Content uploaded by Carol A Wham
Author content
All content in this area was uploaded by Carol A Wham on Aug 02, 2021
Content may be subject to copyright.
REVIEW
An integrative review of the factors related to building age-friendly
rural communities
Stephen Neville, Sara Napier, Jeffery Adams, Carol Wham and Debra Jackson
Aim and objectives. To identify the theories and concepts related to building age-
friendly rural communities.
Background. Global population is rapidly ageing. Creating environments that
support active ageing was a catalyst for the World Health Organization to
develop Global Age-Friendly Cities guidelines. Although the age-friendly move-
ment has captured the attention of some countries, little is known about the par-
ticipation of older people in rural settings.
Method. An integrative review approach was employed to summarise the research lit-
erature on this topic. Using a systematic search strategy, databases including Discover
(EBSCO’s electronic database system), Web of Science, Scopus, PubMed, CINAHL,
PsycINFO, Medline and Google Scholar were searched. Primary, peer-reviewed stud-
ies were included if published during 2007–2014 in the English language.
Results. Nine studies were eligible for inclusion. The studies were set predomi-
nantly in Canada, with the exception of one from Ireland. The findings were sum-
marised and clustered into main topics which included: theoretical perspectives;
geographic and demographic characteristics; collaboration and partnerships; sus-
tainability and capacity; and finally, future research agendas.
Conclusions. Rural communities are changing rapidly and are becoming increas-
ingly diverse environments. Community characteristics can help or hinder age-
friendliness. Importantly, the fundamental starting point for age-friendly initia-
tives is establishing older peoples’ perceptions of their own communities.
Relevance to clinical practice. It is important for nurses, working in primary
health care settings, to understand the needs of older people in the communities
in which they practice. This includes the community characteristics that can be
enablers and barriers to older people being able to remain and age within their
own communities.
Key words: active ageing, age-friendly cities, age-friendly communities, ageing-in-
place, literature review, rural
What does this paper contribute
to the wider global community?
•Identifies that rural communities
have specific challenges that
impact on older people being
able to age-in-place.
•Reinforces that an older persons’
environment is an important
consideration in enabling people
to remain living in their own
homes.
•Identifies that little research has
been undertaken focussing specif-
ically on rural age-friendly com-
munities.
Accepted for publication: 3 February 2016
Authors: Stephen Neville, RN, PhD, FCNA (NZ), Associate Profes-
sor of Nursing, Head of Department, Department of Nursing, AUT
University, Auckland; Sara Napier, RN, PGDip(Nursing), Clinical
Teacher, UNITEC, Auckland; Jeffery Adams, MA, PhD, Senior
Researcher, SHORE & Whariki Research Centre, Massey Univer-
sity, Auckland; Carol Wham, Senior Lecturer, Institute Food,
Nutrition and Human Health, Massey University, Auckland, New
Zealand; Debra Jackson, RN, PhD, Professor of Nursing, Faculty
of Health & Life Sciences, Oxford Brookes University, Oxford, UK
Correspondence: Stephen Neville, Associate Professor of Nursing,
Head of Department, Department of Nursing, AUT University,
Auckland, New Zealand. Telephone: +64 9 9219999.
E-mail: sneville@aut.ac.nz
©2016 John Wiley & Sons Ltd
Journal of Clinical Nursing, doi: 10.1111/jocn.13299 1
Introduction
The ageing population has captured the attention of policy
makers and researchers across disciplines in recent years
(Ball & Lawler 2014). It is estimated that by 2050, the
number of people aged 60 years and over will double from
815 million in 2013 to more than two billion people (Uni-
ted Nations 2013). Furthermore, the oldest old age group,
80 years and over, is estimated to triple by 2050 (United
Nations 2013). While longevity is a positive reflection of
advancements in medical science, public health practices
and the economy, there is a tendency to problematise the
ageing population fuelled by assumed ill-health and frailty
that generates concerns regarding society’s ability to sup-
port the needs of an ageing population (Powell 2010,
Walsh et al. 2012).
In response to unease about the economic and social
implications of a rapidly ageing population, the theme of
the 1999 International Year of Older Persons was ‘active
ageing makes a difference’; a defining point in the World
Health Organisation’s (WHO) work on ageing and health
(Buffel et al. 2012). This work led the way for many coun-
tries to form their own ageing strategies (Buffel et al. 2014).
Subsequently, the concept of ageing-in-place gathered
momentum among policy makers. Ageing-in-place reflects
an acknowledgement that the majority of older people pre-
fer to remain living in their own homes as they age (Six-
smith & Sixsmith 2008, Bacsu et al. 2014). Moreover,
ageing-in-place is supported by governments and policy
makers as it is deemed more cost effective in comparison to
older people living in long-term aged care facilities (Sixsmith
& Sixsmith 2008, Lui et al. 2009). A comprehensive range
of support systems are required to enable older people to
age-in-place (Lui et al. 2009). Wiles et al. (2012) found that
older people had a broad conception of the meaning of age-
ing-in-place that encompassed a range of community fea-
tures in addition to their homes. However, little is known of
older peoples’ perspectives of ageing-in-place in a rural con-
text (Walker et al. 2013, Bacsu et al. 2014).
In response to the demographic trends, highlighted
increasingly over the past two decades, and to accentuate
the potential of an ageing population, the Madrid Interna-
tional Plan of Action on Ageing (MIPAA) was formed in
2002 (United Nations 2013). The purpose of the MIPAA
was to provide priority directions to meet the health and
social policy challenges associated with forming a society
that is accepting of people of all ages (Plouffe & Kalache
2011, United Nations 2013). As a contribution to the 2002
Second World Assembly on Ageing, the WHO launched
‘Active Ageing –A Policy Framework’ to lead a new course
in addressing the challenges and opportunities in an ageing
world (WHO 2002). The WHO define active ageing as ‘the
process of optimizing opportunities for health, participation
and security in order to enhance quality of life as people
age’ (WHO 2002, p. 12).
To support and promote active ageing, the WHO devel-
oped the Global Age-Friendly Cities: A Guide (WHO
2007). This document was the outcome of a research pro-
ject in collaboration with 35 cities in developing and devel-
oped countries. The aim was to identify advantages and
barriers across key features necessary for a city to be age-
friendly. The findings from focus groups of older people,
caregivers and service providers from 33 of the cities,
resulted in the Checklist of Essential Features of Age-
Friendly Cities. The proposed eight domains identified for a
community to be age-friendly were: outdoor spaces and
buildings; transportation; housing; social participation;
respect and social inclusion; civic participation and employ-
ment; communication and information; and community
and health services (WHO 2007). Around the same time,
Canada developed the ‘Age-Friendly Rural and Remote
Communities: A Guide’ to reflect the unique geography of
Canada (WHO 2007, Plouffe & Kalache 2010). Subse-
quently, other regions are developing age-friendly initia-
tives, including the State of South Australia, the Andalusian
Province in Spain and the State of Sao Paulo in Brazil.
Researchers from across disciplines, have identified that a
participatory, collaborative style of governance is a key fea-
ture of the age-friendly model, with engagement needed at
all levels of government (Lui et al. 2009, Plouffe & Kalache
2011, Ball & Lawler 2014, Garon et al. 2014). Other ini-
tiatives, with similarities to age-friendly city initiatives, have
been reported on in the literature, such as the ‘liveable
communities’ in the United States of America (USA) and
‘lifetime neighbourhood’ in the United Kingdom (Lui et al.
2009). Scharlach (2012), in an Internet-based search, identi-
fied 292 ageing-friendly community initiatives in the USA.
Ball and Lawler (2014) contend that while there are numer-
ous successful initiatives operating at a local level in the
USA, the development of a large scale strategic framework
at a federal level is required to sustain age-friendly commu-
nity initiatives.
Demographic characteristics of rural communities are
changing dramatically in many parts of the developed
world, resulting in rural populations ageing more quickly
than in urban areas (Burholt & Dobbs 2012). For example,
in 2013, 23 per cent of the rural population in Canada was
over the age of 65 years compared to the national average
of 13% (Keating et al. 2013) and in Ireland, of those aged
65 years and over, 44% live in rural areas (Walsh et al.
©2016 John Wiley & Sons Ltd
2Journal of Clinical Nursing
S. J. Neville et al.
2012). The paucity of research on the participation of older
people ageing in a rural context has been widely asserted in
the literature (Keating et al. 2011, Burholt & Dobbs 2012,
Bacsu et al. 2014). Furthermore, although age-friendly
community initiatives are advancing in some rural areas,
for example, in Canada, many rural communities are in the
initial stages of implementing age-friendly programmes.
Thus, findings from empirical studies on the efficacy of age-
friendly interventions will add to knowledge development
and provide policy direction (Plouffe & Kalache 2011).
Aim
To identify the theories and concepts related to building
age-friendly rural communities.
Methods
An integrative review is an ideal way to synthesise literature
from an emerging topic to develop new insights and enables
the inclusion of both quantitative and qualitative research
to be synthesised and reported (Torraco 2005, Naef et al.
2013). An integrative review process requires a systematic
literature search process followed by a robust analytic pro-
cess to synthesise the data collected and arrive at a compre-
hensive understanding of the topic under investigation
(Whittmore & Knafl 2005, Naef et al. 2013). Findings are
then presented as a narrative. The methodological strategies
outlined by Whittmore and Knafl (2005) were used to guide
the integrative review process.
Search strategy
Electronic databases, from social sciences as well as health
and nursing, were determined to be most likely to yield
relevant literature. Databases searched included, Discover
(EBSCO’s electronic database system), Web of Science,
Scopus, PubMed, CINAHL, PsycINFO, Medline and Goo-
gle Scholar. The search was focused using key phrases
‘age-friendly’ AND rural, ‘age-friendly communities’ AND
rural and ‘age-friendliness’ AND rural. Rural is the term
used in academic journals; therefore, no other synonyms
of rural were used. A Scopus search alert was set up for
‘age-friendly communities’. Limitations were applied to the
search including, English language, peer-reviewed journals
and published between January 2007–December 2014.
The inclusion dates were selected because of the World
Health Organisation (WHO) launch of the Global Age-
Friendly Cities project that took place in 2007 (WHO
2007).
Terms related to the age-friendly concept including, ‘age-
friendly cities’, ‘age-friendly communities’, ‘elder-friendly’
and ‘lifelong communities’, along with interrelated concepts
such as, ageing-in-place, active ageing, ageing in rural areas,
enabling physical-social environments, and social inclusion
were included in the search to provide background informa-
tion. Boolean operators and truncation symbols were
applied where these could be used to gain all suffixes; for
example, age-friendl*.
Additionally, the table of contents of peer-reviewed jour-
nals, found to have published work on this topic, were
searched for relevant articles back to January 2007. The
journals searched included, Ageing and Society, Aging
International, Journal of Applied Gerontology, Journal of
Rural Studies, Australian Journal of Rural Health, Rural
and Remote Health, Journal of Aging and Social Policy,
Canadian Journal on Aging, and the Planning, Theory and
Practice Journal. Reference lists of retrieved articles that
met the inclusion criteria, were searched extensively. Fur-
thermore, published works of researchers in the field of
age-friendly rural community studies were retrieved. The
search continued until saturation occurred.
Inclusion criteria
•Primary, peer-reviewed studies
•Published between 2007–January 2015 in English
•A focus on age-friendly rural communities
•Papers drawing on studies from a diverse methodology
Exclusion criteria
•Not published in English
•Published before 2007
•Non-peer-reviewed publications, for example, discussion
papers and editorials
•Secondary data analysis
Search outcome
Electronic search of databases were first carried out in
November 2014 and repeated in early January 2015. A
total of 147 records were retrieved that had an age-friendly
rural community focus, with the following distribution;
Discover (31), Web of Science (26), Scopus (25), Google
Scholar (25), PubMed (15), CINAHL (11), PsychINFO (9)
and Medline (5). After removal of numerous duplicates, 51
records remained. Further six records were retrieved from
searching the table of contents from relevant journals and
reference lists to make a total of 57 records. Following
©2016 John Wiley & Sons Ltd
Journal of Clinical Nursing 3
Review Age-friendly rural communities
screening of titles and abstracts, 37 records were rejected.
An additional 11 records were rejected after full text
screening. Ultimately, nine primary studies that met the
inclusion criteria were selected for the review. The studies
consisted of qualitative (n=6) and, quantitative (n=3).
The PRISMA framework was followed to guide the search
and screening process (Moher et al. 2009). This is sum-
marised in Fig. 1.
Quality appraisal and review
The CASP (2014) critical appraisal checklist was used to
review the quality of the six qualitative studies. Similarly,
the three quantitative studies were reviewed against a criti-
cal appraisal of a survey tool (Crombie 1996). Three mem-
bers of the research team independently carried out the
critical appraisals and review for all nine studies. It was
agreed that all studies were methodologically sound and
met the inclusion criteria. Data were extracted, abstracted,
classified and analysed. Following thorough review and dis-
cussion of the findings by the research team, similar find-
ings were clustered into common concepts.
Classification process
Data from the studies were classified and presented in
table 1. The following elements have been displayed: (1)
author’s last name(s) and year of publication, (2) the aim
of the study, (3) design and method of data collection, (4)
number of participants and age range (5) major findings.
Results
Study characteristics
Six out of the nine included studies were qualitative (Keat-
ing et al. 2013, Spina & Menec 2015, Wiersma & Koster
2013, Menec et al. 2014b, Novek & Menec 2014, Walsh
et al. 2014) and three studies were quantitative (Menec &
Nowicki 2014, Menec et al. 2014a, 2015). Various meth-
ods of data collection were used in the qualitative studies
including, focus group discussions (Walsh et al. 2014), indi-
vidual interviews over the telephone (Spina & Menec 2015,
Menec et al. 2014b), various combinations of focus groups,
individual interviews and small group interviews or discus-
sions (Keating et al. 2013, Wiersma & Koster 2013, Novek
& Menec 2014). The three quantitative studies were cross-
sectional, nonexperimental studies. Two of the quantitative
studies used needs assessment surveys (Menec & Nowicki
2014, Menec et al. 2015) and one used separate surveys,
one for older adult residents and one for municipal officials
(Menec et al. 2014a).
Sample and setting
The qualitative study sample sizes ranged from 30 to 106
while the quantitative study sample sizes ranged from 593
to 1373. Only three studies provided the range of ages for
the older adult participants (Spina & Menec 2015,
Wiersma & Koster 2013, Novek & Menec 2014). In three
of the studies (Keating et al. 2013, Menec et al. 2014a,b),
the sample consisted of older and younger adults; however,
the numbers in each age group were not specified. A further
two studies provided the number of participants who self-
identified as seniors (Menec & Nowicki 2014, Menec et al.
2015; see Table 1). All of the nine studies were set in rural
communities. Eight studies were from Canada (Keating
et al. 2013, Spina & Menec 2015, Wiersma & Koster
2013, Menec & Nowicki 2014, Menec et al. 2014a,b,
2015 and Novek & Menec 2014) and one was from Ire-
land and Northern Ireland (Walsh et al. 2014).
Theoretical perspectives
The age-friendly concept was the main theoretic perspective
in all nine studies reviewed. All studies used the eight
domains of the age-friendly framework either in the
research design or to structure the presentation of findings.
147 records identified
through database searching
6 additional records
identified through other
sources
57 records after duplicates removed
57 records screened 37 records excluded
at title/abstract stage
20 full-text articles
assessed for eligibility
6 studies included in
qualitative synthesis
11 full-text articles
excluded, did not meet
inclusion criteria
3 studies included in
quantitative synthesis
IdentificationScreeningEligibility Included
9 full-text articles eligible
inclusion in review
Figure 1 PRISMA flow diagram (Moher et al. 2009)
©2016 John Wiley & Sons Ltd
4Journal of Clinical Nursing
S. J. Neville et al.
Table 1 Summary of included papers
Author, year, country,
setting Aim(s) Design, data collection Participants and age range Major findings
Walsh et al. (2014)
Ireland, Northern Ireland
Explore role of informal practices
across community systems that
support age-friendliness with
regard to rural communities’
capacity to deal with social
exclusion of older people
Qualitative, focus group
discussions
Community stakeholders
representing; private, state,
voluntary and family and friends
systems (n=62) (25 older adults
>65 years)
Informal practices strengthened the
capacity to address social exclusion,
enhancing age-friendliness; there is a
multiplicity of individual roles;
assessment of age-friendliness
complicated by transformative changes
and questions rural communities ability
to achieve age-friendliness due to
geographical and infrastructural
challenges
Wiersma and Koster
(2013) Canada
Examine the experiences of aging-
in-place in a rural community
going through economic
instability in context of being
age-friendly
Qualitative, focused ethnographic
approach, intensive, in-depth
interviews
Older adults and service providers
(n=84) (37 older adults from
mid 50’s –mid 80’s, majority
between 60–70 years)
Civic engagement was central theme;
role of volunteerism in community a
vital issue; lack of volunteers; volunteer
‘burn-out’; community attitudes; time
commitment; transitory lifestyle;
suggests age-friendly framework around
volunteerism too simplistic
Spina and Menec (2015)
Canada
Examine older adult and key
stakeholder perceptions of the
factors that either help or hinder
rural communities from
becoming age-friendly
Qualitative, semi-structured and
unstructured interviews
Older adults and key stakeholders
in 3 rural communities (n=41)
(24 older adults >55 years,
small majority 65–74 years,
n=385+years)
5 main community characteristics
emerged: (1) community size; (2)
proximity from other communities; (3)
demographic composition; (4) securing
investment; (5) leadership and advocacy
Novek and Menec (2014)
Canada
Explore older adults perceptions
of age-friendliness in their
communities Identify priorities
and barriers to making
communities more age-friendly
Qualitative, participatory, photo-
voice technique, photos,
journals, interviews and focus
groups
Older adults (n=30) (54–
81 years)
Age-friendly features were physical
environment, business and services,
housing, social environment, activities
and volunteering, community supports
and health services, transportation;
contextual factors were community
history and identity, ageing in rural and
remote communities and environmental
condition; cross-cutting themes were
independence, affordability and
accessibility
©2016 John Wiley & Sons Ltd
Journal of Clinical Nursing 5
Review Age-friendly rural communities
Table 1 (continued)
Author, year, country,
setting Aim(s) Design, data collection Participants and age range Major findings
Keating et al. (2013)
Canada
What makes a good fit between
older people and their
environment in a rural setting
Qualitative, semi-structured
interviews and small group
consultations
Older adults, family members,
service providers, local policy
makers (n=106)
Two rural communities studied had very
different features and had changed over
time, one bucolic and one bypassed.
The researchers propose a revised
definition of an age-friendly community
as one that strives to find the best fit
between various needs and resources of
older people and those of the
community. Further, that age-friendly is
dynamic, focusing on changes over time
in people and place.
Menec et al. (2014b)
Canada
Formative evaluation of the
implementation of a province-
wide age-friendly initiative
Qualitative, Interviews over
telephone using a questionnaire
with closed-ended and open-
ended questions
Representatives from age-friendly
committees or municipal officers
(n=67)
Substantial progress made in engaging
communities and in communities
becoming age-friendly. Challenges
included lack of capacity, funding,
leadership and direction; top–down and
bottom–up approaches essential;
partnership between university
researchers and non-government
organisations important for success of
age-friendly initiative
Menec et al. (2015) Canada Examine whether age-friendliness
varies across community
characteristics such as
population size.
Quantitative, needs assessment
survey
Older adults and stakeholders
across 56 communities
(n=1373)
The higher the percentage of residents
aged 65+, the higher the age-friendly
index (0298, p<0001) Population
size not significantly associated with
overall age-friendly ratings; age-friendly
does not appear to be dependent on
degree of affluence of older adults;
some age-friendly domains are more
easily addressed compared with others;
more difficult to enhance are physical
environment, housing, healthcare
services and transportation options;
important to differentiate degree of
rurality
©2016 John Wiley & Sons Ltd
6Journal of Clinical Nursing
S. J. Neville et al.
Other theories featured in the reviewed studies were ecolog-
ical theory (Keating et al. 2013, Novek & Menec 2014,
Menec et al. 2015) and place integration theory (Spina &
Menec 2015, Walsh et al. 2014). Three studies underscored
the holistic nature of the age-friendly concept (Menec &
Nowicki 2014, Novek & Menec 2014, Menec et al. 2015),
while Novek and Menec (2014) highlighted the intercon-
nectedness of the age-friendly domains with community
characteristics.
Geographic and demographic characteristics
The geography of rural communities was highlighted in
most of the studies reviewed. Degree of rurality, charac-
terised by communities’ remoteness from, or proximity to
other centres, was a finding in six studies. The degree of
rurality affected access to health and other services, as well
as the power to attract and retain older people to continue
to live in the area (Keating et al. 2013, Spina & Menec
2015, Wiersma & Koster 2013, Novek & Menec 2014,
Walsh et al. 2014, Menec et al. 2015). Menec et al. (2015)
found, for optimising quality of life and to facilitate ageing-
in-place, the physical and social environments needed to be
enhanced to counteract remoteness. The demographic
make-up and size of a community was viewed as being
either hindering or helpful for communities to be consid-
ered age-friendly in seven of the studies (Keating et al.
2013, Spina & Menec 2015, Wiersma & Koster 2013,
Menec et al. 2014a,b, Novek & Menec 2014, Walsh et al.
2014). Moreover, rural decline and the economic recession
impacted on the age-friendly features of social inclusion,
social participation and the availability of support services
for older people (Walsh et al. 2014). When populations
declined and services closed, this affected the ability of
some older residents to remain in their communities (Spina
& Menec 2015, Wiersma & Koster 2013, Walsh et al.
2014). Furthermore, rural communities were found to be
diverse, with changes in people and place over time (Keat-
ing et al. 2013, Wiersma & Koster 2013, Walsh et al.
2014). Harsh winter conditions hindered social participa-
tion and the ability to engage with the community (Novek
& Menec 2014). Findings indicated residents of some com-
munities had a shared history and a sense of pride in place;
thus, enhancing age-friendliness (Keating et al. 2013, Spina
& Menec 2015, Novek & Menec 2014). For others there
was an interdependency between local systems that sup-
ported older people (Walsh et al. 2014). Additionally, in
some small rural communities, there was a perception that
people could work together more easily as networks were
already in place (Menec et al. 2014b).
Table 1 (continued)
Author, year, country,
setting Aim(s) Design, data collection Participants and age range Major findings
Menec and Nowicki
(2014) Canada
Examine communities’ age-
friendliness and relationship
with health-related outcomes in
a rural context
Quantitative, needs assessment
survey
Community residents across 29
communities (n=593) (371
identified as seniors)
Overall age-friendly index is associated
with enhanced life satisfaction (0019,
95%CI 0011–0026, p<00001) and
self-perceived health (0013, 95%CI
0005–0021, p<001). The effect was
stronger for those who identified as
seniors as opposed to younger residents
Menec et al. (2014a)
Canada
Examine the congruence between
two types of age-friendly
surveys, subjective assessments
by community residents versus
objective assessments by
municipal officials
Quantitative, surveys Municipal officials (n=130)
Community residents (n=990)
across 39 rural communities
Congruence generally good between
municipal officials and community
residents although officials consistently
overestimated communities’ age-
friendliness relative to community
residents. Suggests officials can provide
a reasonable assessment of age-
friendliness that may be useful for
cross-community comparisons with
caution needed as may not reflect the
residents’ needs adequately.
©2016 John Wiley & Sons Ltd
Journal of Clinical Nursing 7
Review Age-friendly rural communities
Collaboration and partnership
A consistent finding was the active involvement of older
people in their communities as opposed to being passive
recipients of services and supports (Keating et al. 2013,
Menec et al. 2014b, Novek & Menec 2014, Walsh et al.
2014). However, marginalised older people, who are not
active participants in their communities require support and
services that are sometimes not available (Keating et al.
2013). The perceptions of older people of their own com-
munities is vital to assessing the priorities and barriers to
age-friendliness (Menec et al. 2014a, Novek & Menec
2014). In studies focused on implementation of age-friendly
initiatives, sustained leadership and support from all levels
of government was perceived to be crucial to success (Spina
& Menec 2015, Menec et al. 2014b). A lack of direction
and leadership was seen as a challenge to age-friendly ini-
tiatives (Menec et al. 2014b), whereas strong leadership
helped to counter geographic and demographic disadvan-
tages (Spina & Menec 2015). The top-down approach (gov-
ernment driven) has been found to work well and support
from local government increased success (Menec et al.
2014b). Furthermore, regional government is identified as
playing a vital role in the initial stages of effecting ageing-
friendly strategies, by encouraging rural communities to
implement age-friendly initiatives (Spina & Menec 2015,
Menec et al. 2014b).
Menec et al. (2014a) found municipal (local) officials
tended to over-estimate a community’s age-friendliness,
compared with the assessments of older people themselves.
However, they go on to suggest that if allowances were
made for these over-estimations, municipal officials may be
able to provide useful assessments for cross-community
comparisons. Linking age-friendly priorities to other com-
munity initiatives such as the development of walking trails,
increased the success of accessing and securing funds
(Menec et al. 2014b). Effective partnerships between uni-
versity researchers and non-government organisations were
also considered to be key to the successful implementation
of age-friendly initiatives in Manitoba (Menec et al.
2014b).
Sustainability and capacity
Skilled retirees who could volunteer are seen as being
important for sustaining rural communities and supporting
local economies (Keating et al. 2013). However, a commu-
nity’s capacity to support voluntarism can be threatened by
a lack of volunteers and volunteer ‘burn-out’ (Wiersma &
Koster 2013). Older residents may experience reduced eco-
nomic security (Keating et al. 2013), and Novek and
Menec (2014) found affordability was a common theme
that restricted older peoples’ activities such as volunteering
and access to the social environment. Menec and Nowicki
(2014) found there was a lack of community capacity, par-
ticularly in small communities, where there may not be
enough people to provide appropriate infrastructure, such
as being able to form committees.
Important to setting up and sustaining age-friendly initia-
tives was securing funding from regional government (Spina
& Menec 2015, Menec et al. 2014b), as well as using cre-
ative ways to use existing infrastructure and resources
(Spina & Menec 2015). The formation of intersectoral
partnerships enabled inclusive committees to build the
capacity needed to implement age-friendly projects (Menec
et al. 2014b). Furthermore, Spina and Menec (2015) rec-
ommended clustering age-friendly services and infrastruc-
ture; plus, where geography allows, sharing resources
between towns to increase efficiencies between communi-
ties. Keating et al. (2013) suggested a need for policy mak-
ers to be responsive to communities’ needs by strengthening
resources, particularly in rural areas which access to facili-
ties may be challenging for some older people. Defining and
promoting age-friendliness through the media and conduct-
ing awareness days are ways of sustaining buy-in at a com-
munity level (Menec et al. 2014b). Additionally, awards for
reaching official age-friendly milestones, set by WHO,
recognises achievement thus enhancing sustainability
(Menec et al. 2014b).
Future research agendas
In the light of the momentum in the age-friendly movement
Menec and Nowicki (2014) considered it crucial to for-
mally evaluate the progress communities are making in
becoming age-friendly. Walsh et al. (2014) suggested stud-
ies with a more involved qualitative component are needed
with exploration of how informality supports age-friendli-
ness. Further, Menec and Nowicki (2014) highlighted the
need for more qualitative studies to examine how age-
friendly initiatives have impacted the lives of older people
in diverse communities such as rural and remote communi-
ties. Similarly, understanding older peoples’ perceptions of
their communities and how they relate to healthy ageing is
another area identified for future research (Menec & Now-
icki 2014). In addition, Novek and Menec (2014) suggested
further research is needed on how gender and ethnicity tra-
verse issues such as affordability and environmental fea-
tures, for example exploring how transportation options
affect men differently than women in enabling social
©2016 John Wiley & Sons Ltd
8Journal of Clinical Nursing
S. J. Neville et al.
engagement. In addition, longitudinal studies with multiple
interviews over time, would be useful to reveal how
changes in communities such as demographic composition
affect capacity to become age-friendly (Spina & Menec
2015).
Keating et al. (2013) suggested personal biographies of
ageing would increase understanding of how residents’
views of their life course could contribute to the ongoing
development of the age-friendly concept. Examining rela-
tionships between age-friendliness and health, quality of
life and social connectivity, as well as studies focused on
the processes used by communities to become more age-
friendly should also be on the research agenda (Menec
et al. 2015). Comparisons of communities that have age-
friendly initiatives underway versus those without have
been suggested (Menec & Nowicki 2014). Additionally,
longitudinal quantitative studies, measuring health-related
outcomes over time, would also be useful (Menec & Now-
icki 2014).
Discussion
This integrative review has summarised the findings of nine
studies that focus on age-friendly rural communities. Eight
of the nine studies reviewed came out of Canada with six
of those from the province of Manitoba. This is hardly sur-
prising considering Canada, through provincial and federal
government, has encouraged and supported the age-friendly
agenda in response to the high population of older people
living in rural areas (Plouffe & Kalache 2011). For exam-
ple, Manitoba, a province in Canada, launched the Age
Friendly Manitoba Initiative (AFMI) in 2008 (Menec et al.
2014b). Consequently, this review has highlighted a lack of
available published information about how age-friendly
rural communities may be conceptualised across non-Eur-
opean cultures and operationalised in countries outside of
Canada.
In terms of theory development, conceptualisation of the
age-friendly model is in the early stages (Keating et al.
2013). Ecological theory was highlighted in several studies
reviewed, convincingly linking the notion of person-envir-
onment fit to the age-friendly concept (Keating et al. 2013,
Novek & Menec 2014, Menec et al. 2015). The intercon-
nectedness and holistic positioning of the age-friendly
domains was a common theme across the studies. In light
of this, academics have suggested a multi-disciplinary
approach to research on rural ageing is needed (Burholt &
Dobbs 2012). Four of the studies from the province of
Manitoba arose from a large research programme. For-
malised partnerships between the Manitoba Seniors and
Healthy Aging Secretariat and university researchers were
established (Menec & Nowicki 2014, Menec et al. 2014a,
b, 2015). These four studies highlighted the contribution
that effective partnerships can make to implementing age-
friendly initiatives. In support of this, Glickman et al.
(2014) suggested research can be successfully integrated
into policy and planning for age-friendly communities. The
perceptions, participation and contributions of older people
in implementing age-friendly initiatives have been widely
asserted and were evident in the studies reviewed (Lui et al.
2009, Plouffe & Kalache 2011, Buffel et al. 2012, Novek
& Menec 2014).
For age-friendly initiatives to be sustainable, the follow-
ing factors were considered imperative: strong leadership
from all levels of government; adequate and appropriate
funding; the inclusion of older people who are able to sit
on committees and volunteer across a range of areas.
Hence, older people with skills such as management, mar-
keting and leadership are considered essential to sustain-
ability. All of the studies were set against the background
of distinctive community characteristics including, geogra-
phy, demographic make-up and change, as well as the
degree of rurality. These characteristics could help or hin-
der a community from becoming age-friendly. Because of
the diversity and complexity of people and environments,
the uncertainty of whether some rural communities had the
capacity to become age-friendly was highlighted in several
studies. (Keating et al. 2013, Spina & Menec 2015, Walsh
et al. 2014). Certainly, more empirical studies are required
with a range of future research ideas arising from the
reviewed studies.
Limitations of the review
The studies in this review were predominantly Canadian
with the exception of one study set in Ireland. Although an
extensive and thorough systematic literature search was
undertaken, there remains a possibility that empirical stud-
ies were missed. Exclusion of published articles in a lan-
guage other than English is a further limitation of this
review. The relevance to the oldest old group cannot be
established from the findings with only one study having
included older adults over 85 years (see Table 1). Further-
more, this review focused exclusively on studies of rural
communities.
Conclusion
This integrative review has summarised the findings from
empirical studies that applied the age-friendly framework
©2016 John Wiley & Sons Ltd
Journal of Clinical Nursing 9
Review Age-friendly rural communities
in a rural context. While there were only nine studies
that met the inclusion criteria, this is consistent with a
new and emerging topic. Furthermore, they were all of a
high methodological quality. This review has established
that rural communities have unique and complex charac-
teristics that can help or hinder older people to age-in-
place. Additionally, the findings suggest a large scale
approach that is well resourced, by all levels of govern-
ment, is required, if sustainable age-friendly communities
are to become a reality. For many countries, the chal-
lenge will be significant. Certainly, with the population
rapidly ageing in rural communities, there is urgency that
cannot be ignored. Findings from this review suggest
research focused on older peoples’ perceptions of the age-
friendliness of their communities, is a fundamental start-
ing point.
Relevance to practice
This review has illuminated opportunities and challenges
for older people ageing in rural communities. Accordingly,
it is important for nurses, working in primary health care
settings, to understand the needs of older people in the
communities in which they practice. This includes the com-
munity characteristics that can be enablers and barriers to
older people being able to grow old in communities where
they live.
Contributions
SN, Sara N, JA, CW and DJ were involved in the study
design and manuscript preparation. SN, Sara N, JA under-
took the literature search and analysis.
Acknowledgements
The College of Health, School of Nursing, Massey Univer-
sity provided a $5000 grant to support data collection and
analysis associated with this project.
References
Bacsu J, Jeffery B, Abonyi S, Johnson S,
Novik N, Martz D & Oosman S
(2014) Healthy aging in place: percep-
tions of rural older adults. Educa-
tional Gerontology 40, 327–337.
Ball MS & Lawler K (2014) Changing
practice and policy to move to scale: a
framework for age-friendly communi-
ties across the United States. Journal
of Aging & Social Policy 26,19–32.
Buffel T, Phillipson C & Scharf T (2012)
Ageing in urban environments: devel-
oping ‘age-friendly’ cities. Critical
Social Policy 32, 597–617.
Buffel T, McGarry P, Phillipson C, De Don-
der L, Dury S, De Witte N, Smetcoren
AS & Vert
e D (2014) Developing age-
friendly cities: case studies from Brus-
sels and Manchester and implications
for policy and practice. Journal of
Aging & Social Policy 26,1–2.
Burholt V & Dobbs C (2012) Research on
rural ageing: where have we got to
and where are we going in Europe?
Journal of Rural Studies 28, 432–446.
Critical Appraisal Skills Programme
(CASP) (2014). CASP Checklists
(Qualitative) Oxford. Available at:
http://www.casp-uk.net/#!casp-tools-ch
ecklists/c18f8 (accessed 23 March
2016)
Crombie IK (1996) The Pocket Guide to
Critical Appraisal. BMJ Publishing
Group, London.
Garon S, Paris M, Beaulieu M, Veil A &
Lalibert
e A (2014) Collaborative part-
nership in age-friendly cities: two
cases from Quebec, Canada. Journal
of Aging & Social Policy 26,73–87.
Glickman A, Clark K, Kleban MH, Ring L
& Hoffman C (2014) Building an
integrated research/policy planning
age-friendly agenda. Journal of Aging
& Social Policy 26, 131–146.
Keating N, Swindle J & Fletcher S (2011)
Aging in rural Canada: a retrospective
and review. Canadian Journal on
Aging 30, 323–338.
Keating N, Eales J & Phillips JE (2013)
Age-friendly rural communities: con-
ceptualizing ‘best-fit’. Canadian Jour-
nal on Aging 32, 319–332.
Lui CW, Everingham JA, Warburton J,
Outhill M & Bartlett H (2009) What
makes a community age-friendly: a
review of the international literature.
Australasian Journal on Ageing 28,
116–121.
Menec VH & Nowicki S (2014) Examin-
ing the relationship between commu-
nities’ ‘age-friendliness’ and life
satisfaction and self-perceived health
in rural Manitoba, Canada. Rural and
Remote Health 14, 2594.
Menec VH, Newell NEG & Nowicki S
(2014a) Assessing communities’age-
friendliness: how congruent are subjec-
tive versus objective assessments?
Journal of Applied Gerontology.
doi:10.1177/0733464814542612.
Available at:http://jag.sagepub.com/con-
tent/early/2014/07/21/07334648145426
12.full.pdf+html (accessed 23 March
2016)
Menec VH, Novek S, Veselyuk D &
McAthur J (2014b) Lessons learned
from a Canadian province-wide age-
friendly initiative: the age-friendly
Manitoba initiative. Journal of Aging
& Society 26,33–51.
Menec VH, Hutton L, Newell N, Nowicki
S, Spina J & Veselyuk D (2015) How
‘age- friendly’ are rural communities
and what community characteristics
are related to age-friendliness?
The case of rural Manitoba, Canada.
Ageing & Society 35, 203–223.
Moher D, Liberati A, Tetzlaff J & Altman
DG (2009) Preferred reporting
items for systematic review and meta-
analyses: the PRISMA statement.
Annals of Internal Medicine 151,
264–269.
©2016 John Wiley & Sons Ltd
10 Journal of Clinical Nursing
S. J. Neville et al.
Naef R, Ward R, Mahrer-Imhof R &
Grande G (2013) Characteristics of
the bereavement experience of older
persons after spousal loss: an integra-
tive review. International Journal of
Nursing Studies 50, 1108–1121.
Novek S & Menec VH (2014) Older adults’
perceptions of age-friendly communi-
ties in Canada: a photovoice study.
Ageing & Society 34, 1052–1072.
Plouffe L & Kalache A (2010) Towards
global age-friendly cities: determining
urban features that promote active
aging. Journal of Urban Health 87,
733–739.
Plouffe L & Kalache A (2011) Making
communities age-friendly: state and
municipal initiatives in Canada and
other countries. Gaceta Sanitaria 25
(Suppl 2), 131–137.
Powell JL (2010) The power of global
aging. Ageing International 35,1–14.
Scharlach A (2012) Creating aging-friendly
communities in the United States. Age-
ing International 37,25–38.
Sixsmith A & Sixsmith J (2008) Ageing-in-
place in the United Kingdom. Ageing
International 32, 219–235.
Spina J & Menec VH (2015) What com-
munity characteristics help or hinder
rural communities in becoming age-
friendly? Perspectives from a Canadian
prairie province. Journal of Applied
Gerontology 34, 444–464.
Torraco RJ (2005) Writing integrative lit-
erature reviews: guidelines and exam-
ples. Human Resource Development
Review 4, 356–367.
United Nations, Department of Economic
and Social Affairs, Population Division
(2013) World Population Ageing. ST/
ESA/SER.A/348
Walker J, Orpin P, Baynes H, Stratford E,
Boyer K, Mahjouri N, Patterson C,
Robinson A & Carty J (2013) Insights
and principles for supporting social
engagement in rural older people.
Ageing and Society 33, 938–963.
Walsh K, O’Shea E, Scharf T & Murray M
(2012) Ageing in changing community
contexts: cross-border perspectives
from Ireland and Northern Ireland.
Journal of Rural Studies 28, 347–357.
Walsh K, O’Shea E, Scharf T & Shuck-
smith M (2014) Exploring the impact
of formal practices on social exclusion
and age-friendliness for older people
in rural communities. Journal of Com-
munity & Applied Social Psychology
24,37–49.
Whittmore R & Knafl K (2005) The inte-
grative review: updated methodology.
Journal of Advanced Nursing 52,
546–553.
Wiersma EC & Koster R (2013) Vulnera-
bility, voluntarism, and age-friendly
communities: placing rural northern
communities into context. Journal of
Rural and Community Development
8,62–76.
Wiles JL, Leibing A, Guberman N, Reeve J &
Allen RES (2012) The meaning of “age-
ing in place” to older people. The Geron-
tologist 52,357–366.
World Health Organisation (2002) Active
Ageing: A Policy Framework. WHO,
Geneva.
World Health Organisation (2007) Global
age-Friendly Cities: A Guide. WHO,
Geneva.
©2016 John Wiley & Sons Ltd
Journal of Clinical Nursing 11
Review Age-friendly rural communities
