Age-friendly cities in the Netherlands: An explorative study of facilitators and hindrances in the built environment and ageism in design

Abstract

The World Health Organization (WHO) strives to assist and inspire cities to become more 'age-friendly' through the Global Age-Friendly Cities Guide. An age-friendly city offers a supportive environment that enables residents to grow older actively within their families, neighbourhoods and civil society, and offers extensive opportunities for their participation in the community. In the attempts to make cities age-friendly, ageism may interact with these developments. The goal of this study was to investigate the extent to which features of age-friendly cities, both facilitators and hindrances, are visible in the city scape of the Dutch municipalities of The Hague and Zoetermeer and whether or not ageism is manifested explicitly or implicitly. A qualitative photoproduction study based on the Checklist of Essential Features of Age-Friendly Cities was conducted in five neighbourhoods. Both municipalities have a large number of visual age-friendly features, which are manifested in five domains of the WHO model, namely Communication and information; Housing; Transportation; Community support and health services; and Outdoor spaces and buildings. Age-stereotypes, both positive and negative, can be observed in the domain of Communication and information, especially in the depiction of third agers as winners. At the same time, older people and age-friendly features are very visible in the cityscapes of both municipalities , and this is a positive expression of the changing demographics.

Full text

Original Article
I
Indoor
and
and B
uilt
uilt
Environment
Age-friendly cities in the
Netherlands: An explorative study
of facilitators and hindrances
in the built environment and
ageism in design
Joost van Hoof
1,2
, Jeroen Dikken
1,3
,
Sandra C. Butti _
gie _
g
4,5
, Rudy F. M. van den Hoven
1
,
Esther Kroon
1
and Hannah R. Marston
6
Abstract
The World Health Organization (WHO) strives to assist and inspire cities to become more ‘age-friendly’
through the Global Age-Friendly Cities Guide. An age-friendly city offers a supportive environment that
enables residents to grow older actively within their families, neighbourhoods and civil society, and
offers extensive opportunities for their participation in the community. In the attempts to make cities
age-friendly, ageism may interact with these developments. The goal of this study was to investigate the
extent to which features of age-friendly cities, both facilitators and hindrances, are visible in the city
scape of the Dutch municipalities of The Hague and Zoetermeer and whether or not ageism is man-
ifested explicitly or implicitly. A qualitative photoproduction study based on the Checklist of Essential
Features of Age-Friendly Cities was conducted in five neighbourhoods. Both municipalities have a large
number of visual age-friendly features, which are manifested in five domains of the WHO model, namely
Communication and information; Housing; Transportation; Community support and health services;
and Outdoor spaces and buildings. Age-stereotypes, both positive and negative, can be observed in
the domain of Communication and information, especially in the depiction of third agers as winners. At
the same time, older people and age-friendly features are very visible in the cityscapes of both munic-
ipalities, and this is a positive expression of the changing demographics.
Keywords
Older adults, Older people, City, Urban ageing, Dementia-friendly, Ageism
Accepted: 23 May 2019
Introduction
In Europe and the Western World as a whole, people
live longer and are generally in better health than pre-
vious generations of their age. According to the
Organisation for Economic Co-operation and
Development (OECD),
1
the population share of those
adults aged 65 years old and over is expected to rise to
25.1% in 2050 across its member states. Cities, in par-
ticular, have large numbers of older inhabitants and are
home to 43.2% of this older population. The increase
1
Faculty of Social Work & Education, The Hague University of
Applied Sciences, The Hague, The Netherlands
2
Department of Spatial Economy, Wrocław University of
Environmental and Life Sciences, Wrocław, Poland
3
Faculty of Health, Nutrition & Sport, The Hague University of
Applied Sciences, The Hague, The Netherlands
4
Department of Health Services Management, University of
Malta, Msida, Malta
5
Mater Dei Hospital, Msida, Malta
6
School of Health, Wellbeing & Social Care, The Open
University, Milton Keynes, UK
Corresponding author:
Joost van Hoof, The Hague University of Applied Sciences,
Johanna Westerdijkplein 75, Den Haag 2521 EN, The
Netherlands.
Email: j.vanhoof@hhs.nl
Indoor and Built Environment
0(0) 1–21
!The Author(s) 2019
Article reuse guidelines:
sagepub.com/journals-
permissions
DOI: 10.1177/1420326X19857216
journals.sagepub.com/home/ibe

of our ageing society is a positive yet challenging phe-
nomenon, as population ageing and urbanisation are
the culmination of successful human development.
2
The interaction of ageing and urbanism, which is also
termed urban ageing,
3,4
raises issues for all types of
communities in various domains of urban living.
5
Understanding the relationship between population
ageing and urban change, and the need to develop
supportive urban communities, are major issues for
public policy.
5
According to Caro and Fitzgerald,
6
an
age-friendly city offers a supportive environment that
enables residents to grow older actively within their
families, neighbourhoods and civil society. An age-
friendly city, in their view, offers extensive opportuni-
ties for the participation of older people in the commu-
nity. In other words, a place where older people are
actively involved, valued and supported with infra-
structure and services that effectively accommodate
their needs.
Plouffe and Kalache
2
described the efforts of the
World Health Organization (WHO) to engage and
assist cities in becoming more ‘age-friendly’, through
the Global Age-Friendly Cities Guide and a compan-
ion ‘Checklist of Essential Features of Age-Friendly
Cities’.
7
The WHO project proposed that an ‘age-
friendly’ city is one that promotes active ageing.
7
Such a city optimises opportunities for health, partici-
pation and security in order to enhance quality of life as
people age.
2
There are eight domains of an age-friendly
city, namely Social participation; Communication and
information; Civic participation and employment;
Housing; Transportation; Community support and
health services; Outdoor spaces and buildings; and
Respect and social inclusion. According to the
OECD,
1
ageing societies pose diverse challenges,
such as redesigning infrastructure and urban develop-
ment patterns.
There are many cities world-wide that are in the
process of becoming age-friendly,
8–15
and the process
goes together with practical and scientific questions
about the impact of such efforts on the health, inde-
pendence and well-being of the older people, and the
design of the urban environment and services offered to
the older citizens of a self-proclaimed age-friendly city.
When referring to age-friendly cities, there seems to be
a lack of studies focusing on the outcomes of age-
friendly city approaches at the individual city-level.
4
In the attempts to make cities age-friendly, some of
the features that are intended at improving the quality
of life of older people may actually be based on age-
stereotypes, both positive and negative ones. In prac-
tice, the phenomenon of ageism may interact with the
age-friendly developments, which may sound counter-
intuitive as the process of a city towards becoming age-
friendly is often perceived as something positive.
Ageism as a concept was coined by Butler,
16
who
referred to it as prejudice on the basis of age.
Although the literature provides multiple manifesta-
tions of ageism, there is a lack of consensus on the
conceptualisation of ageism.
17
The most recent and
comprehensive definition of ageism is by S~
ao Jose
´
et al.,
18
namely that:
‘Ageism is defined as negative or positive stereotypes,
prejudice and/or discrimination against (or to the advan-
tage of) us on the basis of our chronological age or on the
basis of a perception of us as being “old”, “too old,”...
Ageism can be self-directed or other-directed, implicit or
explicit and can be expressed on a micro, meso or
macro-level’.
The review by S~
ao Jose
´et al.
18
highlights the need to
raise awareness of underexplored manifestations of
ageism across sectors. Healthcare and long-term care
are popular contexts that have provided examples of
ageism in older adults. Indeed, Buttigieg et al.
19
reported a spectrum of 32 variants of ageism when
mapping the main components of ageism and their
intersections in these sectors. In contrast, the recogni-
tion of the mere existence of ageism in the built envi-
ronment and its potential impact on the design of
age-friendly cities are understudied and unexplored
domains, thereby urgently raising the importance for
stakeholders to address the concept.
When talking about implicit and explicit ageism in
the domain of urban ageing and age-friendly cities,
there are numerous examples to illustrate how these
forms of ageism are manifest in the built environment.
Examples of explicit ageism in the urban environment
are poor or absent accessibility for older people, and,
who, therefore, are often completely ignored by archi-
tects, designers and urban planners. This lack of acces-
sibility can be encountered in public transport, such as
buses with high entrance steps or an underground metro
station without a lift or escalator, or even in public and
private buildings with entrances with steps. Implicit
ageism can be witnessed in buildings that from an aes-
thetic perspective are beautifully designed, but which in
practice do not cater for the needs of older people. In
such buildings, the artistic design takes precedence over
the practical functionality of the building. In practice,
this should not happen as town-planning authorities
should scrutinise designs before being given green light
or permit to build or construct. Apart from the aspects
of explicit and implicit ageism, all citizens of a city that
invested in becoming age-friendly have the right to know
how public money has been spent and how the public
funding has had an impact on the design of the city. In
short, are these features noticeable to laymen when
walking through a neighbourhood, and to older people
2Indoor and Built Environment 0(0)

when venturing outside and whilst making use
of services?
In this study, we aimed to investigate the extent to
which features of age-friendly cities (both facilitators
and hindrances
20
) are visible in the city scape, and
whether or not ageism is manifested explicitly or
implicitly. Explicit ageism implies conscious ageism,
mainly through ageist beliefs, feelings and behaviours,
which are consciously endorsed, while implicit ageism
infers unconscious ageism also through ageist beliefs,
feelings and behaviours, which are spontaneously man-
ifested without cognizant mindfulness.
19
We conducted
this investigation on the neighbourhood level in two
cities (municipalities) in the Netherlands.
City profiles: The Hague
and Zoetermeer
This study was conducted in two municipalities in
the Netherlands, namely The Hague (Den Haag or ’s-
Gravenhage) and Zoetermeer, which are located in the
Haaglanden region in the Province of South Holland
(Zuid-Holland; Figure 1). The Hague is a member of
the WHO Age-Friendly Cities consortium,
21
and
Zoetermeer is a municipality which implements strate-
gies for age-friendliness without being a consortium
member. A total of five neighbourhoods were selected
for this study: (1) The Hague Centre, (2) Laak – The
Hague, (3) Wateringse Veld – The Hague, (4)
Zoetermeer Stadshart (Zoetermeer City Centre) and
(5) Rokkeveen – Zoetermeer (Figure 1).
The Hague
On 1 January 2018, the population of The Hague was
just over 533,000 people, which included 76,465 people
aged 65 years and over.
22
The percentage of older
people (65þyears) living in the city was 14.3%. Of
these older people, 41.9% were 75 years and over.
23
Over three-quarters of the community-dwelling older
people live in a multi-storey building. Approximately
40% of older people (65þyears) living in The Hague
live in a home that is labelled or is known as a home for
older people, a nursing home or a so-called life-time
home, of which a large section is made up of social
housing. Of all senior households in the city, approxi-
mately 17% of residents have a minimum expenditure
(per month) to live on (usually a state pension).
23
Whilst, approximately 75% of the older people are
able to use the Internet,
24
a further 60% of older
people have a physical limitation or chronic disease.
Moreover, 68% of older people experience a limitation
in daily functioning, and approximately 10% deal with
the effects of dementia syndrome.
24
Statistics from 2018 showed 58.9% of people aged
65 years and over live in a single household, 94.6% of
people live independently and 5.4% of people live in
residential or hospital care. In 2015, 73.4% of all
people aged 65 years and over lived in a multi-storey
building, 16.9% of people lived in a house that was
adapted for habitation by older people and 41.9% of
people lived in social housing.
23
Most people aged 65
years and over are generally satisfied with the various
facilities in their neighbourhood, such as shops for
daily needs and public transport (85%), street lighting
(83%), green areas (76%) and the maintenance of
roads and cycle paths (71%). People are less satisfied
with parking facilities (41%). Moreover, 19.7% of
people indicate that they sometimes feel unsafe in
their neighbourhood.
23
In 2017, 27.0% of all the people aged 65 years and
older reported to be involved in voluntary work, and a
further 26.6% of people provided informal care. Over
half (54%) of all people aged 65 years and over feel at
home in their neighbourhood and believe that people in
their neighbourhood interact with each other in a pleas-
ant and positive manner. About 29% of older people
think that they live in a pleasant neighbourhood, and
32% have many social contacts in the neighbourhood.
However, 40% of people aged over 65 years think that
people in their neighbourhood hardly know each other.
In 2015, 9% of all people aged 65 years and over were
involved in neighbourhood activities, and 79% helped
their neighbours once in a while or receive help from
their neighbours. More than half (52%) of those aged
65 years and over were moderately to very severely
lonely in the year prior to the study (in 2016). Another
11% were dealing with serious to very severe loneliness,
and 7% felt socially excluded.
23,24
According to the
Armoedemonitor 2016 (Poverty Monitor 2016),
25
of all
senior households, 25% of people lived on less than
110% of the legal minimum income.
Given the make-up of older residents in this city,
there are three main challenges for the city of The
Hague,
24
and these are: (1) to improve the vitality of
its older citizens, (2) to combat loneliness and focus on
quality of life and well-being and (3) age-in-place.
Improving the vitality of citizens can decrease loneli-
ness (52% of older people in the city experience these
feelings), for instance through community engagement
and simultaneously meeting new people.
24
This is par-
ticularly the case when a spouse dies and one’s social
network becomes smaller. The more active older people
are, the more they are expected to take care of things
themselves and to participate in society. Setting goals
in life should be in accordance with one’s health status
and living conditions.
24
Furthermore, the municipality focuses on improving
safety and security and addresses domestic violence and
van Hoof et al. 3

abuse of older people. For older people with dementia,
a strong network of services and support for both the
individuals and informal carers, offering counselling
and day-care is set up for both people. Inclusion of
other sectors such as arts, culture and sports networks
and community initiatives with aged-care initiatives
and networks should challenge people to explore and
identify new life goals based on their personal abilities.
The 44 neighbourhoods that make-up the munici-
pality of The Hague have been analysed in terms of
their age-friendliness, and their positions were
ranked.
26
For the three neighbourhoods included in
this study, their relative positions are given in Table 1.
Zoetermeer
In January 2019, 124,940 people lived in the municipal-
ity of Zoetermeer, which included 23,114 people aged
65 years and over and 8425 aged 75 years and over.
27
The percentage of people aged 65 years and over living
in the city was 18.5% (Table 2). Currently, 31.4% of
people living in Zoetermeer have a migrant background
(20.6% non-Western and 10.8% Western). Over the
last nine years, the mean percentage of older people
in Zoetermeer grew from 12.6% to 18.5%, an increase
of 5.9% points. Although most neighbourhoods in
Zoetermeer demonstrated an increase (n¼24), not all
neighbourhoods shared the same extremity in increase
(Table 3). For example, Zoetermeer Dorp remained
more or less stable (21.4% in 2010 to 22.1% in 2019),
and even a decrease was observed: the most extreme
scenario was observed in Zoetermeer Zoeterhage
(32.4% in 2010 to 22.2% in 2019).
27
This diversity in the increase of the number of older
people means that different neighbourhoods have dif-
ferent challenges. In 2019, 45.7% of the people who
resided in social housing and of this group, 22% of
people were aged 65þyears. In 2017, people rated
Figure 1. Overview of the five neighbourhoods in Haaglanden region that were analysed: (1) Den Haag Centrum (The
Hague Centre), (2) Laak (The Hague), (3) Wateringse Veld (The Hague), (4) Zoetermeer Stadshart (Zoetermeer City Centre)
and (5) Rokkeveen (Zoetermeer).
4Indoor and Built Environment 0(0)

their living environment and their own homes. Their
living environment scored a 7.6 (0–10 scale), and their
homes scored an 8.0 (scale 0–10). Of the older people
who need care provided by the government (for
instance, aids, domestic care, home modifications,
regional taxi services, individual counselling at home,
day-care and overnight care), 79% rated the quality as
‘good’, and 81% experience the care as fitting to their
needs.
27
Of this group, 65% never/seldom experience
problems with accessibility, and only 16% experienced
accessibility issues when entering public places (pave-
ments, streets and walking routes). Public transport
was never used by 15% of the respondents, 45% of
this group never or seldom experienced challenges
and 40% experienced challenges occasionally or often.
Given the demographic conditions of the population
of Zoetermeer, several challenges for the municipality
lie in the field of ageing-in-place and vitality for the
ageing population. In order to support ageing-in-
place, existing homes need to be modified and or retro-
fitted according to the principles of life-time homes.
Furthermore, the living environment has to meet the
needs of older residents. Finally, there is an increase of
older people in Zoetermeer who need nursing home
care, and the current quantity and quality are insuffi-
cient. In relation to the national developments in the
domain of social care and support, the municipality of
Zoetermeer described that it will adjust or expand the
provisions for welfare care.
29
In order to improve the
vitality of older people in Zoetermeer, the municipality
described in their vision statement that they want
older people to pursue a more active lifestyle, ask
for support from family carers and consider combat-
ting malnutrition. This should be done through offer-
ing leisure, minor sports and other activities for the
elderly, and also do research on how older people
travel outdoors in Zoetermeer, also to support a gov-
ernment project on strengthening the positive health
vision for (future) family carers and to provide infor-
mation on nutrition by organising group meetings
regarding malnutrition.
30
Profiles of studied neighbourhoods
A total of five neighbourhoods in Haaglanden region
were analysed: (1) Den Haag Centrum (The Hague
Centre), (2) Laak (The Hague), (3) Wateringse Veld
(The Hague), (4) Zoetermeer Stadshart (Zoetermeer
City Centre) and (5) Rokkeveen (Zoetermeer).
Table 2. Demographics of studied neighbourhoods in the
municipality of Zoetermeer.
28
Neighbourhood:
Rokkeveen
Neighbourhood:
Stadscentrum
Total population 20,375 4248
65þ18.9%29.8%
People with a migration
background, as a
percentage of the
total population
25.1%35.5%
Table 1. Demographics and rankings of three neighbourhoods in The Hague in terms of their age-friendliness.
22,25,26
The
highest score is 1, and the lowest is 44.
Demographics and scores for age-friendly
city features
26
Neighbourhood:
Laakkwartier
en Spoorwijk
Borough: Laak
Neighbourhood:
Centrum
Borough:
Centrum
Neighbourhood:
Wateringseveld
Borough: Escamp
Total population
22
41,471 19,731 22,022
Number of older people (>65 yrs) and %
of the total population
22
3346 (8.0%) 2283 (12.1%) 2301 (10.4%)
Inhabitants with a migration background
(%of the total population)
22
76.2%56.5%44.7%
Households living of 110%or less of the
national minimum income
25
27.3%22.5%12.1%
Total ranking
26
37 30 21
Outdoor spaces and buildings 43 44 22
Transportation 39 34 8
Housing 8 10 28
Social participation 39 32 28
Respect and social inclusion 43 42 31
Civic participation and employment 33 26 29
Communication and information 17 13 3
Community support and health services 13 6 20
van Hoof et al. 5

Den Haag Centrum (The Hague – Centre) is a large
borough of the municipality of The Hague, which is
made up of eight smaller residential areas. The central
area (Centrum) was part of this study. The area is
known for its segregation in terms of the type of hous-
ing, social economic status and ethnic background of
residents. Also, the area is home to the main shopping
district, which draws 30 million visitors annually, and
numerous cultural venues and political institutions.
The surface area is 2.05 km
2
, and in 2017, there were
102,945 inhabitants.
31
Laak is the smallest borough of The Hague and is
made up of two residential areas. This study focuses on
the Laakkwartier area. This area is known for its mul-
ticultural population. Around the 1900s, the dockyards
were established in this area, which gave the neighbour-
hood its industrial look and feel. Between 1915 and
1935, social housing in the style of the Dutch architect
and urban planner Berlage were built. The surface area
is 4.27 km
2
, and in 2017, there were 42,405
inhabitants.
31
Wateringse Veld in The Hague is a recently devel-
oped residential area that was built between 1996 and
2012, which consists of 7500 dwellings. The area is part
of Escamp borough and was previously a horticultural
area. The surface area is 3.28 km
2
, and in 2017, there
were 21,610 inhabitants.
31
Zoetermeer Stadshart (Zoetermeer City Centre) is
the main shopping district of the municipality. In
1985, the construction of the area commenced, which
also included the construction of a town hall and the
public library. The area has been carefully planned and
consists of two layers, an underground area for logis-
tics and the area for consumers with over 200 shops.
There are also residential tower blocks in the area,
thus, the neighbourhood is vibrant after the closing
hours of the shops and restaurants. The surface area
is 0.55 km
2
, and in 2017, there were 3300 inhabitants.
31
Rokkeveen is one of the largest residential neigh-
bourhoods in Zoetermeer, and was built after 1987.
Rokkeveen is divided into a western and an eastern
section; the latter being the oldest part of Rokkeveen.
Remarkable features of Rokkeveen-West are several
bridges and the Floriadepark. In the eastern area,
there are landmarks such as a water tower and a
large park for public use. The surface area is 3.79
km
2
, and in 2017, there were 20,645 inhabitants.
31
Methodology
Photography
A visual research method was chosen for this study,
namely the photoproduction method.
32–34
Photography facilitates participants to tell a story
through images.
35–37
Images provide a lasting record
of an urban scene and perspective, which can be used
to study the relationship of people and their living envi-
ronments. Photography allows complex environmental
and social issues to be captured and then shared.
Building on existing work by Annemans et al.,
33
this
particular study aims to identify and obtain a thorough
understanding of the city scape and age-friendly fea-
tures visible in the photos whilst also aiming to under-
stand why and how.
This study used the approach of photographing real-
life features at the neighbourhood level during a walk-
through, whilst considering the eight domains of the
WHO’s model of age-friendly cities. The four-page
Checklist of Essential Features of Age-Friendly Cities
7
was used, bearing in mind that aspects of transportation
and the built environment are more visible than the
human-related aspects of an age-friendly city, such as
respect and social inclusion. The purpose of this check-
list is to identify how a city can be improved upon and
to align a city to the definition and checklist created by
the WHO. Assessing age-friendly features in a city in
terms of facilitators and hindrances is based on the
International Classification of Functioning, Disability
and Health of the WHO.
20
Within the classification,
the built environment is an environmental factor that
influences one’s health through the facilitating or hin-
dering impact of features of the physical, social and atti-
tudinal world.
20
Photos were made in September and
October 2018 by an extended research team, mainly
with a background in social work and nursing, who
were aged in their 20s, 30s and 40s; 38 in total receiving
instructions from two principal investigators. There
were 5 þ5 researchers (two groups) taking photographs
in The Hague Centre, 5 þ5 researchers (two groups) in
Table 3. Percentage growth in the number of older people (65þyears) from 2010 to 2019 in Zoetermeer.
28
<0%0.1–5%5.1–10%>10.1%
Number of neighbourhoods (total of 26) 2 9 9 6
Zoetermeer Stadshart
a
X (2.4%decline)
Zoetermeer Rokkeveen-West X (6.9%growth)
Zoetermeer Rokkeveen-East
a
X (7.1%growth)
a
Neighbourhoods included in this study.
6Indoor and Built Environment 0(0)

Laak, 5 þ4 researchers (two groups) in Wateringse
Veld, five researchers (one group) in Zoetermeer City
Centre, and 4 þ5 researchers (two groups) in
Rokkeveen. Researchers were instructed to take pictures
based on the Checklist of Essential Features of Age-
Friendly Cities, with a focus on the built environment,
and the consideration of ageism was not a part of the
photoproduction process.
Ageism
Over the past two to three decades, in reaction to the
ageing demographic changes, governments of devel-
oped countries attempted to respond to the goals and
requirements of older people by reforming social and
public policies and making serious attempts to trans-
form cities into older age-friendly habitats.
38
Ageism,
which is a combination of several connected elements,
namely: prejudicial attitudes towards older people, old
age and the ageing process; discriminatory practices;
and institutional practices and policies that perpetuate
stereotypes about older people, may interact with these
attempts to make cities age-friendly. Of relevance to
this context, it is worthwhile to focus on the three
reported levels of ageism, namely the micro-level at
the individual level – reflected through thoughts, emo-
tions and actions; the meso-level at the group/organisa-
tional/sectoral level – evident in polices or strategies;
and the macro-level at cultural or societal level – man-
ifested through values as a whole and entrenched
within political regulations.
39
One level of ageism
may trigger the manifestation at the other levels. For
example, disabling environments and ageist social
norms generated by political systems that are insensi-
tive to older people’s needs are more likely to elicit
ageism at the group/organisational/sectoral level, trick-
ling down to the individual level ageist behaviour and
decision-making. Indeed, age-friendly cities should
nurture social inclusion and minimise disadvantages
arising from vulnerabilities by ensuring actions that
foster social integration and social support, while safe-
guarding older adults’ access to essential resources.
40,41
In other words, age-friendly cities may only be guaran-
teed by fighting ageism at all levels starting off with
entrenching anti-ageism within social and public poli-
cies and reinforcing, rewarding and incentivizing anti-
ageist behaviour at organisational and individual
levels. The aspects of ageism were analysed in a second-
ary round of data analyses.
Ethics
During the photoproduction, no explicit photographs
were taken of people, who did not want to be photo-
graphed. This study did not involve the participation of
older people, and, therefore, gaining ethical approval
and informed consent was not required from the
ethics committee.
Data analyses. The Checklist of Essential Features of
Age-Friendly Cities
7
was used for the primary data
analyses (a priori thematic analysis). There were 152
photographs made in The Hague Centre, 72 in Laak,
206 in Wateringse Veld, 98 in Zoetermeer City Centre
and 92 in Rokkeveen (620 in total). For every neigh-
bourhood, data saturation was achieved. Photographs
were clustered based on the domains of the WHO’s
checklist, and the stories that relate to these photos
were used to describe the visibility and state-of-the-
art of the age-friendliness in/of the built environment.
After taking the photographs, the set of photos were
presented to at least one healthcare professional work-
ing in a local community/healthcare centre and one or
two older adults, as a form of member check. For each
of the five neighbourhoods, collages were made of
some age-friendly features or hindrances, in order to
support the description of the situation on the neigh-
bourhood level. Some additional stand-alone photo-
graphs were chosen for the same purpose.
The aspects of ageism were analysed in a secondary
round of data analyses, based on the photographic
material available, mainly of features relating to the
implicit and explicit ageism found in the design of fea-
tures of the built environment, and within the domain
of Communication and Information of the WHO’s
Global Age-Friendly Cities Guide model. Photos that
included older people in advertising, signage and other
printed materials were studied for implicit and explicit
ageism. Also, design aspects of the built environment
(architecture and urban planning) were analysed using
the photos only to see if age-friendly features are
in fact age-friendly, or, for instance, related to accessi-
bility only.
Results
In the following sections, each of the five neighbour-
hoods in The Hague and Zoetermeer are described in
more detail.
The Hague – Centre
One of the focal points of this neighbourhood
(Figure 2) is the large shopping district, which is fre-
quented by thousands of people on a daily basis. In this
district, photographs displayed many outdoor benches
and seating facilities. The traffic is generally crowded
and hurried. There is a limitation surrounding older
people based on the varying traffic lanes, including
people riding their bicycles and scooters. Overall,
van Hoof et al. 7

many older people avoid going into the city centre
because of how busy it is. This in turn results in older
populations choosing to visit quieter areas of the city.
At the same time, there are many options for public
transport for people to use in and around the city
centre, including buses, trams and the underground
tram lines. All platforms are accessible for people in
wheelchairs and using wheeled walkers. However, due
to the age of some trams, users still need to climb the
steps to get on board.
Throughout the city centre, many of the buildings,
including the shops, can be easily accessed, because the
shops or buildings have open doors. However, many of
the shops have narrow aisles and are hard to reach
when using a mobility scooter or other assistive
transport (such as wheelchairs). Additionally, elevators
and escalators are present in many shops, which can
offer assistance to user, whilst some of the restaurants
and cafes cannot be reached without climbing out-
door stairs.
Overall, the city centre is largely free of thresholds
and kerbs, and there is sufficient space for users of
mobility scooters to drive around (safely) and park
the device (Figure 3). Furthermore, there are private
mobility scooter parking boxes (Figure 4) that can be
installed when living in this part of the city.
In the City Hall, people can use digital codes
for using the myriad of service available. A number
is pulled by the person (who requires to use the
service) from a machine, and once the number is
Figure 2. Overview of features of The Hague – Centre. (a to d) show the City Hall, the digital devices for making
appointments, as well as the limited access for users of mobility scooters plus the parking lots outside. (e to h) show the options
for wheelchair users to access buildings by pushing special buttons, and the either limited or excellent options for access to
public transportation. (i to l) show outdoor environment with benches, pedestrian crossings (uneven and even access), traffic
blocking pavements and restricted access to customers with mobility limitations in older buildings. (m to p) show options for
entrepreneurs to be age-friendly or not, for instance, by having to narrow alleyways, offering reduced senior fares for the
cinema, having public lavatories available and by advertising for the senior market (a bank’s digital payment service).
8Indoor and Built Environment 0(0)

displayed (both through visual and sound), the person
with the code is able to make an appointment or via a
computer or via the person who is delivering the service.
Across the city, there are a number of community
and health centres, and in some centres, day-care activ-
ities are offered. Providing information to the residents
of the city is important, and during the walkarounds, it
was noted pamphlets and notices were not at eye-height
and only uses small print. This is the same for the sign-
age installed across the city. Inside entrance halls of
social housing, signs depicting older people in relation-
ship to hindrance are put in place (Figure 5).
The overall look-and-feel of the city centre is main-
tained by a team of cleaners, who ensure all rubbish is
collected and the streets are swept daily. Issues regard-
ing safety and security are also paramount, and such
issues were identified through the installation of street-
lights for use during the night. A large number of sur-
veillance cameras are also installed across this part of
the city.
The Hague – Laak
Laak is a multicultural area in The Hague, with multi-
storey homes dating between the 1910 and the 1930s
(Figure 6). The majority of the services are easily acces-
sible, and the pavements have dropped kerbs, while
most buildings have level access or lowered thresholds
for ease of entry. The pavements are often uneven with
many loose tiles. Many of the older houses have stair
elevators put in place for people who cannot climb
stairs without assistance (Figure 7).
It was noticeable that traffic lights do not allow suf-
ficient time for older people to cross the roads and who
were using the traffic lights at pedestrian crossings. The
older people did not have adequate time to cross before
it turned red. Mobility support for older people with
mobility impairments is offered close to their homes,
while the health centre, the municipal office and super-
markets are easily accessible and located centrally in
the area. The provision of public transport is high,
and it was noticed that many outdoor benches often
lack a back rest.
There are several community centres in Laak, which
offer opportunities a myriad of activities for older
people to engage and participate in. For example, the
‘De Laakse Lente’ initiative, which is a special interest’s
group for older people, and the community centre at
Cromvlietplein aims to improve the satisfaction of the
culturally diverse attendees, for instance, by offering a
large variety of activities and culturally-sensitive dis-
cussion groups.
Throughout the Laak area, information is shared
and distributed through posters and flyers throughout
public spaces, advertising the different and forthcom-
ing activities. Throughout the local shopping centres, it
was noticeable that there were many wide doors, which
are always open, and more importantly can provide
easy access for people using mobility scooters or
wheelchairs.
Figure 3. The Hague – Centre: no parking for bicycles and mobility scooters. There are no alternative parking areas in the
shopping district.
van Hoof et al. 9

The Hague – Wateringse Veld
Older people are offered a myriad of activities held in
the community centre in the Wateringse Veld neigh-
bourhood (Figure 8). The different types of activities
offered to the older people are actually organized by
the older people themselves. These activities include,
amongst others, bingo and flower arrangement.
Younger older adults can join a range of sporting activ-
ities, including fit hockey, and there is a gym with addi-
tional activities and fitness classes. The older adults
have the option to seek advice from the ‘ouderenconsu-
lent’ (consultant for older people). This consultant can
assist the older person in choosing the appropriate
activity for them.
In this area, there is a swathe of information distrib-
uted through leaflets and brochures at the community
centre. However, the print on the posters and bro-
chures is small, and some of the brochures can be
seen behind reflecting glass of a community centre
window. This results in the difficult legibility of materi-
als, and more so for those older people with visual
impairments. Furthermore, information is distributed
to people’s residences or placed on noticeboards within
their local supermarket(s), while there is a service point
from the municipality which can distribute
information.
Within the physical space and residential areas,
there are health centres, which house physiotherapists
and general practitioners, which in turn can conduct
blood tests on site. Furthermore, home care services
are housed in these centres; with additional services
focusing on financial matters relating to filling out tax
forms and advising against debt. Having all these dif-
ferent types of services under one roof, in an accessible
building with automated doors and levelled access, can
facilitate older people to make use of the services.
Throughout the neighbourhood, automated external
defibrillators can be found for public use. Some of
Figure 4. The Hague – Centre: not every apartment building is accessible for people using mobility scooters. Parking boxes
have been placed outside for parking of mobility scooters, as at Zuidwal street.
Figure 5. The Hague – Centre: signs with rules of behav-
iour for tenants of social housing apartments, with stereo-
typical older woman depicted on the bottom two cartoons.
10 Indoor and Built Environment 0(0)

the health centres have visual signs of older people on
their fac¸ ades (Figures 8 and 9).
Around these buildings, the pavements are wide and
have dropped kerbs, which can provide assistance for
those who need this additional accessibility. The quality
of pavements across the different streets vary, and there
are many loose tiles and bricks. Additionally, many
walk ways have poles and fences blocking access to
those people who are using wheeled walkers and mobil-
ity scooters, for instance, when wanting to go into the
local park. There are no protective fences along water
ways. It was also noticed the seating located inside the
shopping centre did not have arm rests or back rests,
whilst the outdoor seating at the local nursing home
does have these features. From the standpoint of mobil-
ity scooters, there are limited public parking lots and
facilities for parking one’s mobility scooter in this par-
ticular neighbourhood. At the local nursing home, elec-
tric tricycles can be rented (Figure 10). There are many
public transportation services, but customers in The
Hague cannot pay with cash. Platforms of bus and
tram stops have been raised, and the railway crossings
of the tram are levelled access.
Zoetermeer – Stadshart
Zoetermeer city centre is characterised by an elevated
shopping district, with an urban underground infra-
structure including an urban railway (Figure 11). This
type of public transportation is a positive asset to the
city providing all residents – young and old – with
access to different areas. Whilst, the streets are evenly
paved, there are many loose paving slabs and bricks,
which could cause a person to fall. The exterior land-
scape displayed more than 20 wood-clad benches for
residents and visitors to sit on, but the majority of them
did not feature back rests. The city centre is full of
older visitors using mobility scooters and wheeled
Figure 6. Overview of features of Laak. (a to d) show the densely built-up neighbourhood, which is one of the most
multicultural areas of the Netherlands. There are many steps in the streets, and not all pedestrian crossings are levelled. Old
shops have thresholds and narrow doorways. (e to h) show aspects of transportation, such as outdoor parking of mobility
scooters at the local supermarket and having broad alleys in the store, the availability of parking places for people with
mobility limitations and a ‘canta’, a two-seat microcar from the Netherlands specifically created for disabled drivers. (i to l)
show communication leaflets and posters for older people, including an invitation for a cultural festival as a part of a pre-
viously held age-friendly cities conference.
van Hoof et al. 11

walkers (Figure 12), and there are municipal agree-
ments that the local baker stores, cafes and restaurant
do not mind older people sitting outside their business
if they need to rest. Throughout the city centre, there
are many older people who are walking around. Many
of the pavements are easy access with dropped kerbs,
even at the bus station. Entrances to shops and build-
ings are often without thresholds and easily accessible
for all generations. The platforms at the bus station are
quite narrow and do not offer sufficient space for
people using a mobility scooter, but then again, there
is a special bus service for older people called
‘Ouderenbus’ (Senior bus), which is in service from
Tuesday to Saturday. One of the assets of the city
centre is that most of the streets are either covered or
provide protective overhangs against precipitation.
The so-called Stadhuis-Forum (Town Hall Forum)
located in the municipality building is an important
meeting place, and many organisations have a help-
desk. Many older people come to the Town Hall
Forum to search for information or to meet other
Figure 7. A typical scene in Laak: multi-storey dwellings
dating from the first half of the 20th century. Stair elevators
are the only solution when older tenants are no longer able to
climb stairs.
Figure 8. Overview of features of Wateringse Veld. (a to d) show the shopping centre and the levelled access, as well as the
slippery and reflective tiles. (e to g) show communication in the neighbourhood through brochures, which can be illegible
behind reflective glass. Older people are shown on an advertisement for the gym. (h) shows the recreational room at the local
healthcare centre. (i to l) show images of the public space with dropped kerbs, steep bridges and aspects of public transpor-
tation. Cash payments are no longer allowed in public transportation in The Hague.
12 Indoor and Built Environment 0(0)

people. Within this building, there is a library (renting
out books with large letters/print), a social/cafe
´area
and public restrooms (two of which are wheelchair
accessible). Many visitors come in to sit and rest for
a while, read a book or magazine or have coffee. There
is also a large supply of information via brochures and
leaflets, not just at Stadhuis Forum, but also in the
local home care shop, inside the shopping centre and
in community centres. On many folders and advertise-
ments, older people are shown.
Zoetermeer – Rokkeveen
In the Rokkeveen district of Zoetermeer, there are
many visible features of an age-friendly city
(Figure 13). First of all, inside the former water
tower, all health and welfare services are located
under one roof, including a general practitioner and a
pharmacy. Residents in this district do not have too far
to walk throughout the centre, which is positive for
those who may have mobility issues. In the centre of
the neighbourhood, there is a community/recreational
centre, which offers many activities (such as bingo) to
the residents. These activities and other additional
information are advertised throughout the neighbour-
hood via notice boards located inside the
local supermarket and the recreational centre.
Additionally, there are many posters and pamphlets
(new and old) detailing the variety of activity.
However, given the overflow of past information, this
suggests there is a lack of oversight of the actual supply
of activities. Inside the community centre, there are
also brochures for the local Alzheimer Cafe
´sessions.
There is even a special community centre for people
with dementia, called ‘Carpe Diem’. At the ‘Open
Tafels’ (Open Tables) initiative, people can eat togeth-
er, and meals are serviced by volunteers. Rokkeveen is
a very green neighbourhood, with a large park close to
the water tower. There are many benches around to
take rest.
The central shopping centre is accessible for older
residents and visitors based on the fact there are many
parking lots available, there are dropped kerbs for
mobility scooters and wheeled walker access, and
there are anti-slip mats inside buildings. In contrast,
many paving slabs are uneven or loose, and hamper
the accessibility and walkability of a neighbourhood,
but also increases the risk of a person experiencing a
fall or injury. From the exterior landscape, there are a
limited number of outdoor benches for older people to
sit on. Some of the objects (works of art) are used as
seats but are made of concrete and do not have any
arm or back rests.
There are two bus services that offer older people to
travel between A and B (Ouderenbus initiative, numbers
65 and 66). At the bus stops in Zoetermeer, a special tile
has been laid in the pavement displaying a wheelchair
user, which indicates that the bus stop is accessible for
Figure 9. Overview of Wijkcentrum Lage Veld (community centre), with stereotypical depictions of an older man.
Figure 10. Photograph of an electric tricycle that can be
rented from a care organisation. The tricycle has an engine
for additional support.
van Hoof et al. 13

Figure 11. Overview of features of Zoetermeer – Stadshart. (a to d) seats in the library at Stadhuis Forum are used by
older citizens, and the library offers large-print books. Guide dogs are welcome too. (e to h) show scenes of the outdoor area
with benches and numerous older people walking around. Many of the advertisements of shops are targeting an older pop-
ulation, including ads for assistive devices and incontinence materials. (i to l) show levelled access designs in the city centre,
parking lots of people with a disablement and seats in the local supermarket where older people can enjoy a coffee and read
a paper.
Figure 12. Zoetermeer Stadshart: forbidden in The Hague but still condoned in Zoetermeer. Parking a mobility scooter and
securing it to the railing of a stairway.
14 Indoor and Built Environment 0(0)

people using mobility aids. Customers need to be over
65 years old and can get on and off where needed, close
to home or the final destination. Through the neigh-
bourhood of Rokkeveen, there is a physical divide
from the rest of the town of Zoetermeer, because of
the motorway and a railway line intersecting between
the two places of The Hague and Utrecht. Analysing
the accessibility at the train stations identified a 15–20
cm gap between the platform and the train. For some
people, and in particular older people, with physical
impairments, this gap would cause additional concerns
and increase the risk of falling and injury. There are no
public chargers for mobility scooters and electric
bicycles in the neighbourhood. There also ‘Fokus-wonin-
gen’ (type of housing for people with special needs,
which are modified, wheelchair accessible and single-
floor) in the neighbourhood, which is normally a sign
that many features of accessible design can be found in
the urban planning and infrastructure.
Discussion
The WHO’s Global Age-Friendly Cities Guide
7
showed how features of an age-friendly city can be
manifested in eight domains of an age-friendly city,
namely: Social participation; Communication and
information; Civic participation and employment;
Housing; Transportation; Community support and
health services; Outdoor spaces and buildings; and
Respect and social inclusion. Our field study has
found a large number of features that manifest
mainly in the WHO domains of Communication and
information; Housing; Transportation; Community
support and Health services; and Outdoor spaces and
buildings. Age-friendly features can be found in these
five domains in both municipalities, whether the city
studied is an official WHO age-friendly city’s consor-
tium member or not. Overall, the density of age-
friendly features is rather high, and it seems that the
municipalities are doing well, even beyond the borders
Figure 13. Overview of features of Zoetermeer-Rokkeveen. (a to d) show the quality of streets and pavements, including
loose tiles, levelled pedestrian crossings, the gap between the train and the platform and the special tile for wheelchair users
who wish to use public transportation services. (e to h) show the art work that is used as stools in the public space, the levelled
entrance to the main shopping area and a sign warning for slippery floors. (i to l) show the interiors of apartment blocks for
older people and the spacious layout of corridors. Inside these buildings and community centres, many folders and brochures
show which activities and services can be enjoyed by older citizens.
van Hoof et al. 15

of the well-visited city centres stretching into the more
remote residential areas of both municipalities. In the
current study, we did not specifically identify features
in the domains of Social participation; Civic participa-
tion and employment; and Respect and social inclu-
sion. As the aim of the study was to investigate the
extent to which features of age-friendly cities were vis-
ible in the city scape, aspects that were not encountered
in the built environment were not included in the pro-
cess of data collection. Future studies could explicitly
study the visibility of older people engaging in employ-
ment, in social activities and leisure, in volunteering in
neighbourhood centres, and so on, which would
require a critical assessment of ethical aspects as it con-
cerns observation people in a given context. Some of
the limitations to the current methodological approach
are that some of the age-friendly features (both facili-
tators and hindrances) may be overlooked, and that
because the photographs were taken by relatively
young people instead of older people themselves. In
future studies, older people should be invited in a pho-
toproduction or photo-voice study to map the age-
friendliness of their neighbourhoods, with additional
qualitative data on the interpretation of their findings,
like in the study by Chan et al.
42
This would help
involve older people themselves in improving the
built environment of an age-friendly city. Also, the
everyday activities of urban older adults in public
open spaces should be studied, which can be done
through photography.
43
If we look at the outcomes of this study, it becomes
clear that older people themselves are visible through-
out the street and society. Apart from some areas,
which are not accessible for people in wheelchairs,
streets are generally very accessible, with dropped
kerbs as the most eye-catching feature. Such dropped
kerbs are also a facilitator for young families using
prams and strollers. The main problem in terms of
accessibility is the overall accessibility of pavements
(for instance, the need for more dropped kerbs) and
improvement of the quality of the pavement without
gaps in between the tiles, which may hamper the mobil-
ity of older people using wheeled walkers. It needs to be
noted that biological ageing itself is not a synonym for
mobility problems (i.e. using a wheelchair), although
many older people seen out on the street use mobility
scooters. These mobility scooters are a more prominent
feature in the city scape than wheeled walkers. It seems
that there are plenty of parking places available for
people using wheelchairs, but not all of the parking
lots are broad enough to allow for separate wheelchair
use next to the car itself. Additional challenges relating
to accessibility are the need to use cash to pay for
accessing public transport.
Overall, the built environment is well adapted to the
needs of older people (buildings, roads and infrastruc-
ture and transportation), but especially older buildings
are not. Multi-storey homes have stair elevators when
needed, which are especially visible in Laakkwartier,
and special parking boxes are provided for mobility
scooters, which are installed on municipal land (The
Hague – Centre). The individual garage boxes for
mobility scooters may be perceived as stigmatizing, as
everyone can see where a user of a mobility scooter
actually lives. From the perspective of safety and
security, people may be easily identifiable targets for
burglary. Overall, it seems that both The Hague and
Zoetermeer districts have a lot of age-friendly features
throughout the respective cities, and it seems that these
features are an integral part of daily living for the
society and residents as a whole. Apart from the munic-
ipality playing an important role in making a city age-
friendly, there are numerous other stakeholders, such
as entrepreneurs, social housing associations, shop-
keepers, healthcare facilities and so on, that can help
make their services and buildings more age-friendly by
installing, designing and implementing a large range of
features in the built environment. Many shops and
healthcare centres have implemented strategies to
make their buildings more accessible (levelled access
and wide shopping lanes), to target older clients in
advertisements, and to offer special day-care pro-
grammes for older citizens. Such measures do not
require municipal investments and may even help
improve the turn-overs of these stakeholders. Many
of the public transport vehicles are easily accessible
for people with impaired mobility or even prams, but
if people do not use a digital public transportation
card, then bus tickets can only by purchased using
debit and credit cards.
A recent evaluation by The Hague Senior
Committee
44
showed similar outcomes as the current
study. According to older citizens living in the munic-
ipality of The Hague who were consulted (n¼533), the
city is very age-friendly. A total of 60% stated that The
Hague is age-friendly, 35% stated that the city is partly
age-friendly and only 5% said the city was not. Older
people are satisfied with their own lives (7.7 out of 10),
and they rate the quality of their living surroundings
with a 7.9 out of 10. The most important reasons for
being satisfied with The Hague being age-friendly was
the quality of the public transport services, the service
level in neighbourhoods. The Hague being a city where
one feels at home and where one can live a good life,
the supply of activities, and the city’s focus on older
citizens. Features that can be improved are the frequen-
cy of public transport (in particular after work hours)
and the price level, the maintenance of pavements (lose
tiles) and kerbs, and the presence of obstacles on
16 Indoor and Built Environment 0(0)

pavements, safety and security during evening hours,
the accessibility and supply of social services and pro-
viding a listening ear to the actual needs of older
people.
44
The latter desire can also be related to the
design of the outdoor and built environment, as well
as the implementation of new technologies.
Nevertheless, there are some downsides as well. In
terms of the design (look and feel) of the age-friendly
features, it needs to be mentioned that not all design
solutions are inviting or aesthetically pleasing. For
example, signs saying ‘no access and parking of mobil-
ity scooters’, narrow gangways and access in shops and
public transportation, which does not yet have levelled
access. These are just some of the design features that
can be, and need to be, improved in the coming years if
the cities wish to become fully age-friendly.
All over both municipalities, there are posters, leaf-
lets, newsletters and posters on noticeboards placed
within community centres, shopping centres and super-
markets aimed at older residents (Oud Hagenaar)
highlighting and advertising specific information
about healthcare and social care services, as well as
different activities. Still, many of the leaflets are old
and outdated, and it seems like an overall coordinator
about the contents is lacking. Many of the posters are
put up behind reflective glass and are printed using very
small fonts, which are illegible for most older people.
Overall, it seems that there is always something to do in
the city, free of charge, and covering a broad range of
social activities. The Hague is like a candy store for
older people: everyday, there are events that are free
of charge, there are nice museums, the city centre is
lively, if you have the courage to venture out, there is
always something waiting for you. This is one of the
assets of living in a large city. Many of the events and
places are accessible and can be reached by public
transportation. It is good to understand that not every-
one is willing to venture out alone, which may lead to
social isolation.
Modern technologies may pose barriers to older
people’s participation in daily life as noted by
Marston et al.,
45
who explored the use of technology
by adults aged 65þyears living in one of three coun-
tries (Germany, Australia and Spain). Whilst, Genoe
et al.
46
explored how technology is used on a daily basis
and from the standpoint of leisure residing in rural and
urban locations across the UK and Canada. These
technologies include the information technologies at
the city hall of The Hague, but also ticket vending
machines and the lack of options to pay with cash in
public transport. All these technologies may not be
perceived as age-friendly features of a city, especially
if older adults have little or no experience of using
such machines or if there is a change of machines.
Technology may pose barriers and be perceived as
hindrances. At the same time, one of the Dutch
banks had an advertisement for a digital banking ser-
vice, targeting older people as a potential user group.
One may wonder if this is a form of ageism that man-
ifests itself in the implementation of new technologies
or whether it is just a manifestation of the digital divide
between the generations. The integration and use of
technology within the age-friendly city domain and
frameworks need to be discussed. It should be noted
since the turn of the new millennium, we have seen a
phenomenal growth and interest across society,
research and development by people who are focusing
their attentions on the use and deployment of technol-
ogy to assist citizens with their daily activities.
47
The
increase of ageing populations across Europe and
worldwide means that many families and carers under-
take caring duties for their spouse, parent or dependent
child, or those living with conditions such as demen-
tia.
48,49
Technology has the potential to offer carers
with additional support such as remote monitoring or
assist with day-to-day activities, as discussed by
Marston and Samuels,
50
who explored the use of vir-
tual assistants in the home environment, while also
discussing how intergenerational relationships can
play a part in the age-friendly framework.
Conversely, citizens have bored witness to the rise
and development of mobile phones, with many using
and owning smartphones offering the user a vast has in
turn led to the development of mobile apps (mApps)
and mobile health (mHealth) apps, which facilitate
people to self-monitor their health and share their
data with their friends and health practitioner.
51
Whilst videogames have garnered great interest and
worldwide investigations, focusing on the use of
health and societal benefits,
52–56
little focus has
explored how videogames could be integrated into an
age-friendly city. This seems to be true for the whole
spectrum of technological solutions that are available
on the marketplace to support older people.
Whilst there have been great strides made in the
contemporary literature surrounding the discussions
of age-friendly cities,
6,11,57–61
there is however, a pau-
city in the varying discussions and agendas surround-
ing the integration, use and deployment of technology
into the age-friendly movement. Thus, to move the age-
friendly debate forward, the authors propose future
discussions and research surrounding age-friendly
cities should start to include technology, even if previ-
ously this was not the case. Given the myriad of tech-
nologies available and used by citizens, exploring how
such technologies can be used and deployed in the
home and across different communities to benefit the
citizens in the respective age-friendly communities,
including those communities that are not categorised
as age-friendly by the WHO. Scholars who have
van Hoof et al. 17

conducted research in the domain of digital health and
technology can bring substantial experience and knowl-
edge to the age-friendly agenda and framework.
Building a multi- and cross-disciplinary approach, pri-
marily focusing on technology and its role(s) within the
age-friendly movement, is the key for moving this
agenda forward.
When reflecting on the age-stereotypes in the design
of the age-friendly features, there are two types of
design features that need to be discussed: (1) the built
environment and transportation and (2) advertise-
ments. In the built environment, ageism can be wit-
nessed in signs as the no parking for mobility
scooters (which can actually be seen as a sign of inclu-
sion that not only riders of bicycles are considered) or
signs of social housing associations depicting older ten-
ants as the ones who experience hindrance from fellow
residents the most frequently. Sending a ‘negative’ mes-
sage to older people as a sort of instruction (no park-
ing) is not a sign of ageism at all, it is merely an
instruction how to keep the public space accessible
and liveable for all. It could be considered as a sign
of ageism in a way if benches on public streets are
designed without arm and back rests and to install
raised plateaus with kerbs in order to keep older
people away (as they cannot access such places when
using wheeled walkers or mobility scooters). Such sit-
uations have not been encountered in the city centre.
Nevertheless, it remains important that features in
the built environment, such as benches, can be used by
the main groups of users, such as older adults. Whilst
aspects of human factors should be considered as much
as possible (being able to get up and out of the seats),
as well as making sure the benches are comfortable,
even in cold winters, hot summers and after a
shower, without freezing, scalding or getting wet. In
addition, urban planning and the design of public
spaces should be conducted in relation to the effects
of climate adaptation
62
or socio-environmental vulner-
ability,
63
and besides planning and designing for acces-
sibility, a secondary focus on egressibility should be
chosen in order to facilitate older people being able
to leave their homes or neighbourhoods, for instance,
in cases of emergency.
3,4
The design of age-friendly
places should ideally follow the principles of user-
centred design based on the needs of actual stakehold-
ers.
64,65
Given the demographic changes in our urban
populations (including a large number of tourists visit-
ing the city centre of The Hague, who are also in need
to public lavatories), this seems to be no more than
logical. In the old days, transportation services (trams
and buses) and social housing were not designed bear-
ing the needs of people in mind. Between 1910 and
1930s, in the Laakkwartier district, for example,
people had to be appreciative to have access to social
housing in the first place. These houses had appropriate
sanitation and were dwelled by single-generation
households. Another way of identifying ageism in the
design would be that all homes for older people would
be designed as levelled access (without any thresholds)
and be full of a wide range of home modifications
focusing on disability,
66–69
just because of the condition
that older people are indeed old and perhaps frail,
instead of just offering a sense of a home.
70
All older
people, even those without any impairments, would
then be treated as frail and in need for care. This is
not the case in either of the two municipalities. In
The Hague, measures are often personalised solutions,
such as the stair elevators, which are only provided by
the municipality in case of actual needs. In the case of
public transportation, the special tile with a depiction
of a wheelchair user in Zoetermeer may be a very clear
symbol (Figure 13), but not every older person may feel
attracted to this depiction at all.
This brings us to discussing the use of symbols and
depictions as a form of implicit or explicit ageism.
Many of the posters and advertisements relate ageing
to physical decline, irrespective of which emotions the
person him/herself is showing. Although most posters
and advertisements are made with a great sense of
respect, you may ask yourself if you feel attracted by
a smiling woman who advertises products for inconti-
nence. At the same time, some companies have discov-
ered older people as a specific target group, such as the
advertisement for digital banking, assistive technolo-
gies, and so on, and this seems to be an actual reflection
of the actual age distribution of our societies. Older
people are very visible on the streets, but it seems
that they were omitted from advertisements. Loos
and Ivan
71
analysed representation of older people in
the visual media – print advertisements, television
advertisements and television programs. They exam-
ined whether older people were represented as third
or fourth agers (active, healthy older people versus
care-dependent older people). Overall, the data from
The Hague and Zoetermeer showed that older people
were depicted as third agers, albeit that some of the
advertisements were targeted at physical limitations,
including incontinence and the need for assistive devi-
ces. These solutions could be purchased in order to live
a normal or independent life. Loos and Ivan
71
noted
that there is a trend towards a positive representation
of older people in the media. Still, one of the depictions
of older people on a healthcare centre in Wateringse
Veld showed an older man with a slightly bent back,
holding a cane, which is a stereotype of physical decline
and impaired mobility. The fact that the older woman
cheering on the advertisement for incontinence materi-
al, make her seem like a winner, not a loser. This trend
is also identified by Loos and Ivan.
71
The scholars call
18 Indoor and Built Environment 0(0)

for designing for dynamic diversity as an alternative to
visual ageism, which in The Hague should also include
the visibility of the multicultural society and fourth
agers in the way older people are shown in advertise-
ments in the built environment.
Conclusions
The municipalities of The Hague and Zoetermeer have
integrated a large array of age-friendly features in their
respective neighbourhoods in order to make their soci-
eties more inclusive for older age groups. The city of
The Hague is a consortium member of the WHO’s
Global Age-Friendly Cities Guide. Both municipalities
have a large number of visual features, both facilitators
and hindrances, that can be observed in the streets of
the two cities. These features are manifested particu-
larly in five domains of the Global Age-Friendly Cities
model, namely Communication and information;
Housing; Transportation; Community support and
health services; and Outdoor spaces and buildings.
Both municipalities and entrepreneurs (shops) have
invested great effort in making the cities accessible
for all age groups, and a large set of services and activ-
ities are offered to older people. Future research should
address the solutions offered by entrepreneurs as a way
to make their businesses more age-friendly. Age-stereo-
types, both positive and negative, can be observed in
the domain of Communication and information, espe-
cially in the depiction of third agers as winners. At the
same time, older people are very visible in the city-
scapes of both municipalities, and it is an expression
of the changing demographics that signs and advertise-
ments targeting older people are emerging in our soci-
eties. Other cities in the Netherlands could use the
results of this study to make their own cities more
age-friendly, for instance, by looking at best practices
that can be implemented into their own urban planning
or the design of public services, such as the availability
of parking places for mobility scooters, as such pat-
terns are very similar throughout the country. Cities
abroad could benefit from taking notice of the best
practices and by trying to translate these findings into
the local urban context and level of service provision.
Authors’ contribution
This is the result of an educational project, Rudy F. M. van
den Hoven and Esther Kroon were involved in data collec-
tion and guiding students in the project. Joost van Hoof
and Jeroen Dikken supervised the projected and wrote
the manuscript in collaboration with Sandra C. Buttigieg
and Hannah R. Marston. This was a co-production, all
authors made a minimal contribution of 25%.
Declaration of conflicting interests
The author(s) declared no potential conflicts of interest with
respect to the research, authorship, and/or publication of
this article.
Funding
The author(s) disclosed receipt of the following financial sup-
port for the research, authorship, and/or publication of this
article: The authors would like to acknowledge networking
support by the COST Action IS1402 Ageism – a multi-
national, interdisciplinary perspective.
ORCID iD
Joost van Hoof https://orcid.org/0000-0003-1445-3695
References
1. OECD. Ageing in cities. Paris, France: OECD Publishing,
2015. ISBN 9789264231146.
2. Plouffe L and Kalache A. Towards global age-friendly
cities: determining urban features that promote active
aging. J Urban Health 2010; 87: 733–739.
3. van Hoof J and Kazak JK. Urban ageing. Indoor Built
Environ 2018; 27: 583–586.
4. van Hoof J, Kazak JK, Perek-Białas JM and Peek STM.
The challenges of urban ageing: making cities age-friendly in
Europe. IJERPH 2018; 15: 2473.
5. Buffel T and Phillipson C. Can global cities be ‘age-
friendly cities’? Urban development and ageing popula-
tions. Cities 2016; 55: 94–100.
6. Caro FG and Fitzgerald KG (eds). International perspec-
tives on age-friendly cities. New York, NY, US:
Routledge, 2016. ISBN 9780415720717.
7. World Health Organization. Global age-friendly cities: a
guide. Geneva, Switzerland: World Health Organization,
2007. ISBN 9789241547307.
8. Buffel T, McGarry P, Phillipson C, De Donder L, Dury
S, De Witte N, Smetcoren A-S and Verte
´D. Developing
age-friendly cities: case studies from Brussels and
Manchester and implications for policy and practice.
J Aging Soc Policy 2014; 26: 52–72.
9. Fitzgerald KG and Caro FG. An overview of age-
friendly cities and communities around the World.
J Aging Soc Policy 2014; 26: 1–18.
10. Kendig H, Elias A-M, Matwijiw P and Anstey K.
Developing age-friendly cities and communities in
Australia. J Aging Health 2014; 26: 1390–1414.
11. Menec VH, Means R, Keating N, Parkhurst G and
Eales J. Conceptualizing age-friendly communities.
Can J Aging 2011; 30: 479–493.
12. Scharlach A. Creating aging-friendly communities in the
United States. Ageing Int 2012; 37: 25–38.
13. Scharlach AE and Lehning AJ. Ageing-friendly commu-
nities and social inclusion in the United States of
America. Ageing Soc 2013; 33: 110–136.
14. Chief Secretary for Administration’s Office. Active and
healthy ageing in Hong Kong. Hong Kong SAR: Hong
Kong Government, 2017.
van Hoof et al. 19

15. Buffel T and Phillipson C. A manifesto for the age-
friendly movement: developing a new urban agenda. J
Aging Soc Policy 2018; 30: 173–192.
16. Butler RN. Age-ism: another form of bigotry.
Gerontologist 1969; 9: 243–246.
17. Iversen TN, Larsen L and Solem PE. A conceptual anal-
ysis of ageism. Nordic Psychol 2009; 61: 4–22.
18. S~
ao Jose
´JMS, Amado CAF, Ilinca S, Buttigieg SC and
Taghizadeh Larsson A. Ageism in health care: a
systematic review of operational definitions and
inductive conceptualizations. Gerontologist 2019;
59: e98–e108.
19. Buttigieg SC, Ilinca S, de Sao Jose JMS and Taghizadeh
Larsson A. Chapter 29. Researching ageism in health-
care and long term care. In: Ayalon L and Tesch-
Roemer C (eds) Contemporary perspectives on ageism.
International perspectives on aging. Volume 19. New
York, NY: Springer International Publishing, 2018,
pp. 493–515. doi:10.1007/978-3-319-73820-8_29.
20. WHO. International Classification of Functioning,
Disability and Health. In: Resolution WHA54.21 of the
fifty-fourth World Health Assembly, ninth plenary meet-
ing, agenda item 13.9, 22 May 2001, A54/VR/9. Geneva,
Switzerland: World Health Organization, 2001.
21. van den Bergen C, Noyon L, Booij J, Meerstadt B, Bilkes
R, de Vries E, Beeldman E, van Doesburg N, van Vliet J
and Duimel M. Den Haag seniorvriendelijke stad. Toen en
nu (In Dutch). The Hague, The Netherlands: Stichting
GetOud, 2017.
22. Gemeente Den Haag. Den Haag in cijfers (In Dutch),
https://denhaag.buurtmonitor.nl/jive?cat_open_
code¼c1282&lang¼nl (accessed 4 April 2019).
23. van der Neut S and van der Velden A (eds).
Ouderenmonitor, 2018. De positie van Haagse ouderen in
kaart gebracht (In Dutch). https://ckan.dataplatform.nl/
dataset/dba52bda-3178-48f8-9b75-2faf4048d6d7/resource/
8ee46bb8-c1a6-430f-9fce-e1b6615d1473/download/ouder
enmonitor2018.pdf (2018, accessed 4 April 2019).
24. Den Haag, seniorvriendelijke stad 2015–2018.
Actieprogramma Haags ouderenbeleid (In Dutch). The
Hague, The Netherlands: Gemeente Den Haag, 2018.
https://denhaag.raadsinformatie.nl/document/3338376/1/
RIS285266_bijlage%20Den%20Haag%2C%20seniorv
riendelijke%20stad%202015-2018%2C%
20Actieprogramma%20Haags%20ouderenbeleid (2015,
accessed 24 March 2019).
25. Schoot Uiterkamp T and van Putten B. KWIZ/Gemeente
Den Haag. Armoedemonitor 2016. Gemeente Den Haag
(In Dutch). The Netherlands, Groningen: KWIZ.
https://denhaag.raadsinformatie.nl/document/4307618/1/
RIS295339_Bijlage_Armoedemonitor_2016_gemeente_
Den_Haag (2016, accessed 24 March 2019).
26. http://maps.objectvision.nl/DHseniorvriendelijk/
(accessed 24 March 2019).
27. https://zoetermeer.incijfers.nl/rapporten/Clientervaring-
Wmo-Gemeente-Zoetermeer/554 (accessed 24 March 2019).
28. https://zoetermeer.incijfers.nl/dashboard/bevolking/
(accessed 24 March 2019).
29. https://www.zoetermeer.nl/inwoners/huisvesting-in-zoe
termeer_46587/item/visie-op-het-wonen_86303.html
(accessed 24 March 2019).
30. https://repository.officiele-overheidspublicaties.nl/exter
nebijlagen/exb-2017-41652/1/bijlage/exb-2017-41652.pdf
(accessed 24 March 2019).
31. CBS Kerncijfers wijken en buurten. Centraal Bureau voor
de statistiek, Voorburg/Heerlen (In Dutch), https://www.
cbs.nl/nl-nl/maatwerk/2017/31/kerncijfers-wijken-en-
buurten-2017 (2017, accessed 21 May 2019).
32. van Hoof J, Verhagen MM, Wouters EJM, Marston HR,
Rijnaard MD and Janssen BM. Picture your nursing
home. Exploring the sense of home of older residents
through photography. J Aging Res 2015; ID 312931.
33. Radley A. What people do with pictures. Visual Stud
2010; 25: 268–279.
34. Annemans M, Van Audenhove C, Vermolen H and
Heylighen A. Hospital reality from a lying perspective:
exploring a sensory research approach. In: Langdon P,
Clarkson P, Robinson P (eds) Designing inclusive systems.
London, UK: Springer, 2012, pp. 3–12.
35. Catalani C and Minkler M. Photovoice: a review of the
literature in health and public health. Health Educ Behav
2010; 37: 424–451.
36. Warren S. Show me how it feels to work here: using pho-
tography to research organizational aesthetics. Ephemera
2002; 2: 224–245.
37. Collier J. Visual anthropology: photography as a research
method. New York, NY: Holt Rinehart and
Winston, 1967.
38. Buffel T, Phillipson C and Scharf T. Ageing in urban
environments: developing ‘age-friendly’ cities. Critical
Soc Policy 2012; 32: 597–617.
39. Ayalon L and Tesch-R€
omer C (eds) Contemporary per-
spectives on ageism. International perspectives on aging.
Volume 19. Cham, Switzerland: Springer, 2018. ISBN
9783319738208
40. Scharlach AE and Lehning AJ. Ageing-friendly commu-
nities and social inclusion in the United States of
America. Ageing Soc 2013; 33: s110–s136.
41. Biggs S, Carr A. Age and child-Friendly cities and the
promise of intergenerational space. J Soc Work Prac
2015; 29: 99–112.
42. Chan AW, Chan HY, Chan IK, Cheung BY and Lee DT.
An age-friendly living environment as seen by Chinese
older adults: a “Photovoice” study. Int J Environ Res
Public Health 2016; 13: 913.
43. Ben Noon R and Ayalon L. Older adults in public open
spaces: age and gender segregation. Gerontologist 2018;
58: 149–158.
44. Ouderenpanel: zomerronde 2018. The Hague, The
Netherlands: SOC & Gemeente Den Haag (in Dutch),
2018. https://www.socdenhaag.nl/documents/uitslag-ouder
enpanel-zomer-2018-98d938163e14ab054f9
fad27950144b3.pdf
45. Marston HR, Kroll M, Fink D, de Rosario H and
Gschwind YJ. Technology use, adoption and behaviour
in older adults: results from the iStoppFalls Project. Edu
Gerontol 2016; 14: 371–387.
20 Indoor and Built Environment 0(0)

46. Genoe MR, Kulczycki C, Marston H, Freeman S,
Musselwhite C and Rutherford H. E-leisure and older
adults: findings from an international exploratory
study. TRJ 2018; 52: https://doi.org/10.18666/TRJ-
2018-V52-I1-8417.
47. Peek STM, Luijkx KG, Rijnaard MD, Nieboer ME, van
der Voort CS, Aarts S, van Hoof J, Vrijhoef HJ and
Wouters EJM. Older adults’ reasons for using technology
while aging in place. Gerontology 2016; 62: 226–237.
48. Gaugler JE, Zmora R, Mitchell LL, Finlay JM, Peterson
CM, McCarron H and Jutkowitz E. Six-month effective-
ness of remote activity monitoring for persons living with
dementia and their family caregivers: an experimental
mixed methods study. Gerontologist 2019; 59: 78–89.
49. Braley R, Fritz R, Van Son CR and Schmitter-
Edgecombe M. Prompting technology and persons with
dementia: the significance of context and communication.
Gerontologist 2019; 59: 101–111.
50. Marston HR and Samuels J. A review of age friendly
virtual assistive technologies and their effect on daily
living for carers and dependent adults. Healthcare 2019;
7: 49.
51. Marston HR and Hall AK. Gamification: application for
health and health information technology engagement.
In: Novak D, Tulu B and Brendryen H (eds) Handbook
of research on holistic perspectives in gamification for clin-
ical practice. Hershey, PA: Medical Information Science
Reference, 2015, pp. 78–104. doi: 10.4018/978-1-4666-
9522-1.ch005.
52. Gschwind Y, Eichberg S, Ejupi A, de Rosario H, Kroll
M, Marston H, Drobics M, Annegarn J, Wieching R,
Lord SR, Aal K, Vaziri D, Woodbury A, Fink D and
Delbaere K. ICT-based system to predict and prevent
falls (iStoppFalls): results from an international multi-
center randomized controlled trial. Eur Rev Ageing
Physic Act 2015; 12: 10. doi: 10.1186/s11556-015-0155-6.
53. Marston HR, Kroll M, Fink D and Gschwind YJ. Flow
experience of older adults using the iStoppFalls exer-
games. Games Cult J 2016; 11: 201–222.
54. Marston HR, Freeman S, Bishop KA and Beech CL.
Utilization of digital games for older adults aged 85þ
years: a scoping review. Games Health J 2016; 5: 157–174.
55. Marston HR, Greenlay S and van Hoof J. Understanding
the Nintendo Wii console in long-term care facilities.
Technol Disabil 2013; 25: 77–85.
56. Marston HR and Graner-Ray S. Older women on the
game: understanding digital game perspectives from an
ageing cohort. In: Nierling L and Dominguez Rue E (eds)
Ageing and technology: perspectives from the social sci-
ences. Steinfurt, Germany: Transcript-Verlag (10 May
2016), 2016, pp. 67–91.
57. McGarry P and Morris J. A great place to grow older: a
case study of how Manchester is developing an age-
friendly city. Work Older People 2011; 15: 38–46.
58. Steels S. Key characteristics of age-friendly cities and
communities: a review. Cities 2015; 47: 45–52.
59. Greenfield EA, Oberlink M, Scharlach AE, Neal MB and
Stafford PB. Age-friendly community initiatives: concep-
tual issues and key questions. Gerontologist 2015;
55: 191–198.
60. Buffel T. Social research and co-production with older
people: developing age-friendly communities. J Aging
Stud 2018; 44: 52–60.
61. Buffel T, Handler S and Phillipson C (eds) Age-friendly
cities and communities: a global perspective. Bristol, UK:
Bristol University Press, 2018. doi:10.2307/j.ctt1zrvhc4.
62. Kiełkowska J, Tokarczyk-Dorociak K, Kazak J, Szewra
nski
S and van Hoof J. Urban adaptation to climate change plans
and policies –the conceptual framework of a methodological
approach. J Ecol Eng 2018; 19: 50–62.
63. Szewra
nski S, 
Swia˛der M, Kazak J, Tokarczyk-Dorociak
K and van Hoof J. Socio-environmental vulnerability
mapping for environmental and flood resilience assess-
ment: the case of ageing and poverty in the city of
Wrocław, Poland. Integr Environ Assess Manag 2018;
14: 592–597.
64. van Hoof J, Rutten PGS, Struck C, Huisman E and Kort
H. The integrated and evidence-based design of health-
care environments. Arch Eng Design Manag 2015;
11: 243–263.
65. van Hoof J and Verkerk MJ. Developing an integrated
design model incorporating technology philosophy for
the design of healthcare environments: a case analysis
of facilities for psychogeriatric and psychiatric care in
the Netherlands. Technol Soc 2013; 35: 1–13.
66. van Hoof J, Kort HSM and van Waarde H. Housing and
care for older adults with dementia. A European perspec-
tive. J Hous and the Built Environ 2009; 24: 369–390.
67. van Hoof J, Kort HSM, van Waarde H and Blom MM.
Environmental interventions and the design of homes for
older adults with dementia: an overview. Am J
Alzheimers Dis Other Demen 2010; 25: 202–232.
68. van Hoof J, Blom MM, Post HNA and Bastein WL.
Designing a ‘think-along dwelling’ for people with
dementia: a co-creation project between health care and
the building services sector. J Housing Elderly 2013;
27: 299–332.
69. Kazak J, van Hoof J, 
Swia˛der M and Szewra
nski S. Real
estate for the ageing society – the perspective of a new
market. Real Estate Manag Valuation 2017; 25: 13–24.
70. van Hoof J, Verbeek H, Janssen BM, Eijkelenboom A,
Molony SL, Felix E, Nieboer KA, Zwerts-Verhelst ELM,
Sijstermans JJWM and Wouters EJM. A three perspec-
tive study of the sense of home of nursing home residents:
the views of residents, care professionals and relatives.
BMC Geriatr 2016; 16: 169.
71. Loos E and Ivan L. Chapter 11. Visual ageism in the
media. In: Ayalon L and Tesch-Roemer C (eds)
Contemporary perspectives on ageism. International per-
spectives on aging. Volume 19. New York, NY:
Springer International Publishing, 2018, pp. 163–176.
doi:10.1007/978-3-319-73820-8_11.
van Hoof et al. 21