2.1 Eligibility criteria

2.2 Information sources

Literature from 2010 up to the 9 March 2021 were included for review. The databases and platforms searched included CINAHL, Scopus, ProQuest Central, PubMed, EBSCOHost, APA PsycInfo, Carin.info, and the European Network for Rural Development-Rural Development Policy Projects database. Sources of unpublished studies/grey literature searched included EBSCOHost, ProQuest, government reports, websites, policy papers, and online newsletters. Additional records, particularly articles that were published by experts in age-friendly research known to our network, were identified through a bibliographic hand search.

2.3 Search

A range of key terms, truncations, and the corresponding index terms (subject headings) related to the research aim were identified and used to develop a full search strategy. Variances in terminology and spelling across different countries were considered. These terms were translated from English to Spanish, Chinese, and French to avoid bias towards English-speaking countries. This search strategy was adapted for each database or platform depending on the format of the search required. A research librarian was consulted to refine the search strategy. Keywords included age-friendly, older people/persons, elder-friendly, rural ageing, rural gerontology, ageing in place, and later life. Appendix S1 (Search Terms and Results) provides an example of a full electronic strategy for one database.

2.4 Selection of sources of evidence

Following the search, all identified citations were exported and uploaded into Covidence Software for screening and review. Following the removal of all duplicates, the titles and abstracts were screened initially by at least two independent reviewers (the 1st, 3rd, and 4th authors) for assessment against the inclusion criteria. Where consensus was needed, other authors within the team who are experts in ageing research also reviewed the texts for inclusion. The full-text article of each selected citation was assessed in detail against the inclusion criteria by at least two authors. Experts and topic consultants were consulted for verification and for additional information as part of the scoping review process. The results of the search and the study inclusion process are presented in PRISMA flow diagram (Figure 1).¹³

2.5 Data extraction

The data were extracted from the selected literature using the following headings: author/year; type of article; source; country; program/intervention; methodology; concept; context; justification; and outcome measures. Detailed summary tables and data characteristics are included in Appendix S1 Summary Table. After data extraction, emerging categories were identified (types of interventions; relevance to the WHO age-friendly domains; intervention context; non-evaluated programs and initiatives) and discussed with the team to create an a priori framework in which to group the studies. The literature was then coded based on the study's characteristics.

To ensure that a robust approach in categorising the interventions was undertaken, they were categorised according to their relevance to the eight age-friendly domains. The team used an inter-rater reliability exercise using case studies. This exercise involved the team members allocating the relevant age-friendly domains to the study's intervention as per WHO's descriptions of the domains.⁸ Three case studies were selected. The review team extracted the age-friendly domains from these three case studies independently. Then the overall agreement among the seven appraisers was calculated, and it was shown to be good with W = 0.69 (p < 0.05), confirming the inter-rater reliability. The team was comprised of experts in ageing based in Australia, New Zealand, Hong Kong, and Europe. The team's expertise in ageing research included age-friendly communities (the 1st, 2^nd, and 9th authors), healthy ageing (the 3rd, 5^th, and 6th authors), and aged care policies (all authors). Technical guidance was provided by two WHO Headquarters staff (the 7th and 8th authors). All team members had at least 7 years of experience undertaking research on ageing issues.

3.1 Data characteristics

We identified two sets of literature. Literature group 1, a total of 103 studies, consisted of randomised controlled trials (n = 22), quasi-experimental studies (n = 37), and a range of other quantitative, qualitative, and mixed-methods study designs (n = 44). The summary tables for Literature group 1 (Appendix S1 Summary Table) have been separated into two tables; the first table (Literature group 1A) consists of studies that reported experimental and quasi-experimental study designs while the second table (Literature group 1B) reports on studies with other methodologies. Studies that included both experimental and other methodologies have been repeated in both tables but with different information extracted.

Literature group 2 consisted of 116 non-evaluated initiatives developed within local communities. These articles were published as grey literature on websites, in study protocols, and in community newsletters indexed in databases used for this scoping review. The term ‘interventions’ was used to describe the programs, strategies, and activities implemented for Literature group 1; it also was used to reflect the terminology used in many of the articles. As part of the evaluation of the included articles, they reported either a change in outcomes (outcome evaluation), described the implementation (process evaluation), or both. The term ‘initiatives’ was used to emphasise the non-evaluated and non-peer-reviewed nature of Literature group 2.

The interventions in Literature group 1 were conducted across all six WHO Regions, with most coming from the region of the Americas (n = 54), the Western Pacific (n = 24), Europe (n = 12), and the South-East Asia Region (n = 10). Only a few studies were from the African region (n = 2) or the Eastern Mediterranean (n = 1). The studies were carried out in 26 countries, with the majority being in Canada, Japan, South Korea, and the United States. Few intervention studies were conducted in middle- and low-income countries.

3.2 Summary of themes

The results of this scoping review were mapped and categorised into four themes: (1) interventions with older people as participants, (2) the relevance of these interventions to the features and principles of the WHO Age-friendly Cities and Communities framework, (3) the reasons for conducting interventions in rural and remote settings, and (4) non-evaluated community initiatives. Table 1 provides a summarised context of the themes identified. The first three themes were identified from Literature group 1 and the fourth theme was derived from Literature group 2.

3.3 Theme 1: Interventions with older people as participants

In rural and remote settings, seven main types of interventions were identified, which recruited older people as participants. These types included Community Services (Pension); Community Services (Social); Community Services (Transportation); Education and Training; Exercise and Physical Activity; Health Promotion Programs, and Telehealth (Table 2).

Health Promotion Programs (n = 44) were the most frequently reported interventions and were defined as interventions that fostered the abilities of older people to self-manage their health and increase their knowledge about healthcare services in rural and remote areas. These programs were comprised of specific topics including health education and healthy practices. About two-thirds (64%) of the studies that focussed on Health Promotion Programs utilised an experimental design.

Exercise and Physical Activity interventions (n = 23) measured specific health outcomes: for example in one Bangladeshi study, group exercises using pelvic floor and mobility techniques among older women led to improvements in continence.¹⁴ Others were measured against clinical outcomes related to physical function. A few Japanese studies (n = 3) that evaluated exercise programs measured objective clinical outcomes such as gait stability and motor function.^16-18

Education and Training interventions (n = 15) were largely centred on managing health-related needs by increasing literacy about specific diseases such as diabetes. The study by Ko et al.,¹⁹ for example, delivered an educational intervention about cataracts for older people and aimed to improve the knowledge, attitudes, and access of older people using eyecare services. Only one study provided training to improve the skills of older people to use the internet to access health information.²⁰

Similar to Education and Training interventions, Telehealth interventions (n = 15) also tended to focus on specific diseases or conditions such as obesity, anxiety disorders, and diabetes.^{21, 22} Telehealth interventions were typically delivered via telephone, but in a few cases, video-teleconferencing media was also used.

Only a few interventions related to Community Services (n = 6) that were neither healthcare nor health-related were identified. Interventions that focussed on social groups established in the community and on transportation needs were limited. A shuttle bus service in rural areas in Canada and Ireland provided opportunities for older people to shop and participate in social activities in two studies.^{23, 24} Social clubs in the community generally focussed on process evaluations which tended to include interventions such as resident consultations and older people acting as volunteers.^{25, 26}

3.4 Theme 2: Relevance to the WHO age-friendly cities framework domains

The studies included in Literature group 1 were assessed according to their relevance to the eight domains of the age-friendly cities framework (Table 3). None of the evaluated interventions included any which had been explicitly self-identified as age-friendly. The studies were classified against the descriptions and characteristics of the eight age-friendly domains. This classification was guided by specific components found in the studies such as the aim, the nature of the intervention, and the justification for conducting the studies in rural and remote areas. Some interventions were relevant across multiple age-friendly domains.

As most studies had a health-related focus, most interventions were relevant to the community support and health services domain (n = 92). This was followed by communication and information (n = 27), and social participation (n = 20) (Table 3). Only two studies in Literature group 1 pertained to housing, outdoor spaces, and buildings in rural and remote contexts. Staniuliene and Januleviciene²⁷ designed a domestic and social service within the homes of older people living in rural and remote areas; however, this intervention was aimed at improving health rather than housing. In another example, a case study by Zhenmian and Bixia²⁸ described farming and agricultural economic opportunities for older people in rural Japan, which was relevant to civic participation and outdoor spaces and buildings.

Health promotion programs were classified as being relevant to seven out of the eight age-friendly domains, with the exception being outdoor spaces and buildings. Some interventions were relevant to more than one age-friendly domain. A health promotion program in Thailand, for example, involved volunteers visiting older people in their rural and remote homes with the aim of reducing depression and enhancing their quality of life.²⁹ This Health Promotion Program intervention was relevant to Community Support and Health Services, Respect, and Inclusion, and encouraged Social Participation.

Exercise interventions were relevant to four of the eight age-friendly domains. The majority of interventions relevant to the Social Participation domain were also categorised as Exercise and Physical Activity interventions. This categorisation is supported by individual studies in this review, where exercise interventions conducted in group classes provided opportunities to socialise and engage with others.^{30, 31}

3.5 Theme 3: Rural and remote contexts

Most studies (n = 82) provided the contexts and justification for conducting these interventions in rural and remote areas. The significance of the interventions in rural and remote areas were highlighted in studies that had a focus on Health Promotion Programs, Education and Training, and Telehealth. The most common justifications for conducting the study in a rural or remote context were primarily due to limited access to health-care services and due to an increasingly ageing population in rural communities.

Many studies recognised the limited access to healthcare services in rural and remote areas particularly for the treatment and management of common chronic conditions like diabetes.^{32, 33} There were studies that indicated the limited access to services such as palliative care, general health clinics, mental health, and specialty health services.^{15, 34, 35} Factors such as geographical isolation,³⁶ financial constraints,^{30, 37} transportation issues,^{18, 38} and lack of rural health facilities and healthcare staff^{39, 40} were identified as complicating access to healthcare.

The population characteristics referred to the descriptions of residents in rural and remote areas. There were studies that described rural areas as having an increasing number of older residents.^{41, 42} Studies also identified older people in rural areas as having lower health literacy.^{43, 44} There was some evidence of low engagement with physical activity and health promotion programs,^{45, 46} and some studies reported that rural residents tended to be independent and did not recognise the need for help.^{44, 47} The studies included in this scoping review described how older rural residents commonly experience mental health issues such as depression^{35, 48} and chronic health conditions such as cataracts, diabetes, stroke,^{19, 32, 33, 44} and dementia.⁴⁹ There was also evidence of increased hospitalisation and re-hospitalisations.⁵⁰ One study described the changing family and caregiving dynamics among families in rural communities, where adult children migrated to cities while older parents remained in rural areas.⁵¹

3.6 Theme 4: Non-evaluated programs and community initiatives

The initiatives included in Literature group 2 (n = 16) were categorised based on the typology of the initiative (see Appendix S1 Summary Table). Some initiatives were categorised as having more than one typology. The majority of initiatives were identified under health and wellness (n = 47), followed by community projects (n = 19) and technology (n = 17). Some initiatives were centred around the built environment, specifically transport (n = 16), housing (n = 8) and infrastructure (n = 2). Only a small number were relevant to education and training (n = 4), provision of financial support (n = 4), volunteering (n = 3), or paid employment (n = 1). These programs and community initiatives were implemented at the municipal and/or local level in rural and remote settings as part of ongoing community development and service delivery activities. Due to the lack of evaluation of the outcomes, these were not able to be examined further in terms of their relevance to at least one domain outlined in the WHO age-friendly cities guide.