Universal Design

One means of achieving independent and autonomous living for adults as they age is universal design, defined as intentionally developing environments and products to be easily accessed and used by a wide range of people (Farage et al., 2012). Although employing universal design principles¹ at the initial stages of planning and designing housing results in 1 percent or less additional cost, the concept has yet to be widely adopted (Snider and Takeda, 2008), limiting many older people's ability to perform such activities of daily living as bathing and moving around the home. Policies can encourage the development of accessible housing stock by incentivizing or requiring universal design features for all new homes. Designing homes with features that increase accessibility and independence for those with mobility challenges creates housing stock that is suitable for all members of society, not just older adults.

Availability and Affordability

The availability of affordable housing of adequate size and design and with access to community and social institutions is also a key component of healthy longevity. While many people say they want to stay in their home as they age, which enables more autonomy and continuation of social connections, doing so may pose challenges. For example, if children move out or a spouse dies, houses built for families may be more space than a single older person needs and too much for the person to manage. Depending on housing markets, younger people may be unable to afford to purchase or rent dwellings of the size that their parents could afford, raising questions about intergenerational equity. To address this challenge, policies that make it attractive for older people to downsize as they age are needed. As discussed in Chapter 4, there are also emerging programs pairing older and younger generations to address both the lack of housing available to young people and the need for more assistance for older adults.

Additionally, many older people of lower socioeconomic status are more likely to live in poor-quality housing for much of their younger years, often in environments that are not conducive to social integration and mobility (WHO, 2015). The benefits to their longevity of having them remain in these locations will be limited. Understanding specific demands in different areas can help policy makers and community leaders be more proactive in their approaches to this issue. As found in a study in Mexico, for example, housing arrangements in middle age have been found to predict housing needs in older age. Overcoming typical limitations of not having long-term data, the researchers found that typical living arrangements for adults at age 50 predicted their future living arrangements, with the potential to inform public health and other urban design policies (Huffman et al., 2019). As the older population grows, the need for affordable housing will increase, and policy makers need to take this need into account.

Health and Safety

Health and safety risks posed by poor housing conditions in infancy, childhood, and adulthood are similar in magnitude to those posed by smoking and alcohol consumption and can contribute to downstream mental and physical health conditions later in life (Howden-Chapman, 2004). The WHO Regional Office for Europe compiled a list of factors associated with inadequate housing, such as mold, lack of smoke detectors or window guards, overcrowding, indoor cold, traffic noise, and lead or radon exposure (Braubach et al., 2011). It summarized the evidence for the significant health consequences of these factors, which include asthma mortality and morbidity, injury deaths, lung cancer, respiratory problems, and cardiovascular disease, all of which affect people across age groups. Likewise, a German longitudinal study followed households for 25 years and found that, among people aged 64 and older, those living in homes needing minor renovations or major renovations had, respectively, 6 percent and 20 percent more physician visits than those living in homes needing no renovations (Palacios et al., 2021).

Taking a closer look at safety within the home, “falls are the second leading cause of unintentional injury deaths worldwide” and pose a serious risk to older people, who suffer the greatest number of fatal falls relative to other age groups (WHO, 2021a). However, children are another high-risk group for falls, so improving housing design and standards to prevent falls can address a problem that spans age groups. A study of older adults in Nigeria found that “28.4% [of] respondents believed that houses that were dark, ill-ventilated, damp and dilapidated were dangerous to health of the aged living therein. Poor lighting coupled with steep slope of stairs and slippery floor finish had caused falls and collision with objects among 18.2 [percent of] respondents” (Alabi and Fatusin, 2018, p. 174). Potential modifications to prevent falls and address other health aspects of housing conditions are presented in Box 5-1.

BOX 5-1

Successful Models of Housing Modifications.

Access to Food and Resources

Chapter 4 highlights the critical interplay among social determinants of health, poverty, and life expectancy. A steepening longevity gradient across cities and regions poses troubling questions about how health, prosperity, and environment have uneven impacts across the social landscape. One key aspect of healthy longevity is a healthy diet of nutritious food. But lack of access to and availability of nutritious food can be a challenge for people across the life course depending on their circumstances, particularly income level and geographic location. For example, the effects of poverty can include food insecurity due to a lack of financial security and challenges in the affordability of nutritious food. In addition to affordability, the length of travel necessary to procure nutritious food can be a barrier.

In the Global North, the concept of “food deserts”—“areas with limited access to affordable and nutritious food”—is recognized for its impact on food security for many households (Jones, 2011). Food insecurity intersects with housing-related factors in important ways. For example, researchers in Ontario, Canada, found that, relative to the overall prevalence of food insecurity among seniors, twice as many older adults living in subsidized housing experienced food insecurity (Pirrie et al., 2020). Additionally, women can be more vulnerable than men to food insecurity; researchers in Portugal found that 26.5 percent of older females reported being food insecure, compared with just 18.9 percent of older males (Fernandes et al., 2018). In higher-income countries, the placement of new housing developments, especially for older adults, near community centers or the introduction of farmers' markets in underserved areas can partially fill the gap in food access. But without close proximity to these resources, people will rely on transportation. Thus, communities suffering from decades of structural racism or economic disinvestment that leads to a lack of robust transportation options will also be more food insecure (Beatrice et al., 2021; ODPHP, 2022).

The concept of food deserts, even in urban areas, is less relevant to measuring levels of food insecurity in countries of the Global South (Wagner et al., 2019). Because of the fluidity of the informal food economy in these areas, proximity to sources of food can be difficult to assess. Research on the application of this concept in the Global South is limited, but when analyzing access in Nairobi and Mexico City, researchers concluded that “food deserts in the Global South should not be understood through the proxy measurement of supermarket access” (Wagner et al., 2019, p. 13). Households in both cities accessed multiple types of food-sourcing options (Wagner et al., 2019). Additional research is needed to explore the structural drivers of inequities in food sourcing within urban environments in the Global South. However, given the dependence on agriculture for many in these countries, additional threats to food security, such as climate change, protracted conflicts, and economic stalls (as seen during the COVID-19 pandemic), will continue to be at the forefront and demand attention (Whiting, 2022).

The demographic challenge of population aging also intersects with food insecurity in other ways, as the average age of farmers worldwide is 60 years old (Vos, 2014). In low- and middle-income countries, adults over the age of 55 make up approximately 30 percent of agricultural holders, and agriculture is often their main source of income (Heide-Ottosen, 2014). But, due to age discrimination and the perception of older farmers as unable to learn new skills, they are often excluded from productive resources and training on innovative technologies.

Inequality in access to nutritious food is also seen in low-resourced environments, such as informal settlements or refugee camps in low- and middle-income countries. A HelpAge International study conducted in Kenya found that more than 50 percent of people aged 60 and older living in refugee camps were in need of nutritional support as the result of a lack of access to food rations and a low-diversity diet (Fritsch and Myatt, 2011).

Levers for Empowering Change

Living environments could be redesigned in the near and longer terms to accommodate all ages in society, with attention to affordability, health, and safety. Especially as many countries continue to see a rise in their older populations, it is important to think about how best to accommodate older people with various housing options to promote optimal functionality and healthy longevity. Studies included in a review of evidence assessing housing interventions consistently found that providing housing and supports reduces emergency department visits and hospital stays and can generate a return on investment of USD1.57 in savings for every USD1 spent (Tsega et al., 2017). Multiple approaches can be applied to this end, such as increasing the availability of housing appropriate for independent living and making modifications to increase access to transit and needed services.

Additionally, proximity to resources such as nutritious food can have clear impacts on healthy longevity. Tsega and colleagues (2017) found evidence that access to healthy food among vulnerable populations is associated with lower health care costs and utilization. The ability to access health and social services is an important consideration when developing new housing projects and solutions to promote healthy longevity. Finally, “it is crucial that [older farmers] have equal access to productive resources and training on innovative technologies” (Heide-Ottosen, 2014, p. 21), to benefit farmers and to maintain an adequate global food supply.

Finding 5-1: Housing that encourages independence, social integration, and mobility is a key factor in older adults' ability to realize healthy longevity, but the availability and affordability of this type of housing are limited, especially for those with limited financial resources.

Conclusion 5-1: To achieve global healthy longevity, safe and accessible housing that allows older people to age in place is critical. To ensure that housing and community design meets their needs, older people need to be included in user-centered design processes when modifying existing or creating new housing. Housing that supports aging in place can be encouraged through universal design standards, embedded health and social services, and “smart” technology adaptations that encourage independence. For some countries, especially those with informal settlement environments, providing housing that has sufficient water, sanitation, and hygiene is a critical first step toward achieving healthy longevity.

Finding 5-2: The proximity of a person's living space to critical resources such as food can facilitate healthy longevity. Without food security, people are at risk of several comorbidities, such as dementia, depression, and functional dependence. Studies have found a high prevalence of food insecurity in older populations across several countries, affecting women more than men.

Conclusion 5-2: Given older people's vulnerability to malnutrition and the comorbidities associated with poor nutritional status, housing options for older adults need to take into account the accessibility of such essential needs as nutritious food.

Green Space

Green space, including public parks, playgrounds, and residential greenery in urban environments, has positive health benefits across all ages, ranging from improved physical and mental health to reduced mortality (Braubach et al., 2017). A recent systematic review across seven countries concluded that green urban spaces can help people live longer and avoid premature death. The researchers concluded that “interventions to increase and manage green spaces should be considered a strategic public health intervention” given that all-cause mortality increases as the greenness decreases (Rojas-Rueda et al., 2019, p. e469).

Specific benefits of green space have been demonstrated among different population segments as well, including protective effects on sleep deficiency for people over age 65 and increased physical activity for adults over 60 (WHO, 2016). Another study of older adults in Bogotá, Colombia, found that higher density of public parks was associated with better self-rated health (Parra et al., 2010). Recognizing these benefits, several regional and global agreements and declarations include language about improving access to green space. In particular, SDG Target 11.7 calls for “universal access to safe, inclusive and accessible, green and public spaces, particularly for women and children, older persons and persons with disabilities” (UN, 2022). However, the current distribution of these green spaces within cities is often not equitable, so improving access to these benefits for all populations is an important policy goal for city and country leaders as they consider ways to optimize healthy longevity.

In addition to parks and public squares, community gardens are another form of urban green space that have gained attention recently. The emergence of “urban agrihoods” in the United States represents an attempt to provide an alternative neighborhood growth model, positioning agriculture at the center of mixed-use development. This approach not only increases green space within urban environments but also can encourage mobility and walking while increasing access to locally grown foods. One example is a recent collaboration in Philadelphia, Pennsylvania, that established a community garden program to give older immigrants the opportunity to volunteer, meet community members, and grow food for their families (US Aging, 2022). Community gardens that are accessible to older adults create opportunities for nonstrenuous exercise and social interaction with varying age groups. Community gardens have also demonstrated numerous benefits in the Gambia, including job creation; empowerment of women and youth; and greater levels of food security, nutrition, and health for participants (IFAD, 2019). The International Fund for Agricultural Development supports more than 30 community gardens in the Gambia, with several more to follow, enabling community members to cultivate a diverse array of nutritious foods and create additional income streams. It also reports transformational downstream benefits for the entire rural community—an indication that such programs are beneficial beyond urban environments.

A recent review of the impacts of urban green space demonstrated that such interventions carry positive health benefits, as well as “social and environmental outcomes, for all population groups, particularly those of lower socioeconomic status” (WHO, 2017b, p. 5), thus having a positive impact on health equity. The researchers suggest that the community should be engaged in planning and design at the outset to optimize outcomes, and equity should inform the design and be monitored following implementation. They also suggest that people of all ages who will use a green space be involved in its planning and design, and design criteria should ensure that the resulting space is inclusive of and accessible to people of all ages. Given evidence that the design and maintenance of green spaces can mitigate health risks associated with living in urban areas, equitable access to green spaces is appropriately central to health-oriented urban planning and policies (Daniel, 2022). Indeed, Target 11.7 of the UN SDGs states that by 2030, countries should “provide universal access to safe, inclusive, and accessible green and public spaces, particularly for women and children, older persons, and persons with disabilities” (UN, 2022).

Walkability

While much of the 20th century focused on urban design accommodating cars, buses, or trains, cities around the world have recently focused on reorienting their design around people. Australia's Plan Melbourne centers on the ability of residents to meet most of their daily needs by traveling no more than 20 minutes from home by walking, cycling, or public transit (WEF, 2019). Walkability is the degree to which “the built environment enables the mobility of pedestrians” (Baobeid et al., 2021, p. 2). It is positively correlated with the health of an area's residents, and cities are increasingly recognizing walkability's benefits to individuals' health and to a city's energy and economy. But city living can pose challenges for older adults, because infrastructure is “typically designed for the working population to enhance efficiency and productivity,” such as short street-crossing times and busy sidewalks with bike, scooter, and pedestrian traffic (Loo et al., 2017, p. 812).

High walkability of an area is beneficial for people across the life course, from children to older adults, and numerous relationships have been found across countries between walkability and physical activity levels (Sallis et al., 2016). Spanish researchers, for example, found that older adults living in highly walkable neighborhoods of Barcelona made more trips and spent more time walking relative to their counterparts in less walkable neighborhoods (Marquet and Miralles-Guasch, 2015). But motivations for mobility, especially among older people, often go beyond physical activity to include access to social support from family members and community networks (Gorman et al., 2019).

Overall, across 19 studies published in English or Chinese, walkability was found to have a preventive effect for diabetes, obesity, and hypertension, as well as dementia, for which diabetes is a risk factor (Cheng et al., 2012). One analysis, for example, found higher walkability to be associated with a lower prevalence of diabetes and obesity in 8,777 neighborhoods in Canada (Creatore et al., 2016). Given that physical activity has a direct correlation with physical health and can indirectly impact social engagement, developing neighborhoods and communities that support walking by individuals of all ages can enable healthy longevity. Even benches that allow people to sit and rest can make a difference for both parents with young children and older adults (WHO, 2022b).

More than half of the world (55 percent) lives in urban settings, and by 2050, that proportion will increase to 68 percent (UN, 2018). The United Nations reports that meaningful sustainable development will be critical in low- and middle-income countries, where the pace of urbanization will be especially rapid. Urbanization has played a key role in shaping human interaction, infrastructure, and living styles. With this increase in urbanization in recent years, it is even more important for cities to develop sustainable and feasible transit solutions for residents in ways that encourage community interaction and connection. At the same time, intentionally designing roads and sidewalks for improved walkability is taking place in many locations, with important benefits for people of all ages. The neighborhood of Yonsei-ro in Seoul, South Korea, for example, undertook a transformation that involved widening sidewalks at bottlenecks and developing more connections to subways, public squares, and shopping malls (Kaw et al., 2020). Consequently, the number of traffic accidents was reduced by more than 50 percent in the year following implementation, and the number of visitors increased by nearly 29 percent.

Safety

Safety, which promotes healthy longevity, includes reducing risks of becoming a victim of crime, being injured as a pedestrian, and falling. As with so many other aspects of healthy longevity, people with lower versus higher incomes are less likely to live in safe environments. Public spaces in low-income areas are often unsafe for reasons that range from increased traffic exposure to elevated crime rates. Safety in public spaces is relevant for all people but is particularly important for older adults, who are especially vulnerable to feeling unsafe and less likely to be mobile than younger people. Even if physical infrastructure such as roads and sidewalks is present, older adults will not be as active as needed to benefit their health if they do not feel safe going out.

A recent qualitative study of older adults living in a high-crime neighborhood, for example, found that many reported feeling “trapped” in their apartments, which directly affected not only their physical activity but also their ability to create and maintain social relationships (Portacolone, 2017). In a study of senior housing in Stockholm, researchers found that all criminal incidents described by residents of senior housing took place near their housing (Ceccato and Bamzar, 2016). It is important to note, however, that location and cultural context influence perceptions of crime among older adults. In South Africa, for example, 65 percent of older adults reported feeling unsafe on the street, compared with only 9 percent in Ghana (Lloyd-Sherlock et al., 2016). The effects of crime on fear have a strong association with mobility beyond the home. Where older adults fear crime, they are less likely to leave their home, limiting the physical activity and social connection that promotes healthy longevity.

Leveraging Opportunities for Community Design

While redesigning cities to improve public infrastructure and add various elements can be resource-intensive and time-consuming, the occurrence of a disaster, small or large in scale, offers an opportunity to return to a “better normal,” provided that aspects of safe housing, green spaces, walkability, and social cohesion are incorporated into recovery planning before a disaster occurs. Following the 2012 earthquake and tsunami affecting eastern Japan, for example, authorities and private-sector businesses partnered to redesign a more resilient public housing community, detailed in Box 5-3.

BOX 5-3

Case Study: Tago-Nishi Disaster Resilient Community.

Levers for Empowering Change

“Given the complexity of the built environment, understanding its influence on human health requires a community-based, multilevel, and interdisciplinary research approach” (Srinivasan et al., 2003, p. 1446). Many international reports call for efforts similar to those proposed in this report, and considering these reports in concert and not in competition can maximize the effect of interventions. For example, WHO's Global Network for Age-friendly Cities and Communities, established in 2010, seeks to stimulate and enable cities and communities around the world to become increasingly age-friendly (WHO, 2022b). It provides connections between cities and communities to enable the exchange of information, assist in identifying innovative and evidence-based solutions, and offer a global database of age-friendly practices that members can access.

Individual choices regarding mobility are shaped by the built environment. Urban and transportation planners can create well-designed, mixed-use, compact cities of the future wherein trip length between origins and destinations is short enough to promote active travel (e.g., walking and cycling). Pedestrian-friendly infrastructure—tree-lined streets, quality sidewalks, supportive bus stops (e.g., with benches), traffic aids at crossings, and crosswalks—has the potential to improve perceptions of safety in neighborhoods. Intentional incorporation of evidence-based factors that promote well-being in the design of holistic physical environments can support healthy longevity for all people, including older adults, as described in Vision 2050 (see Chapter 2).

Finding 5-3: Intentionally designed public spaces and built environments can play an important role in influencing healthy longevity. Creating opportunities for mobility, walkability, access to green space, and social engagement can enhance the lives of older people and reduce mortality and morbidity.

Finding 5-4: Public infrastructure, such as sidewalks, bike lanes, and well-lit streets, can influence the usability of an area and adults' perception of safety. Interventions can facilitate more active travel, such as walking and cycling, and reduce sedentary behavior.

Conclusion 5-3: Opportunities exist to translate evidence into action in designing public spaces and infrastructure to promote social cohesion and intergenerational connection, thereby improving health outcomes and enhancing the lives of older adults.

Public Transit

As one of the most widely used forms of transportation worldwide, public transit is widely accessible across income levels because it does not require an upfront cost to purchase a vehicle or the ability to drive. In 118 countries, there are fewer than 200 vehicles per 1,000 people (NationMaster, 2022), emphasizing the critical nature of public transit. Public transit has particular importance for those living in low- and middle-income countries and for people with low incomes living in high-income countries who depend on public transportation and walking to meet their needs.

In addition to being carbon-efficient and accessible, public transit systems generally require physical activity (walking, climbing stairs) for access to stations or transit stops. A longitudinal study of adults aged 40–69 in the United Kingdom found that people who switched from commuting by active or public transit to commuting by car experienced increases in body mass index (BMI), while those who switched in the reverse direction saw decreases in BMI (Flint et al., 2016). Well-designed public transportation can support mobility across the life course, especially for people of all ages with physical disabilities.

However, there are numerous challenges to widespread availability and use of public transit. These include geographic disparities in stations, which influence equity within a city and may increase the distance of first- and last-mile travel to and from those stations for those who live in less favorable neighborhoods. Public transit is also less available outside of urban areas and can be difficult to access for those with physical or cognitive disabilities. Interventions that make public transportation more accessible to older people and others have been piloted and implemented in multiple countries. A transportation welfare project in South Korea, for example, targets rural areas that lack public transit and charges the equivalent of just USD0.09 for a taxi ride (Sang-Hun, 2021), an approach that addresses the “first mile–last mile” challenge for older adults who had a long walk to and from a bus or train stop. Authorities found that the program enabled people in remote villages to travel outside their village twice as often as previously. Similarly, the Freedom Pass in London, which allows free access to extensive public transport for older citizens, was found to provide access to goods and services (Green et al., 2014). As a way to tackle chronic loneliness, bus travel provides a sense of belonging and visibility, as well as opportunities for meaningful social interaction. Thus, where good public transit is widely available and not stigmatized, it can be a major contributor to well-being. Other examples include

• the addition of bicycle lanes and bus rapid transit within urban environments (Stankov et al., 2020);
• free bus passes to increase use of public transit among older people (Webb et al., 2016); and
• shareable mobility scooters for city residents with long distances to walk between their homes and public transportation, addressing first- and last-mile challenges (Portland Bureau of Investigation, 2020).

Driving

Driving is a common mode of travel for older people, especially in high-income countries, where it is the most prevalent mode of transportation among more affluent older people. In contrast to other modes of transportation, it has negative consequences, such as pollution and congestion (Green et al., 2014). For many older adults, driving allows them to spend more time away from home, stay engaged in their communities, and score higher on measures of successful aging (Houser, 2005). But, driving is not an equitable form of transportation. In Los Angeles, low-income older adults residing in inner-city neighborhoods have lower access to private vehicles relative to more advantaged population groups (Loukaitou-Sideris et al., 2018).

Moreover, driving is not always an option as people continue to age. Among older people, reduced functional capacity associated with sensory and musculoskeletal deficits can force older people to stop driving. “[O]lder men and women, ages 70–74, could expect to not be driving and instead be dependent on alternative transportation for the last 7 to 10 years of their lives, respectively” (O'Neill et al., 2019). When older people stop driving, their mobility decreases when they lack other transportation, with negative effects on their health. A systematic review found driving cessation to be associated with greater rates of mortality and depression, as well as premature admission to assistive-care facilities (Chihuri et al., 2016). Pooled data from five of the studies linked driving cessation with nearly double the rate of depressive symptoms in older adults.

Autonomous Vehicles and Other Emerging Solutions

Emerging technologies such as autonomous vehicles (AVs) will likely play an important role in meeting the growing demand to support the travel needs of an increasing older adult population. Once AVs are broadly available and their safety issues resolved, they have the potential to significantly improve the ability of older adults to travel around their communities (Harper et al., 2016; Shergold et al., 2015). Studies have highlighted reluctance to use AVs among older people, a tendency that increases with age (Becker and Axhausen, 2017). Training and awareness programs targeting older adults may help overcome reluctance. Shared AVs may provide a good option for neighborhoods that are designed for aging in place and have higher proportions of older adult residents (Carnemolla, 2018).

Like housing, discussed previously in this chapter, emerging AV technologies can be made more friendly for older adults through incorporation of such aspects of universal design as low-floor vehicle designs for easy entry, comfortable seating, automated journey planning, and the use of audio-visual technologies (Metz, 2000). In addition, integrating currently older people or “future elders” into the design process can ensure consideration of the unique needs of the aging population throughout the conceptualization, prototyping, and validation of AV designs. In addition to AVs, next-generation assistive technologies can support mobility and active lifestyles for older individuals, enabling them to travel both within and beyond their neighborhoods and communities (Marston and Samuels, 2019).

Other potential solutions involve interdisciplinary approaches. As the older population continues to grow, more than 80 businesses in Japan have devoted themselves to the principle of Mobility as a Service transport, which allows for shared ride services in addition to other options through a smartphone app (Doi, 2021). Most of these options are focused on operating in rural regions of Japan with less access to established mass transit infrastructure. In Shobara, a depopulated town in the mountains, new bus stops have decreased the distance older adults must walk to reach a stop. To make this system viable, the town has introduced smaller vehicles and a reservation system to reduce unnecessary use (Doi, 2021).

Levers for Empowering Change

Many opportunities exist to incorporate designs friendly to older adults in transportation systems, whether based on individual driving or public transit. Options include universal design in cars; innovative design of railways and buses that allows older adults to board, alight, and be seated more comfortably; installation of bus shelters, benches, and street lighting at transit stops and stations; and provision of mobility aids for crossings at bus stops (to enhance perceptions of safety). The frequency of services for multimodal linkages can be optimized, and the accessibility of point-to-point services can be enhanced. In addition to increased provision of public transportation links, rideshare companies such as Uber and Lyft, where available, have revolutionized point-to-point transportation for older people, and these services can also be augmented by such innovations as mobility scooters and reservations for specialized routes. These options can address some of the first- and last-mile gaps in public transportation. Finally, economic incentives in the form of travel subsidies have been shown to increase use of public transit.

Finding 5-5: Safe and accessible transportation options can give older adults the opportunity to enjoy independent mobility around their community instead of avoiding social activities and becoming isolated and lonely. In areas where public transit does not meet the last-mile needs of the population, such innovations as rideshare programs and autonomous vehicles are opportunities to increase safe mobility for older adults.

Conclusion 5-4: As older adults begin to make up a larger percentage of populations, countries and cities need to enhance available transpor tation options other than driving. Public transit systems would benefit from older adult–friendly designs and augmented first- and last-mile opportunities to ensure that people of all ages are able to maintain their independence and mobility.

Broadband Access

Access to high-speed internet is integral to a functioning society today, and thus is an essential component of infrastructure. While researchers and policy makers appear to understand the extent to which broadband benefits health and equity, disparities remain in access to the technology. “From economic stability, to education, to social supports, to civic agency, broadband and the digital services it enables are intrinsically tied to collective health and equity outcomes” (Tomer et al., 2020, p. 3). The World Bank has estimated that in 2019, more than 56 percent of the world's population was using the internet, but only 1.2 billion people, or 15 percent of the world's population, had fixed broadband subscriptions (World Bank, 2022). According to the latest research in the United States, 38 percent of households earning less than USD20,000 per year lack a broadband subscription, a gap that greatly impacts equitable access to and adoption of mobile health technologies and other online systems (Sieck et al., 2021). Rural areas are notably unable to access reliable broadband internet services. “For example, while broadband use in the capital cities of India, the Kyrgyz Republic and Moldova and are at the same level as some Organization for Economic Co-operation and Development (OECD) members, usage in these three countries' rural areas is among the lowest in the world” (World Bank, 2021).

Reliable internet access also impacts multiple aspects of life. During the COVID-19 pandemic, reliable access had far-reaching effects on a person's ability to access mobile health technology, work in office settings, continue education during remote learning, and stay connected to social networks. Investments in broadband impact the economy, with one study showing that doubling broadband speed can result in a 0.3 percent addition to gross domestic product growth, and even more modest increases in speed can positively impact household incomes in middle- and high-income countries (Ericsson et al., 2013). Katz (2009) found that if 12 Latin American countries were to add 11 million broadband lines, it would generate at least 378,000 jobs (Katz, 2009).

The digital divide in access to infrastructure is seen within and across countries. The International Monetary Fund (IMF) has noted that this is also the case for businesses in different regions of the world. Only about 60 percent of businesses in sub-Saharan Africa use email, compared with 85 percent of businesses in Europe and Asia (Garcia-Escribano, 2020). Many disparities exist in the United States:

The majority—13.6 million—of digitally disconnected households across the United States live in urban areas, but the gaps in rural areas are an even larger share of the total rural population. Researchers consistently find those least likely to have broadband in America are communities of color and low-income communities, suggesting that systemic barriers remain in place. (Tomer et al., 2020, p. 4)

Even when rural areas have broadband access, they often face slower speeds, potentially limiting economic growth. Box 5-4 outlines examples of opportunities for increasing access to broadband.

BOX 5-4

Case Study: Equitable Access to Broadband.

Information and Communications Technology

Information and communications technology (ICT) systems include the components, devices, and systems necessary for organizations and individuals to interact in the digital world. The proliferation of these systems over the past decade has created opportunities for improving the lives of older adults, ranging from improved social connections to health care augmentation (described more in Chapter 6). In an Israeli study of adults aged 65 and over, for example, researchers found that individuals who used computer-based applications, such as web pages and real-time chat rooms, reported a lower level of loneliness compared with nonusers (Pearlman-Avnion et al., 2020). Another example is the European Union-funded project Eldergames, which was initiated to reduce the natural process of cognitive decline associated with aging (Gamberini et al., 2008). The study found potential benefits of cognitive training performed via videogames offered by the older adult game system. Other similar findings indicate that videogame platforms paired with cognitive training can help reduce cognitive decline and depressive symptoms for those with mild Alzheimer's disease (Fernández-Calvo et al., 2011).

While less common than computers, interactive robotic systems have been developed to assist older individuals with their mental and physical needs. For example, PHAROS—a robotic system developed to enhance older adults' physical activity by recording their exercise performance, categorizing the exercise performed, and recommending physical exercise periodically—showed high accuracy of exercise detection among its older users (Costa et al., 2018). Several studies have examined the benefits of socially assistive robots for older adults. The use of robotic animals as therapy for patients with severe dementia avoid the potential negative health effects of real animals, such as allergies and infection (Hung et al., 2019). However, experts have raised ethical concerns about the use of robotic applications for older people. Unresolved issues “include a potential reduction in human contact; an increase in feelings of objectification and loss of control; loss of privacy and personal liberty; and tendencies toward deception and infantilisation of older people” (Share and Pender, 2018, p. 51). These ethical concerns need to be considered from the design stage.

Interventions to Improve Access to and Use of Digital Technologies

While all countries will need to balance trade-offs when implementing programs to narrow their own digital divides across generations, an analysis focused on countries in Latin America highlights seven key elements that should be included in any new efforts (see Box 5-5).

BOX 5-5

Elements to Consider When Implementing Policies and Programs to Narrow the Age-Based Digital Divide.

Levers for Empowering Change

Whether through expanded broadband access, videogame platforms, interactive robots, or use of technology in everyday life to access transportation, evidence shows that narrowing the digital divide between older and younger generations can have positive effects on quality of life, connection to social networks, and healthy longevity. To realize the goals of Vision 2050, however, these advances need to be delivered with equity as a central focus, ensuring that disparities in access are not worsened across various groups or countries. To support affordable and universal access, for example, IMF suggests ensuring that internet investments are complemented by universal access to electricity and subsidies for groups that might otherwise not enjoy access to those investments (Garcia-Escribano, 2020).

Concerns about the expanded use of technology among populations that are largely unfamiliar with hardware and software can be expected to persist. Due diligence with respect to protecting privacy and preventing cybersecurity threats needs to be part of this continued expansion. Given the increasing age of retirement in many high-income countries, retirement benefit packages can teach vulnerable older adults cybersecurity practices related to the use of ICT and online services and transactions. Similar training programs need to be made available for economically inactive vulnerable retirees to protect them from online scams and predators. Similarly, it will be important to equip future software technologies with fail-safe designs that can identify vulnerable users and implement extra layers of protection accordingly to minimize cybersecurity vulnerabilities.

Finding 5-6: Access to broadband internet is integral to many aspects of society. Low-income and rural households are especially likely to lack broadband access, which greatly influences their equitable access to other resources and their ability to work remotely and stay connected to social networks.

Conclusion 5-5: Broadband is essential infrastructure for achieving Vision 2050. Improving broadband access across socioeconomic demographics will require a combination of public and private incentives and investment. Increased attention to user-friendly functionalities for older adults and additional instructional support need to accompany these investments to ensure equitable access.

Extreme Weather Events and Changes in Ambient Temperature

Extreme weather events caused by climate change have disproportionately adverse impacts on older adults. Migration due to coastal flooding, tsunamis, hurricanes and cyclones, and other extreme weather events often produce “climate refugees,” and the phenomenon is increasing annually. Overlapping vulnerabilities, particularly for older people and those with disabilities, are exacerbated in humanitarian emergencies.

An analysis of the impact of ambient temperatures on years of life lost in low-, middle-, and high-income countries illuminates the systematic association of both extreme heat and cold with life expectancies (Watts et al., 2018). As the intensity and duration of heat waves increase, the risk to older adults will also increase, manifesting in both morbidity and mortality during heat waves. Susceptibility to dehydration and declining physiological homeostasis mean that extreme heat poses a considerable threat to the health of older adults (Schols et al., 2009). Additionally, older people are vulnerable to extreme events such as heat waves due to chronic conditions, and those with limited means may lack good ventilation or air conditioning systems. For older adults aged 65 and over living in São Paulo and Mexico City, for example, exposure to high mean apparent temperature (representing the temperature on the day of death) was associated with a higher risk of mortality (Bell et al., 2008).

Air Pollution

A growing body of evidence points to the association between air pollution and negative health effects. Findings suggest that even slight increases in particulate matter linked to car emissions, soot, and smoke in both urban and rural areas are contributing to negative respiratory symptoms and early deaths among older adults (Friedman, 2022), as well as neuropathology and stroke, Alzheimer's disease, and Parkinson's disease (Block and Calderón-Garcidueñas, 2009). A recent study across the United States revealed that 18,000 older adult lives were lost prematurely from 2016 to 2018 as a result of particulate matter (Weinstock-Platzman, 2019).

Additionally, findings based on animal studies suggest that prenatal and early-life exposure to traffic-related air pollutants is associated with memory impairment, as well as mental and behavioral conditions such as depression. One study found that early exposure to air pollutants in Mexico City negatively affected cognitive functioning in children who had no additional known risk factors, compared with children living in a low-pollution region (Woodward et al., 2018). Adverse physical outcomes are seen as well, as older people in South Africa who lived close (1–2 km) to mine dumps, which have been shown to be associated with air pollution, were found to have significantly higher incidence of “asthma, chronic bronchitis, chronic cough, emphysema, pneumonia, and wheezing” (Nkosi et al., 2015, p. 1).

Interventions to Address the Effects of Climate Change

Recognizing this impact, many countries and cities have taken more intentional action to reduce their levels of air pollution. In Ghana, where nearly 12,000 people die from air pollution each year, city officials in the capital of Accra worked with Norwegian officials and local public health professionals to illustrate the links among air pollution, mortality, and health care costs, providing needed information to citizens on clean air policies (CCAC, 2021). The initiative has now garnered increased engagement from the Ministry of Transport for the use of health assessment tools and is continuing to expand knowledge of these linkages among health care workers. It also has raised awareness within communities of the need to reduce waste burning and develop green public spaces. Environmental staff in Ghana can now “continuously monitor particulate matter and black carbon in multiple areas of [Accra], and produce quality and reliable data to more accurately identify sources of air pollution” (CCAC, 2021).

Heat waves also represent an urgent concern for city planners and policy makers. Some cities offer centrally located cooling centers or provide air conditioners for those in need to keep older adults safe at home. Larger-scale efforts to reduce the impacts of heat in cities include the use of green roofs, water management, and open spaces. Mitigation efforts of Frankfurt, Germany, one of the country's warmest cities, are highlighted in Box 5-6.

BOX 5-6

Case Study: Climate Mitigation Efforts to Keep Frankfurt Cool.

Levers for Empowering Change

As climate-fueled disasters grow in intensity and frequency alongside rapidly aging populations, governments need to develop systems for locating and evacuating vulnerable older people when necessary. In particular, technology-enabled alerts and plans can be used to monitor the status of and provide aid to older people. To this end, civil protection services often maintain registries of vulnerable older people. Additionally, the United Nations recommends best practices from several countries, including engaging older adults in preparedness and disaster risk reduction strategies, providing them with financial support and extended social protections following emergencies, and specifically developing recovery strategies geared toward reintegrating them into normal life following disasters (UN, 2020). Numerous examples during the past two decades have demonstrated the dire outcomes that occur when preparedness for vulnerable populations is not carefully carried out in advance.

The lack of global and robust response to climate change has also widened a divide between younger generations' galvanization around the climate crisis and the perceived inaction of older generations (Milfont et al., 2021). The commission agrees that collective action and solidarity with those most vulnerable to and affected by the consequences of climate change are needed. In the context of healthy longevity, extreme weather and changes in ambient temperature, along with air pollution, are among the most concerning and immediate environmental hazards requiring national and local attention.

Leveraging existing efforts and stakeholders and leaning on multilateral organizations can help countries and cities address the effects of climate change in their own contexts. The Climate and Clean Air Coalition, facilitated through the United Nations, brings stakeholders together across countries and sectors to improve air quality and protect the climate in the decades ahead.³ The Coalition's focus is on rapid action to realize benefits across the areas of climate, public health, energy efficiency, and food security.

Finding 5-8: While the impacts of climate change demand action for all populations around the world, older adults are often faced with overlapping vulnerabilities that make them especially likely to experience adverse events related to extreme temperatures, natural disasters, and air pollution. Older adults suffer some of the most adverse consequences of climate change and extreme weather events through exposure to air pollution, flooding, and extreme heat and cold waves. Studies across countries have found associations between high temperatures and increased risk of mortality and morbidity.

Conclusion 5-7: In their climate change planning and mitigation efforts, cities and countries need to consider the amplified impacts on older adult populations, as well as necessary monitoring and response actions. Systems for locating and evacuating vulnerable older people when necessary, as well as embedded designs in buildings and public spaces that reduce temperatures, could help augment other efforts.