engAGE in Community

Abstract

The growing numbers of older adults in the United States will have a significant impact on community resources, which will affect the ability of residents to live and thrive in their local community regardless of age. For this study, we applied explanatory sequential mixed methods and community-based participatory research (CBPR) to discover how attributes of the physical, social, and service environments determine residents’ perceptions of community age-friendliness and conditions for aging-in-place. A population survey measuring county residents’ (n = 387) perceptions and importance of community resources that support community livability are explained by thematic results of the CBPR, that is, emergent proximal and distal age-friendly factors. Our qualitative approach engaged local people (n = 237) in participatory processes to study and share perceptions of environmental attributes in six communities in one Oregon county. Findings are integrated to explain similarities and differences in older residents’ lived experience of rural and urban settings with regard to age-friendly foci.

Keywords

livability rural aging-in-place photo mapping cooperative extension

Within one generation, the population of adults aged 75 years and older will increase by no less than 175% in nine Oregon counties, of which Clackamas County is one (Oregon Department of Human Services, 2009). The demographic transition is driven by an aging population and the idea of “aging in place,” defined as continuing to live and be engaged in one’s local community, is reported as a top priority for older adults (Farber & Shingle, 2011). Clackamas County, home to a population of just over 375,000 (based on U.S. 2010 census data), is one of three metro (U.S. Department of Agriculture [USDA], 2004) counties in Oregon that include the Portland metropolitan urban growth boundary, geographically a mostly rural place (USDA, 2008) with 95% of area lying outside of the metro boundary, and the only metro county with identified unmet “rural” health care need (Oregon Office of Rural Health, 2013). Approximately 28% of county residents live outside of the Portland metro area in small rural cities and remote, unincorporated farming and forest communities, which as the population ages may burden personal and public resources.

The importance of focusing on aging populations and place-based aging resources is evident. Research supports that creating and improving community environments reinforces behaviors that enhance health and well-being for people of all ages (Srinivasan, Liam, O’Fallon, & Dearry, 2003). Ecological models acknowledge the importance of responsible individual health actions endorsed by population-based prevention efforts at broader organizational, community, and/or public policy levels (Maibach, Abroms, & Marosits, 2007; Stokols, 1996). Maibach and colleagues (2007) proposed an applied ecological model of public health action called the “People and Places” framework. Their framework highlights that attributes of people interact with attributes of places, which function proximally and distally across multiple fields of influence, to shape the health of populations and communities.

The concept of “age-friendly” places evolved from the World Health Organization’s (WHO; 2007) global age-friendly cities project. The foundational research involved significant discussion with older urban residents from over 30 countries, including Portland, OR, USA. The resultant model operationalized the definition of an age-friendly city as having environmental characteristics that “optimize opportunities for health, participation and security in order to enhance quality of life as people age” (WHO, 2007, p. 1). Canadian researchers built upon the WHO framework by applying a social ecological perspective (Menec, Means, Keating, Parkhurst, & Eales, 2011) and “rural” lens (Keating, Eales, & Phillips, 2013). Menec and colleagues (2011) premised that the benefits of community age-friendliness are conditioned across key ecological principles: environmental attributes are interrelated, interactive, and can be described in terms of their vicinity (proximal vs. distal); fit between the residents and the environmental conditions is critical, and leverage points exist within individuals and environments. They suggest the need for a mixed method “holistic and interdisciplinary research approach” (p. 489) that engages older adults in identifying need, prioritizing issues, and determining age-friendly actions (Menec et al., 2011).

Attributes of the environment are related to the ability of people to live and age actively and meaningfully in their place of choice (Wiles, Leibing, Guberman, Reeve, & Allen, 2011). It is not surprising that this relationship is perceived differently among residents in urban compared with rural places (Barber, 2013) and between policy makers and residents (Menec, Newall, & Nowicki, 2014). Spina and Menec (2013) found that age-friendly contextual factors, including policies and community characteristics, such as size, location, demographic makeup, and leadership influenced rural residents’ perceptions of community age-friendliness. Barber (2013) evoked place-based Extension educators, historically familiar with rural issues, to help communities become more age-friendly. Cooperative Extension, a system of integrated research and non-formal educational outreach supported cooperatively by federal, state, and local governments, and provided by public land-grant universities in the United States for over 100 years, is well positioned to help rural communities plan for an older population in the future. Age-friendly planning requires local input with an understanding of the current community context for place-based aging as well as a readiness to adapt—that is, increasing options and minimizing obstacles, so that all people have the opportunity to live and thrive at every age in their community place.

engAGE in Community was initiated as a community-campus health partnership between Clackamas County Social Services, Oregon State University (OSU) Extension, and AARP Oregon with the aim of creating “age-friendly” Clackamas County. Mixed methods and community-based participatory research (CBPR) activities were used to engage and mobilize stakeholders, gather and share information about the interplay between attributes of people (i.e., individual, social, cultural) and attributes of place (i.e., local, county, region) that were experienced as positive or negative conditions for actively aging-in-place. As a qualitative approach to health and local place research (Minkler & Hancock, 2010), CBPR created a linkage between age-friendly concepts, rural and urban communities, and Extension community health educators, addressing what has been recognized as a limitation in the age-friendly literature with regard to the experiences of older people aging in rural places (Lui, Everingham, Warburton, Cuthill, & Bartlett, 2009). Community–Extension health partnerships had the potential to add value for community participants, public health practitioners, and researchers through the use of relevant experiences in communities where people live, and to construct shared knowledge and community-informed health actions (Barber, 2013; Viswanathan et al., 2004) useful for improving their lives and communities.

The specific aim of this mixed-method study was to gain a better understanding of the urban and rural contexts for place-based aging to inform programs and policy. An ecologically grounded adaptation of the WHO (2007) age-friendly topics informed by Maibach and colleagues’ (2007) “People and Places” framework was adopted as the project’s explanatory model (Figure 1). The age-friendly model, represented as a flower, categorizes the topical features of age-friendly places into eight observable focus areas, including transportation, housing, outdoor spaces and buildings, social participation, respect and inclusion, civic engagement and employment, community supports and health services, and communications and information. We organized the eight areas within three symbiotic environmental categories—physical, social, and service—to capture the built or structural, social (person-to-person interactions), and service (person-to-agency interactions) community contexts. These environmental categories overlap and interact; that is contextual attributes of community place work together and interplay with attributes of community people across all ecological spheres of influence. Attributes of place are experienced by people proximally (i.e., local community) and distally (i.e., county or region). Our study objectives were twofold and complementary: (a) to describe the population of adult county residents’ perceptions of availability and importance of age-friendly community characteristics; (b) to engage and mobilize midlife and older community residents to individually and collectively explain the attributes of their local community as supports or barriers to actively aging-in-place. Our approach allowed for a robust examination of differences in residents’ perceived and lived experience of the age-friendliness of urban and rural communities, and explanation of the role of age-friendly environments on midlife and older adults’ experiential quality of community life.

Figure 1.

For the “engAGE in Community Age-Friendly Model,” the World Health Organization’s “age-friendly” topic areas were categorized into three separate (but not isolated) environmental categories: physical (i.e., outdoor spaces and buildings, transportation, housing), social (i.e., social participation, respect and social inclusion, civic participation, and employment), and service (i.e., communications and information, community support and health services).

Method

This study was conducted between January 2011 and July 2012 as a research component of the larger engAGE in Community initiative. Data were collected using mixed methods and an explanatory sequential design (Creswell & Plano Clark, 2011). A quantitative representative sample survey of the Clackamas County adult population was followed by qualitative methods involving middle-aged and older adult residents in mapping environmental assets in their local communities using participatory photographic surveys. The qualitative phase was given priority because a key objective of community mapping was to partner with and engage older residents in explaining how and why environmental assets contribute to their lived experience of community age-friendliness, developing collaborations and designing assessment-driven projects to improve local age-friendly options. As suggested by Viswanathan et al. (2004), we employed CBPR tools to empower people in communities to determine what supports residents have, need, and want to age actively and intentionally in their place of choice, and to use their voices and vision to encourage and enact change. OSU’s institutional review board approved the study #4871 protocol.

Quantitative Telephone Survey

Academic researchers collaborated with agency partners to design a survey to inform a county needs assessment for future aging and disability services. The age-friendly survey components measured adult residents’ perceived availability and importance of community features, and self-reported health and quality of life behaviors related to age-friendly features, such as walking in the neighborhood and using public transit. Age-friendly survey items were selected and adapted from assessments previously developed for urban (WHO, 2007) and rural (Federal/Provincial/Territorial Ministers Responsible for Seniors [F/P/T], 2007) communities. Health behavior items were selected from the U.S. Centers for Disease Control and Prevention (CDC) Behavioral Risk Factor Surveillance System Survey Questionnaire (CDC, 2010). Portland State University’s Survey Research Lab was contracted to administer the final 32-item survey using computer-assisted telephone interviewing software and trained interviewers.

Clackamas County adult residents (n = 387), ranging in age from 21 to 93 years (M = 61 years), voluntarily responded to a random digit dialed telephone survey of a representative sample (N = 2,849) of records proportionally distributed by geography and age of the adult population across Clackamas County, and excluded those living in assisted living, residential care, and nursing facilities. To measure residents’ perceptions, respondents rated a series of statements depicting age-friendly characteristics while thinking of [their] community. Respondents were then asked to rate the importance [to them] of each characteristic. A 4-point Likert-type scale was used for all items with response options varying by category. Once the primary survey questions were completed, respondents were asked a series of demographic, household and community (size/type), and general health and behavioral items. Sampling strategies were employed to ensure adequate representation of older adults (n = 210; age ≥60 years) and from more rural communities.¹ Survey data were analyzed using IBM SPSS Statistics, version 19.

Qualitative MAPPS™ (Mapping Assets Using Participatory Photographic Surveys)

MAPPS™, a CBPR tool developed by Extension researchers (John & Gunter, 2012a, 2012b), integrates community outreach and engagement principles with community asset surveys using participatory photo mapping (PPM; Dennis, Gaulocher, Carpiano, & Brown, 2009) and facilitated community conversations (Carr & Halvorsen, 2001). The engagement and assessment tool provides visualized data and elicits residents’ reflective and collective narratives of their lived experiences of the community qualities and dimensions of community readiness (Edwards, Jumper-Thurman, Plested, Oetting, & Swanson, 2000) to address local health and place concerns.

At the level of local community, a descriptive case study design was utilized for the CBPR. Communities, defined as geographically and politically delineated places or settlements within the county, were mobilized to “engAGE in Community” during a county-wide launch of the initiative. Demographic and other relevant characteristics for our six participating communities, conveniently selected for inclusion because of their community interest in bringing engAGE activities to their locale, are presented in Table 1. Of the three more “rural” communities, one (H) is classified as a remote rural agricultural or woodlands village, one (C) as small rural agricultural town with a densely populated city center, and one (D) as small town on the rural perimeter of the urban growth boundary. The three more “urban” communities are all classified as suburb/small cities within the metropolitan urban growth boundary. Letters have been assigned and used throughout the manuscript as identifiers in place of town names to maintain anonymity.

Table 1.

Characteristics of More Urban and More Rural Study Communities, Clackamas County, OR.

	More urban communities			More rural communities
	Town O	Town M	Town W	Town C	Town D	Town H
City land area	9.05 mi²	4.82 mi²	7.21 mi²	3.75 mi²	16.04 mi²	6.90 mi²
Population density	3,518/mi²	4,206/mi²	2,707/mi²	4,222/mi²	657/mi²	482/mi²
Total housing units	12,900	9,138	8,487	5,890	3,769	3,635
Demographics^a
Population size (n)	31,859	20,291	19,509	15,829^b	10,280^b	4,864
Persons ≥65 years	11.2%	13.6%	13.3%	14.2%	13.3%	15.3%
Education (population ≥25 years)
High school graduate or higher	90.5%	91.5%	89.3%	84.1%	93.0%	87.6%
Bachelor’s degree or higher	21.9%	22.3%	37.8%	23.7%	29.1%	24.0%
Median household income	US$56,153	US$53,207	US$55,881	US$57,427	US$81,827	US$51,031
Families below the poverty level	12.7%	12.6%	10.4%	9.9%	1.9%	3.9%
MAPPS™ participants (n = adults, ≥50 years)	7/23	9/34	9/59	18/37	7/27	12/57

Note. Communities were classified according to descriptive qualifications that included a quantification of population size for survey research purposes. We concur with Menec, Means, Keating, Parkhurst, and Eales (2011) that urban and rural are not dichotomous, and it is more helpful to consider communities on an urban–rural continuum. MAPPS = mapping assets using participatory photographic surveys.

U.S. Census Bureau, American Community Survey.

Rural agricultural or woodland community with population greater than 10,000.

Access to the communities was supported by local public sector sponsors (e.g., adult center directors), community champions with an interest in improving overall community livability. A purposive sample of middle-aged (age 50-64) and older (age ≥65) adult residents reflecting the population most concerned with age-friendly issues, and local sector stakeholders, were recruited from each community using targeted communications and snowball sampling to participate in engAGE MAPPS™ activities. Local volunteers were mobilized to explore the age-friendliness of their community, trained to collect data using qualitative tools, and participated as members of the engAGE MAPPS™ community-based research team.

First, MAPPS™ teams were trained and deployed to collect data using PPM (Dennis et al., 2009) in their residential community. PPM has been used to explore questions of neighborhood health and safety with youth (Dennis et al., 2009) and rural physical activity friendliness with adults (John, McCahan, & Gaulocher, 2012). In each community, individual team members were provided equipment and utilized direct observation, photography and GPS (global positioning system) units to map the community features they regularly encountered. Photographed features were annotated as age-friendly supports or barriers on accompanying field surveys. The team reconvened 2 weeks later for a focus group to elucidate and select photographs for presentation during the community conversation. Two weeks after the focus group, a community conversation was held, which included a hosted dinner open to all community members, presentation and dialog facilitated by an Extension researcher. Narrative data, generated as people reflectively discussed their unique and shared experience of the displayed selection of photographed and mapped features, were qualitatively examined using facilitated guided discovery (Franz, 2013) to give meaning to the disparate experiences of individuals and groups related to place-based attributes, that is, utility, accessibility, and affordability of locally available assets.

Each town was developed as a separate case project using our model (Figure 1). Our community case study design allowed for systematic gathering of information about and with study communities to explore and explain how and why local assets support or limit people’s ability to actively age-in-place and provide a resident-informed descriptive report of the age-friendliness of the town. Provisions to protect the privacy of participating communities and anonymity of data were assured and maintained. From the six participating communities, 62 volunteer MAPPers (age ≥50 years) recruited primarily via local adult centers contributed to the community assessments by individually photographing, mapping (i.e., geotagging), and annotating over 630 environmental features they perceived as either supporting or hindering community age-friendliness. Local residents and stakeholders (n = 237), including many of the community MAPPers, participated in community conversations and contributed to the collective narrative, commenting on the quality and spatial distribution of the physical, social, and service attributes of their local community within Clackamas County.

Community case data from all sources (e.g., MAPPers’ field and focus group annotations, photographs, and maps; presentation slides and transcribed community conversations) depicting subjective qualities of environmental attributes were managed using NVivo 9. Qualitative data were deductively coded into one or more environmental categories and age-friendly topic areas. For this article, conversation narratives and images used to provoke conversation were then inductively coded into nodes labeled supports, barriers, proximal, distal. Data were coded by two members of the project team trained in qualitative research methods, analyzed using a constant comparative method at each conceptual level of influence, triangulated across quantitative and qualitative data sources, and verified by at least one MAPPS™ team member from the respective community who reviewed the queries and draft results report for consistency.

To address the second aspect of our study purpose, that is, to explain differences in residents’ perceptions of community age-friendliness as an aspect of type, community projects from urban (n = 3) and rural communities (n = 3) were merged. Data representing age-friendly supports or barriers in the community as experienced by residents, represented by geo-located photographs and explained through coded narratives, were queried to reveal different age-friendly aspects of urban and rural communities. Triangulation allowed a comparison of the results from different data sources, methods of data collection, and communities to look for similarities and differences, develop and/or substantiate the overall interpretation (Pope & Mays, 1995). Emergent themes and areas of meaning from all communities were examined in relationship to our conceptual model.

Results

Quantitative results of the county population survey measuring perceptions of availability and importance of community characteristic and descriptive characteristics of the sample are reported first. Second, qualitative reports of significant population-level findings are integrated with the thematic results of community-level CBPR, that is, emergent age-friendly assets or obstacles, which are organized and presented by environmental category. Italicized phrases are used to identify thematic factors emerging from the data that conceptually reflect WHO subcategories respective to the environmental category. Verbatim statements from transcripts of community conversations are inserted throughout the text to personify emergent themes.

Survey of People

Descriptive characteristics of the 387 survey respondents are presented in Table 2. Additional descriptive statistics (data not reported) were calculated for the subset of respondents (n = 210) aged 60 years and older to assure adequate representation (78.1% were 65 or older) of older residents.

Table 2.

Characteristics of Representative Sample of Clackamas County, OR, Adult Residents Responding to Telephone Survey.

	Total (n = 387)
Characteristics	n	%
Age
21-49 years old	81	20.9
50-64 years old	133	34.4
≥65 years old	164	42.4
Don’t know or refused	9	2.3
Gender
Men	147	38.0
Women	240	62.0
Race
White	362	93.5
Black or African American	4	1.0
Asian or Asian American	8	2.1
American Indian or Alaskan Native	14	3.6
Don’t know or refused	7	1.9
Ethnicity
Spanish, Hispanic, or Latino/a	5	1.3
Household size
1 person	70	18.1
2 people	175	45.2
3 people	60	15.5
4 people	46	11.9
5-11 people	33	13.1
Don’t know or refused	3	0.8
Annual household income
<US$25,000	51	13.2
US$25,000 to <US$35,000	33	8.5
US$35,000 to <US$50,000	46	11.9
US$50,000 to <US$75,000	67	17.3
US$75,000 to <US$100,000	53	13.7
US$100,000 to <US$150,000	33	8.5
US$150,000 or more	27	7.0
Don’t know or refused	77	19.9
Community type (and size)
Remote rural agricultural or woodlands	80	20.9
Small rural town (<2,500)	65	16.8
Small town (2,500 to <10,000)	31	8.0
Suburb/small city (10,000 to <50,000)	176	45.5
Urban/metropolitan city (>50,000)	27	7.0
Don’t know or refused	7	2.0

Note. A maximum expected amount of variation (i.e., 50/50) was used to calculate the sample size for a sampling error of 5%. A total sample size of at least 383 respondents was needed to be 95% confident that the overall results are those we would expect to find within that specific community. The completion of 387 surveys resulted in a final sample error of 4.98%. A response rate was calculated based on only resolved numbers (n = 902). This calculation resulted in a response rate of 42.90%, which represents the proportion of all resolved numbers that actually completed surveys of the total sample numbers loaded (N = 2,849).

Table 3 presents the results of two-way contingency table analyses conducted to evaluate the relationships between residential community type (rural, urban) and adults’ perceptions of availability and importance of community age-friendly characteristics. Community types reported as urban/metropolitan city (50,000 or more people) and suburb/small city (10,000 to <50,000 people) were classified as urban. Other community types, including small town (2,500 to <10,000 people), small rural town (<2,500 people), and unincorporated remote rural agricultural or woodlands, were classified as rural. Survey items (specific statements describing community attributes) allowed for responses stratified across a continuum (strongly agree, agree, disagree, strongly disagree). For each survey item to which respondents were asked if they agree or disagree, they were asked a follow-up question about how important (very, important, somewhat, not) that characteristic was to them. To account for low numbers of responses in the extremes (e.g., strongly agree/disagree, very/not), data were collapsed into two response categories for the purposes of these analyses. Survey items were dichotomized (agree/disagree; very/somewhat) depending on the item. Data were analyzed by residential community type (rural/urban) for each item with statistically significant results indicated in bold font. For each significant finding, a smaller proportion of respondents in rural compared with urban communities agreed that the age-friendly characteristic was available in their community and/or rated the feature as important to them. Cramer’s V was applied as a post-test to determine strength of associations with the walkability items showing a moderate association. The alpha level for all analyses was .05.

Table 3.

Contingency Table Analyses of Population Survey of Clackamas County, OR, Adults’ Differences in Perceptions and Importance of Age-Friendly Characteristics by Residential Community (Rural or Urban) Types.

Survey category
Community characteristic
Importance of characteristic to respondent	df, n = valid cases	Pearson χ²	Cramer’s V	p value
Physical environment
Walkable with sidewalks/paths maintained	2, n = 380	45.411	.346	<.001
This is important to me	1, n = 380	30.821	.285	<.001
Accessible public buildings to people with different abilities	2, n = 379	7.496	.141	.024
This is important to me	2, n = 380	8.552	.150	.014
Roads are adequately marked with visible signs	1, n = 380	0.083	.015	.773
This is important to me	1, n = 380	0.214	.024	.643
Adequate public transportation features	2, n = 379	12.088	.179	.002
This is important to me	2, n = 380	2.334	.078	.311
Adequate special needs transportation features	2, n = 377	17.666	.216	<.001
This is important to me	2, n = 379	1.091	.054	.580
Driver network supporting those who cannot drive	2, n = 375	2.543	.082	.280
This is important to me	2, n = 378	0.189	.022	.910
Housing options exist that meet a variety of abilities/lifestyles	2, n = 377	5.381	.119	.068
This is important to me	2, n = 378	2.916	.088	.233
Varied long-term care options are available in my community	2, n = 379	15.765	.204	<.001
This is important to me	1, n = 380	4.267	.106	.039
Social environment
Seniors are asked for input on public issues	2, n = 375	0.839	.047	.657
This is important to me	2, n = 378	4.423	.108	.110
Range of outdoor/indoor activities available for all ages	2, n = 380	9.761	.160	.008
This is important to me	2, n = 380	2.969	.088	.227
Range of courses/educational classes offered in community	2, n = 379	12.152	.179	.002
This is important to me	2, n = 380	2.499	.081	.287
Range volunteer opportunities are available	2, n = 380	15.968	.205	<.001
This is important to me	2, n = 380	0.584	.039	.747
Community shows respect, kindness, toward each other	2, n = 380	5.436	.120	.066
This is important to me	2, n = 380	0.547	.038	.761
All ages are valued/included in community life	2, n = 376	5.969	.126	.051
This is important to me	2, n = 379	0.747	.044	.688
Service environment
Local services, programs, events information is available	2, n = 379	9.439	.158	.009
This is important to me	2, n = 380	6.322	.129	.042
Health care and mental services are available	2, n = 379	5.276	.118	.072
This is important to me	2, n = 380	5.168	.117	.075

Note. Degrees of freedom, number of valid cases used in analysis is provided parenthetically for each item. Bolded text indicates items significant at p < .05. All significant results indicate a lower proportion of rural residents reporting the perceived availability of the characteristic in their community and personal importance of the characteristic.

Elucidation of Place

Navigating the community

Across all six communities, participants’ photo mapping routes provided visualized data (see Figure 2) that explained their dependence on a personal motor vehicle to navigate the resource environment and access place-based assets they considered important to the quality of their daily lives. Participants were instructed to utilize the mode of transportation that they typically used to access regularly used community assets, and photograph the features that they directly experienced as age-friendly supports or barriers. Participants in rural, versus urban, communities exclusively utilized personal motor vehicles to complete their routes. However even in urban communities, as exemplified in Figure 2, route maps illustrated the spatial distribution of local resources and allowed the thematic barrier of automobile dependence, in contrast to public transit availability or walkability, to be visualized.

Figure 2.

Residents participated in photo mapping to document the availability and location of environmental features that were experienced as age-friendly, or not, as they navigated life in the local community.

Community conversations

Thematic results of community-level CBPR, that is, age-friendly attributes emerging from conversation narratives, are presented in Table 4. Attributes that emerged across communities are listed as supports or barriers, and as encountered proximally, distally, or both. Results are organized into three environmental categories containing respective WHO (2007) focus areas represented in our model (see Figure 1).

Table 4.

Emergent Age-Friendly Supports and Barriers Proximal and Distal to MAPPS™ Communities in Clackamas County, OR.

Environment
WHO category	Emergent supports	Emergent barriers
Physical
Transportation	Active (walk/bike) transportation system/plan (P)	Automobile dependence (P,D)
	Pedestrian/bicyclist safety (P)	Public transit routing and schedules (P,D)
	Free/low cost public transit (P,D)	Driver (few/no) networks (P,D)
	Light rail (P,D)	Pedestrian/bicyclist safety (P)
		Light rail (P,D)
Housing	Independent and assisted living housing units/options (P)	Independent and assisted living housing units/options (P)
	Universal design and planned neighborhoods (P)	Restrictive neighborhood planning, design, and land use policies (P,D)
	Long-term/adult day care options (P)	Crime and safety (P)
		Long-term/adult day care options (P)
Outdoor spaces and buildings	Accessibility of public spaces (P)	Accessibility of public spaces (P)
	Walkability (P)	Unmaintained, disconnected sidewalks, paths, trails (P)
	Community aesthetics (P)	Neighborhood isolation (P)
	Gardens, parks, green spaces (P)	Exclusionary land use policies (P,D)
	Shared land use policies (P,D)
Social
Social participation	Community culture (P)	Community safety/crime (P,D)
	Tradition norms (P,D)	Exclusionary policies and practices (P,D)
		Economic instability (P,D)
		Low critical mass (P)
		School and school district policies (P,D)
Respect and social inclusion	Community culture (P)	Low critical mass (P)
	Sense of community connectivity (P)	Costs (P)
	Intergeneration and multi-ethnic programs and events (P)	Intergeneration and multi-ethnic programs and events (P)
	Inclusive strategic planning (P)	Exclusionary policies and practices (P,D)
		School and school district policies (P,D)
Civic participation/employment	Volunteer opportunities (P)	Exclusionary policies and practices (P,D)
	Opportunities for productive civic engagement (P)	School and school district policies (P,D)
		Volunteer opportunities (P)
Service
Communication and information	Traditional communications (P,D)	Low participation in civic discussions (P)
	Informal communication networks (P)	Knowledge gaps (P)
	Local communication plans (P)	Quality of information postings (P)
	Information technologies (P,D)	Information technologies (P,D)
Communitysupport andhealth services	Home health care (P)	Home health care (P)
	Adult day and foster care (P)	Limited medical/emergency transport (P,D)
	Meal sites and delivery (P)	Economic conditions and public services (P,D)
	Tax service districts (D)	Disparities in costs/quality/availability of necessary good and services (P,D)
	Urgent care and pharmacies (P)

Note. P = proximal, local/community; D = distal/county and beyond. Themes labeled using bold font emerged as age-friendly supports when available and barriers when unavailable locally or in close proximity to the community within the county, which emerged as a dichotomy between rural and urban communities.

Physical environment

Telephone survey results revealed significant differences by community type for county residents’ perceptions of availability and importance of some characteristics categorized as physical environment topic areas (transportation, housing, outdoor spaces, and buildings). A higher proportion of respondents from rural compared with urban communities disagreed that there was adequate public (48.6% vs. 31%, respectively) and special needs (28.9% vs. 11.7%, respectively) transportation features. However, there was no association between community type and ratings of importance for these attributes with about half of all respondents rating transportation features as important. Proximal transportation-related features emerged as supports, including free/low cost public transit provided locally or regionally and neighborhood improvements that support walking and bicycling to destinations, which were mostly not available in rural communities. Transportation barriers included limited transit routes, restricted schedules, and few destination options for older residents and others who do not/cannot drive themselves; lack of supports at transit stops; no/limited volunteer or commercial driver network; pedestrian/bicyclist safety due to traffic and roadway design; scarce active transportation options and neighborhood isolation. When faced with the inability to drive, older urban and rural residents experienced few/no viable transportation choices, which makes aging in place more difficult in Clackamas County. One resident of an urban community explained,

We always have to use a motorcar, which is not always what older people prefer doing. It is not [our] big pleasure in life to drive around [alone] from place to place.

A large majority of Clackamas County older residents live in their own homes. Most survey respondents from urban (86.5%) and rural (70%) communities reported that varied long-term care options are available in their community, and significantly more rural (20%) versus urban (7.7%) community respondents disagreed that these resources are available locally. Surprisingly, significantly fewer rural (66.6%) versus urban (73.4%) dwellers rated this as an important community attribute. Housing qualities, including local variety in affordable, accessible single and multi-family options, appropriate options for a variety of interest, such as planned villages, and affordable assisted living options, were explained by both urban and rural community residents as contributing to community age-friendliness. Housing-related characteristics that were identified as “age-friendly” included neighborhood safety, walking trails, and green design that have connectivity to social and services features. Barriers to place-based aging were discussed in all community conversations, included scarcity of appropriate housing units, including accessible, affordable owner occupied and rentals despite a plethora of large, single family homes/home sites; land use policies that limit development of mixed-use neighborhoods; perceived crime and safety risks in isolated, low-income neighborhoods; and few/no assisted living options in rural communities. One [W] resident who uses a wheelchair clarified,

Affordable, accessible housing is very necessary here. My place is both . . . and it’s connected (by a covered walkway) with the community center. It’s wonderful and open for only four months—it’s full.

Twice as many residents of urban compared with rural communities agreed that their community is walkable (67.6% vs. 33%, respectively), yet significantly fewer rural (38%) compared with urban (61.8%) community residents report walkability as important. In contrast, conversation data from urban and rural communities revealed accessible outdoor spaces and buildings and improved walkability as very important for promoting active aging and personal mobility, social and cultural participation, and community vitality. Local characteristics that were explained as age-friendly included aesthetic features and destinations; community gardens, rural and open spaces, nature preserves and parks; and shared land use policies and environmentally friendly practices, including public and privately supported mobility supports. Both urban and rural residents experienced certain features as barriers, including unmaintained, unlit, and discontinuous walkways, commercial vacancies; inaccessible or isolated public spaces/venues, for example, parking lots, grange halls, churches, community or recreational centers.

Social environment

Several telephone survey items categorized as social environment were significantly associated with residential status. Although the majority of survey respondents agreed that a range of events and activities, courses, and educational classes are available for all ages, and volunteer opportunities are available in their communities, 2 to 4 times as many rural compared with urban residents disagreed that events and activities (25% vs. 13.5%), educational opportunities (17.3% vs. 6.3%), and volunteer opportunities (12.1% vs. 2.8%) are available. Having these events and activities available to everyone in their community was important to most (65%-75%) survey respondents; perceived importance of social environmental attributes did not differ by urban–rural status. The vast majority of all survey respondents agreed that there is respect, kindness, and courtesy shown in their community (87.6%), everyone is valued and included in community life (76.2%), and that these aspects of their community are important (90.0% and 80.0%, respectively). Clackamas County was qualitatively experienced as supportive with regard to the social environment, as illustrated by photographs of community and adult centers, churches, restaurants, theaters, and music venues although rural community members explained social participation supports differently than urban dwellers. Rural community conversations revealed age-friendly social environment assets as traditional community culture and norms supported through historic features and acts, such as grocery delivery, postal drop boxes, murals, and traditional events. Another aspect of the social environment—sense of community and connectivity—emerged as a strong supporting attribute for the age-friendliness of rural communities with an emphasis on people and place as “community” and a sense of belonging “as good as family.” A rural woman emoted,

The community is a family in [D] and you feel safe . . . most people like the rural feeling, the open spaces, we all like that here . . . the city came up with the core values . . . some were to preserve the rural feel.

Also in rural communities, volunteerism and opportunities for civic engagement were cited as valued and necessary assets, particularly faith groups and churches.

Local barriers to social participation informed perceptions of community age-friendliness, emerging thematically from community conversations, including costs, availability, and accessibility of programs and facilities, economic instability of social venues and businesses, which come and go because they are not fiscally viable, and community safety/criminal activity in public places, which emerged more so in urban communities. Proximal attributes of a respectful and socially inclusive community emerged as intergenerational and multi-ethnic community centers, library programs, and cultural events; a sense of community as “family” and “home”; and community/neighborhood plans that consider the interests and conditions of all community members and groups. Nevertheless, social environment attributes, including respectful, inclusive, and intergenerational participation opportunities were frequently identified during community conversations as areas for improvements, particularly in urban communities. Urban [M] community participants explained,

There are a lot of people who, as they age, can’t get to “their” church; so, it’s either a new or no church and they really feel left out. [I don’t know of] a clearing house, beside the computer, where people can learn of clubs or societies or volunteer groups . . . you come new to the neighborhood and can’t connect. That [clearing house] would be friendly to people who aren’t computer literate . . . like a senior center without walls.

Thematic obstacles to creating a more inclusive age-friendly social environment included accommodating differences with a low “critical mass” even in urban communities, school districting policies (separating families), and exclusionary rules and regulations. A [C] resident clarified,

Sometimes it’s difficult for older adults to volunteer with kids in the community and for kids to help out with seniors . . . because of paperwork, background checks, school policies, et cetera. It should be easier to get generations together to help, to learn from each other.

Service environment

There were no significant differences between urban and rural survey respondents in perceived availability and importance of health care and mental health services. Most (75.4%) respondents rated having health services available in their community as important, yet more rural (31%) than urban (21%) respondents disagreed that health, including mental health, services are available. Although most survey respondents agreed that information about local services, programs, and events is available, significantly more rural compared with urban residents (19% vs. 10%, respectively) disagreed. Both rural and urban residents rated this as an important attribute, but significantly more urban residents rated this to be important compared with rural residents (75.4% vs. 64.7%, respectively).

Three supportive attributes for rural age-friendliness emerged from the qualitative data, including traditional communications, informal communication networks, and community communication plans. Figure 3 provides a photograph of a rural community’s communication and information age-friendly asset along one mapped route, which was explained by [H] community conversation participants,

Grapevine amazing . . . how fast people jump into action—telephone call line, neighbors check on each other, some have the Internet, cell service is spotty . . . very spotty. The weekly [paper] covers some mountain news—it’s free by mail and at pick up boxes. There’s a list of all activities for the month on bulletin boards at the post office, grocery store, bank, and local restaurants . . . and the fire department is a source of community communications.

Figure 3.

Age-friendly characteristics of rural service features were those that supported local communications, social connectivity, and traditional information systems exemplifying residents’ value for a rural quality of community life.

Barriers in both urban and rural communities emerged as a discrepancy between the provision and consumption of information: low participation in public informational events, gaps in knowledge about available information networks, quality and placement of signage and information postings, and skills and access required of new information technologies. An older [M] woman objected,

The whole technological aspect of finding things and linking with people . . . for [our generation] it’s hard to think about how to communicate or connect with people . . . it’s a lot harder.

Community supports and health services themes emerged from community conversations. Proximal supports included adult day and foster care programs, meal sites and delivery programs, urgent care and pharmacies, while tax service districts emerged as a distal support providing stable public funding for programs and services, such as firefighting, law enforcement, parks and recreation, and Cooperative Extension. Barriers to age-friendliness emerged both proximally and distally: absence of home health care providers, limited health transport/emergency medical technician services, economic conditions and reduced public services, disparities in costs of and quality of necessary goods, and services across communities (e.g., gasoline, food, utilities, exercise/therapy, and home/auto maintenance). Residents in rural communities voiced supports and barriers to age-friendliness differently than residents in urban communities. Local health care and health-related services, like medical, dental, health and mental health therapy, vision, pharmacy, ambulance, and alternative health services emerged as minimally or not available in rural communities. When available, health services in smaller communities were “under-utilized” and if “regular” health care became necessary, people were forced to reevaluate their ability to remain in the community.

Discussion

engAGE in Community was envisioned and enacted as a county-wide action research strategy to assess aging-in-place needs of current and future older populations, and to engage and mobilize adults in communities to explore local assets and strengthen active aging supports. Our mixed-methods approach was successful in measuring differences in perceptions of availability and importance of age-friendly characteristics among population subgroups, mobilizing local people to reveal supports and barriers for actively aging-in-place, and identifying locally informed solutions to positively affect community age-friendliness. Furthermore, we were able to explain older adults’ differences in perceptions and importance of their community’s age-friendly features by urban and rural community type. We also found that how residents’ perceived age-friendliness varied by community independent of urban and rural designation.

Cooperative Extension has, for over 100 years, served as trusted resource and collaborator in rural communities to increase access to practical, problem-solving research and local solution-focused education to meet the land-grant university’s outreach mission. In this study, community–Extension health partnerships and Extension-developed tools effectively connected local people with attributes of places. This provided an immediate benefit to the community by constructing and transferring knowledge about the fit between older residents and their local environments, a need suggested by Menec et al. (2011), and others (Keating et al., 2013; Wiles et al., 2011).

Generally, our results support an ecologically conceptualized model of “age-friendliness” based on WHO (2007) focus areas. In particular, our results illustrate the importance of understanding and communicating the interplay between attributes of people and the environmental attributes of place to local residents’ ability to engage and age actively in their community. Our mixed-methods approach allowed us to compare perceived existence and importance of environmental assets and explain how they differ between rural and urban places and among rural and urban residents. Furthermore, locally constructed and pragmatic meanings of community age-friendliness revealed how one aspect of the environment, for example, the social environment “sense of community and connectivity” emerged as a strong, supportive attribute for the age-friendliness of rural communities that connected people in solidarity to place despite the scarcity of physical and service environment supports found in more urban settings.

CBPR data upheld that an age-friendly rural community was linked to people’s experiences of connection, belonging, and autonomy within the social collective rather than their experiences of the structural or service attributes. This finding is in contrast to Barber (2013); however, Barber coded for rurality at the level of county, which operated as a distal factor in our analyses, and would have masked the urban–rural community continuum that exists within a large “metro” county when working on a smaller geographic scale. Our findings are more similar to John and colleagues’ (2012) exploration of rural community “activity friendliness” that found the experiences of rural people in a “micro-metropolitan County” were specific to the town in which they lived, and to what they valued about life in their local community.

Our engAGE in Community Age-Friendly Model (Figure 1) has practical implications. When applied to our data by community case, our model revealed that regardless of where a community fell on the urban–rural continuum, age-friendliness was a function of the distribution of environmental supports for active aging in place within the WHO (2007) focus areas, and people’s values for having those supports locally available and easily accessible. Our model illustrated the added value of multi-level shared responsibility and interagency support for locally driven solutions to a community’s most proximal age-friendly concerns. Highlighted concerns included scarcity of supports in a locally important environmental category, as well as the need for community-informed decision-making for county-level, that is, distal, budgetary and policy actions.

engAGE MAPPS™ emphasized the role of community members as authorities in local issues that affect their health autonomy and confirmed unmet rural health needs for aging in place in a metro (USDA, 2004) county. Navarro, Voetsch, Liburd, Giles, and Collins (2007) posited, and we agree, that if interventionists understand how people experience health where they live, we can better understand how to intervene in meaningful ways within the social ecological context and with diverse populations. Beverly, Mcatee, Costello, Chernoff, and Casteel (2005) determined in an assessment of rural communities with a focus on health needs of older adults, more than half of respondents reported leaving their communities to receive health care, a finding our rural community data supported. Yet, despite what was revealed as dearth of supports for healthy aging in place in the physical health domain, our study approach empowered residents’ to define age-friendly within the social health context of their rural place, suggesting the need for mixed methods and innovative approaches to visualize the health influence of place on people, and of people on place.

Qualitative data explained why, in particular, age-friendly rural community efforts provide more and easier local access to opportunities for older people to stay active and engaged in community life, including opportunities to work with youth, inclusive employment, education, and volunteer policies and practices that are easy to negotiate. These findings are consistent with Gonzales and Morrow-Howell (2009) contention that efforts to evaluate and improve a community’s age-friendliness should centrally consider opportunities for “productive engagement”—employment and volunteer opportunities—of older residents. Quantitative data confirmed the necessity for a comprehensive county transportation plan that considers the diverse conditions that reinforce residents’ dependence on personal motor vehicles and addresses age-friendly transportation needs of urban and rural communities. Our MAPPS™ data explained that local community engagement policies and practices explained as “exclusionary” and “restrictive” did little to support perceptions of age-friendliness. We contend that even policies promoted as “age-friendly,” such as expanding mass transit and public transportation or increasing active transportation supports, which are often determined distally and applied locally, may not operate to support productive engagement and social connectivity for people who are aging in place in urban neighborhoods or rural communities that are geographically or otherwise marginalized, an area for future research.

Conclusion

Perhaps the greatest outcome of this study is the manner in which stakeholders are leveraging the findings. County leaders are driving land-use and budgetary policy decisions with engAGE data that will address distal and proximal age-friendly concerns related to the physical, social, and service environment. This approach reflects a new model of participatory, collaborative governance. Age-friendliness in Clackamas County is viewed as “integrated physical, social, and service environments” that utilizes an upstream approach to inform political decisions, which is representative of Lui and colleagues (2009) “ideal” model.

One urban and two rural communities used data to secure funding to implement resident-informed actions, including increasing public transit ridership in the most urban community, organizing intergenerational community beautification, and planning for a community center in the two rural communities. Two other communities have continued health improvement planning efforts and integrated MAPPS™ results into their plans. An “engAGE in Community” County Coalition organized and continues to expand age-friendly efforts and engage communities not included in this initial cohort through an annual exposition and community grant program. A regional age-friendly network has been formed to advance and evaluate environments and policies that will improve the physical, situational, and service contexts across a four county region, in which Coalition representatives actively participate. One local community stakeholder and county leader proclaimed,

. . . age-friendliness is (emphasized) about both the past and future . . . we [local community and county] need to come together, we need to blend our ideas [old and new] and create the community that we want—a community for all ages.

Footnotes

Declaration of Conflicting Interests

The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The authors received no financial support for the research, authorship, and/or publication of this article.

Notes

Author Biographies

Deborah H. John is an assistant professor in the School of Biological and Population Health Sciences and Health Extension Specialist in the College of Public Health and Human Sciences at Oregon State University (OSU). A faculty affiliate with the Center for Healthy Aging Research, her primary aging research interests are the interplay of healthy, active aging and place.

Katherine Gunter is an associate professor in the School of Biological and Population Health Sciences in the College of Public Health and Human Sciences at OSU. Her healthy aging research examines the effects of a physically active lifestyle on the prevention and management of chronic disease.

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