A matrix was offered which included an outline containing the year, population, country, research method and aspects of active ageing concept (Table A – B / Appendix). The eight articles at the end of the process were published during the time period from 2002 to 2018 among which a great number were recent (e.g. Ko & Yeung (2018)). Also, most of these articles were placed in the U.S. while most of the quantitative ones used either surveys or second data analysis as well as follow-up methods. However, quantitative studies most frequently focused upon social engagement, physical and mental well-being and built environment while qualitative ones emphasized life satisfaction. Figure 2 demonstrates the flow chart adapted from Preferred Reporting Items [28, 120].
3.1 Thematic analysis
Different aspects of active ageing based on " qualitative content analysis" were coded and categorized during the process of data analysis the results of which are shown in Table 2 in the form of codes, sub-themes, and themes through qualitative content analysis. Different aspects have also been presented as summarized in a matrix which consists of 15 sub-themes and 5 themes called 5P model as follows: person (personal status), process, and place (built environment), policy-making and prime as shown in the ecological model demonstrated in Figure 3. Below, themes that were emerged from the data while applying the quotes and statistics of the final group of studies were described in more detail.
3.2 Themes
One of the core themes is “person” which can be divided into two sub-themes: personal characteristics and their behavioral attitude. Most studies conducted on active ageing provided an analysis of the effects of personal aspect including health, age, shared genetic attributes, educational level, personal socio-economic status, ethnicity, self-efficacy and exercise history [23]. In addition to this, many studies included diet and lifestyle factors which are related to the person’s behavior such as adoption of a balanced diet and food restrictions [40]. These restrictive diets and eating habits appear to be aimed for a balance between the imposition of the ageing physique and the limitations resulted from disease and sickness. Therefore, in order to maintain active ageing, a healthy diet must be considered as a major component for older people to provide themselves with strong levels of health and well-being leading them to the possibility of a different experience at maturity [40]. Another component in relation to behavior aspect to maintain active ageing is the attitude towards these behaviors because it can be modified at any point leading to a considerable increase in active ageing [40]. Therefore, several studies found that those elderly who have never smoked or drank had a considerably enjoy active ageing compared to those with such habits [40]. Evidence also suggests that physical activity is a significant factor in active ageing [23, 40].
The ecological model described by Stocks in the context of Healthy Environments is a broad framework which takes into account the physical environment and the psychosocial environment [121]. The proposed ecological model demonstrates the functional relationships between the ageing person and the micro, meso, and macro-system levels of the environment along with the unstable equilibrium between environment and individual competence in very old age [120].
“Prime”, in this narrative review, is a reflection of health and components within the concept of health namely physical, mental and social health. According to WHO definition, health is a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity [122] which shows that several factors must be taken into account in order to grasp the idea of health which could include biological, social and psychological factors, to name a few.
The environment includes the natural and the man-made components alongside each other which significantly affects the health state of an older person. Strong evidence supports the fact that living in an environment of low quality results in decreased physical health, associated with high prevalence of degenerative disease, incidence of falls, cardiovascular mortality and reductions in longevity and increased disability, poor quality of life and poor self-reported health [23, 37, 44, 55, 56, 59, 69, 79, 89, 90]. Several mental health issues were also examined in the literature including depression, anxiety, anger, psychological wellbeing and cognitive functioning (mental processing, speed, and working memory) [23, 55, 59, 67, 81, 89, 90, 95, 117]. Social health [100]and well-being literature, on the other hand, focuses on the quality issues such as interpersonal relationships between the members of society and the amount of their involvement in their community. Several studies conducted on social well-being were assessed as a result of which it was found that in order to propose the level of social well-being for a group of people their performance must be studied in the following areas: (1) family, (2) work, (3) community involvement, and (4) social life or sociability of individuals (e.g., friendships) [119].
However, community health and psychological health are the results of the efforts contributed by epidemiologists and environmental psychologists which include the sense of community identity; community empowerment; social capital; and culture [118].
“Process” as the core ecological theme in active ageing includes the three sub-themes of social, economic and cultural environments which are significantly important in the lives of an ageing older person as these can be barriers for their life activities and thus health outcomes [23]. We focused our literature search on those activities in an active ageing policy framework by WHO which outlined key items as physical, social, cultural, civic, spiritual and economic activities [2]. Many researchers have decided to study the role of social environement which includes proximate social networks, social capital (norms of reciprocity and trust) and incidental social interactions [23]. Also, the important components of social environement that affect an increased active ageing include different social contacts, increased social involvement, wide social network, living children, ethnic homogenity, increased sense of neighborliness, increased literacy, increased social and economic status, increased workforce involvement, time spent with friends as well as an age-specific community [1, 7, 32, 33, 36, 37, 42–44, 46, 53–56, 60, 62, 65, 67, 71, 72, 74, 81, 82, 85, 89, 95, 102–108, 123].
There are some specific characteristics of the social environment that necessitates the elderly to meet specific demands leading to sub-optimal active ageing. These may include family’s financial problems, a partner with health problems, unrealistic expectations from the person themselves to their friends and families, weak social and economic status of the area which is recognized as economic environment [1, 7, 23, 32, 42, 43, 72, 80, 88]. In addition to these, there is also the cultural environment which consists of religious activity, cultural events/rituals/social activity and sense of place [44, 55, 56, 59, 82, 87, 89]. We found that there is strong evidence to support a powerful and supportive social network enhances the well-being and longevity of the elderly in society. However, the composition of this supportive network may differ from one society/person to others [23]. The extent of poverty is also among the commonly mentioned factor that affects the activity involvement of the people. Yet, several studies maintained that lower social and economic status of an area is linked to the physical activity of individuals which of course, as later mentioned by the authors, maybe the case due to these peoples’ need for work and transportation. In fact, active ageing includes social, cultural, civic, spiritual and economic elements, which potentially contribute to health and wellbeing in later life [2, 23].
The theme of “place” consists of land use, physical form, housing themes, access, public space quality, and city image/townscape. There are several reported environmental characteristics which enhance the elderly’s well-being including the proximity to and density of public open space and recreational facilities, high-quality facilities (social and leisure facilities, age-appropriate facilities), peacefulness, cleanliness, , safety of public areas and street crossings, frequent rubbish collection, access to health services, transport availability, closeness to shops and places for walking, living in a retirement village, living in a hillside area, living in an area with high rainfall and living in a residential environment [23] and lack of Littering/vandalism/decay[41].
Furthermore, we identified literature which assessed features of “place” that effectively contribute to active ageing. These included measures of land use characteristics (area deprivation or poverty, neighborhood degradation) [23, 34, 43, 44, 46–53], physical form (neighborhood degradation, accessibility to services and facilities, accessibility of public greenspace, walkability or pedestrian friendliness) [3, 7, 32, 34, 37, 43, 44, 50, 51, 53–81, 83, 84, 124], physical form as security of perceived crime and anti-social behavior, safety to traffic conditions [7, 32, 34, 43, 44, 46, 50, 55–57, 62, 64, 65, 70, 77, 81, 85–89, 125], quality of public space [23] as aesthetics and architecture, landscape (lighting and furniture) [34, 55–59, 66, 77, 87, 89–92], pedestrian-friendly features and availability of benches/sitting facilities[41] , trip hazards in the home and neighborhood, home and environmental adaptations, climate and topography [23] along with favorable physical attributes such as trees and green areas which provides a sense of well-being while supporting resilience. Other positive factors include favorable street design, access to public transportation system as well as several retail outlets which would motivate people for more community involvement which provides a strong supportive social network for them while encouraging more physical activity [10, 34, 55–57, 59, 66, 77, 87, 89–92]. Recognizing such the diverse kinds of environment for careful analysis helps the assessment of home or care centers, the typologies of land use including rural and urban uses, categorization according to population density, defining areas based on time/distance, defining the neighborhood by its members. Interestingly, we found most of the articles in this review, however, provided the researcher-based definitions of a place as-built environment [23, 43, 49–51, 58, 70, 72, 79, 93–99].
Studying environments in the previous body of literature also included government-defined administrative areas as census tracts or postal codes [23] which focused on the key concepts of tolerance, fairness, social justice and good governance (Effective collaboration and political commitment to the elder Performance orientation, Openness, transparency and integrity governance, Equity/Inclusiveness) [63, 72, 75, 93, 109–114, 116, 126, 127] as necessary elements in sustainable development of urban planning. While physical and social environments are both important aspects for the elderly’s health state, favorable governance and planning of the environment are also of great significance in building an age-appropriate community. For this several models have been proposed to date. However, the results show that consensus planning using meaningful community involvement is significantly needed for these complex areas. Collaborative governance efforts with different players and sectors through the stages of building a community are also of great importance as the public was considered as a body to consult with rather than active members in creating knowledge, space or governance centers [128].
3.3 Study quality
A considerable number of the included articles provided clearly set out objectives and methods compatible with their aims of the research. We provide comprehensive details of study quality in Appendices. In brief, since many of these articles applied a self-selected sampling the findings, the results were hugely influenced by their selection and information bias which could affect their internal validity and, probably, the quality of quantitative studies and, to a lesser extent, qualitative studies. In addition to this, there were some observational studies which could not be considered as transferable and generalizable in their findings due to their small sample sizes and specific methods used in these studies. Due to this heterogeneity, we provide narrative review encompassing all relevant literature to derive themes to accommodate smaller qualitative pieces of work which may have specific implications to international communities, small or large, with diverse societal, cultural, religious belief systems.