Older Adults’ Perceptions of Age-friendliness in Hong Kong

Older Adults’ Perceptions of Age-friendliness in Hong Kong Abstract Background and Objectives There is little understanding about how rapid urban development has affected the extent to which communities are able to optimize health and participation opportunities for older adults in Hong Kong. Our objective was to examine what older residents perceive to be the shortcomings of their communities in meeting their psychosocial and physical needs as they age. Research Design and Methods In reference to the WHO Age-Friendly Cities Project Methodology: Vancouver Protocol, we conducted nine focus groups comprising 65 participants for an Age-Friendly City baseline assessment in two districts in Hong Kong, China. Participants were asked to share their views on their respective district of residence, and identify aspects of the city they found unfriendly. Data generated from interviews were analyzed using thematic analysis. Results Five of the following key themes were identified: the failure of public transportation to cater to the needs of older adults; a lack of public space for recreation and socializing; diminishing human interactions in welfare services; physical and financial challenges relating to housing; and workplace discrimination against older adults. Discussion and Implications These findings underscore the importance of prioritizing the social welfare of older adults in building a more inclusive and age-friendly city. They also highlight the difficulties in fostering an inclusive environment while ensuring efficiency and profit maximization. Well-being, Urban, Chinese, East Asia, Qualitative research methods, Productivist welfare regime, Age-friendly cities Population aging is a pervasive global phenomenon unparalleled in human history. Recognizing that existing policies, norms, and social institutions are no longer adequate to meet the needs of aging populations (Lehning, Chun, & Scharlach, 2007), the provision of friendly, supportive, and enabling environments for older adults has emerged as an important agenda for research, practice, and policy in many cities around the world. In line with this, the World Health Organization (WHO, 2007) has made efforts to promote “Age-Friendly Cities” (AFC) to meet the imminent challenges resulting from population aging. The concept of AFC stems from the ecological perspective of aging that links the well-being of individuals’ to their physical and social environments (Evans, Kantrowitz, & Eshelman, 2002; Manzo & Perkins, 2006; Steels, 2015; Yen, Flood, Thompson, Anderson, & Wong, 2014), and the policy imperative to maintain and support older adults living in their own communities for as long as possible (aging-in-place) (Buffel & Phillipson, 2016). AFC is also premised on the belief that older adults can continue to be vital societal resources if they are able to live in environments that enable them to continuously engage in productive activities (Beard & Petitot, 2010). An age-friendly city is one that “encourages active aging by optimizing opportunities for health, participation and security in order to enhance quality of life as people age. In practical terms, an age-friendly city adapts its structures and services to be accessible to and inclusive of older people with varying needs and capacities” (World Health Organization, 2007). Based on this framework, a global collaborative project conceived by the WHO in 2005 identified eight key domains of an AFC, including outdoor spaces and buildings, transportation, housing, social participation, respect and social inclusion, civic participation and employment, communication and information, and community and health services. To date, the WHO Global Network of Age-friendly Cities and Communities comprises 287 cities and communities in 33 countries, covering 113 million people. Most members are economically advanced societies. While efforts to create age-friendly communities are now underway across the globe, many barriers remain, including, inter alia, the implementation of neoliberal policies and resultant welfare retrenchment (Phillipson, 2013), obsolete land-use regulations and policies (Lehning et al., 2007), a lack of opportunities or communication with potential organizations to volunteer, shortages of reliable, frequent and accessible transportation (Emlet & Moceri, 2012), and under-representation of older adults in policy-making processes (Alley, Liebig, Pynoos, Banerjee, & Choi, 2007). Age-friendliness in Asia Literature pertinent to the barriers to implementing AFC has thus far been excessively generated in the West, and findings may not be generalizable to East Asia where cities are typically much denser and geographically smaller in size. Despite the recent expansion of welfare for older adults in many of these societies (Aspalter, 2006), the growth of supply (e.g., provision of nursing homes) simply cannot match the growth in demand created by the sheer size of the older population. Indeed, Asia is now home to the largest population of older adults in the world and Hong Kong, Japan, South Korea, and Taiwan will become the world’s oldest places by 2050 (United Nations, 2015). In light of this imminent “aging tsunami,” city development and planning in many East Asian countries may be under-prepared to provide a friendly environment for older residents. Moreover, it remains unclear how older adults in East Asian cities experience challenges in their everyday lives. To date, there is limited research on the age-friendliness (or lack thereof) of East Asian cities that draws opinions directly from older adults in a contextualized manner. Nevertheless, existing studies do provide insight into the discourse on age-friendliness in the Asian context. For instance, Kadoya (2013) found that older Japanese adults who lived alone and could not drive were reluctant to participate in their communities or social activities, a key feature of an age-friendly city. In Taiwan, Chen et al. (2013) identified five major needs pertinent to AFC for older adults, including the needs to adapt public spaces to their mind-body function and development, to modify transportation systems for comfort, to facilitate harmonious and peaceful family relationships, to reduce barriers of information delivery, and to address the value and importance of older adults in society. While informative, none of these studies examine the possible conflict between age-friendliness, efficiency and commercial interests. As such, drawing from the perspectives of older adults in Hong Kong, this study examines the following research question: in what ways is Hong Kong, a highly urbanized and economically advanced city, under-prepared for its aging population? Hong Kong China as a Case Example Hong Kong is an economically advanced and mostly urban city located in the Southeast part of China. It is only about 1,100 km2 in area, but houses a large population that has grown rapidly in size and age, increasing from 5.18 million in 1981 to 7.31 million in 2015 (Census and Statistics Department, 2016), making it one of the densest cities in the world. The combination of longer life expectancies (the highest in the world) (Ministry of Health, Labour and Welfare, 2016) and lower fertility rates (one of the lowest in the world) has dramatically transformed its demographic structure. The number of older adults aged 65 years and above is expected to increase from 1.16 million (16.6% of the total population) in 2016, to approximately 2.37 million (31.1%) by 2036 (Census and Statistics Department, 2017a). Correspondingly, the median age is projected to increase substantially, from 43.4 in 2016 to 48.9 by 2036 (Census and Statistics Department, 2017a). Changes in demographic structure have direct bearings on the demands placed on social welfare services and town planning. Yet, Hong Kong has for a significant period of time lacked long-term social welfare planning including elderly services (e.g., a Long-Term Care System), and has instead embraced a “big market, small government” governance philosophy. Consequently, the city’s low-tax regime and emphasis on self-reliance prevail (Cheng et al., 2013). Methods Through collaborating with local district elderly centers and open recruitment, our study used convenience and snowball sampling to recruit participants from two out of Hong Kong’s eighteen districts: Wan Chai district and Central and Western district. Compared to the other 16 districts, older adults living in the Wan Chai and Central and Western districts have higher levels of education and wealth (Census and Statistics Department, 2017b). As percentage of district population, 15.0% of people in Central and Western district and 15.4% in Wan Chai district are older adults aged 65 years or above. The district with the highest percentage of older adults is Wong Tai Sin district (17.0%) and the lowest is Tsuen Wan district (13.7%). Compared to the overall district characteristics, our sample has a higher proportion of females (88% vs 56%), higher percentage of owner-occupied households (64% vs 56%) but lower percentage of secondary education and above (42% vs 64%) (Census and Statistics Department, 2017b). To meet the inclusion criteria, potential participants needed to be aged 55 years or above, usually reside in one of the two districts, and be mentally capable of participating in the study. Under this sampling frame, nine focus groups comprising 65 participants in total were conducted between January and February of 2016. The demographic characteristics of the sample are shown in Table 1. Particularly of note is the fact that participants had lived in their districts for an average of 34.2 years (SD = 18.7), suggesting their depth of knowledge regarding their local communities. Table 1. Demographic Characteristics of Focus Group Participants (n = 65) Characteristics  N  %  Mean (SD)  Gender        Male  8  12    Female  57  88    Age      75.1 (9.24)  Age group (years)        55–64 years  11  17    65–74 years  21  32    75–84 years  20  31    ≥85 years  13  20    Duration of living in the district (years)      34.2 (18.7)  10 or below  7  11    11–20  9  14    21–30  13  20    31–40  13  20    41–50  12  19    51 or above  9  14    Marital status        Married  21  32    Widowed  38  59    Others  6  9    Education        Nil/preprimary  9  14    Primary  27  43    Secondary (Form 1–5)  11  17    Secondary (Form 6–7)  9  14    Postsecondary  7  11    Housing        Public rental  20  31    Private, rental  3  5    Private, owned  41  64    Living arrangement        Living alone  16  25    With spouse only  10  16    With spouse and other family members  8  13    With children/grandchildren only  29  45    With other family members  1  2    Monthly personal income (Hong Kong Dollars)        No income  12  19    1–5,999  40  63    6,000–9,999  7  11    10,000–19,999  3  5    20,000–29,999  2  3    Characteristics  N  %  Mean (SD)  Gender        Male  8  12    Female  57  88    Age      75.1 (9.24)  Age group (years)        55–64 years  11  17    65–74 years  21  32    75–84 years  20  31    ≥85 years  13  20    Duration of living in the district (years)      34.2 (18.7)  10 or below  7  11    11–20  9  14    21–30  13  20    31–40  13  20    41–50  12  19    51 or above  9  14    Marital status        Married  21  32    Widowed  38  59    Others  6  9    Education        Nil/preprimary  9  14    Primary  27  43    Secondary (Form 1–5)  11  17    Secondary (Form 6–7)  9  14    Postsecondary  7  11    Housing        Public rental  20  31    Private, rental  3  5    Private, owned  41  64    Living arrangement        Living alone  16  25    With spouse only  10  16    With spouse and other family members  8  13    With children/grandchildren only  29  45    With other family members  1  2    Monthly personal income (Hong Kong Dollars)        No income  12  19    1–5,999  40  63    6,000–9,999  7  11    10,000–19,999  3  5    20,000–29,999  2  3    View Large Table 1. Demographic Characteristics of Focus Group Participants (n = 65) Characteristics  N  %  Mean (SD)  Gender        Male  8  12    Female  57  88    Age      75.1 (9.24)  Age group (years)        55–64 years  11  17    65–74 years  21  32    75–84 years  20  31    ≥85 years  13  20    Duration of living in the district (years)      34.2 (18.7)  10 or below  7  11    11–20  9  14    21–30  13  20    31–40  13  20    41–50  12  19    51 or above  9  14    Marital status        Married  21  32    Widowed  38  59    Others  6  9    Education        Nil/preprimary  9  14    Primary  27  43    Secondary (Form 1–5)  11  17    Secondary (Form 6–7)  9  14    Postsecondary  7  11    Housing        Public rental  20  31    Private, rental  3  5    Private, owned  41  64    Living arrangement        Living alone  16  25    With spouse only  10  16    With spouse and other family members  8  13    With children/grandchildren only  29  45    With other family members  1  2    Monthly personal income (Hong Kong Dollars)        No income  12  19    1–5,999  40  63    6,000–9,999  7  11    10,000–19,999  3  5    20,000–29,999  2  3    Characteristics  N  %  Mean (SD)  Gender        Male  8  12    Female  57  88    Age      75.1 (9.24)  Age group (years)        55–64 years  11  17    65–74 years  21  32    75–84 years  20  31    ≥85 years  13  20    Duration of living in the district (years)      34.2 (18.7)  10 or below  7  11    11–20  9  14    21–30  13  20    31–40  13  20    41–50  12  19    51 or above  9  14    Marital status        Married  21  32    Widowed  38  59    Others  6  9    Education        Nil/preprimary  9  14    Primary  27  43    Secondary (Form 1–5)  11  17    Secondary (Form 6–7)  9  14    Postsecondary  7  11    Housing        Public rental  20  31    Private, rental  3  5    Private, owned  41  64    Living arrangement        Living alone  16  25    With spouse only  10  16    With spouse and other family members  8  13    With children/grandchildren only  29  45    With other family members  1  2    Monthly personal income (Hong Kong Dollars)        No income  12  19    1–5,999  40  63    6,000–9,999  7  11    10,000–19,999  3  5    20,000–29,999  2  3    View Large All focus group interviews utilized an interview guide adapted and translated from the “WHO Age-Friendly Cities Project Methodology: Vancouver Protocol.” In each interview, participants were first introduced to the AFC concept and the eight domains of the WHO’s AFC framework. Next, they were asked to identify domains they thought needed improvement in their respective districts. Participants were asked to elaborate upon their answers and to provide examples from their own personal experiences to illustrate how these domains affected their daily lives. Despite using the Vancouver Protocol as a general guide, we also invited participants to indicate and describe any aspects beyond the eight domains that they found unfriendly. This allowed more flexibility and autonomy for participants to articulate their everyday difficulties. Each focus group interview consisted of 4–12 participants, lasted for approximately 1.5 hr, and was held in a community location convenient to participants. At the beginning of an interview, each participant completed a brief questionnaire to provide information about his or her demographic characteristics. A group leader and an assistant then facilitated the interview. At the end of the interview, each participant was given a store coupon of HK$20 as a token of gratitude for his or her participation. All interviews were conducted in Cantonese and audio-recorded. The study was approved by the Human Research Ethics Committee (HREC) of The University of Hong Kong. The audio records of each focus group were transcribed verbatim. Transcripts were analyzed using thematic analyses (Braun & Clarke, 2006) based on the eight WHO AFC domains, which comprised several stages. In stage one, we familiarized ourselves with the data by repeatedly reading the transcripts. In stage two, we generated an initial list of codes that were relevant to our research question. During this stage, quotes describing aspects of age-unfriendliness in the community, and/ or pertaining to how Hong Kong is under-prepared for its aging population were highlighted. This was followed by stage three, in which themes were identified by categorizing the initial codes generated in the second stage. Codes that fell into overarching themes were categorized by the initial theme. For example, under the WHO Age-friendly domain of “community support and health services,” when it was evident that one emergent pattern was that participants found navigating electronic systems including medical appointment systems and ATM machines very age-unfriendly, we classified these illustrative examples under the theme “Automation replacing human interactions.” Stage four comprised reviewing and refining the themes. To improve overall data reliability, two researchers coded the transcripts independently during the analysis process. The two researchers then compared coding schemes and emergent themes. Agreements had to be reached regarding the emergent themes. Finally, stages five and six involved naming the themes and reporting. The following presents these five themes, within which each category will be discussed and supported by illustrative quotes from participants. Results Five key themes relating to subjectively experienced age-unfriendly features in the city emerged from our thematic analyses. In reporting these themes, we strove to make explicit how participants found these features to be deeply embedded in their daily lives. Transport Efficiency Trumps Inclusiveness The ability of transport systems to meet the mobility needs of older adults is a crucial factor in their quality of life (Paez, Scott, Potoglou, Kanaroglou, & Newbold, 2006), and one of the goals of AFC. Unlike Western countries, where most people are automobile-dependent, the majority of Hong Kong residents rely on public transport to commute. Counterintuitively, we found that the expansion of the underground railway system, the Mass Transit Railway (MTR) which accounts for 42.6% of journeys on public transport each day (Transport Department, 2017), may have adversely affected the mobility of older residents because they usually have poorer physical agility compared to younger cohorts. Participants stated that they preferred that the slower and cheaper aboveground public transport system. However, aboveground transportations had been undermined by the expansion of the underground transport system. For instance, the advent of MTR West Island Line was accompanied by “bus route rationalization” in the district (HKSAR Government, 2016), which resulted in the reduction of some aboveground bus routes that had previously enabled participants to travel conveniently without needing to walk the long distances necessary to reach the underground railway platforms. Many participants preferred less physically and cognitively demanding transportation that did not require multiple railway line transfers. “I prefer taking buses the most. Direct route to the destination. Then I don’t need to walk up and down so much [like when taking the MTR]… I take the MTR only when there are no other choices, since I feel that when I need to make a transfer on the MTR, it’s troublesome.” “Before the MTR service [expanded to this area], the red minibus [service] was quite OK... It was very convenient. However, with the MTR expansion, it runs less frequently.” As for transport software, participants contended that public transport services overlook the needs of the nonworking population. They were dissatisfied that the timetables of public transport services catered primarily to the schedules of working people, with inadequate consideration given to the needs of older adults who often went out during nonpeak hours. “They run more frequently when it’s time for people go to work. When it’s outside of the morning peak hour, it’s when old people like us go out to do grocery shopping. The transport then runs much less frequently. Why?” We posit that transport planning in the city primarily focuses on efficiency: transporting the maximum number of people in the smallest amount of time while minimizing aboveground congestion. However, our findings illustrate how competing interests may pose considerable challenges to providing older adults with accessible public transport, a key factor in influencing active aging as stated in the WHO AFC guide. Public Space Shortages for Older Adults Participants discussed the shortage of accessible public spaces in relation to their quality of life. Land use has been a highly contentious and divisive issue in Hong Kong due to its high population density and the competing demands for housing, commerce, industry, transport, recreation, nature conservation, heritage preservation, and other community needs (Planning Department, 2016). In fact, since the 1980s, scholars have highlighted how Hong Kong’s urban planning strategy has heavily favored commercial interests that focuses on profit maximization while overlooking the social needs of its citizens (Ng, 1995; Ng & Tang, 1999; Yeung, 1997). This is also evidenced by the noticeable increase in the leasing out of public spaces to the private company The Link REIT, which operates high-end shopping malls (So, 2010). Many of these malls have little space for patrons to congregate or even sit. Against this backdrop of privatization, participants indicated that there was limited public space left to conduct their daily leisure or social activities: “The only larger park is not convenient to us. We have to walk a relatively longer distance to reach there.” “I can’t go for a run in the morning sometimes when I want, as the park is so small with many people there.” Indeed, the average amount of open space available per person in Hong Kong is 2.7–2.8 m2, which is far behind other Asian cities like Tokyo (5.8 m2), Seoul (6.1 m2), Shanghai (7.6 m2), and Singapore (7.4 m2) (Lai, 2017). Without sufficient public space to enjoy their leisure time, many older adults tended to spend their time in local restaurants instead: “There are many rules and regulations to follow in elderly community centers, so that’s why many older adults prefer to just stay in McDonald’s…They can stay or leave whenever they want…” “Sometimes I will ask older adults why are you sitting here [the restaurant]? They said it is convenient...The number of older people here is still affordable now, but not for the future with higher number of older population. They [the restaurant] need to do their business, but they can’t expel older adults. “ Regarding the needs of older adults, some participants expressed disappointment when recounting the higher priority given to commercial needs during urban planning or redevelopment in the district: “I had high hopes for where the former slaughterhouse was located… That’s an area under planning [for redevelopment]… However, [the government] already has plans that in the future they will build luxury homes, hotels and shopping malls there… Actually, if it can be redeveloped to become a [public] music hall or a community hall, that would be nice.” Some participants viewed the government’s laissez-faire policy as a contributing factor to the paucity of public spaces. They expressed their wish for the government to take action to negotiate with stakeholders with conflicting interests in public space development. This was illustrated in their advocacy for greater government intervention in a promenade expansion project: “A [path] has to be built to cut through a wholesale food market, a concrete construction company, and a parking lot…before the promenade can be built. There has been a lot of discussion, but I haven’t seen the government taking any real actions. Like, how about relocating the concrete construction company?” As land has become increasingly valuable due to population growth and real estate developers act to maximize profits, the provision of free shared spaces has been minimized. Participants residing in public housing identified how older residential estates had wider and better-ventilated hallways and more communal areas, which facilitated better social interactions whereas new ones do not. “In the new buildings…you can’t even stand there to chat [with your neighbors]… In the old design, there was good ventilation and more public space…” They further denounced real estate developers that tended to construct buildings with a focus on maximizing profits, while neglecting the physical and social needs of older adults. “They thought that as long as they could make money, they built the buildings to take up all the space, and did not think about the pavements for the pedestrians.” “The contractors only care about money and don’t care about people’s well-being”. In light of participants’ frustrations toward these real estate developers, we argue that one possible contributing factor is past governments’ laissez faire policies and the resultant lack of strict regulation imposed on these developers that allowed for such age-unfriendly constructions to occur. Indeed, creating a facilitative physical environment that optimizes older adults’ social participation is a key suggestion within the AFC agenda. However, competing interests in land development, in particular redeveloping land for commercial purposes may have posed increasing barriers for older adults to participate in meaningful communal and social activities, as articulated by study participants. That many of the available spaces were “privatized” and instead used for commercial purposes underscores the juxtaposition between economic, for-profit uses of the city and its age-friendliness and inclusiveness. Automation Replacing Human Interactions Participants valued human interactions when they sought or received services. However, they found that human interactions are rapidly diminishing as the city adopts cost-effective automated services. Nowhere is this more apparent than when accessing public health services, where appointments can only be made via automated telephone appointment booking systems. The lack of a real person to talk to and who could provide assistance often obstructed participants from accessing health care. With deteriorating physical and cognitive ability, some older adults may face disproportionately greater challenges when navigating the automated system. Indeed, participants indicated that they had tremendous difficulties in following the fast-paced instructions requiring patients to enter their identity card numbers and date of birth in quick succession, and in pressing the correct corresponding buttons. “Making phone calls to make medical appointments [with the automated system] is really difficult. Older people don’t know how to press the phone buttons. It is really a hassle.” Personalized services provided by real people were found to be the preferable mode of contact among our participants. For instance, participants recalled appreciatively how tram operators used to help them by carrying their bags, and helping them to their seats. However, these human interactions have been gradually replaced by automated turnstiles. On the one hand, the turnstiles can effectively replace humans to serve gatekeeping and passenger-counting functions; on the other, the age-friendliness of public transport for older adults may have been diminished as a result. In these examples, we see once again the dilemma between catering to the needs of older adults and the objective of optimizing the “cost-effectiveness” of existing systems. Housing Unaffordability: Deteriorating Housing Conditions Participants expressed difficulties in affording maintenance and modification costs to their homes, and most stated that they were reluctant or unable to pay for home renovation even if it would improve their quality of life. “There’s no way [the government] would build public housing in this district. Only the rich can live here now…the rent…the rent is so high…” “[We] don’t have any income now. Now you ask [us] to spend hundreds of thousands of dollars on renovation, how would we be able to do it?” “I have no income. I am retired. Where do I find the money for renovation?” Indeed, Hong Kong has consistently been ranked as having the most expensive and least affordable housing market in the world over the past 7 years (Cox & Pavletich, 2017). It is conceivable that older adults may be disproportionately affected by housing unaffordability compared to other age groups as there is no universal pension or retirement protection system in Hong Kong. Participants pointed out that due to ever-increasing rents, some older adults are forced to live in subdivided units—a typical private flat divided multiple units for lease. “It’s impossible to afford... [the private flat owners] exploit you once…then exploit you more…some older adults have to live in ‘coffin homes. ‘” In discussing whether newer residential buildings were age-friendly, participants indicated the new housing were less spacious and its environment is discouraging social interaction with neighbors. “Everyone close their doors nowadays...The corridor [common area] is so narrow with no windows in these new housing, how can we gather and talk like in the old one?” “Previously the flats were quite spacious with high ceilings…now they [developer] just build very small flats to sell as many and as expensively as possible.” Good quality housing can induce feelings of security, belonging and expression of self, and is often correlated with place attachment among older adults (Brown, Perkins, & Brown, 2003; Buffel et al., 2014) and ability to live independently, whereas subpar housing standards can adversely affect older adults’ psychological wellbeing. Our participants expressed that their deteriorating residential environment may no longer accommodate their needs. Furthermore, the fact that many older buildings do not have elevators gives insight into the how rapid urban development and planning beginning in the 1970s was very much implemented with a “younger generation” in mind as city users. Work Segregation and Employment Discrimination Against Older Adults Participants indicated that the unavailability of paid work opportunities may be the result of ageist attitudes and discrimination. This may be based on the (mis)perception that younger workers have greater productivity and contribute more to the economy than older workers, but perhaps also due to the lack of legal measures to protect older employees from discrimination. Indeed, while Hong Kong has laws against discrimination on the grounds of sex, disability, family status, and race, there is no legislation preventing age discrimination (Equal Opportunities Commission, n.d.). Moreover, it is common practice for employers to request prospective employees’ full date of birth in their job application. Possibly due to these systemic biases against older adults, it was unsurprising when our participants shared that employers did not welcome older workers. I: If older people want to look for jobs, can they find it? P1: No, it’d be very difficult. P2: Very difficult. P3: If I wanted to find a job now, I don’t think I could find one. Participants mainly expressed a sense of resignation, rather than indignation: P1: If they [employers] look for help, they usually look for the young ones. They are more energetic and strong, and can get things done. I: But it’s difficult to find the young ones to hire. P1: Still, they wouldn’t hire the old ones. P2: Once they look at your age, they would not hire you. It appears that many participants have internalized these negative biases against the capabilities of older adults, and thus attempted to rationalize or normalize age-based discriminatory practices in the workplace. They were unconfident in their own abilities and articulated that they would not be able to live up to the high demands of work productivity because they were “old” and “slow,” and that only younger generations are able to fulfill these demands. In relation to the AFC goal of optimizing employment opportunities for older adults, Hong Kong appears to have fallen behind other advanced economies in the region. Indeed, the employment rate among older adults in Hong Kong was only 9% in 2015—far below neighboring East Asian countires such as South Korea (31%), Singapore (26%), and Japan (22%) (Legislative Council, 2016). The city was ranked especially low in income security, and psychological well-being among older adults (CUHK Jockey Club Institute of Ageing, 2017). Discussion Drawing from the perspectives of older Chinese adults, this study provides insight into how older adults interact with, and are shaped by, both the hardware (such as physical environments) and software (such as the dearth of human interactions) in their community. In particular, we identified five emergent themes pertinent to the age-(un)friendliness of the city. In many instances, these dimensions may reinforce, intersect, and affect one another. For example, public space shortages may reduce opportunities for older adults to have meaningful social interactions, a critical component of “living well” (Wong et al., 2014). The identified themes converged with the WHO AFC Guide (World Health Organization, 2007) and suggest that older adults in this study faced several physical, financial, and social barriers in their communities that were deemed unfriendly. Several additional insights can be drawn from this study. First, in the city’s tendency to bid for maximum efficiency and minimal costs, Hong Kong seems to have neglected some key imperatives and policy goals as stated in the WHO Age-friendly City Guide. We found that older adults preferred human interactions over automation, familiarity and inclusiveness over efficiency, and communal public space over land privatization. Yet, these characteristics seem to be rapidly eroding. As indicated by study participants, these characteristics may have adversely affected their quality of life. A possible underlying reason for current shortcomings may be that public policy has long been underscored by a productivist welfare regime (Holliday, 2000) where social rights are often subordinate to the overriding policy objective of economic growth, and where social policies are primarily used as tools to promote economic participation through the market, with the state typically adopting a regulatory role in social welfare policy rather than providing welfare itself (Aspalter, 2006; Aspalter, 2011; Holliday, 2000; Holliday, 2005; Kwon & Holliday, 2007; Wong, 2007). Under this developmental paradigm, it is possible that the regime’s emphasis on individual responsibility and self-reliance has resulted in the state providing minimal social rights and protection for older adults (Cheng, 2013; Cheng, Lum, Lam & Fung, 2013; Wong, 2007). However, such supposition warrants further examination. Second, consistent with the observation made by Handler (2014, p.12), our findings revealed that most participants viewed the city as being operated and “structured with a younger, working age demographic in mind” while neglecting the needs of older adults. Participants were particularly indignant toward what was perceived to be continuous favoritism toward the commercial sector and the maximization of profit over older people’s quality of life. Older adults are especially vulnerable to environmental changes (Buffel, Phillipson, & Scharf, 2012), and many participants in this study attributed blame to the government’s failure to intervene proactively and the city’s (over)emphasis on efficiency, profit-maximization, and economic interests. A central argument of this article is that age-friendliness is unlikely to be realized unless public policy adopts a more inclusive approach that gives due consideration to the welfare and wellbeing of older adults as new urban communities are built and old ones undergo redevelopment. The purpose is to adapt the environment to meet the changing needs of our population, and not to adapt older adults to the changing environment. As Beard and Petitot (2010) argue, aging societies require flexible and evolving environments to offset the long-term societal challenges that result from the physical and social changes associated with aging. In this light, it is suggested that Hong Kong should strive to design its urban environment in a way that sustains and enables older people to perform essential daily tasks within their neighborhoods while minimizing social isolation and cognitive and physical decline (Jackisch, Zamaro, Green, & Huber, 2015), as outlined in the AFC framework. However, attempts to achieve this will require changes in how the city allocates resources in various physical and social domains, including land use, housing design, employment legislations, transportation policies and designs, as identified by the older adults in this study. Building a supportive and inclusive environment would require a high level of political commitment (Jackisch et al., 2015), and one that does not merely focus on efficiency (for young people) but rather on developing strategies that enable older adults to live well in the community. Relatedly, it would also require some form of regulation on part of the government. In terms of housing for older adults, for example, we posit that the negligence of long-term mobility and residential need may have reduced the age-friendliness of housing accommodation for older adults, which in turn may reduce their quality of life. Thus, there is a need for the government to regulate housing prices and to implement legal mechanisms that could better protect the tenancy of older adults. Failure to do so may lead to a significant drop in quality of life for a large and growing proportion of our population. It is therefore imperative to continually promote the AFC agenda in local communities in order to optimize the wellbeing of older adults. Our findings are relevant to other East Asian countries including Japan, Taiwan, and South Korea that are experiencing similar demographic changes in terms of rapid population aging and urbanization. There is a need for our public policy paradigm to further optimize the wellbeing of citizens so as to enable the productive participation of older adults and aging-in-place. Limitations Findings generated from this study should be interpreted in light of several limitations. First, older adults who were unable to go to a community venue to participate in a focus group (e.g., those who were institutionalized, home-bound, bed-bound, or suffering from dementia) were excluded from this study. It is conceivable that older adults of greater disability may experience challenges of a different intensity and type compared to their community-dwelling counterparts. In fact, the experiences of this excluded group would be particularly useful in informing us about the inadequacy of the city in fostering social inclusion, one of the eight hallmarks of an age-friendly city in WHO’s framework (2007). Future studies that examine the experiences of older adults of greater disability are warranted. Second, the generalizability of our findings to older adults in other Asian cities is limited, since Hong Kong is exceptionally dense and urbanized compared to other regions across Asia where there may be a much larger proportion of adults living in rural or suburban areas. Further studies that differentiate how older adults living in rural and urban areas across Asia perceive age-friendliness of their communities may be beneficial. Third, our sample was mainly drawn from local district elderly centers and by snowball sampling. Thus, older adults with less frequent contact with those centers were unlikely to have participated in this study. Moreover, while Central and Western and Wan Chai districts are not entirely representative of all 18 districts in Hong Kong, given the higher education and asset (wealth) levels of older adult residents, it is likely that our findings are translatable to the rest of Hong Kong. Older adults with higher education and income levels are likely to have greater access to resources and social support (Otero-Rodríguez et al., 2011). Hence, if older adults in these two districts identified some features in the city as being unfriendly, it is conceivable that older adults with less wealth and knowledge (e.g., low literacy level) find them even more challenging. Future studies may examine how older adults in different socioeconomic classes view age-friendliness. Fourth, due to the cross-sectional nature of this study, further understanding of the potential associations between rapid urban development and age-friendliness of the community could be better achieved by examining age-friendliness in different political and economic contexts, or by examining the changes in age-friendliness over time when the political or economic priorities change in a society. Fifth, we approached this study using a “deficit model” by asking participants what areas of the city they thought were inadequate in meeting their socioeconomic and physical demands. 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Abstract

Abstract Background and Objectives There is little understanding about how rapid urban development has affected the extent to which communities are able to optimize health and participation opportunities for older adults in Hong Kong. Our objective was to examine what older residents perceive to be the shortcomings of their communities in meeting their psychosocial and physical needs as they age. Research Design and Methods In reference to the WHO Age-Friendly Cities Project Methodology: Vancouver Protocol, we conducted nine focus groups comprising 65 participants for an Age-Friendly City baseline assessment in two districts in Hong Kong, China. Participants were asked to share their views on their respective district of residence, and identify aspects of the city they found unfriendly. Data generated from interviews were analyzed using thematic analysis. Results Five of the following key themes were identified: the failure of public transportation to cater to the needs of older adults; a lack of public space for recreation and socializing; diminishing human interactions in welfare services; physical and financial challenges relating to housing; and workplace discrimination against older adults. Discussion and Implications These findings underscore the importance of prioritizing the social welfare of older adults in building a more inclusive and age-friendly city. They also highlight the difficulties in fostering an inclusive environment while ensuring efficiency and profit maximization. Well-being, Urban, Chinese, East Asia, Qualitative research methods, Productivist welfare regime, Age-friendly cities Population aging is a pervasive global phenomenon unparalleled in human history. Recognizing that existing policies, norms, and social institutions are no longer adequate to meet the needs of aging populations (Lehning, Chun, & Scharlach, 2007), the provision of friendly, supportive, and enabling environments for older adults has emerged as an important agenda for research, practice, and policy in many cities around the world. In line with this, the World Health Organization (WHO, 2007) has made efforts to promote “Age-Friendly Cities” (AFC) to meet the imminent challenges resulting from population aging. The concept of AFC stems from the ecological perspective of aging that links the well-being of individuals’ to their physical and social environments (Evans, Kantrowitz, & Eshelman, 2002; Manzo & Perkins, 2006; Steels, 2015; Yen, Flood, Thompson, Anderson, & Wong, 2014), and the policy imperative to maintain and support older adults living in their own communities for as long as possible (aging-in-place) (Buffel & Phillipson, 2016). AFC is also premised on the belief that older adults can continue to be vital societal resources if they are able to live in environments that enable them to continuously engage in productive activities (Beard & Petitot, 2010). An age-friendly city is one that “encourages active aging by optimizing opportunities for health, participation and security in order to enhance quality of life as people age. In practical terms, an age-friendly city adapts its structures and services to be accessible to and inclusive of older people with varying needs and capacities” (World Health Organization, 2007). Based on this framework, a global collaborative project conceived by the WHO in 2005 identified eight key domains of an AFC, including outdoor spaces and buildings, transportation, housing, social participation, respect and social inclusion, civic participation and employment, communication and information, and community and health services. To date, the WHO Global Network of Age-friendly Cities and Communities comprises 287 cities and communities in 33 countries, covering 113 million people. Most members are economically advanced societies. While efforts to create age-friendly communities are now underway across the globe, many barriers remain, including, inter alia, the implementation of neoliberal policies and resultant welfare retrenchment (Phillipson, 2013), obsolete land-use regulations and policies (Lehning et al., 2007), a lack of opportunities or communication with potential organizations to volunteer, shortages of reliable, frequent and accessible transportation (Emlet & Moceri, 2012), and under-representation of older adults in policy-making processes (Alley, Liebig, Pynoos, Banerjee, & Choi, 2007). Age-friendliness in Asia Literature pertinent to the barriers to implementing AFC has thus far been excessively generated in the West, and findings may not be generalizable to East Asia where cities are typically much denser and geographically smaller in size. Despite the recent expansion of welfare for older adults in many of these societies (Aspalter, 2006), the growth of supply (e.g., provision of nursing homes) simply cannot match the growth in demand created by the sheer size of the older population. Indeed, Asia is now home to the largest population of older adults in the world and Hong Kong, Japan, South Korea, and Taiwan will become the world’s oldest places by 2050 (United Nations, 2015). In light of this imminent “aging tsunami,” city development and planning in many East Asian countries may be under-prepared to provide a friendly environment for older residents. Moreover, it remains unclear how older adults in East Asian cities experience challenges in their everyday lives. To date, there is limited research on the age-friendliness (or lack thereof) of East Asian cities that draws opinions directly from older adults in a contextualized manner. Nevertheless, existing studies do provide insight into the discourse on age-friendliness in the Asian context. For instance, Kadoya (2013) found that older Japanese adults who lived alone and could not drive were reluctant to participate in their communities or social activities, a key feature of an age-friendly city. In Taiwan, Chen et al. (2013) identified five major needs pertinent to AFC for older adults, including the needs to adapt public spaces to their mind-body function and development, to modify transportation systems for comfort, to facilitate harmonious and peaceful family relationships, to reduce barriers of information delivery, and to address the value and importance of older adults in society. While informative, none of these studies examine the possible conflict between age-friendliness, efficiency and commercial interests. As such, drawing from the perspectives of older adults in Hong Kong, this study examines the following research question: in what ways is Hong Kong, a highly urbanized and economically advanced city, under-prepared for its aging population? Hong Kong China as a Case Example Hong Kong is an economically advanced and mostly urban city located in the Southeast part of China. It is only about 1,100 km2 in area, but houses a large population that has grown rapidly in size and age, increasing from 5.18 million in 1981 to 7.31 million in 2015 (Census and Statistics Department, 2016), making it one of the densest cities in the world. The combination of longer life expectancies (the highest in the world) (Ministry of Health, Labour and Welfare, 2016) and lower fertility rates (one of the lowest in the world) has dramatically transformed its demographic structure. The number of older adults aged 65 years and above is expected to increase from 1.16 million (16.6% of the total population) in 2016, to approximately 2.37 million (31.1%) by 2036 (Census and Statistics Department, 2017a). Correspondingly, the median age is projected to increase substantially, from 43.4 in 2016 to 48.9 by 2036 (Census and Statistics Department, 2017a). Changes in demographic structure have direct bearings on the demands placed on social welfare services and town planning. Yet, Hong Kong has for a significant period of time lacked long-term social welfare planning including elderly services (e.g., a Long-Term Care System), and has instead embraced a “big market, small government” governance philosophy. Consequently, the city’s low-tax regime and emphasis on self-reliance prevail (Cheng et al., 2013). Methods Through collaborating with local district elderly centers and open recruitment, our study used convenience and snowball sampling to recruit participants from two out of Hong Kong’s eighteen districts: Wan Chai district and Central and Western district. Compared to the other 16 districts, older adults living in the Wan Chai and Central and Western districts have higher levels of education and wealth (Census and Statistics Department, 2017b). As percentage of district population, 15.0% of people in Central and Western district and 15.4% in Wan Chai district are older adults aged 65 years or above. The district with the highest percentage of older adults is Wong Tai Sin district (17.0%) and the lowest is Tsuen Wan district (13.7%). Compared to the overall district characteristics, our sample has a higher proportion of females (88% vs 56%), higher percentage of owner-occupied households (64% vs 56%) but lower percentage of secondary education and above (42% vs 64%) (Census and Statistics Department, 2017b). To meet the inclusion criteria, potential participants needed to be aged 55 years or above, usually reside in one of the two districts, and be mentally capable of participating in the study. Under this sampling frame, nine focus groups comprising 65 participants in total were conducted between January and February of 2016. The demographic characteristics of the sample are shown in Table 1. Particularly of note is the fact that participants had lived in their districts for an average of 34.2 years (SD = 18.7), suggesting their depth of knowledge regarding their local communities. Table 1. Demographic Characteristics of Focus Group Participants (n = 65) Characteristics  N  %  Mean (SD)  Gender        Male  8  12    Female  57  88    Age      75.1 (9.24)  Age group (years)        55–64 years  11  17    65–74 years  21  32    75–84 years  20  31    ≥85 years  13  20    Duration of living in the district (years)      34.2 (18.7)  10 or below  7  11    11–20  9  14    21–30  13  20    31–40  13  20    41–50  12  19    51 or above  9  14    Marital status        Married  21  32    Widowed  38  59    Others  6  9    Education        Nil/preprimary  9  14    Primary  27  43    Secondary (Form 1–5)  11  17    Secondary (Form 6–7)  9  14    Postsecondary  7  11    Housing        Public rental  20  31    Private, rental  3  5    Private, owned  41  64    Living arrangement        Living alone  16  25    With spouse only  10  16    With spouse and other family members  8  13    With children/grandchildren only  29  45    With other family members  1  2    Monthly personal income (Hong Kong Dollars)        No income  12  19    1–5,999  40  63    6,000–9,999  7  11    10,000–19,999  3  5    20,000–29,999  2  3    Characteristics  N  %  Mean (SD)  Gender        Male  8  12    Female  57  88    Age      75.1 (9.24)  Age group (years)        55–64 years  11  17    65–74 years  21  32    75–84 years  20  31    ≥85 years  13  20    Duration of living in the district (years)      34.2 (18.7)  10 or below  7  11    11–20  9  14    21–30  13  20    31–40  13  20    41–50  12  19    51 or above  9  14    Marital status        Married  21  32    Widowed  38  59    Others  6  9    Education        Nil/preprimary  9  14    Primary  27  43    Secondary (Form 1–5)  11  17    Secondary (Form 6–7)  9  14    Postsecondary  7  11    Housing        Public rental  20  31    Private, rental  3  5    Private, owned  41  64    Living arrangement        Living alone  16  25    With spouse only  10  16    With spouse and other family members  8  13    With children/grandchildren only  29  45    With other family members  1  2    Monthly personal income (Hong Kong Dollars)        No income  12  19    1–5,999  40  63    6,000–9,999  7  11    10,000–19,999  3  5    20,000–29,999  2  3    View Large Table 1. Demographic Characteristics of Focus Group Participants (n = 65) Characteristics  N  %  Mean (SD)  Gender        Male  8  12    Female  57  88    Age      75.1 (9.24)  Age group (years)        55–64 years  11  17    65–74 years  21  32    75–84 years  20  31    ≥85 years  13  20    Duration of living in the district (years)      34.2 (18.7)  10 or below  7  11    11–20  9  14    21–30  13  20    31–40  13  20    41–50  12  19    51 or above  9  14    Marital status        Married  21  32    Widowed  38  59    Others  6  9    Education        Nil/preprimary  9  14    Primary  27  43    Secondary (Form 1–5)  11  17    Secondary (Form 6–7)  9  14    Postsecondary  7  11    Housing        Public rental  20  31    Private, rental  3  5    Private, owned  41  64    Living arrangement        Living alone  16  25    With spouse only  10  16    With spouse and other family members  8  13    With children/grandchildren only  29  45    With other family members  1  2    Monthly personal income (Hong Kong Dollars)        No income  12  19    1–5,999  40  63    6,000–9,999  7  11    10,000–19,999  3  5    20,000–29,999  2  3    Characteristics  N  %  Mean (SD)  Gender        Male  8  12    Female  57  88    Age      75.1 (9.24)  Age group (years)        55–64 years  11  17    65–74 years  21  32    75–84 years  20  31    ≥85 years  13  20    Duration of living in the district (years)      34.2 (18.7)  10 or below  7  11    11–20  9  14    21–30  13  20    31–40  13  20    41–50  12  19    51 or above  9  14    Marital status        Married  21  32    Widowed  38  59    Others  6  9    Education        Nil/preprimary  9  14    Primary  27  43    Secondary (Form 1–5)  11  17    Secondary (Form 6–7)  9  14    Postsecondary  7  11    Housing        Public rental  20  31    Private, rental  3  5    Private, owned  41  64    Living arrangement        Living alone  16  25    With spouse only  10  16    With spouse and other family members  8  13    With children/grandchildren only  29  45    With other family members  1  2    Monthly personal income (Hong Kong Dollars)        No income  12  19    1–5,999  40  63    6,000–9,999  7  11    10,000–19,999  3  5    20,000–29,999  2  3    View Large All focus group interviews utilized an interview guide adapted and translated from the “WHO Age-Friendly Cities Project Methodology: Vancouver Protocol.” In each interview, participants were first introduced to the AFC concept and the eight domains of the WHO’s AFC framework. Next, they were asked to identify domains they thought needed improvement in their respective districts. Participants were asked to elaborate upon their answers and to provide examples from their own personal experiences to illustrate how these domains affected their daily lives. Despite using the Vancouver Protocol as a general guide, we also invited participants to indicate and describe any aspects beyond the eight domains that they found unfriendly. This allowed more flexibility and autonomy for participants to articulate their everyday difficulties. Each focus group interview consisted of 4–12 participants, lasted for approximately 1.5 hr, and was held in a community location convenient to participants. At the beginning of an interview, each participant completed a brief questionnaire to provide information about his or her demographic characteristics. A group leader and an assistant then facilitated the interview. At the end of the interview, each participant was given a store coupon of HK$20 as a token of gratitude for his or her participation. All interviews were conducted in Cantonese and audio-recorded. The study was approved by the Human Research Ethics Committee (HREC) of The University of Hong Kong. The audio records of each focus group were transcribed verbatim. Transcripts were analyzed using thematic analyses (Braun & Clarke, 2006) based on the eight WHO AFC domains, which comprised several stages. In stage one, we familiarized ourselves with the data by repeatedly reading the transcripts. In stage two, we generated an initial list of codes that were relevant to our research question. During this stage, quotes describing aspects of age-unfriendliness in the community, and/ or pertaining to how Hong Kong is under-prepared for its aging population were highlighted. This was followed by stage three, in which themes were identified by categorizing the initial codes generated in the second stage. Codes that fell into overarching themes were categorized by the initial theme. For example, under the WHO Age-friendly domain of “community support and health services,” when it was evident that one emergent pattern was that participants found navigating electronic systems including medical appointment systems and ATM machines very age-unfriendly, we classified these illustrative examples under the theme “Automation replacing human interactions.” Stage four comprised reviewing and refining the themes. To improve overall data reliability, two researchers coded the transcripts independently during the analysis process. The two researchers then compared coding schemes and emergent themes. Agreements had to be reached regarding the emergent themes. Finally, stages five and six involved naming the themes and reporting. The following presents these five themes, within which each category will be discussed and supported by illustrative quotes from participants. Results Five key themes relating to subjectively experienced age-unfriendly features in the city emerged from our thematic analyses. In reporting these themes, we strove to make explicit how participants found these features to be deeply embedded in their daily lives. Transport Efficiency Trumps Inclusiveness The ability of transport systems to meet the mobility needs of older adults is a crucial factor in their quality of life (Paez, Scott, Potoglou, Kanaroglou, & Newbold, 2006), and one of the goals of AFC. Unlike Western countries, where most people are automobile-dependent, the majority of Hong Kong residents rely on public transport to commute. Counterintuitively, we found that the expansion of the underground railway system, the Mass Transit Railway (MTR) which accounts for 42.6% of journeys on public transport each day (Transport Department, 2017), may have adversely affected the mobility of older residents because they usually have poorer physical agility compared to younger cohorts. Participants stated that they preferred that the slower and cheaper aboveground public transport system. However, aboveground transportations had been undermined by the expansion of the underground transport system. For instance, the advent of MTR West Island Line was accompanied by “bus route rationalization” in the district (HKSAR Government, 2016), which resulted in the reduction of some aboveground bus routes that had previously enabled participants to travel conveniently without needing to walk the long distances necessary to reach the underground railway platforms. Many participants preferred less physically and cognitively demanding transportation that did not require multiple railway line transfers. “I prefer taking buses the most. Direct route to the destination. Then I don’t need to walk up and down so much [like when taking the MTR]… I take the MTR only when there are no other choices, since I feel that when I need to make a transfer on the MTR, it’s troublesome.” “Before the MTR service [expanded to this area], the red minibus [service] was quite OK... It was very convenient. However, with the MTR expansion, it runs less frequently.” As for transport software, participants contended that public transport services overlook the needs of the nonworking population. They were dissatisfied that the timetables of public transport services catered primarily to the schedules of working people, with inadequate consideration given to the needs of older adults who often went out during nonpeak hours. “They run more frequently when it’s time for people go to work. When it’s outside of the morning peak hour, it’s when old people like us go out to do grocery shopping. The transport then runs much less frequently. Why?” We posit that transport planning in the city primarily focuses on efficiency: transporting the maximum number of people in the smallest amount of time while minimizing aboveground congestion. However, our findings illustrate how competing interests may pose considerable challenges to providing older adults with accessible public transport, a key factor in influencing active aging as stated in the WHO AFC guide. Public Space Shortages for Older Adults Participants discussed the shortage of accessible public spaces in relation to their quality of life. Land use has been a highly contentious and divisive issue in Hong Kong due to its high population density and the competing demands for housing, commerce, industry, transport, recreation, nature conservation, heritage preservation, and other community needs (Planning Department, 2016). In fact, since the 1980s, scholars have highlighted how Hong Kong’s urban planning strategy has heavily favored commercial interests that focuses on profit maximization while overlooking the social needs of its citizens (Ng, 1995; Ng & Tang, 1999; Yeung, 1997). This is also evidenced by the noticeable increase in the leasing out of public spaces to the private company The Link REIT, which operates high-end shopping malls (So, 2010). Many of these malls have little space for patrons to congregate or even sit. Against this backdrop of privatization, participants indicated that there was limited public space left to conduct their daily leisure or social activities: “The only larger park is not convenient to us. We have to walk a relatively longer distance to reach there.” “I can’t go for a run in the morning sometimes when I want, as the park is so small with many people there.” Indeed, the average amount of open space available per person in Hong Kong is 2.7–2.8 m2, which is far behind other Asian cities like Tokyo (5.8 m2), Seoul (6.1 m2), Shanghai (7.6 m2), and Singapore (7.4 m2) (Lai, 2017). Without sufficient public space to enjoy their leisure time, many older adults tended to spend their time in local restaurants instead: “There are many rules and regulations to follow in elderly community centers, so that’s why many older adults prefer to just stay in McDonald’s…They can stay or leave whenever they want…” “Sometimes I will ask older adults why are you sitting here [the restaurant]? They said it is convenient...The number of older people here is still affordable now, but not for the future with higher number of older population. They [the restaurant] need to do their business, but they can’t expel older adults. “ Regarding the needs of older adults, some participants expressed disappointment when recounting the higher priority given to commercial needs during urban planning or redevelopment in the district: “I had high hopes for where the former slaughterhouse was located… That’s an area under planning [for redevelopment]… However, [the government] already has plans that in the future they will build luxury homes, hotels and shopping malls there… Actually, if it can be redeveloped to become a [public] music hall or a community hall, that would be nice.” Some participants viewed the government’s laissez-faire policy as a contributing factor to the paucity of public spaces. They expressed their wish for the government to take action to negotiate with stakeholders with conflicting interests in public space development. This was illustrated in their advocacy for greater government intervention in a promenade expansion project: “A [path] has to be built to cut through a wholesale food market, a concrete construction company, and a parking lot…before the promenade can be built. There has been a lot of discussion, but I haven’t seen the government taking any real actions. Like, how about relocating the concrete construction company?” As land has become increasingly valuable due to population growth and real estate developers act to maximize profits, the provision of free shared spaces has been minimized. Participants residing in public housing identified how older residential estates had wider and better-ventilated hallways and more communal areas, which facilitated better social interactions whereas new ones do not. “In the new buildings…you can’t even stand there to chat [with your neighbors]… In the old design, there was good ventilation and more public space…” They further denounced real estate developers that tended to construct buildings with a focus on maximizing profits, while neglecting the physical and social needs of older adults. “They thought that as long as they could make money, they built the buildings to take up all the space, and did not think about the pavements for the pedestrians.” “The contractors only care about money and don’t care about people’s well-being”. In light of participants’ frustrations toward these real estate developers, we argue that one possible contributing factor is past governments’ laissez faire policies and the resultant lack of strict regulation imposed on these developers that allowed for such age-unfriendly constructions to occur. Indeed, creating a facilitative physical environment that optimizes older adults’ social participation is a key suggestion within the AFC agenda. However, competing interests in land development, in particular redeveloping land for commercial purposes may have posed increasing barriers for older adults to participate in meaningful communal and social activities, as articulated by study participants. That many of the available spaces were “privatized” and instead used for commercial purposes underscores the juxtaposition between economic, for-profit uses of the city and its age-friendliness and inclusiveness. Automation Replacing Human Interactions Participants valued human interactions when they sought or received services. However, they found that human interactions are rapidly diminishing as the city adopts cost-effective automated services. Nowhere is this more apparent than when accessing public health services, where appointments can only be made via automated telephone appointment booking systems. The lack of a real person to talk to and who could provide assistance often obstructed participants from accessing health care. With deteriorating physical and cognitive ability, some older adults may face disproportionately greater challenges when navigating the automated system. Indeed, participants indicated that they had tremendous difficulties in following the fast-paced instructions requiring patients to enter their identity card numbers and date of birth in quick succession, and in pressing the correct corresponding buttons. “Making phone calls to make medical appointments [with the automated system] is really difficult. Older people don’t know how to press the phone buttons. It is really a hassle.” Personalized services provided by real people were found to be the preferable mode of contact among our participants. For instance, participants recalled appreciatively how tram operators used to help them by carrying their bags, and helping them to their seats. However, these human interactions have been gradually replaced by automated turnstiles. On the one hand, the turnstiles can effectively replace humans to serve gatekeeping and passenger-counting functions; on the other, the age-friendliness of public transport for older adults may have been diminished as a result. In these examples, we see once again the dilemma between catering to the needs of older adults and the objective of optimizing the “cost-effectiveness” of existing systems. Housing Unaffordability: Deteriorating Housing Conditions Participants expressed difficulties in affording maintenance and modification costs to their homes, and most stated that they were reluctant or unable to pay for home renovation even if it would improve their quality of life. “There’s no way [the government] would build public housing in this district. Only the rich can live here now…the rent…the rent is so high…” “[We] don’t have any income now. Now you ask [us] to spend hundreds of thousands of dollars on renovation, how would we be able to do it?” “I have no income. I am retired. Where do I find the money for renovation?” Indeed, Hong Kong has consistently been ranked as having the most expensive and least affordable housing market in the world over the past 7 years (Cox & Pavletich, 2017). It is conceivable that older adults may be disproportionately affected by housing unaffordability compared to other age groups as there is no universal pension or retirement protection system in Hong Kong. Participants pointed out that due to ever-increasing rents, some older adults are forced to live in subdivided units—a typical private flat divided multiple units for lease. “It’s impossible to afford... [the private flat owners] exploit you once…then exploit you more…some older adults have to live in ‘coffin homes. ‘” In discussing whether newer residential buildings were age-friendly, participants indicated the new housing were less spacious and its environment is discouraging social interaction with neighbors. “Everyone close their doors nowadays...The corridor [common area] is so narrow with no windows in these new housing, how can we gather and talk like in the old one?” “Previously the flats were quite spacious with high ceilings…now they [developer] just build very small flats to sell as many and as expensively as possible.” Good quality housing can induce feelings of security, belonging and expression of self, and is often correlated with place attachment among older adults (Brown, Perkins, & Brown, 2003; Buffel et al., 2014) and ability to live independently, whereas subpar housing standards can adversely affect older adults’ psychological wellbeing. Our participants expressed that their deteriorating residential environment may no longer accommodate their needs. Furthermore, the fact that many older buildings do not have elevators gives insight into the how rapid urban development and planning beginning in the 1970s was very much implemented with a “younger generation” in mind as city users. Work Segregation and Employment Discrimination Against Older Adults Participants indicated that the unavailability of paid work opportunities may be the result of ageist attitudes and discrimination. This may be based on the (mis)perception that younger workers have greater productivity and contribute more to the economy than older workers, but perhaps also due to the lack of legal measures to protect older employees from discrimination. Indeed, while Hong Kong has laws against discrimination on the grounds of sex, disability, family status, and race, there is no legislation preventing age discrimination (Equal Opportunities Commission, n.d.). Moreover, it is common practice for employers to request prospective employees’ full date of birth in their job application. Possibly due to these systemic biases against older adults, it was unsurprising when our participants shared that employers did not welcome older workers. I: If older people want to look for jobs, can they find it? P1: No, it’d be very difficult. P2: Very difficult. P3: If I wanted to find a job now, I don’t think I could find one. Participants mainly expressed a sense of resignation, rather than indignation: P1: If they [employers] look for help, they usually look for the young ones. They are more energetic and strong, and can get things done. I: But it’s difficult to find the young ones to hire. P1: Still, they wouldn’t hire the old ones. P2: Once they look at your age, they would not hire you. It appears that many participants have internalized these negative biases against the capabilities of older adults, and thus attempted to rationalize or normalize age-based discriminatory practices in the workplace. They were unconfident in their own abilities and articulated that they would not be able to live up to the high demands of work productivity because they were “old” and “slow,” and that only younger generations are able to fulfill these demands. In relation to the AFC goal of optimizing employment opportunities for older adults, Hong Kong appears to have fallen behind other advanced economies in the region. Indeed, the employment rate among older adults in Hong Kong was only 9% in 2015—far below neighboring East Asian countires such as South Korea (31%), Singapore (26%), and Japan (22%) (Legislative Council, 2016). The city was ranked especially low in income security, and psychological well-being among older adults (CUHK Jockey Club Institute of Ageing, 2017). Discussion Drawing from the perspectives of older Chinese adults, this study provides insight into how older adults interact with, and are shaped by, both the hardware (such as physical environments) and software (such as the dearth of human interactions) in their community. In particular, we identified five emergent themes pertinent to the age-(un)friendliness of the city. In many instances, these dimensions may reinforce, intersect, and affect one another. For example, public space shortages may reduce opportunities for older adults to have meaningful social interactions, a critical component of “living well” (Wong et al., 2014). The identified themes converged with the WHO AFC Guide (World Health Organization, 2007) and suggest that older adults in this study faced several physical, financial, and social barriers in their communities that were deemed unfriendly. Several additional insights can be drawn from this study. First, in the city’s tendency to bid for maximum efficiency and minimal costs, Hong Kong seems to have neglected some key imperatives and policy goals as stated in the WHO Age-friendly City Guide. We found that older adults preferred human interactions over automation, familiarity and inclusiveness over efficiency, and communal public space over land privatization. Yet, these characteristics seem to be rapidly eroding. As indicated by study participants, these characteristics may have adversely affected their quality of life. A possible underlying reason for current shortcomings may be that public policy has long been underscored by a productivist welfare regime (Holliday, 2000) where social rights are often subordinate to the overriding policy objective of economic growth, and where social policies are primarily used as tools to promote economic participation through the market, with the state typically adopting a regulatory role in social welfare policy rather than providing welfare itself (Aspalter, 2006; Aspalter, 2011; Holliday, 2000; Holliday, 2005; Kwon & Holliday, 2007; Wong, 2007). Under this developmental paradigm, it is possible that the regime’s emphasis on individual responsibility and self-reliance has resulted in the state providing minimal social rights and protection for older adults (Cheng, 2013; Cheng, Lum, Lam & Fung, 2013; Wong, 2007). However, such supposition warrants further examination. Second, consistent with the observation made by Handler (2014, p.12), our findings revealed that most participants viewed the city as being operated and “structured with a younger, working age demographic in mind” while neglecting the needs of older adults. Participants were particularly indignant toward what was perceived to be continuous favoritism toward the commercial sector and the maximization of profit over older people’s quality of life. Older adults are especially vulnerable to environmental changes (Buffel, Phillipson, & Scharf, 2012), and many participants in this study attributed blame to the government’s failure to intervene proactively and the city’s (over)emphasis on efficiency, profit-maximization, and economic interests. A central argument of this article is that age-friendliness is unlikely to be realized unless public policy adopts a more inclusive approach that gives due consideration to the welfare and wellbeing of older adults as new urban communities are built and old ones undergo redevelopment. The purpose is to adapt the environment to meet the changing needs of our population, and not to adapt older adults to the changing environment. As Beard and Petitot (2010) argue, aging societies require flexible and evolving environments to offset the long-term societal challenges that result from the physical and social changes associated with aging. In this light, it is suggested that Hong Kong should strive to design its urban environment in a way that sustains and enables older people to perform essential daily tasks within their neighborhoods while minimizing social isolation and cognitive and physical decline (Jackisch, Zamaro, Green, & Huber, 2015), as outlined in the AFC framework. However, attempts to achieve this will require changes in how the city allocates resources in various physical and social domains, including land use, housing design, employment legislations, transportation policies and designs, as identified by the older adults in this study. Building a supportive and inclusive environment would require a high level of political commitment (Jackisch et al., 2015), and one that does not merely focus on efficiency (for young people) but rather on developing strategies that enable older adults to live well in the community. Relatedly, it would also require some form of regulation on part of the government. In terms of housing for older adults, for example, we posit that the negligence of long-term mobility and residential need may have reduced the age-friendliness of housing accommodation for older adults, which in turn may reduce their quality of life. Thus, there is a need for the government to regulate housing prices and to implement legal mechanisms that could better protect the tenancy of older adults. Failure to do so may lead to a significant drop in quality of life for a large and growing proportion of our population. It is therefore imperative to continually promote the AFC agenda in local communities in order to optimize the wellbeing of older adults. Our findings are relevant to other East Asian countries including Japan, Taiwan, and South Korea that are experiencing similar demographic changes in terms of rapid population aging and urbanization. There is a need for our public policy paradigm to further optimize the wellbeing of citizens so as to enable the productive participation of older adults and aging-in-place. Limitations Findings generated from this study should be interpreted in light of several limitations. First, older adults who were unable to go to a community venue to participate in a focus group (e.g., those who were institutionalized, home-bound, bed-bound, or suffering from dementia) were excluded from this study. It is conceivable that older adults of greater disability may experience challenges of a different intensity and type compared to their community-dwelling counterparts. In fact, the experiences of this excluded group would be particularly useful in informing us about the inadequacy of the city in fostering social inclusion, one of the eight hallmarks of an age-friendly city in WHO’s framework (2007). Future studies that examine the experiences of older adults of greater disability are warranted. Second, the generalizability of our findings to older adults in other Asian cities is limited, since Hong Kong is exceptionally dense and urbanized compared to other regions across Asia where there may be a much larger proportion of adults living in rural or suburban areas. Further studies that differentiate how older adults living in rural and urban areas across Asia perceive age-friendliness of their communities may be beneficial. Third, our sample was mainly drawn from local district elderly centers and by snowball sampling. Thus, older adults with less frequent contact with those centers were unlikely to have participated in this study. Moreover, while Central and Western and Wan Chai districts are not entirely representative of all 18 districts in Hong Kong, given the higher education and asset (wealth) levels of older adult residents, it is likely that our findings are translatable to the rest of Hong Kong. Older adults with higher education and income levels are likely to have greater access to resources and social support (Otero-Rodríguez et al., 2011). Hence, if older adults in these two districts identified some features in the city as being unfriendly, it is conceivable that older adults with less wealth and knowledge (e.g., low literacy level) find them even more challenging. Future studies may examine how older adults in different socioeconomic classes view age-friendliness. Fourth, due to the cross-sectional nature of this study, further understanding of the potential associations between rapid urban development and age-friendliness of the community could be better achieved by examining age-friendliness in different political and economic contexts, or by examining the changes in age-friendliness over time when the political or economic priorities change in a society. Fifth, we approached this study using a “deficit model” by asking participants what areas of the city they thought were inadequate in meeting their socioeconomic and physical demands. 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The GerontologistOxford University Press

Published: May 30, 2018

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