outdoor way finding in dementia. Dementia. 5(2):271–81. Spaul M, Hockey A (2011). Older people in unfa- miliar environments: assimilating a multidisciplinary literature to a planning problem. Local Economy. 26(4):236–45. Walker J, Finkelstein R (2008). Age-friendly New York City: overview, findings, lessons. Gerontologist. 48:104. Ward Thompson C, Curl A, Aspinall P, Alves S, Zuin A (2014). Do changes to the local street environment alter behaviour and quality of life of older adults? The ‘DIY Streets’ intervention. Br J Sports Med. 48(13):1059–65. Wu Y, Prina AM, Brayne C (2014). Age-friendly cit- ies and environments: an investigation of the living environment of older people in England based on the MRC Cognitive Function and Ageing Study II. Lancet. 384:89. Age-friendly environments in Europe. A handbook of domains for policy action 26 Domain 2: transport and mobility Transport and mobility 27 Introduction Public transport remains one of the key strategies to make transport systems ecologically and demograph- ically sustainable. This chapter discusses a number of features of age-friendly public transport, as well as other support measures that help remove barriers to transport and mobility. Transport and mobility is the second of three domains of the AFEE framework that aim to make physical environ- ments more supportive. It corresponds to the “trans- portation” domain in the original WHO global guide, in which the majority of issues covered relate to public transport provision (WHO, 2007a). Current research often addresses issues of transport and ageing in broader terms and emphasizes the important health benefits of walking and other active forms of mobility for older people. The AFEE handbook therefore cho- ses to address broader questions of mobility and road safety together in this domain, including other issues that are critical to safe mobility, such as pavements. As with other domains of age-friendly environments, trans- port and mobility have important interconnections with other domains and can reinforce each other. To facil- itate ageing in place and to maintain quality of life as people get older, it is important to understand the role of the built environment in fostering or limiting mobility. Strategic directions for policy interventions For older people, the ability to get “out and about” is crit- ical to well-being (Marsden et al., 2007). Transportation is crucial for maintaining social connections with fam- ilies, friends and neighbours and for keeping engaged in life and participating in society more broadly, includ- ing access to health and social services. Many older people cannot be self-sufficient without transportation if they have reduced mobility (UN-Habitat, 2013). This chapter elaborates major pathways for remaining phys- ically active and being able to participate in social and community life for as long as possible. The goal of interventions in this domain is to promote safe, accessible, appropriate and reliable transport services and infrastructure for active living. The aim is to enable people to maintain their mobility, independence and connections as they get older. Having all the necessary services (including hospitals, doctors’ surgeries and grocery shops), social networks and activities (including friends’ houses, day centres, churches and parks) available in the local neighbour- hood can help to compensate for reduced mobility. As Marsden et al. (2007) have argued, however, there is also evidence of frustration and health consequences if destinations important to older people’s lives cannot be reached easily. Helping older people increase their mobility can help reduce dependence and isolation, and thus prevent or slow down further decline in health and daily functioning. The coming decades will see ageing generations accustomed to car use, high levels of mobility and travel-intensive lifestyles (Hjorthol, Levin & Sirén, 2010). This may help some older people to compensate for their reduced mobility, while others may become more homebound and risk social isolation and loneliness. Domain 2: transport and mobility Age-friendly environments in Europe. A handbook of domains for policy action 28 One of the biggest challenges and the root of many barriers found in age-friendly city assessments is the lack of consideration given by transport planners to mobility difficulties, possible impairments and age-re- lated vulnerabilities (such as reduced walking speed and distances and the need for seating in public places and clear signage). By bringing together public health and transport engineering specialists and older peo- ple, a range of actions have been identified that may lead to better services. According to the European Metropolitan Transport Agencies (EMTA) many of these actions are low-cost and easy to implement and would benefit both older people and other groups of the pop- ulation who use public transport (Fiedler, 2007). Older people use a variety of transportation options including driving, walking, public transport and pri- vate and specialized transport services. Walkability of neighbourhoods (see also the chapter on domain 1: outdoor environments) and accessibility of public transport have been shown to predict older people’s transportation choices and are therefore key areas of intervention for age-friendly environments. Mobility is more than just transport from A to B: it is also an experience in itself, which is important to the self-effi- cacy and subjective well-being of older people. It also opens up opportunities to interact with others and feel part of the city. The following sections bring together main features and initiatives that practitioners, age-friendly action plans and researchers have identified as relevant age- friendly practices for mobility and transport. A table at the end of the chapter provides practical examples that show how local governments have operational- ized areas for action into their action plans. Key facts • The likelihood of living with reduced mobility increases significantly from the age of around 75 years. Age alone, however, is not the direct factor for this decline, which is strongly connected with the state of health and related impairments usually more prevalent among the older age groups, including cognitive and motor impairments. Even in the oldest of old age groups many people still exhibit a high level of autonomous mobility (Bell et al., 2010). • Older people and people aged 15–29 years have the highest road traffic mortality rates in the WHO European Region (Jackisch et al., 2015b). • Every fifth person who dies today on the EU’s roads is aged 65 years and over (European Transport Safety Council, 2008). • It is estimated that around 12 500 people aged 70 years and over die each year in the WHO European Region from road injuries (WHO, 2014a). • Environmental barriers such as poor access to transport, neighbourhood safety and unavailability of exer- cise programmes and equipment are experienced as barriers to physical activity participation (Franco et al., 2015). • In the EU around 25% of people aged over 55 years use public transport (European Commission, 2011). Of people aged over 65 years, 23% experience some or great difficulties in accessing public transport facilities in the EU (Eurofound, 2012). • Older people’s experiences of mobility can be shaped by gender and life events. Although gender differ- ences are changing and differ by country, older women are currently less likely to drive and to own a car; on the other hand, older women use more and different modes of transport. While older men are overall less prepared for a life without car, older women can be seriously affected by loss of a spouse in terms of their unmet travel needs (Ahern & Hine, 2012). • When asked, older adults suggested that motor traffic control measures are one of the most important environmental issues to address (Strath, Isaacs & Greenwald, 2007; Saelens & Handy, 2008). Transport and mobility 29 Infrastructure for active mobility and walkability Walking should be promoted among older people as it has the “win–win” result of being a form of both physical activity and mobility; it enables older people to be independent, to do the things that are important to them and to participate in social life. Walking is the most popular mode of transport of older people for local trips in all European countries. To enable older people to walk and use other modes of active transport, safe infrastructure is crucial. In some countries cycling is also a popular mode of transport among older people. Separating pavements and cycle paths from each other and from motor traf- fic can then foster active mobility in older people. Accessibility, maintenance and other features of the built environment can empower people to walk. Traffic planning is crucial: many older adults may not feel comfortable negotiating street crossings that have issues such as intersections without traffic lights and with relatively large crossing distances. Studies show an increased risk of motor vehicle collisions with pedestrians over the age of 65 years at marked cross- ings with no traffic signals or stop signs (Koepsell et al., 2002). To promote walking, consultations with older people and the available research evidence sup- port a number of factors. • Streets should be well connected and well lit, and should be and feel safe. • Pavements need to be wide enough, free of barri- ers, well maintained, cleared (of snow, leaves and litter), segregated from motorized traffic and other transport users (including cycle and motorcycle users) and free of obstructions from other uses of pavements (such as parked cars and garbage containers). Well connected streets can be achieved by ensur- ing the availability of potential walkable destinations, frequent formal crossings, well laid-out and signalled intersections and traffic lights that allow enough time for older people to cross safely. As outlined in the chapter on domain 1: outdoor environments, the wider characteristics and design of public spaces, facilities and amenities reachable within short distances also support and encourage walking and participation. Well maintained and well designed pavements, walkways and cycle paths are crucial to physical activity. Safe and smooth footpaths and tracks for walking are linked to more frequent walking of older people and the ability to perform activities of daily living independently; they also help to prevent falls (Nyman et al., 2013). Quality of pavements features strongly in many age- friendly audits in which older people have participated (Garin et al., 2014). “Outdoor falls are frequent; approximately half of falls among adults aged 65+ occur in outdoor environments.” Nyman et al. (2013: 2) Local action plans and assessments identify short- comings by consulting both older people themselves and available (national) accessibility guidelines. The lit- erature reveals a notable concentration on the details of pavement quality and maintenance, slopes, curbs and temporary obstacles on pavements, which are important determinants of walking among older people (Annear et al., 2014; Stav, 2014). For example, walk- ways and cycle paths need to be clearly separated and have safe intersections, as accidents tend to happen more frequently at intersections. On hills or stairs older people appreciate the presence of handrails. They dis- like cracked, uneven, steeply sloped or high curbs. Narrow pavements, slippery sidewalk surfaces, holes and cracks also pose barriers (Moran et al., 2014). Interventions can increase confidence for mobility if they reduce motor traffic, reduce traffic speed and increase road safety. Further to the criteria mentioned above, road safety, violence and injury prevention are key determinants of older people’s feelings of safety when walking. In many local needs assessments older adults suggested that they feel motor traffic measures are among the most important environment issues to address (Strath, Isaacs & Greenwald, 2007; Saelens & Handy, 2008). Recreational walking and physical activity have consis- tently been correlated to perceptions of neighbourhood safety and negatively related to neighbourhood prob- lems (Li et al., 2005; Li, Fisher & Brownson, 2005; Piro et al., 2006; Nagel et al., 2008; Mendes de Leon et al., 2009; Shores et al., 2009; Tucker-Seeley et al., 2009). Interventions should therefore also consider calming of motorized traffic, speed limits and road safety cam- paigns, as well as crime reduction. Age-friendly environments in Europe. A handbook of domains for policy action 30 In some countries people up to the oldest of old age groups rely on bicycles to get out and about. The use of cycling as a mode of transport varies greatly, depending not only on the culture but also on the provision of infrastructure for older people to feel confident to cycle (Oxley et al., 2004). When there are balance problems, three-wheeled bikes make it possi- ble to continue cycling, and new technology – such as e-bikes – opens up new opportunities for older people’s mobility. Nevertheless, older people need safe condi- tions to cycle, including segregated cycle lanes and sufficient green phases at traffic signals. In a number of European cities, as well as in some rural areas, bicy- cle-sharing schemes have been set up through which bicycles or e-bikes are available for temporary use and can be returned to a different point from where they are picked up. Initial evaluations of the health benefits of such schemes suggest that, although the majority of users are younger than 45 years, there are also positive health impacts for older users (Woodcock et al., 2014). Public transport Evidence shows that interventions in public transport can prevent a significant reduction in older people’s participation in activities. Such activities include visiting exhibitions, museums and libraries; going to restau- rants; exercise or playing sports; travelling or going on tours; playing with or helping children/grandchildren; participating in community or voluntary organizations; going to professional events or trade union meet- ings; and going to classes or lectures (Hallgrimsdottir, Svensson & Ståhl, 2015). Ageing populations can also be seen as an opportunity for public transport provid- ers to attract an important and growing target group (Box 5). Box 5. Perspectives from the public transport sector An EMTA report pointed out that healthy and active ageing offers potential benefits for both older people and public transport providers – public transport has an important market in the increasing number of older people, while older people can use public transport to remain mobile for as long as possible. The EMTA survey asked metropolitan transport agencies in 2007 which strategies and measures they had planned or implemented to react to the demographic change. Physical accessibility Cleanliness/appearence Information Waiting/interchange Tickets/fares Stakeholder involvement Safety strategy Surveys Staff training Easy use/orientation Service/staff (Marketing) campaigns Dedicated services User training 0% 20% 40% 60% 80% 100% fully implemented partly implemented planned not considered no answer The results highlight the trend of involving older people as stakeholders in consultations, planning and deci- sions for transport. EMTA also recommends clear communication strategies improving the image of public transport among older people and increasing efforts to service quality, cleanliness and punctuality. Source: Fiedler (2007). Transport and mobility 31 Cities need to apply accessibility criteria and guidelines more consistently to overcome barriers by adapting existing public transport systems. Implementation of age-friendly guidelines for public buses, trams and trains has shown promising results for improving satisfaction and perceived usability of the bus system. It may help older people to maintain par- ticipation in social life (Broome et al., 2013). Evidence from both reviews and individual studies suggests that measures to improve transport accessibility may have significant equity benefits. Those who most need improved access – not least the most vulnerable – might gain most (Hallgrimsdottir, Svensson & Ståhl, 2015). Accessible and reliable public transport options affect the health and well-being of older people. A longitudinal study from Sweden found access to transportation and activities to be the third strongest predictor of quality of life, mobility and functional lim- itations, after education and age (Elmståhl & Ekström, 2012). Accessible public transport has to provide more than wheelchair-accessible vehicles because older people perceive many different barriers in access to public transport. These include knowledge and infor- mation; availability, frequency and reliability of trans- port; flexibility of routes and stops; affordable ticket prices; and confidence to navigate transport systems. Gaps exist in the evidence about which barriers and facilitators have the greatest impact, however (Broome et al., 2009). Main areas of intervention for more accessible public transport include: • making public transport easy to use, improving the quality of pre-trip and on-trip information and con- sidering barriers for impaired individuals (no com- plex technical knowledge needed, considering the digital divide – user-unfriendly ticketing machines or complex tariff schemes can contribute to barriers that prevent more frequent usage); • planning of public transport services with all age groups in mind and considering the increasing demand of ageing societies – new approaches are necessary to overcome barriers, including improved demand-responsive services, more frequent sched- uling outside working hours and improved links between pedestrian infrastructure and public trans- port, such as bus buddy programmes or flexible route schemes (Broome et al., 2013); • reduced fees or free transport for older people and for individuals with disabilities that also consider the need for accompanying people. Social facilitating factors are the presence of helpful staff, positive attitudes and willingness to help, such as with information. Age and disability awareness training for staff and enforcement of traffic rules are frequently recom- mended strategies for interventions (European Conference of Ministers of Transport, 2000; OECD, 2001; UNDP, 2010). Incentives and regulatory struc- tures need to be scrutinized. For example, punctual- ity targets for public transport may contribute to bus drivers setting off before people are safely seated. Training and appraisal criteria for drivers and transport staff can encourage staff to strive to be approach- able, inform, assist and improve safety and security (Broome et al., 2011). On-demand services and other support to improve mobility Older people need support in the transition phase when they are no longer willing or able to use their own cars. When people get older they can become trapped in habitual car use as they are not used to, or have little or no experience of, public transport; as such, they are unaware of the available services (Oxley & Whelan, 2008). Encouraging the use of different kinds of active transport options early in life and throughout the life- course is important and has been pointed out as necessary for sustainable development (Nordbakke & Schwanen, 2013). Women over the age of 55 years are less likely to use the car, but are also more likely to live with functional limitations or disabilities: for them, public transport options are particularly important. Impracticality of public transportation (particularly in suburbia and in remote and rural areas) adds to car dependency and disadvantages for participation in older age (Zeitler et al, 2012; Haustein & Siren, 2015). Public transport systems and local transport planning have to adapt to the needs and expectations of the increasing share of older people; public transport will have to attract older passengers and familiarize them with the use of services to be sustainable. For rural areas, the development of appropriate rural alterna- tives and provision of public transport systems could help to secure road safety and support the transition from driver to non-driver (Hanson & Hildebrand, 2011). Age-friendly environments in Europe. A handbook of domains for policy action 32 Specialized community transport can offer services and support (such as taxi vouchers) for disabled people and others with special needs. The services provided by voluntary or private sectors are crucial to mitigate further health consequences for those at risk of exclusion. The community service land- scape is changing rapidly (Freund & Vine, 2010) and new demand-driven opportunities are evolving, based on new technology. Policy can stimulate and promote such alternatives and shape transportation systems of the future that are user-friendly and appropriate for all ages (Box 6). Box 6. Case study: Cyclopousse, Lyon The region of Lyon, France, launched rickshaws as an innovative public–private partnership to provide transportation services accessible by and tailored to older people. The “cyclopousse” can transport two people to the destination of their choice in a perimeter of between 500 metres and 1.5 kilome- tres. The service is free for recipients of home allow- ances and fairly cheap for regular users. It provides friendly, comfortable and secure means of trans- portation, based on a proximity approach, which in particular reaches older people at risk of social isolation. Local authorities can collaborate with private or social enterprises to support other alternative on-demand transport services. Sustainable concepts of transport, such as car-sharing schemes, emerge driven by cities and citizens alike. These might enable older people, who use the car less often or only for short distances, to save money and alleviate the pressure of maintenance. The potential of such innovative sharing schemes for older people is underexplored and it remains unclear whether car-shar- ing could also work in more rural and remote areas. Policy interventions and initiatives by action area and objective Table 2 follows the structure of this chapter’s proposed directions for interventions and objectives and adds examples from existing age-friendly strategies, action plans and case studies. Interventions and initiatives mentioned may be projects already implemented in local contexts or those designed for implementation in an age-friendly action plan. Table 2. Practice examples for transport and mobility from local age-friendly action plans and assessments Action area Objective Examples of policy interventions and initiatives Infrastructure for active mobility and walkability (cross-cutting with domain 1: outdoor environments) Promoting walking among older people • Intersectoral “active city” working group • Health economic assessment tool for walking and cycling • Pedestrian streets with lighting, shade (tree lining) and interesting street fronts • Accessible walking paths with resting points, water points and points of interest along the path (paths with thematic information, billboards with mental exercises, routes along meaningful places) • Guided walking tours on different themes (led by volunteers) • Walking groups (e.g. Nordic walking, women groups etc.) • Intergenerational walks (e.g. historical city walks; older people volunteer to walk children to school) • City map of places suitable for physical activity Transport and mobility 33 Action area Objective Examples of policy interventions and initiatives Pavements • Making walkability audits with older people • Ensuring regular maintenance of pavements with remedial work and repair of slippery and uneven pavements and walkways • Ensuring good room for passage and avoiding obstruc- tions (garbage, parked vehicles, plant pots) • Ensuring new pavements fulfil accessibility criteria and considering special curb design Increasing road safety and reducing motor traffic and speed • Better enforcement of traffic rules and laws • Awareness campaigns and education programmes on road safety • Pedestrian priority in city centres and historic, cultural and social sights, including provision of seating and restricted car traffic (only essential traffic to support local busi- nesses, drop-off/collect and limited free parking) • Speed indication devices (local volunteers to monitor) • Road safety observatory Supporting safe cycling infrastructure • Creation of cycling lanes separate from pedestrians and cars • Well connected network of bicycle lanes with easy access from residential districts and older people’s residences and reaching locations of interest • Safe and wide cycling lanes (that allow riding at different speeds) • Self-service bicycle-sharing schemes • Bicycle traffic counting devices • Intergenerational cycling events and bicycle workshops Public transport Developing and enforcing accessibility standards in public transport • Understanding and investigating barriers to use • Priority seating • Barrier-free vehicles and low-floor buses Offering reliable and affordable public trans- port options • Surveying appropriateness of routes and density of traffic stops (in particular with connections to socioeconomically disadvantaged areas and rural and remote areas) • Real-time information service at bus stops • Considering flexible bus route services • Neighbourhood minibus services on specific routes with door-to-door pick-up and drop-off (shop route; health route) • Considering concessions or free travel schemes Table 2 contd Age-friendly environments in Europe. A handbook of domains for policy action 34 Action area Objective Examples of policy interventions and initiatives High-quality and appro- priate public transport service for older people • Ensuring the presence of staffed service desks and ticket offices in the neighbourhood • Simplifying complex ticketing • Ensuring maintenance and safety of bus shelters • Staff training on age and disability awareness, safety and security • Regular customer satisfaction surveys (including older people) • Adjusting training and appraisal criteria for drivers and transport staff to promote approachable and assisting attitudes On-demand specialized transport services and other support to improve mobility (cross-cutting with domain 6: civic engagement and employment) Technological solutions • Accurate and accessible automated on-trip and pre-trip information with audio and visual information • Consideration of the digital divide; offering “offline” alter- natives for transport planning information and ticketing service • Online private ride-sharing schemes Supporting transition from the car to other means of transportation • Regular car-free days (bicycle parades, street festivals) • Training for road safety and mobility without the car • Special incentives/campaigns for using public transport Specialized community services for people with special needs • Taxi vouchers • Door-to-door transport services for people with special needs (e.g. organizing training and ensuring volunteers, including in remote areas) • Special neighbourhood minibus services at specific times to reach medical and social services, access to local shops, day and community centres and for participation in events (especially in urban fringes, rural and remote areas) Support and facilitation of alternative transport schemes • Car pools and car-sharing • Bicycle and e-bike-sharing • On-demand bicycle taxis with priority rates for frequent users Table 2 contd Transport and mobility 35 Resources and toolkits BASt (2014). European perspective and country spe- cific analysis. In: Ageing and safe mobility: papers [web- site]. Bergisch Gladbach: Federal Highway Research Institute (BASt) (http://www.bast.de/DE/FB-U/ Publikationen/Veranstaltungen/U-Ageing-2014/ Papers.html, accessed 2 October 2015). GOAL project (2013). Transport needs for an ageing society: action plan. Aachen: Institut für Kraftfahrzeuge (ika) (http://www.goal-project.eu/, accessed 2 October 2015). Haustein S, Siren A, Framke E, Bell D, Pokriefke E, Alauzet A et al. (2013) Demographic change and trans- port. Brussels: European Commission (CONSOL Work Package 1 final report; http://consolproject.eu/index. php/deliverables, accessed 2 October 2015). Lynott J (2010). Road safety for all: lessons from west- ern Europe. Washington DC: AARP (http://www.aarp. org/content/dam/aarp/research/public_policy_insti- tute/liv_com/2013/road-safety-for-all-lessons-from- western-europe-AARP-ppi-liv-com.pdf, accessed 2 October 2015). NYC Department of City Planning (2011). Mobility initiatives for an aging population: a scan of cur- rent practices. New York: NYC Department of City Planning (http://www1.nyc.gov/assets/ planning/download/pdf/plans/transportation/td_mobil- ity_initiatives_aging.pdf, accessed 2 October 2015). OECD (2001). Ageing and transport: mobility needs and safety issues. Paris: OECD Publishing (http:// www.oecd-ilibrary.org/transport/ageing-and-trans- port_9789264195851-en, accessed 3 November 2015). Ormerod M, Newton R, Phillips J, Musselwhite C, McGee S, Russell R (2015). How can transport pro- vision and associated built environment infrastructure be enhanced and developed to support the mobility needs of individuals as they age? London: Government Office for Science (https://www.gov.uk/government/ publications/future-of-ageing-transport-and-mobility, accessed 2 October 2015). UNDP (2010). A review of international best practice in accessible public transportation for persons with dis- abilities. Kuala Lumpur: United Nations Development Programme (http://www.my.undp.org/content/ malaysia/en/home/library/poverty/PubPovRed_ PublicTransportation.html, accessed 3 November 2015). WHO Regional Office for Europe (2014). Health eco- nomic assessment tools (HEAT) for walking and for cycling. Methodology and user guide. Economic assessment of transport infrastructure and policies: 2014 update. Copenhagen: WHO Region Office for Europe (http://www.euro.who.int/en/health-topics/envi- ronment-and-health/Transport-and-health/activities/ guidance-and-tools/health-economic-assessment- tool-heat-for-cycling-and-walking, accessed 2 October 2015). Further reading Broome K, Worrall L, McKenna K, Boldy D (2010). Priorities for an age-friendly bus system. Can J Aging. 29(3):435–44. doi:10.1017/S0714980810000425. Buys L, Snow S, van Megen K, Miller E (2012). Transportation behaviours of older adults. Australas J Ageing. 31(3):181–6. Coronini-Cronberg S, Millet C, Laverty A, Webb E (2012). The impact of a free older persons’ bus pass on active travel and regular walking in England. Am J Public Health. 102(11):2141–48. Faskunger J (2011). Promoting active living in healthy cities of Europe. J Urban Health. 90(Suppl. 1):142–53. Frye A (2013). Disabled and older persons and sustainable urban mobility. Nairobi: United Nations Human Settlements Programme (http:// unhabi tat .org/wp-content/up loads/2013/06/ GRHS.2013.Themat ic .Disabled.and_.Older_. Persons.pdf, accessed 27 May 2016). Green J (2014). More than A to B: the role of free bus travel for the mobility and well-being of older citizens in London. Ageing Soc. 34(3):472–94. Jancey J, Cooper C, Howat H, Meuleners L, Sleet D, Baldwin G (2013). Pedestrian and motorized mobil- ity scooter safety of older people. Traffic Inj Prev. 14(6):647–53. Koohsari MJ, Sugiyama T, Lamb KE, Villanueva K, Owen N (2014). Street connectivity and walking for transport: role of neighbourhood destinations. Prev Med. 66:118–22. Age-friendly environments in Europe. A handbook of domains for policy action 36 Lehning A (2014). Local and regional governments and age-friendly communities: a case study of the San Francisco Bay Area. J Aging Soc Policy. 2014;26(1-2):102–16. Satariano W, Guralnik JM, Jackson RJ, Marottoli RA, Phelan EA, Prohaska TR (2012). Mobility and aging: new directions for public health action. Am J Public Health. 102(8):1508–15. Schmocker J, Quddus MA, Noland RB, Bell MGH (2008). Mode choice of older and disabled people: a case study of shopping trips in London. J Transp Geogr. 16(4):257–67. Shimura H, Sugiyama T, Winkler E, Owen N (2012). High neighborhood walkability mitigates declines in middle-to-older aged adults’ walking for transport. J Phys Act Health. 9(7):1004–8. Truong L, Somenahaill S (2015). Exploring frequency of public transport use among older adults: A study of Adelaide, Australia. Travel Behav & Soc. 2(3):148–55. Van Cauwenberg J, De Bourdeaudhuij I, De Meester F, Van Dyck D, Salmon J, Clarys P et al. (2011). Relationship between the physical environment and physical activity in older adults: a systematic review. Health Place. 17(2):458–69. Yen IH, Fandel Flood J, Thompson H, Anderson LA, Wong G (2014). How design of places promotes or inhibits mobility of older adults: realist synthesis of 20 years of research. J Aging Health. 26(8):1340–72. WHO (2013). Pedestrian safety: a road safety manual for decision-makers and practitioners. Geneva: World Health Organization (http://www.who.int/roadsafety/ projects/manuals/pedestrian/en/, accessed 2 October 2015)

Domain 3: housing Housing 39 Introduction It is possible to age at home even when health declines and care needs arise, but the home needs to be suitable for the changing needs of older people. A large part of the housing stock in the WHO European Region and worldwide has not been designed to accommodate the needs of older people in terms of safety, acces- sibility, location and independence. Existing hous- ing stock may therefore need building modification. Moreover, within the home a number of environmen- tal hazards (such as mould, noise, cold, overcrowding and accidents) can threaten health (Braubach, Jacobs & Ormandy, 2011). Even in early old age – and growing in importance with increasing functional limitations – difficulties can appear in keeping up with house maintenance tasks; these increase the risk of injuries. In people of higher old age (over 80 years), especially as the risk of frailty increases, difficulties in moving around, climbing or descending stairs and getting out may lead to increased risk and fear of falls (Rowles & Bernard, 2013). Homes that are maladjusted to the needs of older people can set off a whole chain of consequences that include the risk of accidents and injuries and difficulties in performing the activities of daily living. These can mean that the older resident needs to move into more costly settings of care (Braubach & Power, 2011). This chapter considers housing: the third of the eight domains of the AFEE framework. Housing corre- sponds to the domain with the same title in the orig- inal WHO global guide (WHO, 2007a). This is the third of three domains that address the physical dimension of age-friendly environments. Housing has important interactions with the creation of accessible outdoor environments that support independence, as described in the chapter on domain 1. It is also strongly con- nected with domain 2: transport and mobility, which considers the environment around the house and the connections between residential settings. Issues of housing for the ageing population also have important links with domain 8: community and health services. As most people want to age at home rather than in institutions, an increasing number of older peo- ple will receive social and health care services at home rather than in an institutionalized setting. While this chapter includes sections on the home as a site for pre- vention and rehabilitation, the important topic of home care and health care services at home is covered in the chapter on domain 8: community and health services. Nevertheless, the designs of both new houses and adaptations to the home are essential to assist pro- fessionals and family members in fulfilling these tasks. Private and public houses occupied by older people need to be made fit for these additional functions, so readers are advised also to consult the relevant sec- tions in the chapter on domain 8. Strategic directions for policy interventions The goal of interventions in this domain is to provide adequate, accessible, safe and afford- able housing; a more seamless continuum of housing choices; and support for ageing in place through measures modifying the existing housing stock and making newly built houses better adjusted to older people’s needs. Domain 3: housing Age-friendly environments in Europe. A handbook of domains for policy action 40 Housing is an important determinant of health and quality of life of older people. Housing conditions have been identified as one of the mechanisms through which social inequality translates into health inequality (Braubach & Savelsberg, 2009). One reason housing is so crucial for older people is that they spend a larger amount of their time at home than other age groups (for example, in the United Kingdom older people spend 70–90% of their time at home). Older people wish to stay in their own homes and familiar surrounding as long as possible, rather than moving to potentially more adapted or accommodating locations or residential care facilities (Rosso, Auchincloss & Michael, 2011). The political aim of “ageing in place” is based on this aspiration and has been widely adopted. Homes can be supportive of active and healthy living on multiple levels. The physical design and layout of houses influence healthy living, exposure to risks and the ease of performing daily activities. Moreover, influ- ences of household composition and the direct hous- ing environment can provide opportunities for social contact, social networks and feelings of safety and support. Research has shown that falls can be pre- vented and older adults’ functional ability preserved by multifactorial home-based programmes that include home evaluations and modifications; physical activity or exercise; education, vision and medication checks; and assistive technology to prevent falls (Chase et al., 2012). Alongside assessments and adaptations for homes that reduce physical barriers for impaired indi- viduals, the home is also a setting to support preven- tion by ensuring safe physical activity, healthy living and rehabilitation (Stolee et al., 2012; Geraedts et al., 2013). Studies suggest that the burden of maladjusted and unhealthy housing for older people in the European Region is high, as are the costs to society related to it. A study from England, United Kingdom (Garrett & Burris, 2015), found that the total cost to the national health service attributable to the health outcomes for older people from unhealthy housing is some £1.4 bil- lion (around €1.7 billion) per year. This includes direct costs to the health system alone and represents only a fraction of the total cost to society, which could be saved if hazards were removed or reduced to a non-health-threatening level. It has been estimated that the investment of £10 billion needed to improve all the 3.5 million “poor” homes in England, United Kingdom, would pay for itself in just over seven years Key facts • Older adults spend a large proportion of their time at home; for people aged over 80 years this can be more than 80% (Iwarsson et al., 2007). • In the age groups between 65 and 84 years, the majority (67%) live with a partner, 28% live alone and 2% live in institutions in the 31 countries for which data were available. In the age group 85 years and over, the proportion of those living with a partner decreases to 32%, while almost half (47%) live alone and 13% in institutions (Eurostat, 2016). • Low indoor temperatures have been estimated to cause 13 deaths per 100 000 population each year in the WHO European Region. Older people are at greatest risk of indoor cold-related health effects (WHO, 2006; Braubach, Jacobs & Ormandy, 2011). In 2014 11.8% of people aged over 65 years in the EU reported being unable to keep their home adequately warm (Eurostat, 2015b). • High indoor temperatures are also a health risk, in particular for people of advanced ages and with pre-ex- isting medical conditions. The European heatwaves in 2003 were responsible for more than 70 000 deaths. Significant consequences were also caused by the Russian heatwaves, forest fires and associated air pollution in 2010 (McGregor et al., 2015). In 2012 16.6% of people aged over 65 years in the EU reported being unable to keep their home comfortably cool during the summer (Eurostat, 2016). • In the EU 47% of non-fatal injuries among older people occur at home (EuroSafe, 2013). Poor design or construction of homes plays an important role in home accidents. • Injuries in people aged over 60 years account for almost 60% of all injury-related hospital bed days (Bauer & Kisser, 2013). More than one quarter of all people suffering a hip fracture die within a year of falling; another 50% never return to their prior level of mobility (EuroSafe, 2013). • Of people aged over 65 living independently, 30% fall each year (Bauer & Kisser, 2013). Falls are the most preventable cause of needing nursing home placement. Home-based exercise programmes and home safety interventions can reduce the number of falls by 15–20% (Gillespie et al., 2012). Housing 41 and continue to accrue benefits into the future. More policy efforts are needed to reflect the housing-related needs of older people. A number of policy frameworks at the international level and an increasing number of national frameworks support commitments to improve housing to amelio- rate health and quality of life. The Istanbul Declaration on Human Settlements (UN-Habitat, 1996) features a commitment by Member States to “endorse the univer- sal goals of ensuring adequate shelter for all and mak- ing human settlements safer, healthier and more live- able, equitable, sustainable and productive”. Within the EU the European Social Charter identifies the right to adequate housing under article 31 (Council of Europe, 1996). The following sections bring together potential objec- tives, features and initiatives for the main areas of inter- vention that practitioners and policy initiatives have identified as relevant for age-friendly housing. A table at the end of the chapter provides practical examples that show how local governments have operationalized areas for action into their action plans. Combating inequity through improved housing Ensuring equitable availability of adequate housing for older people is crucial in reducing the health gap and protecting older people under socioeconomic pressures from serious health consequences. Housing quality is an important factor for older people’s mental health (Howden-Chapman et al., 2011; Kendig, Clemson & Mackenzie, 2012). Older people with lower socioeconomic status are more likely to live in disad- vantaged neighbourhoods and occupying lower-quality housing; they are also more exposed to environmental risks in the private home or residential area (Braubach & Fairburn, 2010). Socioeconomic pressure can lead to insufficient investment in maintenance (Begley & Lambie-Hanson, 2015). Research on social determi- nants of health and well-being suggests that housing tenure explains the prevalence of functional limitations in people aged over 75 years, even when it is controlled for higher age, living arrangements and subjective income adequacy (Matthews et al., 2005). In some countries in Europe – in particular in rural and remote areas – essential services such as connection to a sewerage system or basic sanitation like having a bath or shower may be an issue, with older people usu- ally even more affected than other age groups (WHO Regional Office for Europe, 2012c; Eurostat, 2015c). Affordability is critical. High house prices and rents and housing shortages in many metropolitan areas have made living in urban centres less affordable. Living at the periphery, how- ever, may make access to community life and services more challenging. The availability of subsidized housing and housing adapted to the needs of older people or in compliance with accessibility standards varies widely across Europe. Production of social housing in the EU decreased between 2009 and 2012, while at the same time the number of households on waiting lists for social housing increased (Housing Europe, 2015). Housing and related services have also been particu- larly adversely affected by the economic and financial crisis as governments cut expenditure (Frazer & Marlier, 2011). Nevertheless, a number of countries in central, eastern and southern Europe that have traditionally had high rates of home ownership have in recent years started to develop new social housing programmes. Additional financial pressure can be caused by util- ity costs – such as the cost of heating – which may be high compared to pension levels in the area. This creates the risk that older people may face tough choices between spending on heating and on other essentials, such as food or co-payments for medical services. Large differences occur between countries in the European Region, but in some countries over 40% of older people are unable to keep their houses ade- quately warm and another 17% are unable to keep the home cool in the summer (Eurostat, 2015b; 2016). Some countries have shown how collaboration with private landlords can help to tackle housing-related problems. Local authorities or social renting agencies can mediate between private landlords and low-income households. Programmes of such agencies have, for instance, used vacant property for social hous- ing or offered tax incentives to private landlords who charge moderate rents. Taxation on empty homes is an Age-friendly environments in Europe. A handbook of domains for policy action 42 alternative means of reacting to artificially high housing prices (Housing Europe, 2015). With the policy aim of ageing in place, the demand for adaptations of private homes is increasing. Support for home assessments, repair, maintenance and adaptation The wish to stay in familiar homes and environments calls for awareness of risks that increase with age-related decline in functional abilities. Approximately half of falls occurs indoors, so the home environment is critical for avoiding them (Rubenstein, 2006). Four areas of household activities have been identified that may be particularly problematic for older people: entering and exiting the home; moving around at home; climbing stairs; and using sanitary and kitchen facilities (Braubach & Power, 2011). In order to support ageing in place, age-friendly policies need to under- stand these risks better and help to prevent them. Evidence suggests that home safety interventions such as hazard assessment and active modification of homes can reduce the risk of falls in older people. Studies indicate that unsafe features of stairs can be a frequent source of accidents. Risks frequently iden- tified include uneven or excessively high or narrow steps, slippery surfaces, unmarked edges, discontinu- ous or poorly fitted handrails and inadequate or exces- sive lighting (Braubach, Jacobs & Ormandy, 2011). A high risk of falls was also found in homes with irregular pavements leading to the residence, loose carpets on kitchen and bathroom floors, loose electrical wires and inconvenient doorsteps. Poor home surroundings such as garden paths and walks that are cracked or slippery from rain, snow or moss are also dangerous. Entrance stairs and poor night lighting can also pose risks (WHO, 2007b). Prevention of falls can be achieved through programmes of combined home assessments and active interventions in home modification, particularly for older people with functional limitations or a history of falling (Braubach & Power, 2011). There are indications that combining individual assess- ments and home modifications with physical exercise, education and vision checks or assistive technology may yield the strongest effects (Chase et al., 2012). Home safety measures are more effective when deliv- ered by an occupational therapist (Gillespie et al., 2012), when they involve a multidisciplinary team and when targeted at those with a history of falling or known risk factors (Clemson et al., 2008). Whether home modifications by themselves can be effective in reducing injuries (Turner et al., 2011) and which are the best tools and protocols for making home assessments are yet to be established. Nevertheless, measurement of both objective and perceived home environments is recommended (Wahl et al., 2009). Among the factors addressed in a typical home visit are assessment and improvement of lighting; identifi- cation and removal of rugs and other trip hazards; and installation of railings on staircases and in bathrooms and toilets. Home safety interventions and home modi- fications have also been discussed as an important ele- ment in helping people living with dementia to feel safe (Alzheimer Europe, 2013). A number of countries have developed systems to provide programmes and grants for home modifications to adapt existing housing for older people to enable independent living and home care as far as possible. Publicly subsidized provision and easy access to home maintenance and modification services can help to make homes more accessible and support ageing in dignity and autonomy, avoiding injuries or institutional- ization and the high costs related to this (WHO, 2015b). Evaluations of provision of such services in local com- munities consistently found that older people greatly valued such services. Moreover, old people living in more accessible housing perceive their homes as more useful and meaningful (Nygren et al., 2007). Less cen- trally organized solutions in local communities include local repair shops and caretakers in buildings. House maintenance assistance could help to prevent injuries and increase quality of life. Older people spend less on home maintenance and repair and often live in areas where there are more complaints about less well maintained houses. Projects could assist older home owners financially and with practical help to keep up maintenance (Begley & Lambie-Hanson, 2015). The decision to apply for home adaptations or to move to more adjusted housing involves complex processes and decisions that involve the maintenance of self-identity. Well-being and healthy ageing depend not only on accessibility problems but also on the perceived usabil- ity, meaning and satisfaction of home (Nygren et al., Housing 43 2007). Even with declining health, the majority of older people manage to find ways of supporting themselves in mainstream housing. Any offer of support needs to have dignity, autonomy and the choice and agency of the older person at its core. If not, home modifications and other supporting devices or services installed may disrupt routines, remind the older person of disabilities and affect the sense of identity. Interventions that aim to support autonomy, control and self-management are more likely to be successful if aligned with prefer- ences and experiences of the older person (Pettersson, Löfqvist & Fänge, 2012). Setting and enforcing standards for newly built houses A distinction is often made between general housing – made up of houses where older people live inde- pendently or with partners or family – and specific shel- tered housing that is a more age-segregated arrange- ment like residential care, where care can be delivered. A number of topics related to accessibility of public buildings also apply to the design of publicly or privately owned housing. In many countries, guidelines have been developed that cover aspects of safety and accessibility to take account of the changing needs of ageing societies and offer tips for modification and maintenance to make housing more age-friendly (see the section on resources and toolkits). As information and guidance these should also be widely applied to private houses where older people live. Public subsidies can support their implementation. The guidelines can also be used as checklists to assess action and investment needed for public housing options for older people, including for assisted living or similar residential housing. Development and implementation of age- friendly building guidelines should be promoted. Safety from risks is a particular consideration in build- ings built especially for older people, like retirement homes and senior centres, where large numbers of individuals with elevated risk live or visit regularly (WHO, 2007b). In mainstream housing, however, few effective controls on new and existing dwellings are in place. In recent times, a number of more specific design guidelines for age-friendly housing have been developed, such as that under the WelHops project (Box 7). Duties and responsibilities of private landlords can be framed in such a way that they include responsibility for maintenance and safety, backed by regulations and supported by systems and resources to monitor their compliance. Action plans have included campaigns and publicity to inform housing owners and managers (in both the public and private sectors) of the benefits of good Box 7. Applying WELHOPS guidelines in the City of Gyoer, Hungary The municipality of Gyoer, Hungary is among several cities across Europe that use guidelines for the planning of houses for senior citizens, which were developed and piloted through the WELHOPS project. WELHOPS involved partners from five countries: Hungary (Gyoer municipality), Italy, Spain, Sweden and the United Kingdom. The guidelines list design principles that support senior citizens in their goal to live in their own homes for as long as possible, developed by an international working group of sociologists, economists, architects, engi- neers and those responsible for study and research in social welfare. They cover aspects of both the direct home and housing needs of older people and accessibility, as well as the quality and safety of the immediate surroundings and of services closely related to housing such as parking, cleaning or postal services. These guidelines have supported both the planning of new homes and the renovating of older people’s homes. The local government also created a dedicated fund, which allows older people to apply for money to renovate their flats according to the design guidelines. Sources: Interreg IVC (2015); Brighton & Hove City Council (2007). Age-friendly environments in Europe. A handbook of domains for policy action 44 maintenance and improvement, including the protec- tion of their property from deterioration. While aware- ness-raising campaigns are important, their effective- ness could be improved by legal measures placing duties and responsibilities for the maintenance of their housing on landlords, housing companies and managers. Creating broader housing choices that support independence Healthy housing conditions can stimulate active and healthy lifestyles, prevent limitations in activities of daily living and help to avoid unnecessary institutionalization. Local authorities have an important role to play in the provision of housing choices that meet the need of older people, support participation and ageing in place and protect older people from conditions that could threaten their health and safety. Providing appropriate housing choices for an ageing population goes beyond planning for institutional long- term care (see also the chapter on domain 8: commu- nity and health services). For older people the house and direct housing environment often determine the decision of whether living independently is still pos- sible; whether age-related reductions in physical and cognitive capacities can be compensated by building modifications; and whether relocation to a long-term care setting is necessary. For a number of countries (such as the United Kingdom) it has been noted that overall little progress seems to have been made in creating wider housing choices and improving hous- ing affordability for older people (Pannell, Aldridge & Kenway, 2012). While needs and life situations change with increasing age, financial or administrative barriers and a short- age of more supportive housing options in the same neighbourhood may hinder older people from moving to a more adjusted place. In parallel, architectural as well as financial limitations may not allow for the imple- mentation of required building modifications. For older people their apartment or house may have become too big or maintenance might be overburdening, especially for those living alone. Home owners may want to sell their house, in which case special advice regarding the administrative and financial implications of such a decision is needed. Local authorities and urban planners increasingly recognize the importance of housing for the health and welfare of older residents. Housing is highly relevant for the health and well-be- ing of older people, which calls for active involvement, close cooperation and coordination of efforts from pub- lic health professionals, urban planners, older people, social services and housing departments at the munic- ipal level and other actors. Local and regional authorities’ strategies and policies can strengthen the provision of varied and adequate housing that promotes health, intergenerational mix and social contact for an ageing population (Kärnekull, 2011). Local authorities typically assess the housing needs of their areas and have responsibility for developing and implementing strategies for the provision of new housing and the application and enforcement of standards. They can also ensure that inadequate housing in the existing stock is identified and necessary action taken. Especially in countries where local authorities administer a large proportion of the public or social housing that aims to provide housing for less wealthy population groups, public housing can have an impact on the health and well-being of the most vulnerable groups of older people (Braubach, Jacobs & Ormandy, 2011). Some countries have reacted to the demographic shift by providing senior housing, adjusted to the accessibility needs of older people. In some countries, local authorities and housing mar- kets have responded to the changing needs of older people by building new senior housing, mapping and increasing the accessibility of existing neighbourhoods and houses and counselling senior citizens about avail- able age-friendly housing options. Accessibility of age- friendly housing is increased by handling separate wait- ing lists or registers for adults aged over 55 years who are interested in more accessible housing. Where special apartments for older people are avail- able, their attractiveness will depend on where they are located. (See also the chapters on domain 1: outdoor environments and domain 2: transport and mobility on well maintained neighbourhoods with good services – health care, groceries, childcare – at walking distance and with connections to cultural and other leisure-time activities.) Housing 45 Residential care homes are a form of housing that pro- vides a continuum of housing choices from assisted living to more service-intensive settings. They have received more attention in recent years, strengthening their role as a health-promoting setting. An example is the Health has no age project in Austria (Box 8). Access to services needs to be addressed in relation to housing. Older people, especially those in higher age groups, may need support with a number of services in order to be able to lead independent lives and to age in place. This includes small repairs in the home, clean- ing and gardening, which may be expensive and scarce and are often not included in available social services. Volunteering services and family or neigh- bourhood help can provide support with some of these services for older people who live alone or far from their families. Where older people live together and jointly age in place, some neighbourhoods have taken the initiative to create what in the United States of America has been called “naturally occurring retire- ment communities” that commit to mutual support on a voluntary basis, independent from or complemen- tary to family support. The home can be a site of prevention and rehabilitation. Several intervention programmes have explored homes as settings for preventive interventions for healthy living in old age (Geraedts et al., 2013). Home- based individual exercise programmes have been shown to be effective in preventing falls, as are group- based exercise programmes (Gillespie et al., 2012). The home might become a setting for care provision. Particularly with technological innovation and remote surveillance programmes, the opportunities to live at home longer are expanded. Neither mainstream housing nor senior housing is usually built in ways that consider that care may need to be delivered at home. Design guidelines available for service houses and life- time homes could therefore guide the design of new senior flats that would enable care situations at home, or the modification of existing homes to allow people Box 8. Health has no age – a comprehensive settings approach for health promotion in residential homes When older people live in residential care facilities, this has major health effects on users, staff and relatives. In contrast to hospitals with a longstanding tradition of health promotion, however, examples of health promotion are rare in this setting. The innovative health-promoting Health has no age project in Vienna investigated the potential of a compre- hensive settings approach for health promotion in residential care facilities for older people, with the aim of promoting positive health for all stakeholders (residents, staff, relatives and volunteers). It was conducted as a pilot in three sites (with 900 residents and 300 staff) of Vienna’s largest care provider from 2011 to 2013. Evaluation of the pilot used qualitative and quantitative methods. Starting with a systematic needs assess- ment, the project developed and implemented health promotion strategies and measures that comprised: • a mobility enhancement intervention for residents as a randomized controlled trial, which demonstrated effectiveness; • measures to improve the involvement of relatives; • several staff health measures. The project showed that it is possible to implement a comprehensive health promotion approach in this setting. Agenda-setting for health promotion in this setting seemed especially successful. Experiences and results of a follow-up project have led to further specification and the scaling-up to other homes in Vienna in 2013–2015. Scaling-up/transfer projects were undertaken in Styria. Sources: Krajic, Cichocki & Quehenberger (2015); personal communication from Ursula Huebel, Wiener Gesundheitsfoerderung/Vienna Health Promotion. Age-friendly environments in Europe. A handbook of domains for policy action 46 in need of care to remain in their local and social set- tings. Despite promising results from home-based interventions, the socially isolating effects of home- based prevention and rehabilitation programmes have to be considered (see the section on ambient assisted living in the chapter on domain 8: community and health services). Alternative models of living: collaboration with private and user- driven initiatives Alternative housing options for older people include sharing close neighbourhood ties with people who are not necessarily from one’s own family. Such arrange- ments enable spaces that respect older people’s wish for autonomy while encouraging social support networks – for instance, in the form of older peo- ple babysitting neighbours’ children and neighbours helping with shopping and gardening. To enable such neighbourhood ties, however, houses need to be built and designed in a way that supports social contact and exchange with neighbours, while giving the possibility of retreat. Extra-care houses can be an alternative to residential care. Special service houses or “extra-care houses” have been developed in some countries as an alternative to classical residential care services. Such houses typi- cally provide self-contained accommodation adapted to some limitations in functioning and activities of daily living (such as mobility, hearing and visual limitations) and offer a number of services and care packages that can support people living with limitations and can mit- igate the need for relocating to institutional care. Often staff offices offer 24-hour support, and access to other services such as catering, activity rooms, library, hair- dresser and similar is provided in the house or neigh- bourhood (Croucher, Hicks & Jackson, 2006). Cohousing is a created community of private homes clustered around shared space. In cohouses people have their own self-contained apart- ments but are also living as a group sharing common rooms (such as a guest room, hobby room, large kitchen or dining room) in a building designed for ease of access and stimulating social interaction. Cohouses emerged mainly as the result of civil society campaigns that estab- lished close cooperation with public housing authorities. Exact models for cohouses differ from country to coun- try, ranging from building/home owners’ cooperatives to rental arrangements with municipal housing providers. The participative management of the house and com- munal facilities gives older people the opportunity to make decisions together and stay socially integrated in the community (Choi, 2004; Killock, 2014). In multigenerational houses different generations live under one roof. In some countries communal forms of living – similar to cohouses – have developed around the concept of multigenerational living. By co-locating families, stu- dents, working adults and seniors in the same house, multigenerational housing stimulates social living activ- ities and facilitate neighbourhood support in the hous- ing community. Its aims are to increase intergenera- tional understanding and support. Another form of intergenerational housing has emerged in particular in university cities – namely, intergenera- tional flat-shares or home-shares that exchange hous- ing space for help in the home (Fox, 2011). The con- cept recognizes that older people may have a room to spare in their house or apartment while in need of support or company, and that younger generations are often in need of cheaper housing while having some time and enjoying physical fitness. Not-for-profit orga- nizations match older people and younger people and provide assistance in case of problems. Typically, rent would be cheaper for the young person in exchange for company and/or an agreed level of support (like cook- ing or cleaning, but not including care) and trial peri- ods are arranged to test that a mutual understanding of what is expected works in practice (Sánchez et al., 2011). A nursing home in the Netherlands has applied such a system on an institutional level, allowing uni- versity students to live rent-free in small apartments in a retirement home in exchange for 30 hours of “good neighbouring” services. Villages and retirement communities facilitate access to existing services and aim to enable older adults to enhance their own well-being. Village concepts take the idea of service homes one step further by enabling older people to remain in an inde- pendent home and maximizing the potential of commu- nity social organization (Scharlach et al., 2014). People live in specifically designed supportive environments and can access specialized services and programmes without relying on family and friends. Individual villages have been built for people living with dementia, such as De Hogewijk in the Netherlands. While first evaluations from similar projects in the United Kingdom have been Housing 47 positive, various ethical debates and concerns about dignity, costs and equity in access remain to be fur- ther explored (Liddle et al., 2014). Support for relocation The aim of ageing in place is to enable people to stay in their home as long as possible. Nevertheless, there may be a time when relocation into safer, more adapted or more supportive settings is necessary. Such transitions are important moments when older people can be supported in order to avoid negative consequences. Relocation can be supported in a number of ways (Granbom et al., 2014), including into care facilities and assisted living. Easing the negative impacts of giving up a home and sustaining a sense of continuity can be supported by return visits to the former residence or neighbourhood. Case workers, family and local actors can help older people who relocate to retain social relationships and have opportunities to make return visits. In some instances, maintaining membership in local asso- ciations, churches or clubs can help to facilitate the transition. Security and safety, including crime prevention Housing professionals can offer an important contribution to making housing safer and healthier. All those involved in the design, construction, man- agement, maintenance and repair or rehabilitation of housing and building-related equipment need to be aware of the links between housing conditions and health. By involving different sectors and approaches, new and innovative solutions can be developed to avoid health- and safety-threatening housing conditions. Failing to consider the needs of older people can cost lives in times of emergencies like heatwaves, flooding or earthquakes. Extreme weather conditions and their effects on health are already felt. Future projections in the face of climate change suggest that events with the magnitude of the Russian heatwave of 2010 could become more com- mon. In the light of both a growing proportion of peo- ple over the age of 65 years and continuing migration to cities, the risk of mortality represent a high potential risk to human health (Watts et al., 2015). Emergency preparedness calls for well coordinated intersectoral planning, such as for an increasing number of heat- waves, floods or storms (Vandentorren et al., 2004). Heat-related health risks, for instance, can be reduced through systematic development of heatwave early warning systems (McGregor et al., 2015). Effective measures to communicate risks and prevent disas- ters require cooperation between environmental, social and medical organizations (WHO Regional Office for Europe, 2013b). A concern in a number of countries in Europe is so-called “excess winter deaths” among older age groups of the population. Poor control of indoor temperature (cold in winter or heat in summer) causes deaths and other adverse health events among older people and people with pre-existing health problems. The quality and energy efficiency of housing across the social gradient should be reconsidered (WHO Regional Office for Europe, 2012c). Ensuring fuel efficiency is a key priority in both new housing developments and refurbishment of older housing stock, with older people often more affected and the oldest of old age groups at higher risks of adverse health effects. Crime prevention is crucial to increasing the feeling of safety at home. Concerns over safety at home also include the per- ceived threat of crime and burglary. Concerns over both safety and fraud targeted at older people threaten housing satisfaction and are often raised in age-friendly assessments with older people. In Ireland, for exam- ple, a number of communities have started to collab- orate with the local police to improve older people’s awareness of common security risks. Intersectoral collaboration between local security forces and seniors in a specific neighbourhood are very popular and well accepted initiatives that can increase feelings of safety (Age Friendly Ireland, 2015). Policy interventions and initiatives by action area and objective Table 3 follows the structure of this chapter’s proposed directions for interventions and objectives and adds examples from existing age-friendly strategies, action plans and case studies. Interventions and initiatives mentioned may be projects already implemented in local contexts or those designed for implementation in an age-friendly action plan. Age-friendly environments in Europe. A handbook of domains for policy action 48 Table 3. Practice examples for housing from local age-friendly action plans and assessments Action area Objective Examples of policy interventions and initiatives Combating inequity through improved housing (cross-cutting with domain 1: outdoor environments, domain 2: transport and mobility and domain 5: social inclusion and non-discrimination) Ensuring equitable availability of adequate housing • Enforcing maintenance and quality guidelines of public and private housing • Ensuring the possibility of housing allowances or subsi- dies (including for age-friendly flats) Ensuring appropriate- ness and affordability of age-friendly housing options • Regulating the housing market to provide alternative housing options for home owners • Ensuring adequate quantity of social or low-cost housing • Counteracting socioeconomic segregation of neighbour- hoods by mixing areas of subsidized rental and owner- occupied housing • Ensuring non-discrimination in access to adapted housing options (based on individual assessments rather than age barriers) Ensuring access to essential services • Offering subsidies to ensure access to safe water and sanitation • Providing information and subsidies for heating and energy efficiency Ensuring supportive neighbourhoods • Ensuring accessible and well lit and maintained outdoor environments and entrances to buildings • Building ramps and connecting barrier-free footpaths and cycle paths to apartment buildings • Ensuring accessible transport options (distance to trans- port stops of less than 300 metres) Support for home assessments and modifications (cross-cutting with domain 6: civic engagement and employment) Providing support for repair and maintenance • Providing a small repairs home service (also by organizing volunteers and/or general “caretaker” professions) • Providing home hazard assessments and professionally supported evaluations of fall risks • Organizing local repair shops to carry out or provide guidance for repairs and adaptations (such as car repair shops run by people in the neighbourhood or volunteers) • Caretakers/concierges in buildings Providing support for home modifications • Establishing local services to advise on individual needs and feasible modification measures in a given home • Offering grant schemes for home adaptations and maintenance • Offering government-subsidized home maintenance support • Providing specialized advice and support for home adap- tations for people suffering from dementia Housing 49 Action area Objective Examples of policy interventions and initiatives Setting and enforcing standards for newly built houses Age-friendly building and design guidelines • Developing adjusted or implementing existing design guidelines for adapted housing for older people • Application of “lifetime homes and neighbourhoods” concepts – ordinary homes designed to incorporate design criteria that can be universally applied to new homes at minimal cost • Setting up “20-minute neighbourhoods” with key facilities within easy reach of older people’s housing • Ensuring intergenerational mix in newly constructed apart- ment blocks Creating broader housing choices that support independence (cross-cutting with domain 7: communi- cation and informa- tion and domain 8: community and health services) Developing a vision and strategy to meet changed housing needs of older people • Using housing needs assessments and surveys to under- stand the needs and preferences of older people and how well they are met by the available housing market (such as a fairer housing delivery plan) • Monitoring and regulating trends in the real estate market, creating favourable conditions for provision of accessible housing • Setting up a multisectoral working group or partnership • Mapping accessible housing and identifying sites where adaptable structures and diverse housing options could be developed • Including older people in urban and residential planning committees (also reaching out to very dependent and isolated groups) Informing and helping older people to plan for ageing in place • Providing municipal guidance on available services, sup- port, housing options and application procedures • Raising awareness of fall prevention in home settings • Offering counselling and information on grants to solve older people’s housing problems and help to apply for support • Accessible housing registers where older people inter- ested in more accessible housing can register Making existing housing stock appropriate and safe for older people • Providing sufficient numbers and diverse sizes of age- friendly and accessible flats in the community (to fit the diverse needs of older people) and assisted housing for older people • Providing information, support and incentives for the modification of existing homes • Providing timely access to accessible housing for older people • Considering technical solutions to support older people who are dependent or need more support • Decentralizing distribution of age-friendly and specialized housing so that older people who are willing to relocate do not need to leave their district Table 3 contd Age-friendly environments in Europe. A handbook of domains for policy action 50 Action area Objective Examples of policy interventions and initiatives Access to services • Maintaining services in neighbourhoods • Keeping a registry of reliable and honest services and handy people (sometimes connected to information cen- tres or telephone hotlines) • Providing agencies to coordinate services and provide information on services that enable people to stay at home for longer (such as a home improvement agency, geriatric centres) • Developing options for home delivery (such as, most prominently, a meals on wheels services) • Developing service housing (see the chapter on domain 8: community and health services) Multisectoral collaborations • Collaborating with small businesses to support integra- tion, proximity and co-location of services (in particular commercial services such as bakeries, grocery stores, pharmacies and health centres) • Collaborating with care providers, third sectors and net- works of professionals to provide support to people in their homes • Creating initiatives with private tenants to build more accessible housing and make their houses more age- friendly – e.g. avoiding noise and litter • Municipal bank offering support products useful and safe for older people Home as a site for pre- vention, rehabilitation and care provision • Offering remote (phone- or IT-based) support or home courses to encourage physical activity • Offering gym and exercise at home programmes • Providing visiting services from specialists (occupational or physiotherapists) to find solutions and offer training on how to overcome functional limitations Alternative models of living Extra-care housing • Providing choice of houses with care (cross-cutting with domain 4: social participation) Cooperative housing • Setting up cooperative housing arrangements with com- mon areas that allow for joint activities Intergenerational housing • Intergenerational flat-share: centralizing municipal services to bring together students in need of accommodation and older people who would like to share their houses with a young person • Offering support for intergenerational housing projects Village models • Offering supported housing solutions, service housing, grouping of individual apartments and houses around an infrastructure that enables autonomy Table 3 contd Housing 51 Action area Objective Examples of policy interventions and initiatives Support for relocation Access to residential care for all if needed and wanted • Creating effective and responsive systems for exchange of flats (e.g. from larger houses to smaller more adapted housing) • Organizing day care and assisted living solutions for those who do not require 24-hour complex care • Providing assisted and safe housing and access to day care services for people living with dementia • Integrating residential housing in communities Supporting a feeling of “home” • Providing adequate space in residential care facilities, and for retention and storage of private possessions and artefacts/memories • Reconnecting people with their past Security and safety (cross-cutting with domain 5: social inclusion and non-discrimination) Crime prevention • Collaborating with police on crime prevention pro- grammes to protect older people from fraud • Organizing ambassador and peer-to-peer initiatives (e.g. Seniors for Themselves; Crime Prevention Ambassadors) • Organizing community policing initiatives, with police pres- ence in neighbourhoods that are perceived as unsafe • Having regular meetings between older people in the neighbourhood and police forces (cross-cutting with domains 1: outdoor environments) Feeling of safety at home and in the neighbourhood • Offering free home safety checks • Offering technical support for personal alarms (buttons or pendants), video surveillance, door phones and security lights • Fire prevention at home • Setting up call centres for older people with or without remote sensors in ambient assisted living • Combating antisocial behaviour • Setting up text alerts and friendly call initiatives (that have a registry of older people at risk of isolation), and organiz- ing visiting services if the person does not respond to the phone in the morning Extreme weather events • Organizing visiting schemes during heatwaves • Offering support for energy-efficient adaptations or fuel subsidies during extreme cold Emergency preparedness • Ensuring emergency exit doors adapted to the needs of people with reduced mobility • Developing services to identify, locate and reach at-risk populations Table 3 contd Resources and toolkits Andrews J, Molyneux A (2013). Dementia: find- ing housing solutions. London: National Housing Federation. Braubach M, Jacobs DE, Ormandy D, editors (2011). Environmental burden of disease associ- ated with inadequate housing: summary report. Copenhagen: WHO Regional Office for Europe (http://www.euro.who.int/en/publications/abstracts/ Age-friendly environments in Europe. A handbook of domains for policy action 52 environmental-burden-of-disease-associated-with-in- adequate-housing.-summary-report, accessed 2 October 2015). Davidson M, Roys M, Nicol S, Ormandy D, Ambrose P (2010). The real cost of poor housing. Watford/ Bracknell: IHS BRE Press (http://www.brebookshop. com/details.jsp?id=325401, accessed 2 April 2016) Fuggle L (2013). Designing interiors for people with dementia, fourth edition. Stirling: Dementia Services Development Centre. German Federal Ministry for Family Affairs, Senior Citizens, Women and Youth (2014). Länger zuhause leben [Living at home for longer]. Berlin: Bundesministerium für Famile, Senioren, Frauen und Jugend (in German). Homes and Communities Agency (2009). Housing our ageing population: panel for innova- tion (HAPPI). London: Homes and Communities Agency (https://www.gov.uk/government/ publications/housing-our-ageing-population-pan- el-for-innovation, accessed 2 October 2015) Housing LIN (2011). EVOLVE tool – evaluation of older people’s living environments. Sheffield: University of Sheffield (http://www.housinglin.org.uk/Topics/type/ resource/?cid=7997, accessed 1 April 2016) Pfeiferova S, Lux M, Dvorak T, Havlikova J, Mikeszova M, Sunega P, editors (2013). Housing and social care for the elderly in central Europe: WP3 main findings report. Prague: HELPS project. RH Environmental Limited, BRE Group (2012). Housing health cost calculator [website]. Swansea: RH Environmental Limited (https://www.housing- healthcosts.org/, accessed 2 April 2016). Scott Ball M (2012). Aging in place: a toolkit for local governments. Atlanta: Atlanta Regional Commission. Todd C, Skelton D (2004). What are the main risk fac- tors for falls amongst older people and what are the most effective interventions to prevent these falls? Copenhagen: WHO Regional Office for Europe (http:// www.euro.who.int/en/health-topics/Life-stages/ healthy-ageing/publications/pre-2009/what-are-the- main-risk-factors-for-falls-amongst-older-people-and- what-are-the-most-effective-interventions-to-prevent- these-falls, accessed 2 October 2015). Further reading Brandt A, Samuelsson K, Toytari O, Salminen AL (2011). Activity and participation, quality of life and user satisfaction outcomes of environmental control sys- tems and smart home technology: a systematic review. Disabil Rehabil Assist Technol. 6(3):189–206. Frazer H, Marlier E (2011). Social impact of the cri- sis and developments in the light of fiscal consolida- tion measures. Brussels: EU Network of Independent Experts on Social Inclusion. Health Quality Ontario (2008). Prevention of falls and fall-related injuries in community-dwelling seniors: an evidence-based analysis. Ont Health Technol Assess Ser. 8(2):1–78. Jones P, Patterson J, Lannon S (2007). Modelling the built environment at an urban scale: energy and health impacts in relation to housing. Landscape Urban Plan. 83(1):39–49. Lee HC, Chang KC, Tsauo JY, Hung JW, Huang YC, Lin SI (2013). Effects of a multifactorial fall prevention program on fall incidence and physical function in com- munity-dwelling older adults with risk of falls. Arch Phys Med Rehabil. 94(4):606–15.e1. Letts L, Moreland J, Richardson J, Coman L, Edwards M, Ginis KM et al. (2010). The physical environment as a fall risk factor in older adults: systematic review and meta-analysis of cross-sectional and cohort studies. Aust Occup Ther J. 57(1):51–64. Liu CJ, Mab VE, Horton SBK, Mears KE (2013). Occupational therapy interventions to improve perfor- mance of daily activities at home for older adults with low vision: a systematic review. Am J Occup Ther. 67(3):279–87. Lorenc A, Pedro L, Badesha B, Dize C, Fernow I, Dias L (2013). Tackling fuel poverty through facilitating energy tariff switching: a participatory action research study in vulnerable groups. Public Health. 127(10):894–901. Lyons RA, John A, Brophy S, Jones SJ, Johansen A, Kemp A et al. (2006). Modification of the home Housing 53 environment for the reduction of injuries. Cochrane Database Syst Rev. 4:CD003600. Nyman SR, Ballinger C, Phillips JE, Newton R (2013). Characteristics of outdoor falls among older peo- ple: a qualitative study. BMC Geriatr.13:125. doi: 10.1186/1471-2318-13-125. Nyman SR, Victor CR (2012). Older people’s partici- pation in and engagement with falls prevention inter- ventions in community settings: an augment to the Cochrane systematic review. Age Ageing. 41(1):16–23. doi: http://dx.doi.org/10.1093/ageing/afr103. Rubenstein LZ, Josephson KR (2005). Intervenciones para reducir los riesgos multifactoriales de caidas [Interventions to reduce the multifactorial risks for fall- ing]. Rev Esp Geriatr Gerontol. 40(Suppl. 2):45–53 (in Spanish). Schoessow K (2010). Shifting from compensation to participation: a model for occupational therapy in low vision. Br J Occup Ther. 73(4):160–9. Skelton DA, Howe TE, Ballinger C, Neil F, Palmer S, Gray L (2013). Environmental and behavioural interventions for reducing physical activity limitation in community-dwell- ing visually impaired older people. Cochrane Database Syst Rev. 6:CD009233. Thomson H, Thomas S, Sellstrom E, Petticrew M (2012). Housing improvements for health and associated socio-economic outcomes. Cochrane Database Syst Rev. 2:CD008657. doi: 10.1002/14651858.CD008657. pub2. Tse T (2005). The environment and falls prevention: do environmental modifications make a difference? Aust Occup Ther J. 52(4):271–81. Van Loenhout JA, le Grand A, Duijm F, Greven F, Vink NM, Hoek G et al. (2015). The effect of high indoor tempera- tures on self-perceived health of elderly persons. Environ Res. 19;146:27–34. doi: 10.1016/j.envres.2015.12.012. Age-friendly environments in Europe. A handbook of domains for policy action 54 Domain 4: social participation Social participation 55 Introduction The goal of reducing loneliness and social isolation and reaching out to people at risk of social exclusion is at the heart of many interventions in local action plans for age-friendly environments. An international review of longitudinal data on individuals’ social relationships and mortality risk suggested that older people with ade- quate social relationships had a 50% greater chance of survival than those with poor or insufficient social rela- tionships. Lack of social relationships was a risk factor for mortality comparable with, if not greater than, such well established risk factors as smoking, obesity and physical inactivity (Holt-Lunstad et al., 2010). Social participation affects all aspects of health and well-being, from mental health and dementia to the risk of emergency admissions to hospital resulting from avoidable conditions such as severe dehydration or malnutrition (WHO Regional Office for Europe, 2012a). Local initiatives have consequently created numerous interventions and programmes that aim to combat loneliness and isolation in older adults. Nevertheless, important gaps in research and evaluations remain, and more in-depth studies are needed on the effec- tiveness of interventions in this domain to improve the evidence base. Social participation is the first of three domains of the AFEE framework that address the social dimension of age-friendly communities. It corresponds to the domain with the same title in the original WHO global guide (WHO, 2007a). In this chapter “social participa- tion” is used in the sense of a person’s involvement in activities that provide interaction with others in society or in the community. This encompasses participation not only in formal structures and leisure activities (such as social, cultural and leisure activities, meetings and religious participation) but also in informal structures of socializing and communicating that can take place in private spaces (in the form of neighbourhood contacts, virtual and telephone contacts and visiting friends and family). This comparatively broad view of social partic- ipation builds on a synthesis of definitions that have been used in studies of ageing (Levasseur et al., 2010). Social participation of older people can positively affect emotional and spiritual well-being, mental and physical health and quality of life. If social participation is restricted due to a perception of barriers to social life, older people can become socially isolated. Social isolation and loneliness are often used interchangeably: while they have strong links, however, they are not the same. Social isolation refers to an indi- vidual’s lack of contacts or ties with other people, such as with family members, friends, neighbours or others. In this sense, it is often regarded as an objective mea- sure of individuals’ personal social relations. Loneliness is typically seen as a subjective and negative experi- ence, felt by individuals based on perceptions of their personal social relationships. Loneliness is therefore often understood as a mismatch between the actual and desired quality and quantity of an individual’s social interactions (Heylen, 2010; Burholt & Scharf, 2014). Social isolation can exist without loneliness and lone- liness without isolation. While some people may have many social contacts and still feel lonely, others may have few contacts and not experience loneliness. Some older people may be content in their own company or even actively seek to live away from others; they may not feel that the lack of social interaction has a negative influence on their quality of life, so they might not wish to participate in social activities. Others may prefer to Domain 4: social participation Age-friendly environments in Europe. A handbook of domains for policy action 56 have more contact with people or a greater quality of contact with people to whom they feel close, and this may lead to feelings of loneliness. Unwanted social isolation and loneliness can be a consequence of non-supportive social environments and may lead to adverse outcomes for individuals and communities. Social isolation has a tendency to occur alongside other risk factors of poorer well-being (such as health problems, limitations in functioning, financial difficulties and political or neighbourhood exclusion). This can challenge age-friendly policy approaches that aim to promote active ageing and ageing in place by increasing the gap between those who age actively and those who are not reached and remain isolated (see also the chapter on domain 6: civic engagement and employment). The following sections bring together potential objec- tives, features and initiatives for the main areas of intervention that practitioners and policy initiatives have identified as relevant for increasing social par- ticipation and combating loneliness of older people, and that are part of age-friendly action plans in many instances. A table at the end of the chapter provides practical examples that show how local governments have operationalized areas for action into their action plans. Strategic directions for policy interventions The goal of interventions in this domain is to pro- mote older people’s participation in social life and to combat loneliness and isolation. This can be achieved by creating, maintaining and promot- ing supportive environments that enable social interaction and active lifestyles and by providing opportunities for meaningful social activities that encourage older people to leave their homes and maintain supportive social networks. The right of older people to live a life of dignity and independence and to participate in social, economic, cultural and civic life is firmly embedded in the EU’s commitment to active ageing and solidarity between generations (Council of the European Union, 2012). Participation of older people is also a key concept of the 2002 WHO active ageing policy framework (WHO, 2002b). Moreover, the recent World report on age- ing and health reconfirmed that social participation of older people is one of the main pathways but also one of the main aims of active ageing (WHO, 2015b). The original WHO global guide showed that older people wish to have a good balance between differ- ent kinds of activities – leisure, creative, spiritual or productive (WHO, 2007a). It also pointed out that local authorities should ensure good accessibility and affordability of such activities, as well as advertising them via a broad range of information channels (see also the chapter on domain 7: communication and information). Over the past 10–15 years evidence on good prac- tice relating to older adults’ participation and social relationships has grown considerably. Research has found a relatively high prevalence of loneliness in the European Region. Exclusion from social relations has been linked to a range of negative health and well-be- ing outcomes (Houtjes et al., 2014; Dumitrache et al., 2015). Several factors can put older women and men at greater risk of loneliness and isolation; in order to be effective, interventions need therefore to respond to existing needs and be sensitive to the specific situ- ations of different target groups. Loneliness, social isolation and social exclusion are risk factors most relevant for those in very old age and those without family networks or with insufficient support from a net- work of friends in the neighbourhood (Dykstra, 2009). Living in poverty or in rural and remote areas can act as additional risk factors. Loneliness and social isola- tion affect women more frequently than men. People with dementia are often faced with stigma and may find it even more challenging to continue partic- ipating in social activities. Moreover, organized com- munity support for social inclusion and activities may be more limited for many who live in rural or remote communities, making well functioning informal com- munity support all the more important. Finally, many older people who are informal caregivers in their fam- ilies can themselves be at risk of loneliness and isola- tion. For them, respite services and support groups of caregivers in the community can help them maintain a socially active life (see the section on supportive ser- vices for informal care givers in the chapter on domain 8: community and health services). Evidence supports the idea that people who have higher levels of activity as they become older are Social participation 57 happier and have better functional ability and lower mortality (Menec, 2003). Different activities can influ- ence health and well-being in older ages in different ways, but in general, research has found that being active in social and productive activities is positively related to happiness, functioning and reduced mor- tality. (For details on the importance of voluntary or economic activity see the chapter on domain 6: civic engagement and employment.) While the social activities offered at the community level often find enthusiastic attendance, they may tend to attract those older people who represent a healthier and more active part of the population, missing out on some groups of older people most at risk of social iso- lation and loneliness. A challenge for local authorities’ initiatives in this domain is to reach out to older people most in need of social interaction, emotional and prac- tical support, such as older men living alone or people from ethnic minorities (see chapter on domain 5: social exclusion). The extent to which older people feel lonely or to which the empowerment of older people to take active roles in creating their own social activities has been success- ful across Europe, however, reflects differences in the traditional roles of family and neighbourhood cohesion. For example, the proportion of older people who live with their extended family and receive informal help if they need support with everyday living differs widely between countries in Europe. The following sections describe the range of interven- tions that communities have developed for promoting social participation of older people and counteract- ing social isolation and loneliness. A table at the end of the chapter provides practical examples that show how local governments have operationalized areas for action into their action plans. A range of opportunities for social participation accessible for older people Many age-friendly community activities empower older people to participate in activities and increase awareness of the range of activities available. The range of activities from local initiatives and action plans usually comprises both interventions targeted at special groups of older people and integrated activities. Among the activities most frequently included in action plans are: • joint events for everyday activities, such as common meals and leisure activities; • activities offered at seniors’ clubs or community centres, such as talks, crafts classes, music or dancing; • cultural activities; • sport and physical activity events; • traditional activities and events; • educational activities (see the section on lifelong learning below); Key facts • More than 50% of men aged 80 years and over still live as part of a couple household, while in 18 EU countries the majority of women of this age live alone. There is also a north–south divide in living arrange- ments among those aged 80 years and over: most live alone in northern Europe, while it is less common in southern European countries (Rodrigues, Huber & Lamura, 2012). • In the EU, almost 18% of people aged 65 years and over participate in the activities of recreational groups or organizations (Eurostat, 2006). • Among EU countries, between 3% and 45% of older people on average meet friends, relatives or col- leagues less often than once a month or never; between 5% and 30% report that they lack a friend who could provide emotional support (Eurostat, 2006). • Late-life social engagement is linked to a lower risk of mortality, and for older people with mild cognitive impairment it is linked to a lower risk of decline to moderate-to-severe cognitive impairment (Marioni et al., 2012). • Social interventions that aim at alleviating social isolation are generally more likely to be effective if devel- oped within the context of a theoretical basis, and when offering social activity and/or support within a group format. Interventions in which older people are active participants also appear more likely to be effective (Dickens et al., 2011). Age-friendly environments in Europe. A handbook of domains for policy action 58 • information and awareness-raising events to make existing community offers better known (including community days or weeks dedicated to activities with and for older people, which also provide a “market place” where the full spectrum of activities and initiatives in a community can be presented); • special events for intergenerational activities, such as knowledge exchanges. To make activities affordable, public subsidies and pri- vate sponsorship are often needed, including offers of public space. Community action plans should keep these aspects of affordability in mind. For example, for some cultural activities and access to public insti- tutions, the community might offer reduced prices or free access (for example, public libraries and access to computers and Internet in the public space). Other issues of access – such as transport, location and timing – can be crucial issues for reaching out to target groups. Activities in this domain can often build on existing engagement and a range of community assets from different private initiatives, nongovernmen- tal organizations (NGOs) and other stakeholders, and on initiatives by older people themselves. An exam- ple is the city of Udine’s volunteering network No alla solit’Udine that aims to foster social participation and combat loneliness (Box 9). Building on these assets, it is important that older people are involved in planning and implementation of activities and helping to tailor them to their interests, wishes and requirements. The special needs of people with disabilities and those living with dementia have to be taken into account. Activities need to consider the areas in which they can conveniently reach out to older people. Local authorities can build on existing community assets, volunteers and initiatives and support them – for example, by ensuring continuity of offers, coordination and awareness and by supporting accessibility for older people. In many places, bottom-up initiatives organize formal or informal opportunities that help facilitate social con- tact and participation. Such initiatives involve volun- teering to organize events, create networks of older people and reach out to people at risk of isolation. Many activities are organized by older people or with the active involvement of older people, which is crucial to empower the community, and using existing assets (Green & Tsouros, 2008). Box 9. No alla solit’Udine [No to loneliness]: a network of volunteering action in the city of Udine, Italy The activity of voluntary associations and their contribution to the community’s life represent irreplaceable social capital in many countries in Europe. With one quarter of the population above the age of 65 years, the Italian city of Udine has a strong tradition of volunteering when it comes to providing support for its elderly citizens. The publicly managed telephone helpline No alla solit’Udine [No to loneliness] coordinates a broad volunteer services network. It serves older citizens who live with frailty or disability, or who are at risk of social exclusion. It is open for four hours every morning. The helpline is organized by the municipality of Udine and serves older people, many of whom have no family or network to support them or lack the economic means to pay for commercial services. Moreover, the ser- vices provided complement the standard public home care services, with a focus on preventing social isolation of older people. Three telephone operators are employed by the municipality to answer calls from older people and connect them with the services they need, the bulk of which are provided by volunteers. As of 2016, around 1000 vol- unteers from 30 organizations offer a variety of services, from delivery of groceries to providing advice, offering help for small repairs or with transportation, shopping or visiting and providing company; for example, reading the newspaper or books to those with limited eye sight. Since 2004, when the project started, there has been a continuous increase in use of the services. Sources: Municipality of Udine (2015); personal communication from Gianna Zamaro, Stefania Pascut and Furio Honsel. Social participation 59 Reaching out to new participants and raising awareness of activities can also be achieved via word of mouth from people already engaged in them. Social activities are usually reported as popular and attractive to many older people in the community. Older people in the neighbourhood and volunteers in seniors’ organizations provide opportunities to reach out and motivate others to participate by showing them ways to profit from the social life of their community. For some groups in the population and in special cultural contexts, however, reaching out to older people to overcome iso- lation can be more challenging. In some cases, offering targeted activities for some groups – such as for older men or for people from ethnic minorities – has been considered to provide an entry- point to community participation. Finally, a relatively recent emphasis has been given to the organization of activities with and for people living with dementia to enable them to continue to participate in everyday life. Reaching older men in social and health- promoting activities poses specific challenges. Provision of community-based activities for men may contribute positively to the physical, mental, social and occupational health of older men (Ormsby, Stanley & Jaworski, 2010). Reaching men in social and health-pro- moting activities has been found a challenge, in particu- lar for men from lower socioeconomic groups. Interventions that target men specifically are initiatives such as “men’s sheds” projects (Golding et al., 2008; Milligan et al., 2013). As a much-cited practice example, the men’s shed movement has grown popular in sev- eral countries including Australia, Canada and Ireland. Men’s sheds can be successful in providing men with a place where they feel they can be in control of, use and share common activities – in other words, develop a sense of purpose, accomplishment, control and social engagement (Ballinger et al., 2009). They therefore aim at improving important determinants of health and well-being (Golding, 2011; Wilson & Cordier, 2013). Increasingly, information technology can play a supporting role in creating awareness of existing activities that enable social participation. New technologies (computer forums, Internet telephony and video calls) allow for new ways of keeping in contact, exchanging news and seeking social support remotely with families and friends. Many communities therefore offer computer courses for older people, which are very well received (Blažun, Saranto & Rissanen, 2012). Staying connected through new technological means might offer important benefits and counteract loneliness, in particular for older people with mobility limitations or when family members live far away. Municipalities increasingly use online information plat- forms and forums for older people to help them find activities that are relevant. A number of more specific innovative practice examples aim to use information technology for isolated individuals (see also chapters on domains 7 and 8). This broader use of innovative models and of technology to support older people to combat social isolation is only just emerging. Examples include: • tele-links to call centres of social service providers for people living alone; • access to and training in the use of technology to foster intergenerational exchange and bridge geo- graphical distances within families; • moderated phone conferences to link older people with severely reduced mobility. Intergenerational activities have the potential to effectively promote social participation and at the same time help tackle age segregation. Another focus of community action is frequently the con- tribution of intergenerational activities and “help to self- help” support in communities. Intergenerational activities encompass a whole range of options, including: • joint activities with shared spaces or facilities (such as intergenerational community centres or multigen- eration houses); • activities of passing on experience and memories to younger generations; • volunteering of older people in nurseries, museums and after-school centres; • volunteering of children or young people in institu- tions for older people; • activities at schools where adults or older people are invited; • intergenerational learning activities. Supportive environments for social exchange in the community Attractive local meeting places and accessible neighbourhood centres can create important incentives for participation. Communities may be able to offer buildings and facil- ities for activities organized by seniors’ organizations Age-friendly environments in Europe. A handbook of domains for policy action 60 or for spontaneous events. The presence of a dedi- cated space that is part of a larger infrastructure, such as an intergenerational community centre for informal and formal activities, can foster social participation in the neighbourhood. Ways to organize meeting spaces range from facilities dedicated to services for older people – such as those linked to day care and respite centres – to multipurpose senior centres and houses that can host a multitude of activities, and social ser- vice centres or completely community-organized meet- ing places. Religious and church facilities/activities also play a traditional role in many communities. Existing infrastructures can often be used more effectively, such as by co-locating activities for older and younger people. Intergenerational facilities and activities can contrib- ute to overcoming age segregation and stereotypes about “typical activities” for older people. In order to facilitate such activities, however, spaces and loca- tions where people of different generations can inter- act are required. Local authorities can help to foster such intergenerational spaces by promoting the use of typically age-segregated spaces by other groups. For instance, local communities have established senior clubs and activities in schools, libraries and district centres, or have located after-school centres, residen- tial care centres or public housing with older people closer together. Such approaches do not need new buildings but rather aim at more efficient use of existing infrastructure. Another example aiming at more efficient use of resources is to use school buses during school hours to transport older people. Meeting places can also be fostered in NGO or private settings with public support. Open (drop-in) meeting spaces or centres in neigh- bourhoods that are organized by local NGOs or com- munities can play an important role in promoting social integration and providing space for activities organized by private/volunteer activities. These may include bot- tom-up events such as courses, workshops or meet- ings. Courses and activities may rely on the provision of special equipment, such as for sports or educational activities or libraries: this is an area where local author- ities are often enabling partners of bottom-up move- ments. The range of equipment for rent or booking could include games, computers and other workshop equipment. Another example comes from Israel, where older peo- ple are supported by ESHEL – the Association for the Planning and Development of Services for the Aged – to live in apartments, which are large enough to act as meeting places, in exchange for regular gatherings of a group of older people – so-called “warm homes” (Berg- Warman & Chekhmir, 2006). Lifelong learning Activities of lifelong learning provide continuing options for personal development in older age and for learning in an intergenerational context. Opportunities for lifelong learning offered by local com- munities include training, seminars, lectures, confer- ences and “universities of the third age”. Senior acad- emies and universities of the third age are among the most widely implemented measures at the local level across the WHO European Region. They can provide a wide range of benefits, including: • personal development of older people; • fostering social contact and preventing social isolation; • intergenerational exchange and mutual learning; • mental training and protective measures against a decline in brain capacity; • acquiring knowledge and skills that are essential for benefiting from innovation and the “silver economy”, such as ICT for ageing populations; • continual learning and improvement of basic skills, obtaining new qualifications and re-skilling or up-skilling for better employment chances, includ- ing self-employment and volunteer activities. A wide range of actions are undertaken in cities and communities. Austria, Luxemburg, Slovakia, Slovenia and the Scandinavian countries are reported to have the highest participation rates in lifelong learning activ- ities across the EU, with the lowest observed in the Baltic states (except Latvia), Hungry, Greece, Spain and Poland (EAEA, 2006; 2015). The disparities between countries, however, are large: the concept of lifelong learning barely exists in some countries, whereas in others it is well developed (Mercken, 2004). Some uni- versity of the third age initiatives have gained experi- ence and developed over many years, as in the exam- ple from Slovenia (Box 10). The European agenda for adult learning and the EU expert group on adult learning provide support for adult learning initiatives: experience from EU-wide initiatives may provide inspiration and guidance on activities that can be initiated (Box 11). Social participation 61 Box 10. The Slovenian Third Age University Since 1984, the Slovenian Third Age University has grown steadily. It offers learning, educational and social- izing opportunities and fosters social participation with retired people, older workers and those in the pre-re- tirement period as a target group, as well as professionals and volunteers. As of 2016, it comprised a national network of 52 universities in 51 localities with about 21 000 students, more than 1000 mentors and 1000 volunteers. Its practice has been widely researched, which resulted in the development of its own educational and organizational model. The Slovenian Third Age University aims to: • provide access to cultural events and education for personal growth, better employability and active citi- zenship of older adults; • provide integrated advice and guidance, as well as opportunities within a broad range of topics related to active and healthy ageing; • enable older people to mobilize interpersonal support (knowledge, skills, information and emotional support); • conduct and publish research of older adult education and learning; • train professionals as well as volunteers of all generations who want to be active in the field of older adult education; • raise awareness and conduct public campaigns about older people, old age and the role of older adult education. The scope of the network has grown steadily and now includes activities such as employment services for older adults. Source: Slovenian Third Age University (2017). Box 11. Experience from existing European Commission initiatives Each year, the European Association for the Education of Adults (EAEA) recognizes achievements in innovation and excellence in adult education. The EAEA Grundtvig Award highlights project results that produce new ideas, new partnerships, new methodologies and a new understanding how adults’ learning can be improved. In 2012 the specific topic of the award was projects that promote the active participation of older learners in society. Projects received included aspects of intergenerational learning and innovative partnerships. The winning Crosstalk project aimed to give seniors, schoolchildren, young people and migrants the skills and confidence to communicate effectively with local media, and thus to make an active contribution to their own communities. Parts of the project motivated young and old people, from different backgrounds, to come together and share stories. Furthermore, a media education course provided different generations with the desire, self-confidence and necessary expertise to become involved in local media production and to tell sto- ries about the games they played or play today. Participating seniors and children/young adults visited their favourite places, interviewed each other in turn and produced an audio guide, interactive maps and a manual with course materials. The project was designed and carried out by a team of nine European partners in seven countries, which included community media practitioners, adult education specialists and university researchers. Source: EAEA (2012). Age-friendly environments in Europe. A handbook of domains for policy action 62 While lifelong learning programmes are very popular among participants, there is little evidence of the benefits for people at specific risk of isolation. Participation tends to be influenced by social class, gen- der, ethnicity and previous years of education (NIACE, 2010). A positive link is evident between previous levels of education and socioeconomic class and likelihood to engage in further learning (Aldridge & Tuckett, 2007), and women are slightly more likely than men to par- ticipate (Jenkins & Mostafa, 2012). Although available participation surveys use different methodologies and definitions, there is some evidence that relatively more advantaged populations are more likely to be engaged in activities of lifelong learning – including at higher age groups – than more disadvantaged groups, pointing to the challenges in reaching out to the latter. Links between learning and health in older age have received increasing attention. The focus on the impact of learning interventions on health has been pursued by a number of studies, producing evidence that such a link exists. There remain gaps, however, in the evi- dence about causal pathways that transform participa- tion to health. In particular, there are issues of potential selection bias, as healthier older people are more likely to participate in lifelong learning activities (Desjardins, 2008). This also raises the question of potential barriers to participation, which the following section explores. Overcoming barriers to participation in lifelong learning among older people is crucial. Three main levels of barrier to lifelong learning interven- tions exist (Slowey, 2008). Attitudinal barriers: those with low confidence, resil- ience, self-esteem and other factors relating to mental health may question their ability to engage in learn- ing. Individuals might cite lack of interest and “I’m too old to learn” as a reason for non-participation (Moss & Arrowsmith, 2003; Aldridge & Tuckett, 2007). For some, the term “learner” has connotations of some kind of deficit or inadequacy and they can therefore have reduced expectations or capacity to learn. Any experience of discrimination across the life-course might have a negative impact on self-confidence and the social and cultural capital available to the individual (McNair, 2007: 61). Situational barriers: there is some evidence that those who are less mobile and living in rural areas are less likely to engage in learning (Department for Work and Pensions, 2004). The same may be the case for those with health issues or disabilities (Dench & Regan, 2000). Institutional barriers: these can arise from chal- lenges to commit to the cross-sectoral cooperation that should be inherent in governing initiatives of life- long learning for older people, which calls for own- ership and responsibility cutting across government departments and organizations. Besides health and social departments, the education sector can be cru- cial to success. Equity of access and broader reach can remain a challenge. Older people participating in adult learning activities often tend to be in relatively good health (Findsen & Carvalho, 2007), predominantly middle class, female and with previous higher levels of formal education. Given some evidence that older people in better health who are more socially active and integrated in their communities are more likely to engage in lifelong learning activities, reaching out for more balanced participation – including of those facing the barriers listed above – remains an important concern. Policy interventions and initiatives by action area and objective Table 4 follows the structure of this chapter’s proposed directions for interventions and objectives and adds examples from existing age-friendly strategies, action plans and case studies. Interventions and initiatives mentioned may be projects already implemented in local contexts or those designed for implementation in an age-friendly action plan. Social participation 63 Table 4. Practice examples for social participation from local age-friendly action plans and assessments Action area Objective Examples of policy interventions and initiatives Range of opportunities for social participation that are accessible for older people (cross-cutting with domain 7: communi- cation and information) Empowering older people to participate in activities and increasing awareness of existing activities • Conducting needs assessments and providing evidence-based offers and activities accordingly • Regular activity calendars including information on accessibility or special support available for people with impairments and limita- tions, with a special section on events targeted at older people • Mapping of existing activities and services and identifying gaps (including activities to promote physical activity and sports, dancing, cultural activities, educational offers, cognitive activities and training, performing arts, crafts, computer courses, spiritual activities) • Day and field trips for older people • Communication campaigns to increase awareness of existing activities • Funny and appealing communication tools that present evi- dence-based information on well-being effects of active lifestyles • Personal invitations to events sent to older people • Announcements of local and neighbourhood events not only online but also in local media and in accessible print formats • Encouraging participants to spread the word and bring friends and peers (cross-cutting with domain 5: social inclusion and non-dis- crimination, domain 6: civic engagement and employment and domain 7: communi- cation and information) Supporting exist- ing community assets and ser- vices from differ- ent stakeholders and NGOs, and making them accessible and appropriate for older people • Involving older people in planning and implementation of activities (e.g. physical activity leader training) • Supporting and maintaining infrastructure of NGOs’ and commu- nity-based initiatives • Facilitating formation and support initiatives of local groups – e.g. providing opportunities for informal education sharing experi- ences, feelings, learning, skills exchange and peer-to-peer sup- port (for instance, through goal setting and reporting back in next group meeting) Meeting poten- tially divergent needs sensitive to health and functional abil- ities, gender, age, ethnic background, education and income • Door-to-door transport services for interested participants with mobility limitations • Buddy system or volunteer services that offer the possibility of organizing an accompanying person (and reduced entry fees for such volunteers) • Supporting culture-specific activities and events led by ethnic and minority groups (cultural festivals, associations) • Volunteer befriending schemes to support “getting out and about” and accompanying to activities those at risk of isolation (especially in rural areas) (cross-cutting with domain 2: transporta- tion and mobility) Monitoring and supporting equi- table access and affordability • Providing activities and events free of charge • Analysis of participation in events (including analysis of barriers to participation among non-participating older people) • Concessions and senior cards that give free or preferential access to activities and institutions of culture, tourism and sport Age-friendly environments in Europe. A handbook of domains for policy action 64 Action area Objective Examples of policy interventions and initiatives Supportive environments for social exchange and places and providing opportunities for social contact in the community, neighbourhood Decentralization of activities • Coordinating a plan of well dispersed activities across cultural, social and recreational centres and private locations Creating local meeting places and support neighbourhood centres • Creating and supporting open (drop-in) meeting spaces/centres in neighbourhoods and communities that promote social integra- tion and provide space for bottom-up activities • Senior centres/houses to host a multitude of activities and volun- teer centres • Providing an equipment library (e.g. sports or educational equip- ment) for leisure activities in neighbourhood and community cen- tres that can be booked or rented, such as indoor bowls, table tennis, games, billiards, computers and workshops (cross-cutting with domain 3: housing) Using existing infrastructures more effectively by collocat- ing activities for older and younger people • Marketing of activities not only for older people but for everyone or as intergenerational activities (avoiding the image that they are only “for old people”) • Establishing senior clubs and activities in schools, libraries and district centres (such as handicrafts, chess, card games, knitting, sewing, cooking, IT and web 2.0) • Locating nurseries or after-school centres together with residen- tial and day centres for older people • Computer courses open for older people in schools and youth clubs • Using school buses during school hours for community transport of older people • Awards for clubs with the highest membership and participation in relation to population • Policy to allow flexibility in urban planning for uses for older peo- ple in public and private properties allowing for integrated and mixed uses in buildings designed for older people (e.g. places of worship and central places for older people) • Alzheimer’s/senior cafés Support day care and activity centres • Establishing daily activity centres, resource and active senior cen- tres in neighbourhoods in order to animate older people • Creation and support to senior clubs – providing “clubhouses” offering social and educational activities, health and psychosocial support and a variety of leisure-time facilities • Facilitation and encouragement of neighbourhood networks and regular neighbourhood meetings – for instance, incentives to use private houses for senior activities, clubs for older people etc. Creating oppor- tunities for social interaction attractive to older men • Opportunities to meet and share experience targeted and led by older men, e.g. “men’s sheds” programme • Allotments and community gardens Table 4 contd Social participation 65 Action area Objective Examples of policy interventions and initiatives Multilevel interventions Combining the promotion of physical activity with social and cognitive activity • Animating open group exercises (can be conducted by volunteer trainers professionally trained to adapt exercise programmes to specific needs of older people) • Involving people in disadvantaged districts in designing walking paths and tours in their own neighbourhoods • Facilitating formation of local groups of older people to meet reg- ularly to exercise brain training, games and other skills Multilevel inter- ventions tar- geting social isolation and loneliness • Group-based interventions, like community-based exercise pro- grammes, support and self-help groups • Individual interventions for homebound, isolated or frail older peo- ple, like visiting programmes and befriending schemes • Technological interventions such as hearing aids, telephone calls, web-based social media for older people, video call-based support Lifelong learning Promoting life- long learning in collaboration with educational institutions • Universities of the third age • Schools for all ages: involving older people in school activities, reading groups, field trips etc. • Promotion of informal learning in workshops for memory and cognitive training, life-story writing workshops and other local activity groups • Talks and workshops related to healthy living and physical activity • Capacity-building to train older volunteers as trainers Multisectoral collaborations Collaboration with institutions of arts and culture • Museum-organized workshops and activities in residential homes and neighbourhood centres • Accessible infrastructure and tours in museums, including tac- tile and audio-supported visits (e.g. information in braille, audio guides) • Special offers for accessible cultural events (opera, cinema and theatre) like senior subscriptions, free shows for members of pensioner associations, preferential rates etc. • Collaborating with libraries to provide mobile and decentralized services in neighbourhoods and in assisted living and residential homes and delivery of books at home • Libraries as meeting places for intergenerational reading groups, talks and lectures Collaboration with the private sector • Supporting age-friendly business community and ethics through communication structures of chambers of commerce • Offering accessible holidays and senior tourism Table 4 contd Resources and toolkits Age UK (2010). Loneliness and isolation: evi- dence review. London: Age UK (http://www. ageuk.org.uk/documents/en-gb/for-professionals/ ev idence_ rev i ew_ lone l i ness_and_ i so l a t i on . pdf?dtrk=true, accessed 2 October 2015). EAEA (2014). Engaging new learners in adult educa- tion: short guide for policy-makers and adult educa- tors. Brussels: European Association for the Education of Adults. European Commission (2011). Action plan on adult learning: achievements and results 2008–2010. Age-friendly environments in Europe. A handbook of domains for policy action 66 Brussels: European Commission (Commission Staff Working Paper SEC(2011)271 final; http://www.cede- fop.europa.eu/en/news-and-press/news/action-plan- adult-learning-achievements-and-results-2008-2010, accessed 6 June 2016). Findsen B, Formosa M (2011). Lifelong learning in later life: a handbook on older adult learning. Rotterdam: Sense Publishers. Health Quality Ontario (2008). Social isolation in com- munity-dwelling seniors: an evidence-based analysis. Ont Health Technol Assess Ser. 8(5):1–49. Joling K, Vasileiou K (2015). Promising approaches to reducing loneliness and isolation in later life. London: Age UK. Further reading Alma MA, Van der Mei SF, Groothoff JW, Suurmeijer TPBM (2012). Determinants of social participation of visually impaired older adults. Qual Life Res. 21(1):87–97. Berger S McAteer J, Schreier K, Kaldenberg J (2010). Occupational therapy interventions to improve leisure and social participation for older adults with low vision: a systematic review. Am J Occup Ther. 67(3):303–11. De Jong Gierveld J, van Tilburg T (2006). A 6-item scale for overall, emotional, and social loneliness: confirmatory tests on survey data. Res Aging. 28(5):582–98. Githens RP (2007). Older adults and e-learning: opportu- nities and barriers. Q Rev Distance Educ. 8(217):329–38. Nef T, Ganea RL, Müri RM, Mosimann UP (2013). Social networking sites and older users: a systematic review. Int Psychogeriatr. 25(7):1041–53. Withnall A (2008). Best practice approaches to policy and delivery of older people’s learning: a review of the literature. Warwick: University of Warwick.

Age-friendly environments in Europe. A handbook of domains for policy action 68 Domain 5: social inclusion and non-discrimination Social inclusion and non-discrimination 69 Introduction Everyone has a right to health, regardless of gender, age, disability, mental health, social position and eth- nicity. Nevertheless, social exclusion, isolation, harmful stereotypes, discrimination and abuse threaten healthy ageing and increase the equity gap in old age (WHO, 2015b). Social exclusion and isolation can put older people, and particularly the oldest of old age groups, women and minority groups, in vulnerable positions and may prevent them participating in society (WHO, 2007c). This chapter presents the fifth domain – social inclu- sion and non-discrimination – of the AFEE framework. This is the second of three domains that address the social dimension of age-friendly communities and cor- responds to the “respect and social inclusion” domain in the original WHO global guide (WHO, 2007a), which referred to different experiences of disrespect and exclusion among older people. Drawing on the grow- ing evidence base on social determinants of health, this chapter puts social inclusion in age-friendly cities in the context of the wider debate about equity in health (SEKN, 2008). People who are socially included have access to resources – economic, as well as social and personal – and make use of these opportunities. They can par- ticipate actively in society and family and are more resil- ient in the face of environmental stress and ill health. In contrast, socially excluded or marginalized individ- uals or groups experience (often multiple) disadvan- tages that can both limit this access to the social, cul- tural, economic, political and environmental resources required for health and lower their quality of life (Scharf, Phillipson & Smith, 2005a). Related concepts relevant to inclusive age-friendly environments are social cap- ital, social networks, intergenerational relations and actions to improve these for older people: these will be discussed in the following sections. From consultations with age-friendly cities it has become clear that it is particularly challenging for local actors to reach out to those older people who are most in need and at risk of disadvantage or social isolation. Compared to the WHO global guide, the AFEE project has therefore broadened this domain to include issues of health equity and social exclusion that researchers and practitioners have identified as important in recent years. A key feature of the WHO global guide (2007a) was a focus on developing an age-friendly approach from a citywide perspective. Research since the mid-2000s, however, has focused at least as much on the role of individual neighbourhoods (De Donder et al., 2013) and this chapter addresses these findings. Strategic directions for policy interventions The goal of interventions in this domain is to create environments that are socially inclusive places, where all people – regardless of age, gender, social position, health or disability – are respected and have opportunities to participate and contribute. To enhance equity, it is crucial to complement population-based interventions with targeted efforts, reaching out to people most at risk of poor health and exclusion, understanding their specific needs and promoting their health and quality of life. Domain 5: social inclusion and non-discrimination Age-friendly environments in Europe. A handbook of domains for policy action 70 Negative health outcomes are correlated with social exclusion, adverse life events and isolation at all levels of health (WHO Regional Office for Europe, 2013b). WHO defines social exclusion and vulnerability as “dynamic, multi-dimensional processes driven by unequal power relationships across four dimensions” (SEKN, 2008:2). Box 12 describes the four dimensions of exclusion – economic, political, social and cultural – defined by the Social Exclusion Knowledge Network (SEKN) and adds a new fifth dimension of environ- ment. These create a continuum of inclusion/exclu- sion characterized by unjust distribution of resources and unequal access to capabilities and rights, result- ing in health inequities. Box 12. Forms of social exclusion in later life 1. The social dimension is constituted by proximal relationships of support and solidarity (e.g. friendship, kinship, family, neighbourhood, community … social movements) that generate a sense of belonging within social systems. Along this dimension social bonds are strengthened or weakened (see the following sec- tions on social capital and neighbourhood cohesion and on intergenerational spaces and activities). 2. The political dimension is constituted by power dynamics in relationships which generate unequal pat- terns of both formal rights embedded in legislation, constitutions, policies and practices and the conditions in which rights are exercised – including access to safe water, sanitation, shelter, transport, power and services such as health care, education and social protection. Along this dimension, there is an unequal distribution of opportunities to participate in public life, to express desires and interests, to have interests taken into account and to have access to services (see also the chapter on domain 6: civic engagement and employment). 3. The cultural dimension is constituted by the extent to which diverse values, norms and ways of living are accepted and respected. At one point along this dimension diversity is accepted in all its richness and at the other there are situations of stigma and discrimination (see the following section on respect and non-discrimination). 4. The economic dimension is constituted by access to and distribution of material resources necessary to sustain life (e.g. income, employment, housing, land, working conditions, livelihoods, etc.) (see the follow- ing section on combating social exclusion). 5. The environmental dimension is constituted by the perception of inclusive and supportive environments. Described as “neighbourhood exclusion” in the literature, it relates to the bond between people and their surrounding environment and the feeling of being able to influence changes affecting the community (see the following section on combating social exclusion and the chapter on domain 1: outdoor environments). Sources: 1–4: SEKN (2008); 5: adapted from Scharf, Phillipson & Smith (2005b). The consequences of social exclusion can be severe and contribute to wide gaps in morbidity and mortal- ity – such as from cancer and cardiovascular disease – emergencies, hospital admissions and re-admissions and mental health consequences (such as depression) among older people (WHO Regional Office for Europe, 2013b). The pathways between social exclusion and health consequences can be direct – for instance, through inequalities in access to health and care sys- tems – or indirect, through social exclusion processes. These can even stem from experiences early in life, such as poor nutrition, working conditions or similar, creating a vicious circle (WHO Regional Office for Europe, 2010). Poverty or economic exclusion is only one (albeit a central) element of social exclusion. The risk of older people in Europe facing poverty is influenced by exist- ing social services and social protection. In some countries of the EU older people are at higher risk of poverty and deprivation than the rest of the general population. In contrast, in some countries older peo- ple face lower poverty and social exclusion rates com- pared to other age groups. In most countries women face a greater risk of poverty and severe material deprivation than men; this gap is far greater for the generation aged over 65 years than for younger peo- ple (Eurostat, 2015d). Social inclusion and non-discrimination 71 Social isolation and exclusion in older age are often linked to processes of exclusion throughout the life- course, such as disadvantages and structural inequal- ities experienced in early life and during working age. Policies in cities often address “excluded” groups, but a better understanding of the dynamic processes that lead to inequalities and the potential agency of mar- ginalized people can inform more sustainable policies. These focus on addressing the generative processes embedded in social relationships and on supporting genuine and full participation of those most margin- alized by identifying challenges, developing interven- tions and transforming relationships (SEKN, 2008). Research in these areas still has many gaps, however: older people and populations who are vulnerable to multiple disadvantages have been underrepresented in much of the literature (Levitas et al., 2007). Research on implementation and evaluation of corresponding age-friendly interventions is only now emerging. The following sections synthesize some of the path- ways that have been explored in the literature, fol- lowed by practice examples from cities aspiring to become more age-friendly. They bring together main approaches and initiatives that researchers, practi- tioners and age-friendly action plans have identified as relevant for tackling social exclusion, challenging negative stereotypes of older people and combating economic exclusion, as well as recognizing the var- ied needs of different groups within the ageing pop- ulation, strengthening resilience in individuals and neighbourhoods and fostering intergenerational activi- ties and spaces. A table at the end of the chapter pro- vides practical examples that show how local govern- ments have operationalized areas for action into their action plans. Respect and non-discrimination About a quarter of older European citizens some- times or frequently experience discrimination because of their age (van den Heuvel & van Santvoort, 2011). Large differences between countries, however, show that ageism is not inevitable but rather amenable to cultural, political and social contexts and interventions (Eurostat, 2015d). Ageism is “stereotyping and discrimination against individuals or groups on the basis of their age; ageism can take many forms, including prejudicial attitudes, discriminatory practices, or institutional policies and practices that perpetuate stereotypical beliefs”. WHO (2015b: 226) Ageism and stereotypes can cause barriers for older people to accessing services and to realizing their full potential; they can even lead to violations of human rights, neglect of care needs or maltreatment. Discrimination in the form of ageism obscures the understanding of ageing processes and shapes pat- terns of behaviour in both older people and society at large, which have a negative influence on healthy and active ageing (WHO, 2015b). Key facts • Some evidence exists that urban environments may place older people at a heightened risk of isolation and loneliness (Scharf & De Jong Gierveld, 2008). • The social situation of older people varies widely between countries. According to Eurostat, the statistical office of the EU, in 2013 the risk of people aged 65 years and over living in poverty or social exclusion ranged from 6.1% in the Netherlands to 57.6% in Bulgaria. Older women and the highest age bracket cohorts tend to face substantially higher risks in some countries (Eurostat, 2015d). • Social exclusion in rural areas and deprived inner cities poses specific challenges (Scharf & Bartlam, 2008). • Social cohesion and social capital among neighbours can result in higher degrees of social organization, including instrumental support to neighbours, contributing to higher levels of well-being in older people (Cramm, van Dijk & Nieboer, 2013). • WHO estimated in 2011 that 4 million older people in the European Region have experienced physical abuse; 29 million mental abuse; and 6 million financial abuse. The prevalence of elder abuse in the WHO European Region is high (3%) and levels among people with disabilities, cognitive impairment and depen- dence can be as high as 25% (Sethi et al., 2011). Age-friendly environments in Europe. A handbook of domains for policy action 72 Ageism is common, widely accepted and largely over- looked (Abrams et al., 2011). Consequences of ageism include negative impacts on the sense of self and mental health of older people, age segregation, cardiovascular stress, early institutionalization, loss of autonomy and the most devastating: elder maltreatment (WHO, 2015b). Promoting more positive images of older people and ageing is one of the most frequently used strategies by local authorities to promote respect and combat ageism. It is a crucial task for age-friendly environments to dispel the myths of ageing and the negative views of older peo- ple (Ritsatakis, 2008). Older people are a great resource for local communities and neighbourhoods and are also very diverse. It is important to increase awareness of the diversity of older people, and to value their rich expe- rience and the contributions they make to society in general (WHO, 2015b). Social marketing and promoting the role of the municipality in setting good examples for combating age discrimination and stereotypes of ageing are critical. Negative stereotypes are not necessarily a conscious or deliberate exclusion of older people but can simply be a product of how people categorize other people. Discrimination on the basis of age is often subtle and can arise from well intended yet patronizing expressions or lack of awareness. Data from the European Social Survey revealed that older people (over 70 years of age) in participating countries were least likely to be perceived as compe- tent, among other characteristics, and were viewed as having the lowest social status compared to other age groups. The survey also showed that people aged over 70 years were more likely to be viewed with pity than other age groups, but were also almost equally likely to be viewed with admiration (Abrams et al., 2011). The English Longitudinal Study of Ageing found that specific sociodemographic characteristics such as older age, lower household wealth, higher education and being retired or not working were associated with perceived age discrimination in older age (Rippon et al., 2014). To combat ageism, other stigmas that can exist alongside it have to be addressed, such as the stigmas of dementia or incontinence, which can affect different age groups (WHO, 2015b). Conventions and charters adopted at the international and national levels promote the principles of equity and protect the rights of citizens. The Second United Nations World Assembly on Ageing recognized the special needs of older people, which led, among others, to the Toronto Declaration on the Global Prevention of Elder Abuse (WHO, 2002c). In 2010 the United Nations General Assembly estab- lished an open-ended working group on strengthen- ing protection of the human rights of older people, comprising all Member States of the United Nations. This group identified existing gaps in protecting the rights of older people, which sparked an ongoing dis- cussion on the development of an international legal instrument to promote and protect the rights and dignity of older people. Against this backdrop, other regional and local charters and frameworks have been developed and can serve as an inspiration for local actors. A public health approach and evidence-based interventions are needed to prevent and effectively respond to elder abuse, neglect and fraud affecting older people. A number of local authorities have developed tool- kits for elder abuse awareness training and mentor- ship programmes. For example, the BC Centre for Elder Advocacy and Support developed a three-year project with the aim of helping local communities to create volunteer-driven programmes for older peo- ple, enabling seniors to reach out to other seniors about elder abuse (BC Centre for Elder Advocacy and Support, 2012). A lack of high-quality evaluation studies limits the available evidence on effectiveness of interventions to prevent elder abuse, but some promising programmes exist both at the population level and targeted at vic- tims and potential perpetrators. Approaches for inter- ventions include those designed to reduce risk factors for maltreatment by changing attitudes towards older people, those that improve support for and mental health of caregivers and those that strengthen social support (Sethi et al., 2011; WHO, 2016a). Wherever possible, programmes and interventions should be carefully monitored and evaluated and the findings shared between local governments. Social inclusion and non-discrimination 73 Enabling skills, experience and knowledge exchange – including from the older generation to the younger – can contribute to intergenerational solidarity. While many interventions for age-friendly environ- ments benefit younger and older population groups at the same time, different generations and different groups within the older population face contrasting issues. It has been argued that the rapid increase in older populations, and increased efforts to accom- modate needs of older people, might stoke issues of age bias and generational justice (North & Fiske, 2013). One study also found that pressures associ- ated with gentrification exacerbate divisions between age groups (Lager, van Hoven & Meijering, 2012). Moreover, age-friendly environments cannot be made responsive to the needs of older people to the detri- ment of other groups. Contact between different age groups can reduce prejudice, and older people who have positive contact with young people can improve self-worth and are more likely to be buffered from the negative effects of stereotypes against their group (Christian et al., 2014). To create inclusive and sus- tainable environments, the needs of different genera- tions within local contexts have to be recognized and a better exchange between the different social groups needs to be facilitated. Combating social exclusion New and concerted efforts are needed to combat economic exclusion and promote health equity for age-friendly environments. Age-friendly environments require a response to the highly unequal contexts experienced by older people in their local environments. For instance, older people who live in areas of concerted poverty can experience a wide set of interlocking disadvantages. Partnerships need to be engaged to tackle cycles of exclusion, supported by local authority efforts to understand the spatial dimensions of healthy ageing and actively sup- port empowerment of older people and carers, as well as mobilizing different forms of welfare provision. Prevention of poverty of older people is crucial, as financial security is a major determinant of functional ability, health and well-being. Exclusion from material resources and very low incomes can limit the lives of older people and cre- ate barriers to healthy ageing. Economic exclu- sion is closely linked to other forms of exclusion that concern social relationships, civic participa- tion, services and health care (Scharf, Phillipson & Smith, 2005b). Research has shown that poverty (particularly where combined with ill health or dis- ability) hampers older people’s participation in com- munity activities (Barrett & McGoldrick, 2013). Living in poor housing is one possible indicator of material deprivation and has an important impact on health and well-being of older people (see the chapter on domain 3: housing). Monitoring of people’s health and social needs has been proposed in order to broaden assessments of economic exclusion. Health needs are often lacking from calculations of minimum income. To address this gap, a mini- mum income for healthy living proposes to take into account the means necessary for a healthy diet and the costs of physical activity (Morris et al., 2000, WHO Regional Office for Europe, 2012b). It also proposes to take account of social norms and expectations by counting costs related to social integration and sup- port networks, such as those for telephone, television and presents (Hartfree, Hirsch & Sutton, 2013). Monitoring and understanding inequalities within and across neighbourhoods helps policy- makers target action at groups of older people most in need of supportive environments. Older people in deprived areas may be particularly at risk of social exclusion in several dimensions (Day, 2008). Fair society, healthy lives: the Marmot Review highlighted the fact that 45% of those living in the most deprived areas of England had either some or a severe lack of support; this compared with 35% in the least deprived areas (Marmot Review Team, 2010). Evidence is growing that exclusion tends to be spatially concentrated in localities such as disad- vantaged inner-city areas (EUROCITIES, 2009). These inequalities need to be monitored and resources made available to avoid worse environ- mental impacts on older people in socioeconom- ically deprived areas (Day, 2008; Smith, 2009). Moreover, evidence shows that neighbourhoods’ access to transport can be linked to social exclu- sion. Interventions and policies to improve access and public transport to certain neighbourhoods (see the chapter on domain 2: transportation and mobility) can therefore be highly relevant for addressing social exclusion (Lucas, 2012). This is especially the case for rural or remote areas (Box 13). Age-friendly environments in Europe. A handbook of domains for policy action 74 Fast social and economic changes in the neighbour- hood, however, or negative experiences both in and beyond the home can be turning points that can under- mine the confidence of older people in their neighbour- hoods (Scharf, Phillipson & Smith, 2005a). These find- ings reflect the attachments older people have to their neighbourhoods but can also be linked to a feeling of inability to influence the type of changes affecting their communities (Smith, 2009) – relating to the environ- mental dimension of social exclusion. Urbanization and social change can create additional environmental pressures, resulting in fast turnover of residents, changes in housing prices and closure of amenities and local services; these may affect older people in particular. Again, there is evidence of an overlap between socially excluded people and socially excluded places (Forrest, 2004). Older people may often have lived in a neighbourhood for many years – as revealed in different studies in west- ern Europe – and develop attachments to it. Pathways to neighbourhood exclusion can hence be viewed in relation to individuals’ life-courses. Older people who have lived in their communities for many years are especially sensitive to the perceived deterioration of their local environment or of other social change more generally, such as gentrification or other change of the social composition in their neighbourhood. These can manifest in slowly emerging negative perceptions of the neighbourhood. Research to understand the effects of social change in the neighbourhood, experiences of inclusion and exclusion and the needs of older people ageing in dis- advantaged communities is only in its infancy, however. More needs to be done to understand the complex dynamics between exclusion, ageing, participation and health. Neighbourhood exclusion can not only affect those peo- ple that grow older in deprived areas but also be a con- sequence of income inequalities within neighbourhoods. A Dutch study showed that discrepancies between indi- vidual income and neighbourhood status matter: low-in- come older adults who lived in high-status neighbour- hoods had poorer physical functioning and were more lonely than low-income adults who lived in low-status neighbourhoods (Deeg & Thomése, 2005). Targeted action for individuals in vulnerable situations Strategies need to be developed and targeted at different groups within the older population (Buffel, Phillipson & Scharf, 2013). To tackle social exclusion, local authorities have to find out which groups of older people are at increased risk of social exclusion in their communities. Understanding their specific needs and assets, as well as increased community participation in finding solutions, have been suggested as approaches to tackle this issue. Policies can support and stimulate the process of local negotiation between the interests Box 13. Healthy ageing and social exclusion in rural areas An empirical study conducted in 10 rural communities in the Republic of Ireland and Northern Ireland helped to shed light on rural social exclusion. From in-depth interviews and focus groups with community stakeholders and older people, five intersecting dimensions were identified that characterize social exclusion in old age in rural areas: • social connections and social resources; • services; • transport and mobility; • safety, security and crime; • income and financial resources. The community itself can also act as a source of exclusion; this can be amplified through austerity-related cuts in spending, reduced services and demographic pressure, which are challenges of age-friendliness. Exclusion can be mediated by individual capacities (sense of agency and independence), however, and informal support and service provision in the community can partially counterbalance the lack of formal services by drawing on close links and cooperation between all possible actors. Sources: Walsh, O’Shea & Scharf (2012); Walsh et al. (2014). Social inclusion and non-discrimination 75 of representatives from different groups in the popula- tion. A mediating role might also be needed to ensure that the voices of those with limited opportunities or less experience in speaking up are heard, and their agency promoted. Vulnerable groups in communities include those experiencing some degree of frailty and those experiencing issues of mental health. Frailty develops as a consequence of cumulative phys- iological decline over the life-course and manifests itself as age-related greatly increased vulnerability to endogenous and exogenous stressors that expose an individual to a higher risk of negative health-related outcomes” (WHO 2015b; see also Glossary). Frailty is a practical concept that diverts attention from hav- ing one specific disease to a more person-centred assessment of a holistic state of vulnerability. Although correlated with age, frailty can be a useful indicator to assess older people’s risks and vulnera- bilities (Duarte, Paul & Martin, 2013). Frailty increases the risk of adverse outcomes such as falls, worsen- ing mobility, disability, hospitalization and death (Fried et al., 2001). Many community-dwelling older people have some symptoms of frailty; about 1 in 10 people aged over 70 years and 1 in 4 people aged over 85 years experience a noticeable degree of frailty, includ- ing all five indicators of unintentional weight loss, self-reported exhaustion, low energy expenditure, slow gait speed and weak grip strength (Clegg et al., 2013). Several approaches to reduce frailty have been investigated in clinical trials, among which are com- plex interventions based on comprehensive geriatric assessment delivered to older people in the commu- nity, including home-based and group-based exercise programmes. Such interventions can increase the likelihood of continuing to live at home and reduce falls (see Introduction for a broader discussion on measures of falls prevention). Age-friendly communities face the challenge of understanding dementia and raising public awareness to foster social inclusion for people living with dementia and their caregivers. Between 70% and 90% of people living with dementia live in their own homes in the community, mostly receiv- ing care from a female family member/caregiver (WHO, 2012b). As people living with dementia often feel safest in the close surrounding of their home, a major area of work has emerged across Europe around “dementia-friendly neighbourhoods”. The body of literature emerging on this topic is very dynamic and can provide more specific guidance for community efforts. WHO has launched a global dementia observatory to provide an entry-point for further information exchange (WHO, 2015d). Building community social capital and inclusive com- munity institutions and capacity can be important points of synergy where age-friendly communities can ensure that people with dementia are not excluded. Dementia- friendly communities can also benefit, however, from the broader approach of age-friendly communities to ensure they receive the benefit of actions for the larger age- ing population and value the contribution every citizen makes, including combating stereotypes about dementia (Box 14). This includes the need to consult people living with dementia in order not to exclude them from giving their opinions and to enable them to continue to con- tribute towards society. Gatherings of people living with dementia and their families and friends at an Alzheimer’s café are an example of action that can contribute to destigmatization through community engagement. Dementia-friendly communities are “communities that show high levels of public awareness of dementia and are able to offer support and understanding to people living with it, as well as their caregivers. These communities are ultimately more inclusive to people living with dementia and help them to preserve independence and control in their lives.” Haggarty et al. (2013: 3) Key dimensions for making a difference to people with dementia are the physical environment, local facilities (see domains 1–3), support services (see domain 8), social networks and local groups (see domain 4) (Crampton, Dean & Eley, 2012). Many types of intervention that pro- mote dementia-friendly communities, however, so far lack systematic evaluation (Keady et al., 2012). Migration greatly affects how people age and is still poorly understood, in both the ways ethnic diversity of older people creates different needs and the geographical patterns of migration of different age groups and their effects on the demography of age-friendly environments. Ethnic and cultural diversity in ageing populations are important issues for many urban areas in the European Region and there is scope for better reflecting on the different experiences of ethnic and cultural groups among older migrants. Older people (from a range of Age-friendly environments in Europe. A handbook of domains for policy action 76 ethnic groups) may experience migration in different ways (Phillipson, 2015): • as first-generation migrants growing old in their second homeland (Burholt, 2004); • as migrants moving “back and forth” between fam- ilies living across different continents (Lager, van Hoven & Meijering, 2012; Victor, Martin & Zubair, 2012); • as a group left behind, coping with the loss of younger generations (Vullnetari & King, 2008); • as people involved with the management of trans- national caregiving (Baldassar, 2007); • as “return migrants” moving back to their first homeland (Percival, 2013). Migration patterns of different age groups can result in specific local patterns and challenges of social exclusion. Some geographical areas see specific migration pat- terns of people. For example, there are specific chal- lenges in rural areas where young people have moved away, resulting in higher concentrations of older peo- ple. On the other hand, a number of older people, as they approach retirement age, move out of cities into smaller attractive communities for retirement, creating so-called “naturally occurring retirement communi- ties”. Some of those older migrants might risk social exclusion and social support gaps when they become frail or more vulnerable (Hall & Hardill, 2014). Remaining older populations tend to be poorer and risk social exclusion. Migration of older people also occurs from the country and suburbs into the city. When children have left home and family homes and gardens become too big and tiresome to maintain, older people may be attracted to move into city cen- tres with easier access to various services, where they are more independent without using a car and closer to family and amenities. Again, the influences on an older person’s desire to age in place or to move are not yet well understood (Smith, 2009); nor is how this influences those older people staying behind in cer- tain suburbs or smaller towns. Diversity among older people, including gender differences, shapes opportunities for healthy ageing that need to be better understood. Encouraging socially inclusive approaches to urban space needs to take account of the different experi- ences of men and women and different ethnic groups – migrant and non-migrant. Gender dimensions bring to light differences in needs and opportunities for healthy ageing, as well as differences in use and experiences of local spaces. For instance, being a caregiver for both the young and the old generations is traditionally a woman’s role; this places women throughout the life-course at greater risk of economic exclusion (see the chapter on domain 8: community and health services). Box 14. Dementia-friendly communities combat stereotypes about dementia Cities and communities can have an important role in combating stereotypes, myths and negative views associated with dementia. They can help with raising awareness and understanding of dementia among the general population in order to improve inclusion in the community of people living with dementia, making them feel more fully part of the community. In Scotland, United Kingdom, for example, Alzheimer Scotland orga- nizes Dementia Awareness Week each year to work towards reducing stigma and raising awareness of this condition. Information on dementia needs to be targeted to address the involvement and concerns of the entire commu- nity, including health professionals, caregivers, families and the general public. This increasingly includes cus- tomer service training, offered to service providers and businesses in the community such as banks, libraries and shops. Employees are trained to recognize symptoms of dementia and to be respectful and responsive to people living with dementia. In Bruges, Belgium, for example, the symbol of a knotted handkerchief is displayed in the windows of local businesses to indicate to those with dementia that they will receive empathic reception. In the United Kingdom specific guidance has been assembled to strengthen the role of local councils in making areas better places to live for people with dementia. Sources: Alzheimer’s Society (2013); Alzheimer Scotland (2014); Alzheimer’s Disease International (2013); Local Government Association (2015). Social inclusion and non-discrimination 77 Despite changing gender roles and greater participation in the workforce, the gap in financial security between women and men persists into old age. Finding sustain- able models of care that do not increase the pressure on women and put them at risk of social exclusion is therefore an important policy challenge. Moreover, urban space can create social barriers to participation that differ for men and women. This can be illustrated by research on migrants from different ethnic groups living in Brussels and Manchester, which highlighted that older women developed strategies of navigating space on the basis of their perceptions of safety or danger (Buffel & Phillipson, 2011; De Donder et al., 2012). Older women’s fears in public space were based primarily on feelings of vulnerability to unknown men, “strangers” or groups of youths who were per- ceived as “intimidating”. Victor, Martin & Zubair (2012), in a study of south Asian communities in the south- east of England, suggested that the gendered use of space could place women at greater risk of isolation in middle and later life. Qualitative interviews with differ- ent migrant groups in England and Brussels also noted differences between men and women in terms of the use of public space (Buffel, Phillipson & Scharf, 2013). For example, older migrant men tended to have more informal gatherings with friends outdoors than migrant women. Some research is emerging on the different needs and experiences of ageing in lesbian, gay, bisexual and transgender older adults (McCann et al., 2013) but the topic remains underexplored. A qualitative study in Manchester focused on older people (aged 50 years and over) in the lesbian, gay and bisexual communities, highlighting areas in the city centre where people had experienced homophobic hate crimes. More positively, respondents also noted areas and venues (such as arts and cultural centres) that were more accepting of dif- ferent lifestyles and identities (LGBT Foundation, 2015). Social capital and neighbourhood cohesion Social capital has an important role to play in support- ing age-friendly environments, as well as in the preven- tion and mitigation of the detrimental effects of social exclusion. A common theme in the literature is social cohesion, which considers the extent to which com- munities with strong norms of trust and reciprocity pro- mote increased levels of social participation; this leads to a higher quality of life and improved mental and physical well-being (Rocco & Suhrcke, 2012). It is important for policy-makers to take into account not only the socioeconomic characteristics of individuals but also the contexts of their everyday lives and the strength of community ties. A WHO review of mental health, resilience and inequali- ties reported that high levels of social capital can buffer some of the effects of stress or adversity (Friedli, 2009). At the same time, deprivation and inequalities erode the resources needed for good mental health and social relations. Being socially excluded and isolated can be a continuation of longstanding difficult relationships with other people or a consequence of particular life events, onset of chronic ill health or age-related losses (such as becoming a widow or loss of close friends). A study from Rotterdam found that although single and poorer older people reported lower levels of well-be- ing than those who were better off and married, this was mediated by neighbourhood characteristics, with community services, social capital and social cohe- sion acting as a buffer against the adverse effects of poverty and limited social ties. Good social relation- ships and engagement in community life are neces- sary for positive mental health (Cramm, van Dijk & Nieboer, 2013). Efforts to reach out to excluded and isolated individuals need to be carefully coordinated between different social actors and services and can benefit from evaluation. Involuntary exclusion from social relations and loneli- ness can have a major impact on people’s quality of life. Significant life events such as the loss of a part- ner and other forms of bereavement can increase the risk of becoming socially excluded. Bereavement has also been shown to be an important risk factor for depression among older people living in the commu- nity. Social isolation often comes with other forms of disadvantage, generating multiple exclusions. Many local initiatives or voluntary programmes try to reach out to older individuals who are at risk of social exclusion or isolation (see the example of initiatives under the Milan City Welfare plan, Box 15), but many age-friendly communities report difficulties in reaching disadvantaged and isolated older adults. Moreover, evidence is mixed on whether more targeted or Age-friendly environments in Europe. A handbook of domains for policy action 78 broader population-based initiatives are more apt at addressing social exclusions and loneliness (Cattan et al., 2005; Dickens et al., 2011). Interventions for age- friendly communities can create added value if they monitor carefully the effect on societies and vulnera- ble and isolated individuals, paying special attention to not widen the equity gap. Intergenerational spaces and activities The original WHO global guide (2007a) promoted intergenerational interactions as a key dimension of promoting inclusion. This was more recently sup- ported by Lager, van Hoven and Huigan (2015: 95), who concluded that it is important for older adults to develop “bridging social capital” with younger genera- tions in order to “secure continuity of social and instru- mental support” (see also Gray, 2009). Furthermore, recent research has extended this theme, examin- ing intergenerational dimensions relating to spatial aspects of inclusion or exclusion and patterns of age segregation. Holland et al. (2007: 39), in an observational study of an English urban town, conclude that “a striking finding is the extent to which older people involved in this study as interviewees or through observa- tion, either perceived themselves as excluded or actively excluded themselves from public space for large stretches of the time”. Lager, van Hoven and Huigan’s (2015) qualitative research of social contact between different age groups, set in a neighbourhood in the northern Netherlands, observed that trusting relationships between older and younger people in neighbourhoods are not easily established, at least in part because of the different time geographies of both groups, with younger residents out at work. In Czechia, Temelová and Slezáková (2014) noted the potential for conflict between young and old in relation to the use of public space in housing estates. The research raises issues of how to create an urban environment that acknowledges the equal rights of older people with other age and social groups to a “share” of urban space. This is especially important to implement at a local level, with a particular focus on improving the quality of urban design and promot- ing safety and inclusion as key features of urban living (Gehl, 2010; Mehta, 2014). New models are needed that counteract age segregation. Vanderbeck and Worth (2015: 4) suggest that “pat- terns of age segregation have been both produced and reinforced by approaches to urban and regional planning that have contributed to the production of spaces – such as city centres – that can prove rela- tively inaccessible and unwelcoming to people at par- ticular life stages”. Puhakka et al. (2015) examined issues relating to the age-friendliness of living environments by examining spatial usage and place attachment in Lahti, Finland. Drawing on quantitative datasets covering children and adults, the research examined how and where older and younger people spent their leisure time and the importance of different kinds of urban locations for them. A major conclusion from the study was that Box 15. Combating loneliness and reaching out to those people most at risk in Milan, Italy As part of the Milan City Welfare plan, a 2012 initiative developed actions aimed at combating loneliness and improving services for older people. This built on the existing Hot weather plan, a service whose goal was to monitor and provide assistance during the summer to those older people identified to be a high-risk group. By connecting services and interventions and developing a neighbourhood culture, a coordinated and con- tinuous programme was created. In particular, this included a model to create local, neighbourhood-based safeguards capable of monitoring the most vulnerable citizens on a daily basis. The model also contributes to building supportive communities, having at its root the idea that social connectedness acts as social protec- tion. It now includes a large number of places for socializing and connecting to existing activities, thus allowing NGOs and individual citizens to enjoy places to foster relationships or through social projects. By 2012, more than 40 NGOs were involved in the initiative. Source: Belfast Healthy Cities (2014). Social inclusion and non-discrimination 79 “the lives of children, young and older people have been largely segregated and urban places directed for certain age groups” (Puhakka et al., 2015: 78). Examples of such age-segregated environments range from playgrounds, houses, bars and clubs to concert halls – these are all often highly age-segre- gated, even though they could belong to all genera- tions. Even virtual spaces tend to be tailored to spe- cific age groups. Policy interventions and initiatives by action area and objective Table 5 follows the structure of this chapter’s proposed directions for interventions and objectives and adds examples from existing age-friendly strategies, action plans and case studies. Interventions and initiatives mentioned may be projects already implemented in local contexts or those designed for implementation in an age-friendly action plan. Table 5. Practice examples for social inclusion and non-discrimination from local age-friendly action plans and assessments Action area Objective Examples of policy interventions and initiatives Respect and non-discrimination (cross-cutting with domain 7: communica- tion and information) Combating ageism • Awareness and education campaigns challenging the representation of ageing in the public, media, local busi- nesses and in communications and publications from local government and service providers • Identifying and combating age discrimination of service providers, media and employers • Intersectoral collaboration to develop a charter of rights of older people and quality standards in long-term care • An international conference to combat ageism Promoting a positive image of ageing and increasing awareness of ageing issues • Striving for positive representation of older people and activities in the media • Promoting positive role models • Putting ageing issues on the political agenda • Promoting awareness among the business community, agencies and service providers about access barriers older people face and how they can be overcome (e.g. age-friendly assessment of all services) Strengthening pre- vention of elder abuse, neglect and fraud • Creating awareness of different forms of elder abuse (awareness day) • Education and capacity-building programmes, including an elder abuse manual and a fraud awareness toolkit • Installation of a post of elder abuse officer • Collaboration with the police force to enforce persecu- tion of suspected perpetrators of elder abuse • Intersectoral collaboration to help victims • Educational programmes to inform older people of their rights and protect them from scams and exploitation (peer educators) • Strong quality control of home care providers (e.g. home health worker registry to include those terminated for reasons of abuse and fraud) Age-friendly environments in Europe. A handbook of domains for policy action 80 Action area Objective Examples of policy interventions and initiatives Enabling skills, expe- rience and knowledge exchange between generations • Enabling older members of the community to be speak- ers or trainers • Activities in different areas and fields led by older people either for peers or for all generations • Promoting intergenerational work teams Social exclusion (cross-cutting with domain 4: social par- ticipation, domain 6: civic engagement and employment and domain 8: community and health services) Preventing economic exclusion • Financial and social assistance for those in need (food aid, clothing aid, fuel subsidies, subsidized lunch, monthly financial aid etc.) • Monitoring and regulating the real estate market and housing subsidies • Providing services and activities free of charge • Discount schemes • Case manager or volunteer support in filling in forms for financial and social assistance Focus on equity between and within neighbourhoods • Neighbourhood regeneration programmes • Assessment of inequalities and gaps in health across and within neighbourhoods • Linking community action with neighbourhood regen- eration projects (comprehensive rehabilitation plans of areas with specific problems) Preventing loneliness and isolation • Anti-solitude plan; strategy/action to prevent isolation • Adequate mental health care and counselling for coping with loss • Increasing social participation, particularly in districts with many people who live alone • Information about existing and development of new opportunities for volunteering Support for carers and families with dependent older people • Financial aid to families with dependent older people • Extending concessions and discount schemes to peo- ple accompanying functionally limited seniors • Providing possibilities for temporary and periodic accommodation of older people in existing residential care homes or day centres • Internet forums, newsletters and social media networks for trusted information and peer support • Banks for temporary loans of technical aid and equip- ment (wheelchairs, crutches, bed lifts etc.) • Volunteer temporary host families • Providing psychosocial counselling and support for carers • Capacity-building programmes and training • Administrative support for steps after the death of a partner Table 5 contd Social inclusion and non-discrimination 81 Action area Objective Examples of policy interventions and initiatives Targeted action for individuals in vulnerable situations Reaching out to excluded and isolated individuals • Installing a telephone hotline and referring to tailored services and social activities • Registries of frail or vulnerable people living alone (or those that have asked for volunteer visits or support) • Coordination of volunteer visiting networks and services • Regular telephone chains to those at risk of isolation • Financial support/calls for community-based projects to reduce the health impact of social isolation • Including isolated and or bed-bound older people in participatory processes and consultations (e.g. via tele- phone links) Social capital Strengthening com- munity ties • Neighbourhood networks • Small grants programmes to promote social inclusion • Systematic strategies to promote neighbourhood ties and social capital Encouraging inter- action between neighbours • Providing community facilities • Community-based initiatives to promote health and well-being • Neighbourhood festivals • Meeting rooms in neighbourhoods • Neighbourhood awareness and community alert initiatives Intergenerational spaces and activities (cross-cutting with domain 4: social participation) Increasing intergen- erational contact, understanding and exchange of values, skills and experiences • Intergenerational activities (most prominently computer courses and cooking courses) • Intergenerational tournaments – for instance, literature competition and prize for intergenerational relations unit- ing residents from residential homes and schools • Older community members invited as guest speakers in youth clubs • Intergenerational learning programmes empowering older people to access teaching and learning activities in third-level educational institutions • “Volunteer grandma” schemes • Mentoring programmes • Collaboration projects between schools, nurseries and residential homes Strengthening the role within families • Awards for families who adequately care for their older member Resources and toolkits BC Centre for Elder Advocacy and Support (2012). Starting a seniors reaching out to seniors workshop program: a toolkit for local agencies. Vancouver: BC Centre for Elder Advocacy and Support (http://bcceas. ca/starting-a-seniors-reaching-out-to-seniors-work- shop-program-a-toolkit-for-local-agencies/#sthash. sao7Z0Ea.dpuf, accessed 2 April 2016). Canadian Bankers Association (2016). Your money seniors [website]. Toronto: Canadian Bankers Association (http://yourmoney.cba.ca/seniors/, accessed 2 April 2016). Table 5 contd Age-friendly environments in Europe. A handbook of domains for policy action 82 Coalition to Strengthen the Rights of Older People (2010). Strengthening older people’s rights: towards a UN Convention – a resource for promoting dialogue on creating a new UN Convention on the Rights of Older Persons. Dublin: Centre for Ageing Research and Development in Ireland (http://www.cardi.ie/publications/ strengtheningolderpeople%E2%80%99sr ight- stowardsaunconvention, accessed 7 June 2016). Eastern Community Legal Centre (2013). Elder abuse toolkit for local governments working with older peo- ple. Australia: Eastern Community Legal Centre. EUROCITIES (2009). Social exclusion and inequal- ities in European cities: challenges and responses. Brussels: EUROCITIES (http://www.eurocities. eu/eurocities/publications/Social-exclusion-and- inequalities-in-European-cities-challenges-and- responses-WSPO-8PLF4M, accessed 2 October 2015). Khan S, Combaz E, McAslan FE (2015). Social exclusion: topic guide, revised edition. Birmingham: GSDRC, University of Birmingham. UK International Longevity Centre (2011). Intergenerational projects for the LGBT community: a toolkit to inspire and inform. London: International Longevity Centre. WHO (2002). The Toronto Declaration on the Global Prevention of Elder Abuse. Geneva: World Health Organization (http://www.who.int/ageing/publica- tions/toronto_declaration/en/, accessed 2 October 2015). Further reading Age Friendly Edmonton (2013). Annotated bibliog- raphy on ageism and respect & inclusion of older adults. Edmonton: Respect and Inclusion Working Group, Age Friendly Edmonton. (http://www.edmon- ton.ca/city_government/documents/PDF/AF-_ RespectAndInclusionAnnotatedBibliographyFinal.pdf, accessed 2 October 2015). Age UK (2010). Loneliness and isolation: evi- dence review. London: Age UK (http://www. ageuk.org.uk/documents/en-gb/for-professionals/ ev idence_ rev i ew_ lone l i ness_and_ i so l a t i on . pdf?dtrk=true, accessed 2 October 2015). Hoff A (2008). Tackling poverty and social exclu- sion of older people – lessons from Europe. Oxford: Oxford University Institute of Ageing (Working Paper 308; http://www.ageing.ox.ac.uk/files/Working%20 Paper%20308.pdf, accessed 2 October 2015). McGarry P (2015). Local government, ageing and social inclusion: past, present and future. J Poverty Soc Justice. 23(1):71–6. National Resource Center on LGBT Aging (2015). Age-friendly inclusive services: a practical guide to creating welcoming LGBT organizations. New York: National Resource Center on LGBT Aging (http://www. lgbtagingcenter.org/resources/resource.cfm?r=708, accessed 2 October 2015). Powell J, Chiu T, Eysenbach G (2008). A systematic review of networked technologies supporting carers of people with dementia. J Telemed Telecare. 14:154–6. WHO (2012). Risks to mental health: an overview of vulnerabilities and risk factors. Background paper by WHO Secretariat for the development of a compre- hensive mental health action plan. Geneva: World Health Organization (http://www.who.int/men- tal_health/mhgap/consultation_global_mh_action_ plan_2013_2020/en/, accessed 2 October 2015). WHO (2016). Interventions for carers of people with dementia. In: WHO mental health programme [web- site] (http://www.who.int/mental_health/mhgap/evi- dence/dementia/q9/en/, accessed 7 June 2016). WHO Regional Office for Europe (2010). Poverty and social exclusion in the WHO European Region: health systems respond. Copenhagen: WHO Regional Office for Europe (http://www.euro.who.int/en/ publications/abstracts/poverty-and-social-exclu- sion-in-the-who-european-region-health-systems-re- spond-2010, accessed 2 October 2015).

Age-friendly environments in Europe. A handbook of domains for policy action 84 Domain 6: civic engagement and employment Civic engagement and employment 85 Introduction Staying actively engaged as a personal choice beyond economic necessity has been shown to have a number of benefits for physical and mental health and well-be- ing (von Bonsdorff & Rantanen, 2011; Cattan, Hogg & Hardill, 2011; Anderson et al., 2014). It is also critical for the future sustainability of social trends in ageing societies. Volunteering supports different aspects of older peo- ple’s lives, such as leisure activities (culture/sports), social and health care services, political engagement, involvement in education/tutoring and other aspects of community life. In some cases where volunteering has a strong tradition, the engagement of volunteers has become more formalized. For example, in the Nordic countries recruiting volunteers has in some instances become part of the planning process for local services, such as for nursing homes. This chapter on civic engagement and employment presents the third of three domains of the AFEE frame- work that address the social dimension of age-friendly communities. This domain corresponds to the “civic participation and employment” domain in the original WHO global guide (WHO, 2007a). It also has links to topics under other domains, such as public support for informal caregiving (see the chapter on domain 8: com- munity and health services) and training and lifelong learning (see the chapter on domain 4: social inclusion and non-discrimination). Strategic directions for policy interventions The goal of interventions in this domain is to make better use of the potential of ageing societ- ies by creating more and better opportunities for older people to engage in political, economic and public life and to increase employment, social engagement and volunteering opportunities for older people. Large differences exist between European countries in their cultures and traditions of engagement in volun- teering activities at various ages. Differences are also wide in employment rates for people aged 50 years and over and in other aspects of civic engagement, such as engagement in politics and local governance. Both are topics monitored by the Active Ageing Index (UNECE & European Commission, 2015). “Civic engagement means working to make a difference in the civic life of our communities and developing the combination of knowledge, skills, values and motivation to make that difference. It means promoting the quality of life in a community, through both political and non-political processes.” Ehrlich (2000: vi) Compared to countries with the highest commitment to continuing active engagement, both as volunteers and in paid work or political activities, many countries have a large untapped potential for more civic participation Domain 6: civic engagement and employment Age-friendly environments in Europe. A handbook of domains for policy action 86 and employment for people aged 50 years and over (Zaidi et al., 2013). In some parts of Europe older people lead active work- ing lives as long as they can – many of them in agri- culture – in order to contribute to the economy of their families or for their own subsistence (European Commission, 2013a). This is illustrated by relatively high labour force participation of higher age groups in coun- tries like Cyprus, Estonia, Portugal and Romania. Self- employed people may lack adequate retirement income or have traditional roles in agriculture. When they live in rural or remote communities, they may face additional challenges of access to services that help them to stay healthy and allow them to continue their working lives (Hatfield, 2015). For them, community actions to sup- port them can be crucial but may frequently be lacking. The following sections review the role of local authori- ties and of age-friendly initiatives to foster civic engage- ment and employment of older people. Because these initiatives and relative actions are central to both local government and the macroeconomic concerns of age- ing societies, many have been studied extensively in European projects and research. A table at the end of the chapter provides practical examples that show how local governments have operationalized corresponding areas for action into their action plans. Engagement in political life and decision- making Political participation of older people and their influence on local government activity has been growing in Europe over the past few decades. The level of older people’s influence on political decision-making at the local and regional levels on issues that are of concern for age- friendly environments differs widely, however. There are also variations between urban centres and rural or remote places, or the “hinterland” of larger metropolitan areas. Political participation of older people can take various forms (Sidorenko, 2012): • direct involvement and participation; • indirect involvement by selecting representatives among groups and associations; • political involvement by elected representatives; • information-based involvement by sharing informa- tion (for example, gathered via participatory research); • virtual involvement via social networks. Organizations of older people have taken on more formal roles over time. Seniors’ organizations have become more influential over time as a result. These include both civil society organizations and official senior councils, whose roles may be regulated by national or subnational law. Besides this, many older people may choose to stay politically active in organizations not specifically designated as being for older people. For example, many choose to continue membership of a trade union after their retire- ment, for which they can be valuable supporters, such as by donating their time as volunteers (FERPA, 2015). Senior councils aim to empower citizens to have a voice and take an active role in decision- making. In line with the trends stated above, many local author- ities have changed political structures in order to insti- tutionalize older people’s voices and advisory roles. Key facts • In the EU around 9% of the population aged 55 years and over reported providing unpaid voluntary activ- ities through organizations such as community and social services or cultural and sports associations at least once a week. This ranges from 1.2% to 20.6% between European countries (UNECE & European Commission, 2015). • In 2014, around 17% of the population aged 55 years and over in the EU participated in the activities of a trade union, a political party or political action group, with a range between 5.3% and 43.8%. The propor- tions were 20.5% for men and 14.6% for women (UNECE & European Commission, 2015). • Employment rates in the EU in the age range 55–64 years increased from 46% in 2010 to 52% in 2014 (Teichgraber, 2015). • The proportion of inactive population aged 50–64 years in selected United Nations Economic Commission for Europe (UNECE) countries ranges from around 15% to over 60% (UNECE, 2012). • Engagement in formal volunteering activities is more prevalent in early older age groups, particularly among women and people with higher educational attainment (Archibald, 2014). Civic engagement and employment 87 One or several commissions or councils are in many instances in place that involve older people in all rel- evant policy-making at the local level. Elected senior councils often hold such executive power, with an offi- cial mandate to be consulted on any decisions that concern the lives of older people by the local authority. In this role they are champions of the rights of older people. For larger regional entities, these may be replicated at various local government levels – for example, in the form of either a city council or neighbourhood councils that involve older people both individually but also as repre- sentatives of NGOs and senior associations. In addition, special interdisciplinary working groups on specific tasks related to age-friendly environments usually involve older people to jointly plan, lead and implement actions, such as those on a neighbourhood scale. Beside their advisory function, senior councils com- mand their own resources to varying degrees; this allows them to undertake a range of activities, such as organization of participatory events; leadership work- shops looking at challenges and developing solutions for specific community issues; and community forums to influence planning and prioritization of interventions. Many communities have developed new forms of participatory mechanisms. As well as senior councils, which have overall coordi- nating and leadership roles, groups of older people in a number of other stakeholder alliances can influence policy development and implementation of age-friendly environments either directly or indirectly. This can include special tasks for pilot testing interventions, with community involvement in steering groups as a form of participatory evaluation. Other participatory forums that involve a broader public are roundtables, panels and public discussions to present findings from assess- ments and enable participation in future planning. Various forums involve older people in the definition of problems and actions needed. Focus groups and community forums play an import- ant role in participatory age-friendly assessments of neighbourhood and community environments, as well as needs assessments to identify gaps in ser- vices or local policies for older people, for example. Traditionally, this has been in the form of public infor- mation and consultations. Participatory qualitative and quantitative research for community diagnosis is a rel- atively new form of involving older people, their families and other stakeholders in community planning, moni- toring and assessment. This can take the form of inter- views, street audits, questionnaires or surveys (AFE- INNOVNET, 2015b). Economic life and employment In many European countries the workforce is ageing quickly. This is the case not only for EU countries but also for Commonwealth of Independent States coun- tries outside the EU (Sidorenko & Zaidi, 2013). This trend is driven by different factors: • demographic change, with an increase in the median age of those of working age (traditionally defined as those aged between 20 and 65 years); • changes in pension policy, with higher mandatory or effective retirement ages; • the economic necessity for many pensioners to complement their retirement income with paid employment; • the wish of many older people in middle- or high-in- come countries to stay active, including as a way of staying socially connected (WHO, 2007a). Beyond the economic incentives, staying active in paid employment can help older people to stay connected, play an active role in their communities and continue to contribute in different ways. WHO’s World report on ageing and health (WHO, 2015b) identified a number of factors that facilitate the ability of older people to stay active, with a focus on employment and pension policies (Box 16; see also OECD, 2006). Many of the policy measures listed in Box 16 require policy changes at the national level, but local authorities can contribute to increasing the opportunities for older people to remain active in employment in various ways. An example is employment programmes for older peo- ple in Israel (Shnoor, 2011). Local governments usually play an important role as one of the largest employers in their communities; they are therefore well placed to adopt sound age management in their role as employers. Moreover, perhaps more than for other domains, advancing the social goals of domain 6 calls for cross-sectoral engagement across community departments and reaching out to other stakeholders, including private initiatives and the busi- ness sector. Collections of case studies illustrate the important role of initiatives to promote the health of an ageing workforce that have been implemented by local Age-friendly environments in Europe. A handbook of domains for policy action 88 authorities at various government levels (Meggeneder & Boukal, 2005). Local authorities thus have an import- ant role in creating flexible work arrangements, retrain- ing older workers or investing in improved occupational health measures relevant to older people. At an organizational level a number of benefits of including older workers have been identified. For example, older employees can be important for passing on “institutional memory” in an organization: their networks, knowledge and experience are important capital. Retaining them can result in lower costs for hiring and training new staff, who may also have a higher turnover than older employees (Federal/Provincial/Territorial Ministers Responsible for Seniors, 2012). In order to reap these benefits, however, a number of misconceptions or outdated views have to be addressed, such as those that older workers are less productive or that investing in their continuous training is not cost-effective and is more difficult to achieve than for other employees (WHO, 2015b). Strategies for age management help to create better employment options for older workers and more opportunities for an age-diverse workforce. Legal changes to enable people to stay in employ- ment despite reaching retirement age usually concern changes in national legislation (WHO, 2015b: Chapter 6). Local authorities have increasingly become important actors in this field, however. Beside their role as employ- ers, local authorities can contribute by developing initia- tives that assist employers in planning support for older workers with the goal to remain in work as long as they wish. Communities can foster age management in a num- ber of ways (Morschhäuser & Sochert, 2006), for which numerous tools have been developed. For example, the ESF-Age Network (2015) provides a variety of tools of this nature, including practice examples of age man- agement from EU countries and regions. Local authorities can also play a role in developing guidelines for age-friendly workplaces and promoting their use. Such guidelines have explored a number of options, including: • making use of intergenerational work teams; • vocational training or reorientation programmes that support people aged 50 years and over to get back into work and to work according to their abilities, including those with chronic health conditions; • more flexible arrangements and employment opportunities for older people (such as temporary and part-time work, working from home and tech- nological support). New business or entrepreneurial opportunities can be created in various ways. Communities and local authorities can provide special career guidance services and job search workshops for older people. These can be organized in partnership and cooperation with local employment agencies or in the form of cooperation with the private sector – for example, in the form of age-friendly trade fairs or busi- ness forums. Cities and communities can also support older peo- ple to stay active in employment by providing training courses for start-ups and guidance on self-employment to encourage continuation of professional activity after retirement. Examples including the creation of specific small job profiles for older people and opportunities for Box 16. What works in facilitating older people’s ability to stay active in employment Policies to facilitate older people’s ability to work and volunteer in ways that promote healthy ageing should: • challenge ageism and create inclusive work environments that embrace age diversity; • abolish mandatory retirement ages; • reform pension systems that incentivize early retirement or penalize a return to work; • support gradual retirement options and flexible work arrangements; • consider incentives that encourage employers to retain, train, hire, protect and reward older workers; • help older adults plan for the second half of life and invest in lifelong learning; • invest in health and functioning by improving occupational health interventions for older workers. Source: adapted from WHO (2015b: Chapter 6). Civic engagement and employment 89 professional development and training (such as grand- parent babysitters, companions, home helps and infor- mation officers). Engagement in public life: co-creation and volunteering A number of older people in EU countries are engaged in voluntary work: proportions range from over 40% to under 10%, including both formal and informal engagement. Volunteering is most prevalent in coun- tries including Austria, the Netherlands, Sweden and the United Kingdom and least so in some southern and eastern EU countries. Evidence from some countries shows that the role of public administrations and NGOs has become more important in actively promoting and supporting volunteering engagement, complementing other more informal types of civil engagement and vol- unteering (Observatory for Sociopolitical Developments in Europe, 2011). Those who have engaged in volun- teering before retirement are more likely also to become engaged in later life. “Volunteering is unremunerated work that older people do for people outside their own household and for the wider community.” WHO (2015b:189) The balance of evidence suggests that there is a link between engaging in volunteering and positive health benefits (Heaven et al., 2013; Jenkinson et al., 2013; Archibald, 2014). The physical and intellectual activi- ties associated with volunteering exercise a protective function against functional decline in older age (WHO, 2015b: 189). Moreover, evidence is growing that the volunteering movement among older people benefits from sound organization and representation in associations (such as pensioners’ or seniors’ associations and local clubs for older people). These can provide crucial support and be important partners in negotiations with other stakeholders, such as providers of formal services. Involving older people in the design and delivery of services that affect their lives is an important part of co-creation/co-production of age-friendly environments. Co-creation or co-production (terms that are often used synonymously (NDTI, 2009)) that involves older people in designing age-friendly environments has been high on the policy agendas of the 2011 European Year of Volunteering and the 2012 European Year for Active Ageing and Solidarity between Generations (Robertson, 2012; AFE-INNOVNET, 2015b; Council of the European Union, 2012). In a number of countries the role of volunteering is now formally recognized in law and regulations. Examples include social protec- tion of volunteers or the exemption from VAT of dona- tions supporting volunteering. Volunteering initiatives can reach beyond their tradi- tional roles and become more involved in monitoring the design and delivery of services (such as health and social services) by providing feedback – for exam- ple, in the form of complaints gathered from public meetings. New roles for volunteering include training and capacity-building, such as training for trainers to become leaders of activities and collaboration with universities of the third age (see also the chapter on domain 4: social participation). This can include flexi- ble activities and workshops where people can either learn or teach. To make co-production more sustain- able, community-driven non-profit initiatives with legal and administrative advice and supportive frameworks play an important role. Voluntary work has become an important way of promoting social inclusion of older people. National laws on volunteering have spread in recent years but vary widely in scope and con- tent (Observatory for Sociopolitical Developments in Europe, 2011). Such laws can regulate important aspects that protect volunteering; for example, obli- gations for social and health insurance. Traditionally, word of mouth and informal channels (rel- atives and friends) have been central to creating aware- ness of the opportunities and benefits of volunteering. A trend is being seen, however, in a number of countries and local authorities of putting more formal structures in place to provide information about volunteering and recruit volunteers. Formal structures support volunteer- ing by covering expenses and providing other recog- nition of efforts. In addition, they can provide essential services such as help with getting adequate insurance coverage for volunteers and providing training. Older people themselves usually manage these information platforms, which reach out to seniors. In some coun- tries, including Denmark and Sweden, the needs for volunteering are analysed and monitored in cooperation with public service providers that are also engaged in developing new forms of voluntary activities (see Box 17 for an example from the city of Horsens). Age-friendly environments in Europe. A handbook of domains for policy action 90 An increasing number of programmes in European countries are also organized or co-funded at the national level to support volunteering and to provide help with research and analysis (Observatory for Sociopolitical Developments in Europe, 2011). New forms of net- working and information technology support ways of volunteering such as time banks, online information platforms and volunteer job banks. The question of how best to design volunteering activities has recently been the subject of more systematic research at the local, national and European levels. An example is the “Let us be active!” project implemented in three Baltic countries (Box 18). Box 17. Actively recruiting volunteers in the city of Horsens, Denmark The Nordic countries have well developed voluntary sectors that engage in their communities in various roles. In the Danish city of Horsens, the social care sector has managed to build up an important infrastructure of volunteers. Since 2000, the Municipality of Horsens has had a volunteer policy that sets out goals and frame- works for cooperation with associations of volunteers. As of 2016, some 1000 volunteers were engaged in support of older people, many of them seniors themselves. Coordinated by the Horsens Healthy City Shop, volunteers are engaged in a range of activities. Examples include the following. • Volunteers support the work of activity centres for older people and of nursing homes – for example, by visiting seniors in nursing homes to join them at lunch time. • Volunteers act as “Hospital Friends” in cooperation with the biggest local association for senior citizens. • Other network groups support senior citizens with weak social networks and those at risk of experiencing loneliness. • Volunteers staff 14 ICT clubs for older people, offering ICT support for senior citizens. • A mentoring system has been set up in which older people help younger citizens who experience difficulties in the employment sector. Source: Horsens Healthy City (2016). Box 18. Let us be active! Social inclusion of older people through volunteering in three Baltic cities Initiatives under the project entitled “Let us be active! Social inclusion of older people through volunteering in Estonia, Latvia and Finland” promote social activity and inclusion among older adults, with the participation of seniors as volunteers. These address social exclusion and loneliness through volunteering opportunities in three Baltic cities: Pärnu (Estonia), Riga (Latvia) and Turku (Finland). Older people in each of the cities were invited by health care professionals and social workers and through other relevant organizations to participate in the project. It developed volunteer activities for older adults, applying a number of participatory approaches, including: • surveys and interviews of older people to find out how they could be involved in volunteering actions; • development of workshops and training courses with older adults and social workers; • consulting with relatives of older adults; • providing comprehensive information on existing volunteering activities by creating information and support systems for older adults. Examples are a call centre in Riga and online platforms in Pärnu and Turku. The volunteer activities were shared between cities to better develop support systems for older adults. Source: EU Central Baltic Programme (2014). Civic engagement and employment 91 Policy interventions and initiatives by action area and objective Table 6 follows the structure of this chapter’s proposed directions for interventions and objectives and adds Table 6. Practice examples for civic engagement and employment from local age-friendly action plans and assessments Action area Objective Examples of policy interventions and initiatives Engagement in political life and decision-making (cross-cutting with domain 4: social participation and domain 5: social inclusion and non-discrimination) Empowering citizens to have a voice and take an active role in local decision-making • Changing structures and institutionalizing older peo- ple’s voices and legal powers • Special interdisciplinary working groups (professionally facilitated) involving older people to jointly plan, lead and implement actions in neighbourhoods (such as a neighbourhood motor group) • Senior councils with executive powers to be consulted on any decisions that concern the lives of older people in the local authority • Involvement of older people and their representatives (NGOs and associations) in the city council or neigh- bourhood councils • Commissions/councils established as advisory and initiative bodies representing the interests of spe- cial groups in the local authorities (such as women, older people, children, young people or people with disabilities) Other forms of partici- patory mechanisms • Organization of participatory events: leadership work- shops looking at challenges and developing solutions; community forums to influence planning and prioritiza- tion of interventions • Roundtables, panels and public discussions to present findings from assessments and enable participation in planning • Pilot testing of interventions with community involve- ment in steering groups and participatory evaluation Consultation of older people in the definition of problems and actions needed • Participatory age-friendly assessments and needs assessments, e.g. via focus groups, community forums, participatory research (such as on-street conversations) • Qualitative research, needs assessments, community diagnosis, e.g. interviews, street audits, questionnaires and surveys • Public information and local consultations about plans and decisions and opportunities to get involved, oppose or comment for people who want to examples from existing age-friendly strategies, action plans and case studies. Interventions and initiatives mentioned may be projects already implemented in local contexts or those designed for implementation in an age-friendly action plan. Age-friendly environments in Europe. A handbook of domains for policy action 92 Action area Objective Examples of policy interventions and initiatives Economic life and employment (cross-cutting with domain 5: social inclusion and non-discrimination) Employers providing better opportunities for an age-diverse workforce • Initiatives to support local employers in planning sup- port for older workers to remain in work as long as they wish • Making use of intergenerational work teams • More flexible arrangements and employment opportu- nities for older people (temporary and part-time work; working from home; technological support) • Adult vocational training or reorientation programmes (support to people aged over 50 years to get back into work; working according to abilities) • Changing employment practice to enable people to stay in employment despite reaching retirement age • Development and use of guidelines for age-friendly workplaces Creating new busi- ness or entrepreneurial opportunities • Special career guidance services and job search work- shops for seniors in local employment agencies • Creation of specific small job profiles for older people and opportunities for professional development and training (grandparent babysitters, companions, home helps, information officers) • Provision of training courses for start-up and self-em- ployment to encourage continuation of professional activity after retirement • Age-friendly trade fairs/business forums Engagement in public life: co-creation and volunteering (cross-cutting with domain 4: social participation) Promoting co-creation: involving older people in the design and delivery of services that affect their lives • A protocol, charter or act on how to involve older peo- ple to be followed by agencies • Reviewing mechanisms of procurement, commission- ing and grants to enable asset-based practice and social enterprises guided by social impact • Involving older people in quality control and evaluation of services targeted at them • Improving feedback following complaints and after public meetings • Community grants for small projects with the aim of social integration of seniors • Opportunities for training and capacity-building, e.g. training for trainers to become leaders of activities, col- laboration with universities of the third age • Flexible activities and workshops where people can either learn or teach • Facilitating community-driven non-profit initiatives with legal and administrative advice and supportive frameworks • Involving senior advisors and older people as experts and in mentoring opportunities • Mutual reciprocal support among older people (“not a one-way street”) Table 6 contd Civic engagement and employment 93 Action area Objective Examples of policy interventions and initiatives Promoting social inclu- sion of older people though voluntary work • Creating awareness of the benefits of volunteering • Local volunteer bank and centre for support • Time banks • Increasing recognition of existing well functioning pro- grammes and volunteers (e.g. awards, compensations) • Information platforms to reach out to seniors (managed by older people themselves) • Online information platforms and volunteer job banks • Incentives for neighbourhood support and family support • Covering expenses and recognition of efforts Resources and toolkits AFE-INNOVNET (2015). Guidelines for co-producing age-friendly environments with older people. [web- site]. Brussels: Thematic Network on Innovation for Age-Friendly Environments (http://afeinnovnet.eu/ content/guidelines-co-producing-age-friendly-environ- ments-older-people, accessed 2 October 2015). Cedefop (2015). Increasing the value of age: guidance in employers’ age management strategies. Thessaloniki: European Centre for the Development of Vocational Training (Cedefop Research Paper no. 44; http://www.cedefop. europa.eu/en/publications-and-resources/publications/ 5544, accessed 8 June 2016). Ehlers A, Naegele G, Reichert M (2011). Volunteering by older people in the EU. Dublin: European Foundation for the Improvement of Living and Working Conditions (http://www.eurofound.europa.eu/publications/ report/2011/quality-of-life-social-policies/volunteer- ing-by-older-people-in-the-eu, accessed 8 June 2016). ENWHP (2015). ENWHP [website]. Leuven: European Network for Workplace Health Promotion (http://www. enwhp.org/ accessed 2 October 2015). ESF-Age Network (2015). ESF-Age Network [website]. The Hague: Ministry of Social Affairs and Employment (http://esfage.isfol.it/, accessed 2 October 2015). Eurofound (2012). Volunteering: a force for change – resource pack [website]. Dublin: European Foundation for the Improvement of Living and Working Conditions (http://www.eurofound.europa.eu/resourcepacks/vol- unteering, accessed 2 October 2015). Federal/Provincial/Territorial Ministers Responsible for Seniors (2012). Age-friendly workplaces: promot- ing older worker participation. Quebec: Government of Canada (http://www.seniors.gc.ca/eng/working/fptf/ promoting.shtml, accessed 8 June 2016). Harbers MM, Achterberg PW, editors (2012). Europeans of retirement age: chronic diseases and economic activ- ity. Bilthoven: Dutch National Institute for Public Health and the Environment (RIVM) (http://www.healthyageing. eu/news/rivm-report-europeans-retirement-age-chron- ic-diseases-and-economic-activity, accessed 8 June 2016). HelpAge International (2006). Guidebook for devel- oping and supporting older persons’ organizations. Chisinau: HelpAge International (http://www.helpage. org/resources/publications/?adv=0&ssearch=mol- dova&filter=f.yeard&type=&region=&topic=&lan- guage=&page=2, accessed 8 June 2016). Heslop M (2002). Participatory research with older peo- ple: a sourcebook. London: HelpAge International. INNOVAGE (2014). Guidelines on involving older people in social innovation development. Sheffield: INNOVAGE (http://www.age-platform.eu/age-work/age-poli- cy-work/health/age-work/2813-guidelines-for-involve- ment-of-older-people-in-social-innovation-develop- ment, accessed 8 June 2016). NAAS (2015). Civic engagement in an older America Project [website]. Washington DC: National Academy on an Aging Society (h t tp : / /www.ag ingsoc ie ty.o rg /ag ingsoc ie ty / civic%20engagement/about_civic_engagement.htm, accessed 2 October 2015). Table 6 contd Age-friendly environments in Europe. A handbook of domains for policy action 94 Naegele L, Thode E, Dhéret C (2013). Creating sec- ond career labour markets: towards more employment opportunities for older workers. Brussels: European Policy Centre (http://www.epc.eu/pub_details.php?- cat_id=1&pub_id=3278, accessed 8 June 2016). Robinson L (2005). CoCreate: a facilita- tor’s guide to collaborative planning. Victoria: Neighbourhood Environment Protection Program (http://www.enablingchange.com.au/ facilitation.php, accessed 8 June 2016). Further reading AARP (2012). Civic engagement among mid-life and older adults. Findings from the 2012 Survey on Civic Engagement. Washington DC: AARP (http://www.aarp. org/politics-society/advocacy/info-12-2012/civic-en- gagement-adults.html, accessed 8 June 2016). AGE Platform Europe (2011). Guide for civil dialogue on promoting older people’s social inclusion. Brussels: AGE Platform Europe (http://www.age-platform.eu/news- press/age-publications-and-other-resources/age-publi- cations, accessed 2 October 2015). AGE Platform Europe (2014). Guidelines on involving older people in social innovation development. Sheffield: INNOVAGE (http://www.age-platform.eu/age-work/ age-projects/social-innovation-and-research/1628-in- novage, accessed 8 June 2016). AGE UK (2009). Engaging with older peo- ple: evidence review. London: Age UK (http:// w w w. a g e u k . o r g . u k / p r o f e s s i o n a l - r e s o u r c - e s - h o m e / r e s e a r c h / r e p o r t s / c o m m u n i t i e s / archive/, accessed 8 June 2016). Buffel T, editor (2015). Researching age- friendly communities: stories from older peo- ple as co-investigators. Manchester: University of Manchester (https://extranet.who.int/ agefriendlyworld/researching-age-friendly-cities-sto- ries-from-older-people-as-co-investigators/, accessed 8 June 2016). Goth US, Småland E (2014). The role of civic engage- ment for men’s health and well-being in Norway: a con- tribution to public health. Int J Environ Res Public Health. 11(6):6375–87. Hank K, Erlinghagen M (2010). Dynamics of volunteering in older Europeans. Gerontologist. 50(2):170–8. Löffler E (2009). A future research agenda for co-pro- duction: overview paper. Swindon: Local Authorities Research Council Initiative. Mathies AL, editor (2006). Nordic civil society orga- nizations and the future of welfare states: a model for Europe? Copenhagen: Nordic Council of Ministers. Morrow-Howell N (2010). Volunteering in later life: research frontiers. J Gerontol B Psychol Sci Soc Sci. 65B(4): 461–9. doi:10.1093/geronb/gbq024. Pettigrew S, Jongenelis M, Newton RU, Warburton J, Jackson B (2015). Research protocol for a randomized controlled trial of the health effects of volunteering for seniors. Health Qual Life Outcomes. 13:74. Small M (2000). Understanding the older entrepreneur. London: International Longevity Centre (http://www. ilcuk.org.uk/index.php/publications/publication_details/ understanding_the_older_entrepreneur, accessed 8 June 2016). World Café Europe (2013). European Voices for Active Ageing (EVAA) [website]. Munich: World Café Europe (http://www.worldcafe.eu/ f ron tend / i ndex .php?page_ id=142&ses_ id= 83b81538b8feef5ba3a1aef5b247182f, accessed 8 June 2016).

Age-friendly environments in Europe. A handbook of domains for policy action 96 Domain 7: communication and information Communication and information 97 Introduction Activities to improve communication and information aimed at all groups of older people play a key role in closing the gaps in access to services, activities and events, and in reaching out to more vulnerable parts of the population. Domain 7 covers a diverse set of aspects of communication and information: issues of accessibility, technology and the contribution of infor- mation to preventing the risk of social exclusion, to name the most important. It recognizes that a reliable flow of information on community news, activities and opportunities that is adapted to the needs and prefer- ences of older people is vital – in particular for those liv- ing alone in the community and who may have reduced connections to formal or informal networks. Communication and information is the first of two domains of the AFEE framework that address the dimension of municipal services for age-friendly com- munities. Activities in this domain include many events organized by the third sector and supported by volun- teering, so it has strong interconnections with domain 6: civic engagement and employment. This domain corresponds to that of the same title in the original WHO global guide (WHO, 2007a). Community activities for healthy ageing are often attended by groups of relatively healthy older people – they tend to be part of social and family networks that help them to stay connected with community life and informed about the range of activities and services available for them, including their rights and how to access public services. Opportunities to access infor- mation are therefore not equally spread among older people. Among the topics addressed in this chapter, a focus is placed on initiatives that aim to bridge what has been called the “digital gap” (Mason, Sinclair & Berry, 2011) and to foster health literacy among older people, which is crucial for older people to make informed decisions and to manage their health (IROHLA, 2015a; 2015b). Both topics are related: the transfer of health resources and health care by electronic means (eHealth) and health information from the Internet are specific aspects for health literacy of older people (CDC, 2009). Strategic directions for policy interventions The goal of interventions in this domain is to assist older adults in accessing timely, reliable, relevant and understandable information about their com- munity, ways of engagement, available services and health topics through word of mouth, general press or the use of information technology. To reach these goals, age-friendly action plans identify special groups of older people at risk of exclusion from information that can be important for them. Among these are people who live with a limited network of family or friends, who are homebound or who are living with dementia. Different interventions and information channels are needed to address these different needs. For example, information provided by formal or infor- mal caregivers can help people living with dementia remember scheduled activities and events and main- tain their active participation in the community. The right information can have a protective function and contribute to a feeling of being safe and connected. Domain 7: communication and information Age-friendly environments in Europe. A handbook of domains for policy action 98 Tailored information can also protect older people from abuse, such as financial abuse. Seniors’ NGOs play a key role in many cases, reaching out and talking directly to older people in the commu- nity who would not easily be reached by other means of communication. This is the case both for relatively wealthy communities and for resource-constrained settings. Modern information technology is seen as a promis- ing way to help older people to stay connected and provide them a range of support, including when they are living with reduced mobility. Access to technology is currently very uneven, however, including basic access to the Internet. Rates of Internet use are relatively low for the highest age groups. This fact and the special challenges posed by the spread of the Internet as gen- eral portal for accessing services – such as eGovern- ment systems – are discussed in this chapter. Communication and information are indispensable for staying socially connected. It is vital for accessing ser- vices covered under other domains, such as domain 2: transport and mobility. This domain also has links to training and lifelong learning (see the chapter on domain 4: social inclusion and non-discrimination), which contribute to helping older people adapt to new technologies and ways of communication. The oppor- tunities and challenges for older people to access infor- mation and to benefit from advances in modern com- munication technology receive special attention. This is an area that is currently actively researched but many challenges remain, not least the issue of how to ensure that older people find health information on the web that is accurate and safe (Moore, 2005). Moreover, this domain has links to domain 8: commu- nity and health services, as those providing home help or other services, for example, can also act as sources of reliable information for older people. The same is the case for day care and other community centres for older people. The following sections describe the range of inter- ventions that communities have developed for better reaching out with information and communication to older people, families and other stakeholders in order to create more age-friendly environments. A table at the end of the chapter provides practical examples that show how local governments have operationalized areas for action into their action plans. Age-friendly information Examples of deficits of formats and design of informa- tion and communication that are not age-friendly are still widespread. Listening to older people, such as in the context of focus groups has helped to reveal them. Awareness is growing that communities and local authorities have an important role in ensuring that infor- mation about local activities and services reaches older people. This is increasingly seen as a cross-sectoral concern and has led to the development of communi- cation strategies tailored to the needs of older people. These include a broad range of communication media – such as free local newspapers for pensioners – but Key facts • Regular information events or “fairs” where older people can get involved and receive information about the broad spectrum of community activities available to them have in many cases become celebrations of healthy ageing (such as “senior days” or “positive ageing weeks”). • Health literacy – the ability to access and comprehend health-related information – is limited in every sec- ond older person (Sørensen et al., 2015). This presents a challenge for healthy ageing. • Internet use among those aged 55–74 years has been growing quickly over the last 10 years in most EU countries. Changes over time have favoured those with middle and higher education more than those with lower formal education in most countries (Eurostat, 2011; Rodrigues, Huber & Lamura, 2012). • There remain large differences between countries in Internet use among those aged 55–74 years, rang- ing from just over 5% in Turkey to over 70% in Iceland and Norway (Eurostat, 2011; Rodrigues, Huber & Lamura, 2012). • Regular Internet use is much lower among people aged 75 years and over compared to other age groups. Communication and information 99 also points of contact, where older people receive sup- port with information they need. This requires work across service providers and cooperation between public services, private providers and volunteering activities. Age-friendly information ensures quality and accessibility of information for older people. The use of more age-friendly formats is now sup- ported in a growing number of countries by national or subnational guidelines on accessible information to ensure quality and accessibility of information for older people. Among the common elements are clear, con- cise formats and use of easy language; large print ver- sions (for example, of forms, manuals and directories); and better legibility of LED signs and displays. Where communities use automated telephone information systems or call routing systems, it is worth testing their user-friendliness with older users, including in pilot schemes. Local authorities can make use of a variety of dissemination channels. Local authorities and communities have direct infor- mation channels that they can use to disseminate information that reaches out to older people and their families and friends. These include broadcasts on local television and radio; tailored information material produced as leaflets, brochures or maps; newsletters; poster campaigns; and message boards (for exam- ple, in libraries, churches, public meeting places and neighbourhoods). An accessible way of informing a broad public about age-friendly initiatives is the pub- lication of illustrative personal stories of older people (see, for example, Manchester City Council, 2016). More investment, however, may be needed in some cases to make existing municipal websites more accessible, both for structure and easy navigation and by making use of web content accessibility guidelines (W3C, 2008). Public events are important information sources for older people. Those communities with longer traditions of age- friendly initiatives often make use of senior weeks or days: these are given various titles, such as “posi- tive ageing weeks” or annual “festivals of the third age”. These events provide opportunities to share information between activities and initiatives, and to learn about and try out the broad range of existing and new activities and services available in the com- munity. Other publicly organized information sources include public lectures, seminars and discussions on gerontological topics or conferences on healthy age- ing issues. A clearing house for health- and ageing- related information For older people it can be challenging to access the information that is needed to stay healthy and active. When information is fragmented or inaccessible for older people they might miss existing opportunities to stay actively connected with the community and may simply not be aware of the range of publicly or privately available services and activities (such as volunteering). The Internet is increasingly the main hub for publicly available information: while this offers good opportuni- ties, it also creates a barrier for many older people who do not use the Internet. Many communities have responded to the needs of older people for comprehensive and reliable information by establishing single entry-point information services. Single entry-points for comprehensive information come in different forms, such as walk-in information centres and telephone hotlines linked to call centres. Such services provide a “one-stop shop” for older peo- ple to receive reliable core information and answers to frequently asked questions, together with guidance on how to access further information if needed. Comprehensive information refers to both publicly organized services and information and guidance on broader community activities, as well as opportunities for social participation and volunteering. Among core information frequently requested is: • information on health and social services; • information regarding (other) entitlements and rights of older people; • financial advice, including age-friendly banking services; • information on community life and activities. One-stop shops have, for example, been linked to senior day centres, in the form of information desks or rooms. In addition, 24-hour telephone services are available in many cases – a strategy that can be used for communities at all income levels (Box 19). Besides their information function, walk-in centres have been designed in ways that offer basic services, such Age-friendly environments in Europe. A handbook of domains for policy action 100 as initial sociomedical assessments (see the chapter on domain 8: community and health services). They can also provide help with intersectoral services, such as filling in administrative forms and service requests or accessing eGovernment services (see the section on addressing the digital gap below), by allowing assisted access to computers and online content. Information can also be provided on volunteering orga- nizations that can help with these issues or offer related support. One-stop shops can build up expertise over time on the range of information that older people need. Focus groups or other means of participatory research with older people as participants can help in evaluating and improving the quality of services rendered in this way. Improving health literacy Health literacy is one of the success factors for healthy ageing, enabling people to cope with the demands of different health situations and maintain quality of life. Understanding age-related changes in health, the role of good nutrition and sufficient physical activity can make a difference for health trajectories in older age (WHO, 2015b). Knowing how to communicate effec- tively with health and social care professionals is critical in order to navigate complex health and social systems. Health literacy levels vary greatly in the population; they are lower among older age groups (Swedish National Institute for Public Health, 2006; Zamora & Clingerman, 2011). This is a special concern in regard to geriatric patients, who often have only marginal health literacy levels, with risks for their health outcomes and cost of services (Cutilli, 2007). Older people with less edu- cation, lower incomes or poor mental and physical health can be at higher risk of marginal or inadequate health literacy. Those older people with poor health, who are therefore most in need of health literacy, have been found to have lower health literacy levels than other groups of older people (Oldfield & Dreher, 2010). Numerous national health promotion and disease pre- vention programmes therefore specify older people as special target group and aim at promoting and sup- porting implementation at all levels of government, including cities and communities (Box 20). Health literacy is “the degree to which an individual has the capacity to obtain, communicate, process and understand basic health-related information and services to make appropriate health decisions.” IROHLA (2015a: 5) Enhancing the competencies of health professionals and care providers is an important component towards achieving better health literacy. To address gaps in health literacy capacity and com- munication, training is required for health and social care staff to improve their knowledge and awareness of how to communicate better about health and age- ing topics with older clients. Special translation ser- vices for people from ethnic minority groups among health and social service users also become more urgent when people with migrant backgrounds enter higher age groups. Box 19. Silver Line helpline for older people in the United Kingdom The Silver Line is a free confidential helpline in the United Kingdom. It provides information, friendship and advice to older people and is open on a 24/7 basis throughout the year. The helpline disseminates information about services and activities that people can access in their communities. The Silver Line supports vulnerable older people, including those who want to remain anonymous. Information is offered on both services and community actions and projects. Callers can, however, also get help by addressing loneliness and isolation, and in situations of abuse and neglect. Moreover, the helpline can orga- nize regular friendship calls. Around two thirds of the calls are received at night and during weekends. The majority of callers live alone and say they have no one else to speak to. The Silver Line works with volunteers (around 3000 in 2016) that are trained to act as “telephone friends” (or “letter friends”). Source: The Silver Line (2017). Communication and information 101 Empowering older people, their families, social networks and communities by increasing general communication skills and knowledge of ageing and health-related issues can be effective. Better information and training for older people and their families is needed. Increasing general awareness of ageing-related health issues can be beneficial, in particular, to people with low health literacy and those suffering from multiple diseases (IROHLA, 2015b). Capacity-building to support self-management is important to increase health literacy in a broader sense (Findley, 2015). This is a central goal of many interventions organized for older people at the local level. These comprise lecture series and talks on health-related topics; workshops and skills training; training to use assistive technologies; and training to monitor information (from the use of step counters to the monitoring of blood pressure or blood sugar levels). eHealth refers to the use of information and communication technologies in support of health and health-related fields. mHealth is a subdomain within eHealth. It refers to the use of mobile and wireless technologies to support the achievement of health objectives. (WHO, 2015e) Older people may need support with eHealth literacy interventions in order to improve their health in new ways. eHealth literacy has been defined as the ability to seek, find, understand and appraise health information from electronic sources and apply the knowledge gained to addressing or solving a health problem (Norman & Skinnner, 2006). eHealth and mobile health (mHealth) provide new opportunities for older people to find health information over the Internet or the mobile phone and to engage in an exchange with others to communicate on health interests and challenges. Specific interven- tions may be needed to assist older people to access, find their way around and use new technologies to their full benefit (Watkins & Xie, 2014). Among those most in need of such interventions are older people in poorer households and other vulnerable older adults – in particular, those that are homebound (Choi & Dinitto, 2013). Addressing the digital gap Improving computer literacy and access to the Internet allows older people to access a range of information sources on healthy ageing in their communities. Among these are: • Internet portals and platforms on activities and sup- port services; Box 20. Local initiatives in Germany to implement the national action plan IN FORM In German, a national action plan for 2008–2020 is called “IN FORM: Germany’s initiative to promote healthy diets and increased physical activity”. It has led to the development of a range of information brochures on nutrition tailored to older people and disseminated in various ways, including over the website Fit im Alter [Fit in old age]. As well as guidelines to increase awareness and health literacy among older people and their families, quality standards and nutritional guidelines were developed and published for nursing homes and homes for older people, meals on wheels, hospitals and rehabilitation facilities. IN FORM is a joint initiative between the federal Ministry of Health and Ministry of Nutrition and Agriculture. It is implemented in close cooperation and coordination with federal states and local governments, including those of cities and communities, many of which use the nationally developed guidelines and brochures for local distribution, health education and promotion activities at the community level. For this purpose, guides for cities and communities have been developed on how to use and disseminate the national guidance in local initiatives with older people. Sources: German Association for Nutrition (2017); Federal Ministry of Food and Agriculture (2017). Age-friendly environments in Europe. A handbook of domains for policy action 102 • publications on “healthy ageing profiles” and healthy ageing observatories for cities, communities or regions; • access to age-friendly strategies and action plans; • online expert forums and consultations (such as “Ask your geriatrician”); • websites for family caregivers with information on available support and opportunities for an exchange with peers. Not all information available from these sources may be easily accessible, however, and its quality can vary. It is often posted without professional quality checks, such as those into whether information is adequate or safe, in particular in the case of online health communities. In order to address a digital gap among older people, information technology and computer courses can aim specifically at learning how to access information rele- vant to older people (and those in rural areas). These courses therefore need to be tailored to the diverse needs – for example, for those who want to use social media, communication technology (such as Skype) or email, or for those who want to find information online or search for employment. Publicly accessible computers with Internet access in libraries or senior centres support those without equipment and connections at home. In order to navigate eGovernment systems, some older people need special guidance and support. In societies where more and more information is dissem- inated electronically and the Internet has become a key gateway to the world, many older people are at risk of being left behind if they are computer illiterate. Among United Nations regions, the European has the highest development of eGovernment (UN DESA, 2012:29). Where eGovernment legislation aims at fully switching to electronic forms for communication with public adminis- tration, however, special attention needs to be paid to ensure that older people are not excluded. Social net- works and face-to-face contacts are among the means of support for older people to foster their adoption of eGovernment services (Righi, Sayago & Blat, 2011). Action at the community level is crucial to help older people both become computer literate and learn how to use modern technology for their own communica- tion, such as for staying connected with family and friends. Intergenerational activities where younger peo- ple help older people to overcome this barrier have become popular models in some cities; they are also popular in the context of more resource-constrained settings, such as in eastern European countries. Where electronic devices such as computers or tablets are still too costly for older people, community centres or clubs can be hubs to provide access. Computer literacy is, however, only one precondition to overcoming barriers of access to information. Finding one’s way around the Internet can be challenging for a number of other reasons. Webpages are too often not designed with older people in mind. Even where fol- lowing web standards of accessibility has become the norm, the way information is presented and the navi- gation between pages can still be confusing, and older people may still need help from families or volunteers to access and navigate online information. Policy interventions and initiatives by action area and objective Table 7 follows the structure of this chapter’s proposed directions for interventions and objectives and adds examples from existing age-friendly strategies, action plans and case studies. Interventions and initiatives mentioned may be projects already implemented in local contexts or those designed for implementation in an age-friendly action plan. Communication and information 103 Table 7. Practice examples for communication and information from local age-friendly action plans and assessments Action area Objective Examples of policy interventions and initiatives Age-friendly information (cross-cutting with domain 4: social participation and domain 5: social inclusion and non-discrimination) Increasing accessibility of information • Better information on activities and services, particularly in rural areas • Free local newspapers for pensioners • Making existing municipal websites age-friendly • Ensuring maintenance of face-to-face services and service counters • Senior citizens’ centres at the neighbourhood level (see the chapter on domain 4: social participation) • Working across service providers to agree on guide- lines for accessible information to ensure quality and accessibility of information for older people • Developing communication strategies and making sure that older people are not excluded through web-only services Ensure effective dissemination of information • Regular information broadcasts for older people on local television and radio • Tailored information material: leaflets, brochures and maps • Sections on healthy ageing in local newspapers • Newsletters, poster campaigns and message boards (in libraries, churches, public meeting places and neighbourhoods) • Avoiding automated telephone information systems or call routing systems, or testing their usability with older people • Encouraging word of mouth among older people • Regular information on home care and home service providers and general practitioners • Reliable information points for all issues concerning older people Age-friendly formats • Pilot testing of promotional materials with older people • Use of the web content accessibility guidelines of the World Wide Web Consortium (W3C) • Better readability of LED signs and displays • Clear, concise formats and use of easy language • Large print versions (e.g. of forms and manuals and directories) • “Browse aloud”: reading aloud services of web content and documents Age-friendly environments in Europe. A handbook of domains for policy action 104 Action area Objective Examples of policy interventions and initiatives Clearing house for health-related information (cross-cutting with domain 4: social participation and domain 5: social inclusion and non-discrimination) One-stop shops for information for older people, their families and carers • Creation of information centres: single entry-points for comprehensive information about ageing, matching of opportunities for social participation and volunteering, switchboard for local age-friendly services • Reception for first orientation and sociomedical assessments • Intersectoral special consultation services, including help with filling in forms and applications • Telephone hotline and call centre • Places to allow assisted access to computers and online content • Places of reflection and laboratories for ideas Capacity-building to support self-management • Lecture series and talks on health-related topics • Workshops and skills training • Assistive technologies and training to monitor informa- tion (e.g. step counters) • Articles and reports concerning older people’s health and well-being in local media • Information leaflets distributed through health and med- ical centres • Library and media/video library for ageing topics Providing the range of information that older people need • Information regarding entitlements and rights of older people • Financial advice, including age-friendly banking services • Information regarding community life and activities • Clear information on health and social services • Register of reliable and trusted services and age- friendly businesses Health literacy (cross-cutting with domain 4: social participation, domain 5: social inclu- sion and non-discrim- ination and domain 6: civic engagement and employment) Making sure that information provided reaches older people • Surveys of health literacy in the local population and analysis of barriers to access information • Simplified bureaucracy and administration procedures • Capacity-building and communication training for health care and service providers • Talk and translation services for ethical minority groups using health services • Training and campaigns to increase capacity to under- stand health-related information • Cross-agency coordination of information provision through a network of service providers to assist in con- tacting harder-to-reach older people • Training for trusted community and home care workers to give reliable information on support services Table 7 contd Communication and information 105 Action area Objective Examples of policy interventions and initiatives Public events Providing opportunities to learn about and try out existing and new activities and services • Senior weeks/positive ageing weeks • Public lectures, seminars and discussions on geronto- logical topics • Annual festival of the third age as an information-shar- ing platform for older people at the national level • Conferences on healthy ageing issues Digital gap (cross-cutting with domain 4: social participation, domain 5: social inclu- sion and non-discrim- ination and domain 6: civic engagement and employment) Providing websites /Internet platforms for older people • Centralized indicator and monitoring system: data- base and profile of healthy ageing/healthy ageing observatory • Making age-friendly strategies and plans accessible • Online expert forum and consultation (“Ask your geriatrician”) • Internet portal and platform on activities and support services • Website for carers: information, available support and forum to exchange with peers • Development of more user-friendly smart phone appli- cations to improve information and security of seniors (but with awareness that access is not universal) Decreasing the digital gap • Information technology and computer courses that aim specifically at accessing information relevant to older people (particularly those in rural areas) • Tailoring courses to diverse needs, e.g. for those who want to use social media, communication technology (such as Skype) or email, or for those who want to find information online or search for employment • Providing publicly accessible computers with Internet access (at libraries or senior centres) • Building digital connectivity in cities that can be used for good access to assistive technologies in the home Resources and toolkits Age UK (2013) Information and advice for older people: evidence review. London: Age UK (http://www.ageuk.org.uk/professional-re- sources-home/research/reports/communit ies/ archive/, accessed 9 June 2016). CARDI (2013). Online government – offline older peo- ple? A summary of e-government and older people in Ireland north and south. Dublin: Centre for Ageing Research and Development in Ireland (http://www. cardi.ie/publications/onlinegovernmentofflineolderpeo- plecardisummary, accessed 9 June 2016). Handler S (2014). A research and evaluation framework for age-friendly cities. Manchester: UK Urban Ageing Consortium. IROHLA (2015). 20 ways to improve health literacy in Europe [website]. Groningen: Intervention Research on Health Literacy among Ageing Population (http://www. irohla.eu/news/article/20-ways-to-improve-health-liter- acy-in-europe/, accessed 9 June 2016). Public Health Agency of Canada (2010). Age- Friendly communication: facts, tips and ideas. Ottawa: Public Health Agency of Canada (ht tp: / /www.phac-aspc.gc.ca/sen iors-a ines/ Table 7 contd Age-friendly environments in Europe. A handbook of domains for policy action 106 publications/public/various-varies/afcomm-commave- caines/index-eng.php, accessed 9 June 2016). W3C (2008). Web content accessibility guidelines (WCAG) 2.0 [website]. Cambridge MA: World Wide Web Consortium (http://www.w3.org/TR/WCAG20/, accessed 02 October 2015). Further reading Car J, Lang B, Colledge A, Ung C, Majeed A (2011). Interventions for enhancing consumers’ online health literacy. Cochrane Database Syst Rev. 6:CD007092. doi: 10.1002/14651858.CD007092.pub2. DG CONNECT (2010). Digitizing public services in Europe: putting ambition into action. Brussels: European Commission Directorate-General for Information Society and Media (https://www.capgem- ini.com/resources/2010-egovernment-benchmark, accessed 9 June 2016). Kobayashi LC, Wardle J, Wolf MS, von Wagner C (2014). Aging and functional health literacy: a system- atic review and meta-analysis. J Gerontol B Psychol Sci Soc Sci. 71(3):445–57. doi: 10.1093/geronb/gbu161. Manafo E, Wong S (2012). Health literacy programs for older adults: a systematic literature review. Health Educ Res. 27(6):947–60. doi: 10.1093/her/cys067. Tan CC, Cheng KK, Wang W (2015). Self-care man- agement programme for older adults with diabetes: an integrative literature review. Int J Nurs Pract. 21(Suppl 2_:115–24. doi: 10.1111/ijn.12388. Ubaldi B (2010). Denmark.: efficient e-government for smarter public service delivery. Paris: OECD Publishing (http://www.oecd.org/gov/digital-government/den- mark-efficiente-governmentforsmarterpublicservicede- livery.htm, accessed 9 June 2016). Virkar S, Dutton WH, Margetts H, Eynon R, Hicks T, Guimarães MTM (2007). Breaking barriers to

Age-friendly environments in Europe. A handbook of domains for policy action 108 e-government: overcoming obstacles to improv- ing European public services. Brussels: European Commission. Zickuhr K, Madden M (2012). Older adults and Internet use. Washington DC: Pew Research Centre (http:// www.pewinternet.org/2012/06/06/older-adults-and- internet-use/, accessed 9 June 2016). Domain 8: community and health services Community and health services 109 Introduction This chapter presents the eighth domain – community and health services – of the AFEE framework. This is the second of two domains that address the dimen- sion of municipal services for age-friendly communi- ties. Following the example of the original WHO global guide (WHO, 2007a), this domain brings together a broad range of services. Countries in Europe differ widely in the degree to which local authorities are responsible for financing, organizing and providing health and social services – services for which older people are often major, if not the main, users. To decide on the roles of com- munities and other local authorities in providing and improving health, social and community services, it is therefore essential to consider the division of labour and different responsibilities across levels or tiers of governments in Europe. This calls for strategies and action plans to be adapted to the situation of the community or region in question. In general, however, communities have an important role in empowering patients, older people in need of social support and their formal and informal caregivers, in a number of ways outlined in this chapter. Strategic directions for policy interventions Communities can contribute greatly to increasing the well-being of older people and the quality and effi- ciency of health and social services by acting on some of the broader social determinants of health-seeking behaviour and inefficiencies. For example, there is evi- dence of “bed-blocking” in hospitals and unnecessary admissions to residential care that result from social causes rather than the health and functional status of older people (Leichsenring, Billings & Nies, 2013). Introducing or expanding respite care services and dis- cussing with hospital managers ways to improve dis- charge procedures for older people can contribute to a more seamless continuity of services (Colombo et al., 2011). The goal of interventions in this domain is to pro- mote and provide older adults with a broad range of well located, easily accessible health and community services. These include preventive, nutritional guidance and mental health services, affordable meals and help with everyday activi- ties, home care arrangements and person-cen- tred health services and residential care facilities. In most countries a divide (financial, legal, organiza- tional, professional and in responsibilities) between health and social care leads to inefficient allocation of resources and is particularly felt by older people in need of different types of care (and their carers). It can lead to delays, uncoordinated service delivery, lack of information, financial burdens, long waiting times and reactive – rather than preventive – service approaches. Older people prefer to stay at home as long as possi- ble, in many cases with their partner or another fam- ily member caring for them. Nevertheless, such care arrangements need to be facilitated by professional health and social care services, and sometimes also by residential care facilities and primary care structures, for which local governments often have an important coordinating role. The development of community care Domain 8: community and health services Age-friendly environments in Europe. A handbook of domains for policy action 110 has been a great success in many countries, reducing the proportion of older people having to move to care homes; however, reform of long-term care is ongoing, with new methods of quality assurance, integrated delivery and funding, posing challenges to communi- ties in charge of these services. The uptake of modern eHealth support for older peo- ple is one of the emerging policy areas in Europe and there are still gaps in knowledge about its success fac- tors and outcomes. Addressing these gaps is a major concern of recent initiatives in the EU and is covered in a separate section at the end of this chapter. The following sections describe a range of interven- tions that communities have developed to provide better adapted, affordable and accessible community and health services as part of more age-friendly envi- ronments. These ensure more seamless provision and coordination of the core health and social services that many older people need, in particular the oldest age groups. A table at the end of the chapter provides prac- tical examples that show how local governments have operationalized areas for action into their action plans. Community action for coordination and integrated care provision Communities and other local authorities can play an important role in the coordination of services across providers and branches of social protection. This may include, for example, providing information services to older people, their families and carers on service availability, rights and responsibilities and supportive local services, including volunteer action (see also the chapters on domain 4: social participation and domain 6: civic engagement and employment). Better coordination and integration of services, in par- ticular at the boundary between health and social ser- vices for older people (including long-term care), has been identified as critical to improving the efficiency and effectiveness of these services (WHO Regional Office for Europe, 2015c; 2016c). Deficits in the coor- dination of services are still widespread in Europe, although much has been learnt in recent years from practice examples of improving coordination of care, or moving more fully to integration (Osborn et al., 2014). While some evidence from successful exam- ples shows improved care, less evidence is available on whether this can lead to overall cost savings (see, for example, Øvretveit, 2011). Among core strategies and notable practice examples for local government initiatives are the following (see also WHO Regional Office for Europe, 2012a: 13): • public information systems to monitor and eval- uate the living situation, health and well-being of older people living in the community – these can be supported by a number of existing and emerg- ing technologies (see also the chapter on domain 7: communication and information and the section on ambient assisted living and “ICT for ageing well” services below); • one-stop shops of information and empowerment for older people and their families (see the chapter on domain 7: communication and information); Key facts • Public spending on long-term care differs widely across Europe, ranging from more than 2.5% of GDP in a few countries to less than 0.5% of GDP in many countries (OECD, 2015). • Private contributions in the form of out-of-pocket spending for long-term care are usually large, especially for those living in residential care, requiring older people to use a large share of their pension income to cover costs. Public expenditure may also be means-tested, and there are filial obligations for shared fund- ing in some cases. Local communities may have to contribute out of social assistance budgets for those not able to cover their private share (OECD, 2011). • In all countries informal care, often given by family members, supplies a large share of the support and care needed by older people with disabilities. Most informal caregivers are women, many still of working age, but up 10% are both men and women aged 75 years and older (Rodrigues, Huber & Lamura, 2012). • Older people are disproportionally affected by disasters. For example, 56% of those who died during the Japanese tsunami in 2011 were aged 65 years or over, while older people accounted for 23% of the local population (HelpAge International, 2015). Community and health services 111 • day care and respite care facilities (the former services can be an integrated part of residential facilities); • information systems at the community level to mon- itor and control adverse events in care institutions; • local adaptations/development of quality stan- dards for geriatric concerns across all types of provider; • initiatives to improve health literacy and empower- ment of older people, their relatives and voluntary support networks, as well as self-management programmes such as “expert patients” or “patients like me” (see the chapter on domain 7: communi- cation and information). Providing a seamless continuum of support for people with dementia remains a challenge in many instances, and in particular for community services. Issues include raising awareness and understanding of the needs of people with dementia, both for families providing informal care and among health and social care providers, and informing and educating a broader public, including front-line staff of local businesses and services (WHO, 2015b: Chapter 5; OECD, 2015). People with dementia need access to a full range of risk reduction strategies that include, for example, maintaining social interaction, nutrition and physical activity. Broader use should be advocated for demen- tia care pathways, with a focus on primary health care and early screening and diagnosis (WHO, 2012b; Alzheimer’s Disease International, 2015). Health services, including health promotion and prevention services Barriers to access to affordable, high-quality health and social services are still a reality for too many older peo- ple in Europe. This includes cases of age discrimina- tion and age rationing (see Huber et al., 2008; WHO Regional Office for Europe, 2012a: 11–12; WHO, 2014b). Inequalities in health care utilization are com- mon in many countries: those with better education and those in the higher income groups tend to be less likely to be excluded from needed care (Terraneo, 2015). More could also be done in many cases to prevent further functional decline and the onset of frailty (see the action group on frailty prevention under the EIP on AHA). Examples of proactive approaches aim at the early identification of people at risk of functional decline and the provision of support for independent living at home (see Box 21). Health and social care settings themselves can pose important, but often preventable, health risks for older people (Benjamin et al., 2014). Among these are hos- pital-acquired infections, malnutrition and falls, and people living with dementia are often most at risk (OECD, 2015; WHO, 2012b). Older people in residen- tial care often have inadequate access to essential ser- vices, such as dental care or foot care (Huber et al., 2008). The primary care sector is often not adequately equipped or trained to coordinate care for older people across providers, in order to prevent adverse effects, such as from harmful over-medication. People living with dementia have special needs of enhanced community-based services and support to continue to age in place. Similarly, service provid- ers need to be adequately trained to care for people with cognitive impairments (WHO, 2012b; Alzheimer’s Disease International, 2015). Moreover, when peo- ple face high co-payment or out-of-pocket payments they may forgo essential preventive services, such as monitoring and control of high blood pressure or reg- ular control of visual health, with the risk of potentially unnecessary or early health and functional decline. Among notable practice examples of interventions at the community or local authority level are the following (see WHO Regional Office for Europe, 2012a; WHO, 2015b: Chapter 4): • focusing community- and population-based public health services on the issues of older people; • supporting community supplies (such as on a rental basis) of assistive advices, including modern tech- nology for mobility; • preventive health services, including vaccinations and home visits; • improved access to mental health services for older people in the community; • addressing gaps in rehabilitation and palliative care for older people. Home care and support for informal care Where communities are in charge of home care they have an important responsibility for monitoring it and improving access and quality, as well as for providing Age-friendly environments in Europe. A handbook of domains for policy action 112 support for informal care (OECD, 2013). Communities can provide these services with a focus on a continuum of care choices. A basic package of publicly funded support for informal caregiving (including self-care) is vital in order to make informal care offered by family members and friends sus- tainable. This public support can be provided in coor- dination with and supported by volunteer action (see also the chapter on domain 6: civic engagement and employment). It both contributes to improving the health and well-being of those in need of care and protects the health and well-being of informal caregivers. This public support includes the training of older adults in self-care and the training of informal caregivers. Where communities are responsible for home care, they also have an important role and mandate to improve quality and access to care provided by professional ser- vices. This includes attracting appropriate skill mixes of staff with sufficient general knowledge and awareness of gerontological and geriatric issues. Quality issues in the care of people with dementia are particularly severe and widespread in many cases; awareness is growing of the need to address these (WHO, 2012b). Carers or families with dependent older people are the largest source of care and support in the WHO European Region; they need to be supported to continue playing this important role. Caring for an older family member, spouse or friend can have an important impact on the lives of families and the person who takes over the primary care role. The unpaid care role can result in significant physical, emotional and economic strain for the care provider and can even put the carer at risk of ill health (WHO, 2015b: Chapter 5). Carers need to be supported to enable them to continue this role. Support includes adequate information, skills to assist caring, finan- cial support and respite to enable some freedom to engage in other activities (WHO, 2012b). A range of programmes have been developed to assist informal carers, many of which have well proven effects for both the carer and the care recipient. Carer respite services and home-based support for carers are important interventions and can help reduce the burden of caring (Colombo et al., 2011). For carers for people with dementia, psychoeduca- tional interventions should be offered to family and other informal caregivers at the time the diagno- sis is made. Training of carers involving active carer participation can support carers who are coping with behavioural symptoms in people with dementia (OECD, 2015). Furthermore, psychological strain of carers should be addressed with support, counselling and cognitive-behaviour interventions, with particular attention to carers who develop depression, which should be managed according to depression guide- lines (WHO, 2012b). The WHO iSupport website is an online training programme to support caregivers for people living with dementia (WHO, 2017b). Box 21. Services of early support to promote independent living in Kuopio, Finland The city of Kuopio, Finland, developed proactive measures and early support to promote independent living at home for older people. To this end, collaboration was cultivated between primary health care staff, specialists and other stakeholders (including NGOs) and geriatric and gerontological expertise of staff was fostered. As a result, the Early Support of Older People in their Daily Lives (VAMU) project developed a care model that provides tools for early identification of risks, assessment of service needs and follow-up planning. A team of experts trained and supported project staff in early observation to promote proactive skills of staff in geriatric and gerontological care. The project helped to improve practices across administrative and professional boundaries. This has become part of jointly agreed annual personal development plans for all service providers involved. As a result, the available resources are better able to meet the service needs of older people. In addition, older people’s own active involvement was fostered, as well as empowerment of their families and friends. Source: European Commission (2015). Community and health services 113 Residential care facilities A number of trends in good practice within residen- tial care have emerged in Europe and can be used as checklists for communities that are in charge of providing residential care (OECD, 2013; Leichsenring, Billings & Nies, 2013). They include the following strategies: • providing a continuum of choices between inde- pendent living in one’s own home and living in homes (or departments within homes) that care for those with intensive long-term care needs; • de-institutionalization of residential care by provid- ing an “everyday” living environment for as long as possible, with individualized living space, including (and in particular) for those with dementia – this can include shared apartments with integrated care services, embedded in community life (much has been learnt in this respect about the impor- tance of integrating residential facilities in the com- munity and avoiding placing homes at the outskirts of cities – examples are flat-living communities in Austria, Germany and the Netherlands (OECD, 2015: 44)); • supporting the creation of health-promoting resi- dential care facilities that provide a comprehensive range of services, including for health promotion and disease prevention (such as adequate physi- cal activity, high-quality nutrition and improved falls prevention) – examples include “health-promot- ing nursing homes” in Vienna (see the chapter on domain 3: housing, Box 8); • creating incentives for training and retaining staff with sufficient skills in gerontological and geriatric issues and reducing staff turnover (WHO, 2015b: Chapter 5); • fostering cooperation with the health care sec- tor to avoid preventable admissions to residential care – for example, by providing adequate nutrition and care to prevent the onset of pressure ulcers in hospitals that may result in the need for intensive long-term care; • putting in place quality-of-care strategies and con- tinuously monitoring their implementation, includ- ing with the participation of local organizations of older people, and giving more attention to the psychological and well-being aspects of those liv- ing in residential care (WHO, 2015b: Chapter 5; Willemse et al., 2015). Ambient assisted living and “ICT for ageing well” services This section reviews the roles that ICT, ambient assisted living (AAL) and e/mHealth and care tech- nologies can play in creating more age-friendly envi- ronments, with a focus on their applications for AAL and “ICT for ageing well” services. These are seen as important for the future development of efficient long- term care systems in Europe (European Commission, 2013b; Carretero, 2015), as well as for the integra- tion/better coordination of services (see WHO, 2015b: Chapter 5). Compared to the topics covered in the other parts of this chapter, this area of interventions is more exper- imental in many instances. Moreover, few European overviews are currently available that comprehensively review the lessons learnt in order to support munic- ipalities to identify and implement ICT/AAL policy solutions that can enhance older people’s quality of life while simultaneously strengthening municipal ser- vice accessibility, effectiveness and sustainability. This remains the case, despite the fact that ICT and AAL solutions and services are making an ever-increasing contribution to how older people experience their lives in cities and communities throughout Europe. While the technology market is growing and changing rap- idly, these developments are often fragmented and unequally distributed across countries and between population segments within countries (European Commission, 2007; 2014c; 2014d). Although ICT/AAL solutions are often cross-cutting and support applications and services across all eight domains of the AFEE framework, they play a par- ticularly important role within the cluster of domains addressing municipal services: domain 7: communi- cation and information and domain 8: community and health services. To foster discussion of this complex topic, this section presents a three-dimensional conceptual model (Fig. 6) that helps with visualizing the application landscape for many ICT/AAL solutions, to provide insight into rel- evant questions of ICT/AAL policy development and implementation. This conceptual model aims to pro- vide an overview of ICT/AAL applications, for which a common taxonomy is still broadly lacking in the litera- ture (AALA, 2015). Age-friendly environments in Europe. A handbook of domains for policy action 114 In line with widespread policy and service design prin- ciples, the citizen/service user is situated at the centre (or origin) of Fig. 6, and the areas of application expand outward and around, in three axes or dimensions. Rather than explicit gradients, each axis represents a continuum of support to enhance older people’s func- tioning in a city’s social and environmental ecosystem. The red axis is characterized as a continuum where ICT/ AAL provides applications and services that incremen- tally strengthen older people’s social and informal con- nection to their community. This is generally the municipal policy area of social care and community development. At the most immediate level, this addresses application areas such as those that reinforce older people’s sense of safety and security at home. These tend to be ori- ented towards alarm and emergency response – where sensors trigger alarms for breaches of property (intruder alarms, door and window closures), personal accident pendant alarms (for incidents such as falls) and warn- ings of environmental risks (smoke detectors, gas leaks and water overflows). Sensors usually trigger a voice call connection to a call centre, where an adverse event can be managed, including direct connection to relevant emergency service providers (see Box 22). Extending along this continuum are social connectivity support services; these may include websites for ser- vice/event awareness, senior helplines (such as “good morning call services”) and social networks around areas of common interest. Many of these types of service are directed at combating social isolation; promoting aware- ness of services and entitlements; encouraging physical, social and cognitive activity; and connecting and engag- ing with social groups and activities. Further along this axis of informal community connec- tivity are proactive services that encourage and support greater participation of older people in the civic and eco- nomic life of the city or community – whether through formal employment (full time or part time) or volunteer- ing. Applications in this area range from portals providing seek/search services for work engagement, opportuni- ties to contribute for limited amounts of time, time-bank- ing/social credits, mentoring services, intergenerational activities, online skills development and lifelong learning. The blue axis is characterized as a continuum where ICT/ AAL provides applications and services that incremen- tally strengthen connectivity with the health system. This is generally the municipal policy area of health, primary Fig. 6. A conceptual model for ICT/AAL applications Predictive Preventive Reactive Safety/security Remote consultation Self-management Vital signs Social connection Civic/social participation Strengthening social/informal connectivity Streng thenin g conn ectivit y with health syste m Co nt ex t a wa re ne ss Source: Rodd Bond, personal communication, 2016. Community and health services 115 and long-term care services. A broad range of technol- ogy area definitions are used along this axis including telehealth, eHealth, mHealth, connected health, eCare and telemedicine. With its more clinical/medical data focus, health professional involvement, public health system orientation and procurement models, the area of eHealth is sometimes differentiated from ICT/AAL as a market segment. From an older person’s perspective, however, living at home and using ICT both to interact within the social and environment milieu and to manage health conditions presents significant overlaps in terms of technology acceptance, usefulness and costs. The most immediate level along this continuum is home-based vital signs monitoring, where older people use a range of devices to gather personal physiological information about chronic conditions at home. Typical devices include scales, blood pressure cuffs, heart rate monitors, respiratory and breath analysis flow meters and blood glucose-level analysers. At a minimum, these data are recorded manually and shared with a doctor or nurse at scheduled meetings/visits. More automated processes support the transfer of these data to remote telehealth call services via phone, text message or Internet services, where they are monitored and where alarms can be triggered and responses ini- tiated if values transgress thresholds agreed between service recipients and providers. A natural extension of these devices is to provide a richer range of services around these regular home- based data gathering and upload activities to support greater individual empowerment to self-manage health and well-being. These self-management enhance- ments involve applications on interactive devices such as iPads and smartphones, which can record addi- tional qualitative health assessment inputs; locally anal- yse and display trends in symptoms, behaviours and condition management knowledge; provide motiva- tional messages; and channel multimedia educational, learning and training material. Additional sensors to monitor movement, gait, sleep quality and activity levels are augmenting the range of devices and services now on the market. While some of these additional services have evolved from a health and clinical service perspective (such as sleep quality monitoring) there is now a growing range of pervasive health monitoring devices (such as fit-bit wrist bands, activity physiology monitoring watches and similar devices). These are directly aimed at the personal con- sumer-oriented health and wellness market and will increasing become available to older people. Applications and services further along this axis of strengthened connectivity to the health system can be characterized by ICT/AAL that can significantly improve Box 22. Telesupport at home: improving access to services and combating social isolation in Maltepe municipality, Turkey To increase access to health care services for older people who live alone in their own homes and to support those at risk of isolation, Maltepe municipality in Turkey has introduced a telesupport system in the form of a wireless device with a call button to wear or place in the home. The call button is linked to a call centre run in partnership with a private provider. Pressing the button connects older people directly to someone they can talk to. This can be used as emergency call system, but it is also used by older people who miss having someone to talk to or who have questions about health concerns, for which they can receive basic information on prevention and healthy living and be referred to services including home care, health and psychological counselling services. In the case of emergency, or if the person calling for support does not respond, an alarm is triggered and the location from which the call was placed is registered and sent to the emergency and ambulance services. This service is part of a reorganization of community services in Maltepe that was finalized in 2013, with the aim of increasing quality of life of older people. This telesupport service is part of a package of home-based care interventions that aim to increase quality of life, offer support to families and improve access to health care. Services include support for leading healthy lives for those over the age of 65 years, including dietitian advice and psychological counselling, and are avail- able free of charge around the clock. Source: Marmara Ambulans (2013). Age-friendly environments in Europe. A handbook of domains for policy action 116 patient-centred screening and assessment, consulta- tions and clinical decision-making in terms of diagnos- tic information quality, timeliness and multidisciplinary team participation. Applications in this area build upon data gathered through monitoring and call centres but bring the client into direct online contact with their clin- ical team, who may be distributed in multiple locations. The green axis is characterized as a continuum where ICT/AAL provides applications and services that are incrementally more sensitive to and aware of a person’s individual, social and environmental context. This axis is oriented towards the current and future quality and ambition of ICT/AAL applications. It is closely linked to innovation and design advances in the components and systems architecture of ICT/AAL platforms, as well as the ability of organizations – both individually and operating in cooperative ecosystems – to exploit these advances effectively and ethically. This axis has some similarities with the “three gener- ations” model of telecare systems, where higher gen- erations involve more advanced systems with larger amounts of data to support proactive care service inter- ventions (Kubtischke & Cullen, 2009). ICT/AAL devel- opments along this axis are characterized by their abil- ity to manage risk better in the “orange zone” – where older people, carers and health and social care profes- sionals can jointly mediate and negotiate risk – through greater insight, awareness and responsiveness. The starting-point of this axis is ICT/AAL systems that are very reactive to events and that trigger alarms and emergency responses based on predefined protocols. First and second generation telecare systems are of this type. They are primarily designed to reduce anx- iety among older people and their carers, and they may reduce the use of primary health care services (Department of Health, 2009; Beale et al., 2010). Further along this continuum are systems that gather and analyse additional information in many formats from older people and their surrounding social and physical environments. These data can be stored over time in order to analyse changes in health status, behaviour and levels of activity. Trends can be displayed and insights into changes can be extracted by looking at patterns in the information over time. An objective of these systems is that the additional “contextual data” and feedback that are part of these solutions can improve awareness and understanding of conditions. They can encourage and empower preven- tive actions, proactively managing risks at home and reducing pressures on health systems. While there are some early commercial implementations of solutions with these ambitions, considerable ongoing research and innovation activity is continuing into these types of system. Evidence of their efficacy and impact on health and well-being outcomes is still underdevel- oped, however. Emergency planning and disaster preparedness Older people are among the most vulnerable groups during disasters and conflicts, but their special needs and roles have often not been addressed sufficiently by emergency programmes or planners (Hutton, 2008; WHO, 2015b; Dodman et al., 2012). A number of guid- ance documents and case studies have been published in recent years that propose awareness-raising strate- gies about older people in disasters and emergencies, analyse factors that affect them and provide exam- ples of policies and practices to address vulnerability and health concerns for older people in emergencies (Box 23). The need to protect older people in emer- gencies is illustrated by the experience with (natural) disasters and emergency situations in Europe in recent years, which points to gaps in current emergency planning at the local level (Vandentorren et al., 2006; Åstrøm, Forsberg & Rockløv, 2011). Governments in Europe usually have emergency and disaster plans in place, with detailed planning for the case of emergencies or (natural) disasters, including at the regional and local levels. Cities and communities differ in the ways they have adapted them to their local contexts, however, and in how they pay special atten- tion to the risks to which vulnerable older people might be exposed. This has to take into account that some risks – for example, from extreme weather conditions (extreme high or low temperatures) – pose substantially greater health risks for older people than for the popu- lation at large. A special challenge of emergency situations is how to reach out to vulnerable older people who may live alone, without family or community support, and who are thus more difficult to reach to inform about ade- quate measures or provide rescue. In this respect a number of lessons can be learnt from recent emergen- cies in Europe, with a focus on natural disasters such as earthquakes, flooding and extreme weather conditions Community and health services 117 and the current state of play of contingency plans for heatwaves and cold weather (see, for example, Kovats & Ebi, 2006). A final aspect to consider in emergency preparedness is the role older people can play them- selves in sharing information in times of emergency. Again, older people should be seen not only as a vul- nerable population but also potentially as contributors and helpers in an emergency situation. Policy interventions and initiatives by action area and objective Table 8 follows the structure of this chapter’s proposed directions for interventions and objectives and adds examples from existing age-friendly strategies, action plans and case studies. Interventions and initiatives mentioned may be projects already implemented in local contexts or those designed for implementation in an age-friendly action plan. Box 23. Guidance on helping older people in emergencies Recognition of the importance of planning for disaster preparedness with a special focus on older people is growing. The topic of older people in emergencies has therefore received increasing attention over the last 10 years, as documented by a number of guides and studies (Hutton, 2008; WHO, 2008; Pan American Health Organization, 2012; WHO, 2013). WHO’s World report on ageing and health gives a list of topics and exam- ples for action (WHO 2015b: Table 6.1). Moreover, HelpAge International has developed a number of guides with a focus on resource-constrained settings and for humanitarian aid (HelpAge International, 2015). These can also serve as resources for design- ing emergency plans with the specific vulnerabilities of groups of older people in Europe in mind (see also the reviews of the Inter-Agency Standing Committee (IASC) Working Group on the inclusion of older people in humanitarian action) (IASC, 2015). Table 8. Practice examples for community and health services from local age-friendly action plans and assessments Action area Objective Examples of policy interventions and initiatives Coordination of care and integrated care provision (cross-cutting with domain 4: social participation, domain 6: civic engagement and employment and domain 7: communica- tion and information) Facilitating access to seamless service deliv- ery for those in need of health, social and long- term care • Doctors’ referrals to physical or social activities for older people (gentle fitness, walking groups, theatre etc.) • Health and social care workers with the task of improving the integration of health and social care for patients with complex and multiple needs • Multiservice centres for older people and case workers that connect the different services available • Local information and coordination centres • Developing a local service providers forum to enhance collaboration between different agencies Health services, including health promotion and prevention services (cross-cutting with domain 4: social participation) Including prevention and health promotion in health services • Health checks and effective interventions to control and manage chronic diseases and follow-up care • Tobacco cessation advice and counselling • Mental health promotion and memory training in health centres and community centres • Promotion of physical activity in group setting or at home • Information and activities to promote healthy diet • Screening and vaccination services (e.g. mobile screening service campaigns in neighbourhoods) Age-friendly environments in Europe. A handbook of domains for policy action 118 Action area Objective Examples of policy interventions and initiatives Home care and support to infor- mal care (cross-cutting with domain 4: social par- ticipation and domain 6: civic engagement and employment) Provide home care services • Home improvement agencies tasked to provide services that enable people to remain independent at home as long as possible • Improvement of availability and accessibility of in-home medical and social help • Cleaning and personal hygiene services at home • Food services Support to carers and families • Differential financial aid and support programmes for fami- lies with dependent elders • Family assistance at home: ability to get help with main- tenance, personal hygiene, household help for the older person in the family • Providing day care services • Online information platforms for carers • Psychological support services also for carers • Funeral support services • Emergency services • Telephone assistance services • Temporary loan of technical equipment (walking frames, wheel chairs etc.) Residential care facilities (cross-cutting with domain 4: social par- ticipation and domain 6: civic engagement and employment) Ensure long-term care services of good quality for those in need • Increasing the availability and affordability of sheltered housing for those in need • Improving and monitoring quality of care • Ensuring a seamless continuum of care after release from hospital • Health promotion and prevention services in residential care setting AAL and “ICT for ageing well” • Remote security alarms • Technological solutions for communication from home to nurse, doctor or hospital • Remote sensors of activity • Virtual ward to develop new services (e.g. Hospital at home project) Emergency plan- ning and disaster preparedness • Designing protocols and programmes to reach out to vul- nerable old people in case of an emergency • Making emergency plans for extreme weather events and emergencies • Monitoring system through a registry of vulnerable and frail older people • Ensuring arrangements are in place locally to respond effectively to infectious outbreaks Table 8 contd Resources and toolkits Genet N, Boerma W, Kroneman M, Hutchinson A, Saltman R, editors (2012). Home care across Europe: current structure and future challenges. Copenhagen: WHO Regional Office for Europe (h t tp : / /www.euro .who. in t /en/about-us/par t - n e r s / o b s e r v a t o r y / p u b l i c a t i o n s / s t u d i e s / home-care-across-europe.-current-structure-and-fu- ture-challenges, accessed 9 June 2016). Community and health services 119 HelpAge International (2012). Protecting older people in emergencies: good practice guide. London: HelpAge International (http://www.helpage.org/resources/prac- tical-guidelines/emergency-guidelines/, accessed 2 October 2015). HelpAge International (2014). Disaster resilience in an ageing world: how to make policies and pro- grammes inclusive of older people. London: HelpAge International. HelpAge International (2015). Emergency guidelines [website]. London: HelpAge International (http://www. helpage.org/resources/practical-guidelines/emergen- cy-guidelines/, accessed 2 October 2015). HelpAge International and International Federation of Red Cross and Red Crescent Societies (2011). Guidance on including older people in emergency shel- ter programmes. London: HelpAge International (http:// www.helpage.org/resources/practical-guidelines/ emergency-guidelines/, accessed 2 October 2015). K4Health (2015). Glossary. In: The mHealth planning guide: key considerations for integrating mobile tech- nology into health programs [website]. (http://www. k4health.org/toolkits/mhealth-planning-guide/glossary, accessed 5 June 2015). Matthies F, Bickler G, Marin NC, Hales S, editors (2008). Heat-health action plans. Copenhagen: WHO Regional Office for Europe (http://www.euro.who.int/en/publica- tions/abstracts/heathealth-action-plans, accessed 9 October 2017). Schulmann K, Ilinca S, Leichsenring, K (2017). Community care for people with dementia: a handbook for policymakers. Vienna: European Centre for Social Welfare Policy and Research. Tarricone R, Tsouros AD, editors (2008). The solid facts: home care in Europe. Copenhagen: WHO Regional Office for Europe (http://www.euro.who.int/en/publica- tions/abstracts/home-care-in-europe.-the-solid-facts, accessed 9 June 2016). Toleikyte D, Oostdam N, van Kats-Dernee N, Todorovic N, Vracevic M (2013). Community-based care and sup- port: a toolkit for NGOs, local authorities and service providers in the care for the elderly. Belgrade: Red Cross of Serbia. WHO (2015). The MAPS toolkit: mHealth assess- ment and planning for scale. Geneva: World Health Organization. (http://www.who.int/reproductivehealth/ publications/mhealth/maps/en/, accessed 13 October 2015). WHO Regional Office for Europe (2011). Public health advice on preventing health effects of heat. New and updated information for different audi- ences. Copenhagen: WHO Regional Office for Europe (http://www.euro.who.int/en/health-topics/environ- ment-and-health/Climate-change/publications/2011/ public-health-advice-on-preventing-health-effects-of- heat.-new-and-updated-information-for-different-audi- ences, accessed 9 October 2017). World Meteorological Organization and WHO (2015). Heatwaves and health: guidance on warning-sys- tem development. Geneva: World Meteorological Organization (http://www.who.int/globalchange/pub- lications/heatwaves-health-guidance/en/, accessed 9 October 2017). Further reading AGE Platform Europe (2012). Age- and dementia-friendly environments as investment for a sustainable EU [press release]. Brussels: AGE Platform Europe (http://www. age-platform.eu/age-a-the-media/age-communica- tion-to-the-media-press-releases/1552-age-and-de- mentia-friendly-environments-as-investment-for-a-sus- tainable-eu, accessed 12 October 2015). European Commission (2015). The 2015 ageing report: economic and budgetary projections for the 28 EU Member States (2013–2060). Brussels: European Commission (http://ec.europa.eu/economy_finance/ publications/european_economy/2015/ee3_en.htm, accessed 9 June 2016). Finkelstein J, Knight A, Marinopoulos S, Gibbons MC, Berger Z, Aboumatar H et al. (2012). Enabling patient-centered care through health information tech- nology. Rockville MD: Agency for Healthcare Research and Quality (Evidence Report/Technology Assessment no. 206; https://www.effectivehealthcare.ahrq.gov/ search-for-guides-reviews-and-reports/?pageac- tion=displayproduct&productID=1157, accessed 9 June 2016). Age-friendly environments in Europe. A handbook of domains for policy action 120 Goodwin N, Dixon A, Anderson G, Wodchis W (2014). Providing integrated care for older people with complex needs: lessons from seven international case studies. London: The King’s Fund (http://www.kingsfund.org. uk/publications/providing-integrated-care-older-peo- ple-complex-needs, accessed 9 June 2016). INNOVAGE (2015). How the database of exemplars was compiled [website]. Sheffield: INNOVAGE (http://www. innovage.group.shef.ac.uk/about-the-exemplars.html, accessed 12 October 2015). Kesselring A, Smith S, Dobner S, Schrammel M (2014). Social innovation for active and healthy age- ing: a case study collection. Brussels: King Baudouin Foundation (https://www.kbs-frb.be/en/Activities/ Publications/2014/312599, accessed 9 June 2016). Rechel B, Doyle Y, Grundy E, McKee M (2009). How can health systems respond to population ageing? Copenhagen: WHO Regional Office for Europe (http:// www.euro.who.int/en/health-topics/Life-stages/ healthy-ageing/publications/2009/how-can-health-sys- tems-respond-to-population-ageing, accessed 9 June 2016). Scheil-Adlung X (2015). Long-term care protection for older persons: a review of coverage deficits in 46 countries. Geneva: International Labour Organization (ESS Working Paper no. 50; http://www.ilo.org/sec- soc/information-resources/publications-and-tools/ Workingpapers/WCMS_407620/lang--en/index.htm, accessed 9 June 2016). Scheil-Adlung X, Bonan J (2012). Can the European elderly afford the financial burden of health and long- term care? Assessing impacts and policy implications. Geneva: International Labour Organization (ESS Working Paper no. 31; http://www.ilo.org/secsoc/informa- tion-resources/publications-and-tools/Workingpapers/ WCMS_207669/lang--en/index.htm, accessed 9 June 2016).

Age-friendly environments in Europe. A handbook of domains for policy action 122 Glossary and references Glossary and references 123 Glossary This glossary contains definitions of key terminology and concepts in active/healthy ageing. The definitions are primarily drawn from existing international docu- ments. They are quoted verbatim from these sources and detailed references are provided to enable the reader to refer to the complete source document to obtain further information or context. The citation pro- vided relates to the source from which the definition was extracted for inclusion in this glossary; it should be noted that this may not necessarily be the source in which the definition was first coined. Where a more recent source confirms a prominent earlier one, in some cases both have been listed. Accessibility This describes the degree to which an environment, service or product allows access by as many people as possible, in particular people with disabilities (WHO, 2011; 2015b). Accessibility standards A standard is a level of quality accepted as the norm. The principle of accessibility may be mandated in law or treaty, and then specified in detail according to inter- national or national regulations, standards or codes, which may be compulsory or voluntary (WHO, 2011). Activity limitations In the International Classification of Functioning, Disability and Health, these are the difficulties an indi- vidual may have in executing activities. They may range from a slight to a severe deviation in terms of quality or quantity in executing the activity in a manner or to the extent that is expected of people without the health condition (WHO, 2011). Active ageing This is the process of optimizing opportunities for health, participation and security in order to enhance quality of life as people age WHO (2002b; 2015b). Age-friendly cities and communities These are cities or communities that foster healthy and active ageing (WHO, 2015b). Age-friendly environments These are environments (such as in the home or com- munity) that foster healthy and active ageing by building and maintaining intrinsic capacity across the life-course and enabling greater functional ability in someone with a given level of capacity (WHO, 2015b). Ageism This refers to stereotyping and discrimination against individuals or groups on the basis of their age. Ageism can take many forms, including prejudicial attitudes, discriminatory practices or institutional policies and practices that perpetuate stereotypical beliefs (WHO, 2015b). Ambient assisted living (AAL) This is a combination of intelligent systems of assistive products and services, integrated in the preferred living environment, to constitute “intelligent environments” to compensate predominantly age-related functional limitations and support an independent, active and healthy course of life (European Commission, 2013). Assistive technology (or assistive devices) This refers to any device designed, made or adapted to help a person perform a particular task; products may be generally available or specially designed for people with specific losses of capacity. Assistive health technology is a subset of assistive technologies, the primary purpose of which is to maintain or improve an individual’s functioning and well-being (WHO, 2015b). Communication This includes languages, display of text, Braille, tactile communication, large print and accessible multimedia, as well as written, audio, plain-language, human-reader and augmentative and alternative modes, means and formats of communication, including accessible ICT (United Nations, 2006). Determinants of health These are the conditions in which people are born, grow, live, work and age, including the health system. The circumstances are shaped by the distribution of money, power and resources at global, national and local levels, which are themselves influenced by pol- icy choices. The social determinants of health are mostly responsible for health inequities – the unfair and avoidable differences in health status seen within and between countries (WHO Regional Office for Europe, 2013a). Digital divide This refers to the gap between individuals, households, businesses and geographical areas at different socio- economic levels with regard to both their opportunities Age-friendly environments in Europe. A handbook of domains for policy action 124 to access information and communication technolo- gies and their use of the Internet for a wide variety of activities (WHO, 2011). Disability This is an umbrella term for impairments, activity limita- tions and participation restrictions, denoting the neg- ative aspects of the interaction between an individual (with a health condition) and that individual’s contextual factors (environmental and personal factors) (WHO, 2001; WHO, 2015b). Functional ability This refers to the health-related attributes that enable people to be and to do what they have reason to value. It is made up of the intrinsic capacity of the individual, relevant environmental characteristics and the interac- tions between the individual and these characteristics (WHO, 2015b). Functioning This is an umbrella term for body func tions, body struc- tures, activities and par ticipation. It denotes the pos- itive aspects of the interaction between an individual (with a health condition) and that indi vidual’s contextual factors (WHO, 2001, WHO, 2015b). Health literacy This refers to the cognitive and social skills that deter- mine the motivation and ability of individuals to gain access to, understand and use information in ways that promote and maintain good health (WHO Regional Office for Europe, 2013a). Health equity Equity is the absence of avoidable, unfair or remedia- ble differences among groups of people, whether those groups are defined socially, economically, demograph- ically or geographically. “Health equity” or “equity in health” implies that ideally everyone should have a fair opportunity to attain their full health potential and, more pragmatically, that no one should be disadvantaged from achieving this potential (WHO Regional Office for Europe, 2013a). Healthy ageing This is the process of developing and maintaining the functional ability that enables well-being in older age (WHO, 2015b). Informal care This refers to unpaid care provided by a family member, friend, neighbour or volunteer (WHO, 2015b). Institutional care setting This refers to institutions in which long-term care is provided. These may include community centres, assisted living facilities, nursing homes, hospitals and other health facilities; institutional care settings are not defined only by their size (WHO, 2015b). International Classification of Functioning, Disability and Health (ICF) This is the classification that provides a unified and standard language and framework for the description of health and health-related states. ICF is part of the “family” of inter national classifications developed by WHO (WHO, 2001). Life-course approach This suggests that the health outcomes of individuals and the community depend on the interaction of mul- tiple protective and risk factors throughout people’s lives. The life-course approach provides a more com- prehensive vision of health and its determinants and a focus on interventions in each stage of their lives (WHO Regional Office for Europe, 2013a). Long-term care This consists of a range of medical and personal care services that are consumed with the primary goal of alleviating pain and suffering and reducing or manag- ing the deterioration in health status in patients with a degree of long-term dependency (OECD, 2011). It refers to the activities undertaken by others to ensure that people with a significant ongoing loss of intrinsic capacity can maintain a level of functional ability con- sistent with their basic rights, fundamental freedoms and human dignity (WHO, 2015b). Quality of life This is individuals’ perceptions of their position in life in the context of the culture and value system in which they live, and in relation to their goals, expectations, standards and concerns. It is a broad-ranging con- cept, incorporating in a complex way a person’s phys- ical health, psychological state, level of independence, social relationships, personal beliefs and relationship to salient features in the environment. As people age, their quality of life is largely determined by their ability to maintain autonomy and independence (WHO, 2002b). Supportive environments for health These offer protection from threats to health and enable people to expand their capabilities and develop self-reliance in health. They encompass where people live, their local community, their home and where they Glossary and references 125 work and play, including people’s access to resources for health and opportunities for empowerment (WHO Regional Office for Europe, 1991; 2013a). Universal design This refers to the design of products, environments, programmes and services to be usable by all people, to the greatest extent possible, without the need for adaptation or specialized design. It should not exclude assistive devices for particular groups of people with disabilities where this is needed (United Nations, 2006; WHO, 2015b). References AALA (2015). 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The WHO Regional Office for Europe The World Health Organization (WHO) is a specialized agency of the United Nations created in 1948 with the primary responsibility for international health matters and public health. The WHO Regional Office for Europe is one of six regional offices throughout the world, each with its own programme geared to the particular health conditions of the countries it serves. Member States Albania Andorra Armenia Austria Azerbaijan Belarus Belgium Bosnia and Herzegovina Bulgaria Croatia Cyprus Czechia Denmark Estonia Finland France Georgia Germany Greece Hungary Iceland Ireland Israel Italy Kazakhstan Kyrgyzstan Latvia Lithuania Luxembourg Malta Monaco Montenegro Netherlands Norway Poland Portugal Republic of Moldova Romania Russian Federation San Marino Serbia Slovakia Slovenia Spain Sweden Switzerland Tajikistan The former Yugoslav Republic of Macedonia Turkey Turkmenistan Ukraine United Kingdom Uzbekistan World Health Organization Regional Office for Europe UN City, Marmorvej 51, DK-2100 Copenhagen Ø, Denmark Tel.: +45 45 33 70 00 Fax: +45 45 33 70 01 Email: euwhocontact@who.int Website: www.euro.who.int