The Age-Friendly Cities framework optimizes opportunities for health, participation, and security to enhance quality of life as people age and has been broadly applied in 1,000 cities and communities in 41 countries, covering >240 million people worldwide (World Health Organization [WHO], n.d.). Age-friendly cities must evaluate their community through the lens of eight evidence-based domains, including: outdoor spaces and buildings; transportation; housing; social participation; respect and social inclusion; civic participation and employment; communication and information; and community support and health services (Figure 1) (WHO, 2007). This movement is important for gerontological nursing in that it promotes community supports and services for older adults who want to age in place (Jeste et al., 2016). The global pandemic, impacting every aspect of life, offers a new opportunity to promote health for older adults using this framework. As the ecological model of aging emphasizes, context matters to health, wellness, and life satisfaction, and should inform any new programs, services, policies, or decisions (Lawton et al., 1977).
Method
To guide new approaches for age-friendly cities during COVID-19, a brainstorming meeting was held in June 2020 with 10 gerontologists on the West Coast, including Hawaii, Oregon, and California, followed by focused interviews. The purpose was to begin to understand the far-reaching effects of the pandemic, as well as identify best practices that promote safety, wellness, and empowerment for older adults and persons with disabilities. The study consisted of focus group interviews and individual phone interviews using a semi-structured interview guide while trained researchers took notes. The interviews explored participants’ perspectives about how the COVID-19 pandemic is affecting implementation of age-friendly initiatives. Interviews were conducted in the language of participants’ choice, including English, Spanish, and Chinese.
Notes were analyzed using Dedoose, a qualitative analysis software, with excerpts coded according to their relevance to the eight age-friendly domains and the impact of the COVID-19 pandemic. As this research used de-identified secondary data, it was exempt from Institutional Review Board review.
Findings
Concurrently, five focus groups were held between April and June 2020 by videoconference with representatives from San Mateo and Colma, California. Three focus groups included 22 participants, aged 55 to 93, and two focus groups included 12 senior service providers. In addition, 30 phone interviews were conducted with adults aged ≥55 years. Of these, six interviews represented the Latinx perspective and were facilitated by a Spanish translator, and 11 interviews were held in Chinese. Focus group and interview participants were 70% female. Participants identified issues and concerns related to the eight domains and potential solutions. These are summarized below. Table A (available in the online version of this article) provides actionable items with examples offered by participants and the research team.
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Table A: Recommendations to Promote Age Friendly Cities During the COVID-19 Pandemic |
Outdoor Spaces and Buildings
Public health guidance emphasizes that gathering indoors increases risk of COVID-19 spread. Therefore, there has been an increasing trend to move outdoors—for exercise, recreation, and socialization (at a safe distance of 6 feet). The Centers for Disease Control and Prevention (CDC; 2020c) states, “Staying physically active is one of the best ways to keep your mind and body healthy. In many areas, people can visit parks, trails, campgrounds, and open spaces to relieve stress, get some fresh air, and stay active” (para. 1).
Notably, the COVID-19 pandemic reduced access to important resources, such as parks, museums, and amenities. Many older adults also deal with fear of walking outdoors in environments where others are exercising or where there may be less acceptance of wearing masks to protect others.
Outdoor spaces may need to be thought about in a different way moving forward, than the way we’ve been thinking about them. (Senior service provider, San Mateo, April 2020)
There are several examples of best practices to restructure outdoor spaces and built environments to promote mobility, socialization, and safety. Museums, parks, and farmers markets could offer senior hours. Masks, bottled water, handwashing stations, a variety of sanitized seating options, public restrooms, and trash cans can be provided to facilitate a safe and inviting atmosphere. Community services and activities can be moved outdoors, including dining, fresh food markets, vendors and outdoor retail, mobile libraries, pet grooming, manicures, hair styling, art and exercise classes, live music, and free activities. With one third of adults aged ≥65 years living alone, it is essential to provide safe ways to get outside, interact with neighbors safely, and be around others in the community.
Transportation
Convenient, affordable, and accessible transportation options remain a top concern of older adults, caregivers, and the communities where they live. Currently, public transportation, on-demand ride sharing apps (e.g., Uber, Lyft), and volunteer driver programs carry a risk of COVID-19 transmission, further highlighting the need to innovate new mobility and transportation options for older adults (CDC, 2020b).
The city needs to do something for seniors who are having difficulty with transportation as a result of the COVID-19 situation. (San Mateo focus group participant, age 71+, April 2020)
The CDC recently released guidelines for all types of transportation. Tips include limiting travel when possible, maintaining 6-foot distance from other passengers, wearing masks, washing hands frequently, avoiding touching surfaces, and opening a window and/or changing air conditioning to non-circulation mode (CDC, 2020b). It would be helpful for transportation providers to communicate safety measures taken to protect passengers.
Outside trips can be limited by bringing groceries, health care, and socialization directly to the home. COVID-19 has driven an exponential increase in use of grocery and takeout delivery services (e.g., Instacart®, Amazon Fresh, Uber Eats, DoorDash®), telehealth services (e.g., Teladoc®), video communication platforms (e.g., Facetime, WhatsApp, Zoom), and online dating sites (e.g., SilverSingles). These services must ensure their websites are intuitive and designed with an older adult user in mind. Voice user interfaces or artificial intelligence assistants could enhance usability. Alternatively, a phone concierge system could be made available to place orders or provide technical assistance.
Finally, air travel is a great challenge during the pandemic. It is difficult to visit distant family members, and tough choices are being made about what types of trips are worth the risk. Some families are finding safe ways to connect through cross-country road trips in recreational vehicles and outdoor picnics. This pandemic is causing families to re-think living far apart.
Housing
A variety of pandemic-related factors are driving multi-generational living arrangements, including economic challenges and increased flexibility to work from home. Multigenerational houses allow for flexible, private spaces for adult children, caregivers, or housemates of any age. Despite an initial slowdown in permit approvals, COVID-19 is expediting the move from outdated paper practices to online applications, which will streamline the process for building multigenerational housing projects.
As public guidance discourages interaction with people outside one’s household, many are choosing to quaranteam, intentionally choosing a group of people to live with during the pandemic. Shared housing programs that connect those seeking housing with older adults with spare rooms have the double benefit of addressing social isolation and COVID-related economic challenges.
More time spent isolated at home can be counteracted by community design that intentionally fosters social and intergenerational interaction. People living in walkable neighborhoods see their neighbors more often and are more likely to know and trust them, which corresponds to higher levels of health, life satisfaction, and community engagement. Multi-unit developments can facilitate interaction of all ages, incomes, and race by including a mix of apartments, condominiums, townhomes, detached homes, and accessory-dwelling units.
Shared alleyways, parks, parklets, and even clustered mailboxes are intentional spaces that foster chance meetings among neighbors. Sometimes called “third places,” shared outdoor areas can also act as a collective living room for a community, providing an informal and comfortable outdoor space for a socially distanced knitting circle, tea party, or picnic. Balconies and front porches allow safe spaces to get outside, see neighbors, and interact. Memorable scenes early in the pandemic included neighbors jointly cheering and applauding essential service workers from their balconies. Merrill Gardens, a senior living facility in San Diego, offers daily balcony fitness classes led by an instructor from the sidewalk below (Luke, 2020).
Social Participation
The importance of social participation and connection was already receiving increasing attention prior to the COVID-19 pandemic. Now, social isolation has become even more of a pressing issue and we have seen an acceleration in technological innovation to meet these growing social needs.
Before the pandemic, I always found a number of social participation opportunities to attend. During the pandemic, I have, at times, become lonely but I feel fortunate I can reach out anytime to connect with people who care about me. (Colma focus group participant, age 55+, June 2020)
Older adults who had not embraced video conference technology are adopting rapidly. Mainstream corporations are designing an array of tablets and software platforms geared to promote social connection for older adults. Online classes, games, virtual tours of national parks and museums, as well as online music performances offer a variety of ways to stay engaged. Grandparents may be participating in online school with grandchildren, as well as offering tutoring support. Several governmental agencies and nonprofits have organized phone banks to reach out to older adults to mitigate social isolation. Older adults are also engaged in volunteering to make outgoing calls to at-risk community members.
The question remains, however, who is still isolated during this time?
We may know that someone is living in that house by themselves, and may be at-risk, but we may not know them or know how to find out who they are and what they need. Some do not answer their door. We need to know who these residents are. (Colma focus group participant, age 55+, June 2020)
Respect and Social Inclusion
New examples of ageism have surfaced with the COVID-19 pandemic. There is an increasing portrayal of all individuals older than 65 as being alike—helpless, frail, and unable to contribute to society. Older adults of color experience double prejudice, as well as those who are disabled or are part of other marginalized groups (Block & Mayer, 2020; Chan, 2020; Fraser et al., 2020). Ageism insidiously affects employment opportunities, health care, cultural attitudes, and even internal beliefs.
Older workers may be stereotyped as unable to keep up with jobs that are now remote and require increasing tech proficiency. As companies analyze their budgets, they may be tempted to cut senior salaries first. Employers who require customer contact may view older adults as a liability and some employers may be compelled to place older workers on involuntary leave or require them to engage in safety precautions not required of younger employees.
Increasingly, there is an “us versus them” mentality. Older adults are viewed as more of a burden—sometimes even seen as the reason for unemployment and the economy shutting down (Kessler & Bowen, 2020). Many young adults choose to continue to ignore public health guidance, citing low death rates in their own age categories. Many older adults feel increasingly invisible when out in public.
As a result of the pandemic, many people seem fearful of infecting older people and, as a result, sometimes avoid them. (San Mateo focus group participant, age 55-70, April 2020)
Even well-meaning volunteers perpetuate ageism by offering to help when help is not needed, belittling, and degrading ones’ sense of self-efficacy. COVID-19 has become yet another excuse for over-helping.
All of these experiences can lead to negative self-perceptions of aging and constricted mindsets about ones’ own limits. Internalized ageism can impact ones’ own mental health and even, ultimately, mortality (Levy et al., 2002).
Bonds between generations need to be strengthened. Older mentors can share valuable life experiences, including how they lived through other global emergencies and came out stronger. Research shows that older adults have been more resilient to COVID-19-pandemic–related stress compared to younger adults (Klaiber et al., 2020).
The media could highlight some of the many positive examples of older adults offering valuable contributions to their communities in response to COVID-19. The pandemic requires all ages to work together for our collective health, safety, and economic resilience, and older adults need to be recognized as essential to surviving the COVID-19 pandemic.
Civic Participation and Employment
Civic participation, employment, and volunteerism have all been drastically impacted by the COVID-19 pandemic. Local city council meetings have moved to Zoom, which limits participation to those who have access to the technology. Controversy continues around mail-in voting rights and how in-person polls will impact access and health. In addition, most poll workers and election judges are older than 60, and a massive shortage of workers is predicted for in-person polls (Sprunt, 2020).
Older adults have experienced disproportionate job loss. High rates of unemployment impact financial security of those near retirement. According to the Retirement Equity Lab, between March and June 2020, 7% of workers ages 55 to 70 left the workforce, compared to 4.8% of workers ages 15 to 54 (Papadopoulos et al., 2020). Many are retiring involuntarily due to the pandemic (Papadopoulos et al., 2020). Others are engaging in online learning to upgrade skills so they can find new work remotely.
The pandemic has reduced traditional opportunities for older adults to volunteer. Early in the pandemic, Hawaii Meals on Wheels lost 60% of their delivery volunteers (Kawano, 2020). Now, volunteers have shifted to dropping containers off at clients’ front doors.
Due to the pandemic, to protect the most vulnerable people right now, volunteer organizations do not accept anyone 60 or older. These places don’t normally have the age limit but, unfortunately, older people are being excluded at the present time. (San Mateo Focus group participant, age 55-70, April 2020)
Some volunteers have shifted to virtual opportunities. Other volunteers have shifted to letter writing, making masks, tutoring, or making friendly phone calls. Older adults offer an incredible resource to engage in contact tracing and other efforts to strengthen our nation’s health and the economy.
Communication and Information
The pandemic has led to more information and services moving online. Although older adults are more tech savvy than is commonly believed, the digital divide must be addressed to ensure that no one is left behind. Some older adults may not have access to dependable broadband internet or may not be able to afford technology-related costs. Language barriers, hearing or visual impairment, or other health conditions may impair one’s ability to use technology. In addition, some older adults may struggle with or lack interest in keeping up with increasingly complex technologies.
The COVID-19 pandemic has led to an increase in communication around emergency preparedness and safety. State departments on aging are offering webinars, emails, and infographics to guide residents in setting emergency plans in place, for example, if a primary caregiver develops COVID-19 (Coalition for Compassionate Care of California, 2020). There needs to be proactive efforts to combat false media and important messages should be offered in multiple languages.
I have not heard of any information on emergency preparedness/training and how to access information in the case of an emergency. For instance, now with the virus, knowing to wear a mask, etc. I am not able to access information. (Latinx San Mateo focus group participant, age 55+, April 2020)
Community Support and Health Services
Community-based organizations are critical to enable older adults to stay at home, especially while older adults face shrinking support networks due to self-quarantine, illness, and new financial realities. Since March 2020, adult day centers have shuttered their doors and family caregivers are facing increased demands. Many non-profits lost funding from grants and donations, leading to severe staff and program cuts. Although state governments face budget deficits, services that support older adults need to be maintained or increased, rather than being cut from budgets.
Senior service providers are adjusting to maintain safety and well-being for clients and staff. For example, In Home Supportive Services case managers are conducting assessments via video calls rather than home visits. Outpatient rehabilitation has transitioned to one-on-one therapy sessions in patient homes. Programs of All-Inclusive Care for the Elderly are limiting attendance or using telehealth to provide patient assessments. Congregate meal programs and food banks have transitioned to drive through pick-up meals and Meals on Wheels has ramped up to deliver to many more homebound adults.
I receive a bag of surplus food once per week. One week, I also received a face mask that I use when I go out. During the pandemic, the recreation center is calling seniors to see if they need anything, or if they need help…I am very appreciative of this outreach. (Colma focus group participant, age 55+, June 2020)
There is an increased need for professional in-home caregivers. Although there were already shortages in the caregiver workforce before COVID-19, the challenge of finding caregivers is even greater today. These workers are often at high risk of COVID-19 themselves. Many work in multiple facilities, multiple homes, or a mix of facilities and homes. They are paid low wages, and many have spouses who work in essential services or have lost jobs. One third of professional caregivers are immigrants, with one fifth of these individuals being undocumented (Poo, 2015). What efforts are being made to provide personal protective equipment, testing, training, and support to these frontline workers? A few homecare agencies are requiring workers to call in and report their temperature before they go into their clients’ homes, but there is a great need for more support.
The COVID-19 pandemic has driven unprecedented innovation and adoption of telehealth (Brody et al., 2020; Young & Fick, 2020; Young et al., 2020). Telehealth increases health care access in rural areas and for those with transportation challenges. Long-distance caregivers can now more easily participate in their parents’ health care visits.
During the pandemic, efforts to use telehealth in some areas has been able to reach more older adults who cannot get to a doctor. We need to continue developing this capacity in the City of San Mateo and the surrounding area as we move forward after the pandemic is over. (San Mateo focus group participant, age 55-70, April 2020)
However, telehealth may not be the solution for all health care needs. Providers lose the ability to read body language, and it may be more difficult to build rapport with new patients. Mandated reporters may also miss out on key warning signs of elder abuse or neglect. In addition, patients with hearing loss and impaired vision face barriers to telehealth. Captioning options and good headphones can help, but there is a need to provide technical support.
Many adults have delayed non-urgent health care in fear of going to clinics, where there is a perception of greater risk of COVID-19 transmission. Education is needed to assuage fears and assure safety of visits.
