Preventing Frailty Through Healthy Environments: The Slovenian Systemic Pre-Frailty Project

Abstract

As society ages, there is a growing concern about the comfort and health of elderly people. Although populations around the world, including Slovenia, are rapidly aging, evidence that increasing longevity is being accompanied by an extended period of good health is scarce. An increasing number of older adults live with chronic diseases, functional limitations, or frailty. In 2025, Slovenia launched the project Systemic Approach to Frailty with a Focus on Pre-Frailty for Healthy and Hight-Quality Ageing, within the European Cohesion Policy Programme 2021–2027, aiming to address frailty through multidimensional and community-based interventions. In addition to presenting the project framework, this paper provides an analytical preliminary review of existing literature, critically reflecting on research gaps in the field. The main aim of this paper is to explore the possibilities for creating healthy living environments that support the prevention and management of frailty. The project’s core innovation lies in the integration of public health principles into urban planning and design through a structured, community-based approach and the use of the Living Environmental Assessment (OBO) Tool. This tool enables urban planners, municipalities, and local communities to collaboratively evaluate and co-design living environments (e.g., optimizing walkability, green space access, barrier-free design, and social amenities) to build resilience and independence among older adults. Designing inclusive, accessible, and health-promoting environments can help to prevent frailty and improve well-being across all age groups.

1. Introduction

As society ages, there is growing concern for the comfort and health of elderly people [1]. Although populations worldwide are rapidly aging, evidence that increasing longevity is accompanied by an extended period of good health is scarce [2]. This shortening of healthy years often leads to a prolonged pre-frailty or frailty phase with significant clinical and social costs [3,4]. These global trends highlight the growing challenges of frailty and the importance of preventive, early-stage interventions.

Slovenia is no exception: in 2024, 22.1% of the population was older than 65 years [5,6]. In recent decades, life expectancy in Slovenia has increased significantly. According to the National Institute of Public Health, life expectancy at birth reached 78.6 years for men and 84.1 years for women in 2022, yet healthy life expectancy was only 65 and 68.5 years, respectively—meaning that most Slovenians (over 80%) spend their final decade or more in compromised health [7]. These demographic shifts highlight the urgency of designing environments that support quality aging. To mitigate frailty in later life, we must look beyond healthcare alone and consider how our built and social environments can foster resilience and independence among older adults.

For a long time, infectious diseases were the biggest health problem of populations all over the world [8]; however now, non-communicable diseases significantly undermine the health and well-being of the European population (including Slovenia), as well as the sustainability of healthcare systems and social prosperity [9]. Furthermore, elderly individuals experience deteriorating oral health, sarcopenic muscle loss, and progression to frailty [10,11,12,13,14,15]. Frailty is an emerging global health burden and recognized as a cornerstone of geriatric medicine, with major implications for clinical practice and public health. The prevalence of frailty is expected to rise alongside rapid growth in the aging population. The course of frailty is characterized by a decline in functioning across multiple physiological systems, accompanied by an increased vulnerability to stressors. Having frailty places a person at increased risk of adverse outcomes, including falls, hospitalization, and mortality [15,16]. Although it is driven in part by modifiable factors such as poor diet, sedentary lifestyle, comorbidities, and low socioeconomic status [15,17,18], frailty can be delayed or even reversed through early identification and targeted interventions, such as regular physical activity, tailored nutrition programs, and comprehensive geriatric assessment.

In addition to clinical strategies, the built environment plays a critical role in frailty prevention, especially in slowing or accelerating the progression of frailty by shaping opportunities for movement, community interaction, and access to essential services with features like accessible sidewalks, safe parks, and barrier-free housing [19]. Designing these environmental elements in an inclusive, health-promoting manner is therefore critical to both preventing and managing frailty across diverse communities. By combining holistic preventive interventions with supportive environmental design, we can improve health outcomes and quality of life for older adults.

Previous European initiatives (e.g., ADVANTAGE JA, SUNFRAIL, SPRINTT) have advanced policy frameworks, screening tools, and clinical interventions for frailty [20,21,22], but none have combined systematic environmental assessment with participatory, community-based intervention design at the neighborhood level.

The European Commission and 22 European Union Member States cofounded the first Joint Action (JA) in frailty: ADVANTAGE (2017–2020). It aimed to build a common framework to push frailty as a public health priority contributing to a homogeneous and evidence-based approach across Europe [23]. Overall, these messages intended to be an instrument of added value to advocate for policy driven decisions on frailty prevention and management in the JA participating MSs and subsequently towards a frailty-related disability-free older population in Europe [14]. The core outputs of the project demonstrated frailty intervention domains spanning physical prevention and management strategies with integrated social components. However, ADVANTAGE lacked structured tools for assessing the built environment’s impact on frailty, and it provided no systematic methodology for engaging different stakeholders and local communities in co-design or neighborhood-level implementation.

The SUNFRAIL project (2015–2017), co-funded under the EU Health Programme, validated and standardized frailty and multimorbidity models in community settings by building an integrated, multimodal framework and tested it in living labs across several EU regions [21]. Its follow-up, SUNFRAIL+ (2024–ongoing), extends this work by linking it to the original SUNRAIL tool [24]. The SPRINTT project (2016–2019), an IMI-funded Horizon 2020 clinical trial, operationalized physical frailty and sarcopenia, developed a user-friendly “identikit” for at-risk older adults, and evaluated combined exercise and nutrition interventions across 16 sites in 11 countries [22]. While these initiatives have significantly advanced frailty screening and clinical intervention strategies, they have not addressed systematic environmental assessment or community-based approaches. These gaps are filled through our project.

1.1. Project “Systemic Approach to Frailty with a Focus on Pre-Frailty for Healthy and High-Quality Aging”

In 2024, Slovenia prepared the project “Systemic Approach to Frailty with Focus on Pre-Frailty for Healthy and High-Quality Aging”. The operation is implemented under the European Cohesion Policy Programme 2021–2027 in Slovenia, Priority 7: “Long-term Care and Health, and Social Inclusion”. The project ran from 1 August 2024 to 31 December 2028. This initiative directly addresses gaps left by earlier efforts by (1) expanding the basic concept of frailty to include its physical, mental, and social dimensions, each directly influenced by the environments in which individuals live; (2) developing a Living Environment Assessment tool that uses different indicators to evaluate physical and social environmental factors; (3) using a community-based health model that brings together local communities, urban planners, and local decision-makers to identify priority intervention; and (4) piloting the proposed Living Environmental Assessment tool and Community-based approach in five diverse Slovenian communities in order to evaluate the living environment and propose different interventions.

By addressing these gaps, our “Systemic Approach to Frailty with Focus on Pre-Frailty for Healthy and High-Quality Aging” project advances the field from high-level frameworks to actionable, environment-centered, and community-based solutions for frailty prevention and management. By combining environment assessment with community-based engagement and real-world solutions, this integrated method produces important improvements in living environments that support resilience, independence, and overall well-being. Unlike ADVANTAGE, which addressed frailty at the policy level, this project integrates qualitative analysis and participatory methods to generate localized, actionable solutions. While SUNFRAIL and SPRINTT advanced frailty screening and clinical interventions, neither developed structured tools for environmental assessment nor engaged communities in co-creating place-based strategies.

1.2. Research Question and Objectives

The main research question is: How can living environments be designed and adapted to prevent and manage frailty among older adults? To answer this question, this paper focuses on the development of the Healthy Communities work package of our larger project, to build a clear, actionable framework. We address two objectives: (1) Identify key determinants: Conduct a preliminary literature review to define the physical and social environmental factors that most strongly influence frailty risk in older adults. (2) Develop the conceptual framework: Based on those findings, design the Healthy Communities work package for assessing living environments with the Living Environment Assessment (OBO) tool.

This paper outlines the submission process for project targeting living environment improvements. In the next section, we describe the methodological framework employed in this study.

2. Methodology

The project content was developed through following methods: (1) Foundations and recommendations synthesis from the Advantage Joint Action (Slovenia Roadmap) and European Guide for Management of Frailty at Individual Level Including Recommendations and Roadmap, (2) Member States Survey, (3) Good practices and narrative literature review and (4) Conceptual framework development—Expanding the Frailty Framework: mental, social, and living environment improvements. Our holistic framework integrates environmental determinants of aging (beyond physical/psychosocial factors), identified through a narrative review that informed the ‘Healthy Communities’ work package. A narrative review of the literature was performed to develop the conceptual basis for the working package addressing healthy living environments and community engagement. The Section 3 details our principal findings and assigned tasks.

Recommendations from the Advantage Joint Action were prioritized through a dual feasibility-impact assessment. The process incorporated evidence-based guidelines developed using GRADE methodology.

2.1. Data Sources and Tools

We relied on five key data sources and tools to support our project (Figure 1). First, we relied on the ADVANTAGE Slovenia Roadmap and the European Guide for Management of Frailty provided evidence-graded recommendations. Second, we used a structured Member States Survey that provided structured inputs from different authorities. Third, we created an evidence map of peer-reviewed articles, technical reports, and case studies to define environmental, social, and clinical determinants of frailty. Fourth, the JAHEE Place Standard Tool served as the basis for our Living Environment Assessment (OBO) tool, which will be adapted to capture frailty-related environmental factors. Finally, field data collection established national baseline conditions and helped shape our conceptual framework.

Figure 2 and Figure 4 were created with the assistance of DALL·E 4.0, which was used solely to generate the visual components of the figures presented in this study.

2.2. Data Description

Here, we provide a more detailed description of the data sources used in this study:

• Policy frameworks: Reviewed the ADVANTAGE Joint Action Slovenia Roadmap and the European Guide for Management of Frailty at Individual Level [25] to extract foundational guidelines and evidence-graded recommendations that served as the conceptual baseline for our project.
• Member-States Survey: In early 2018, a 24-question survey developed by ADVANTAGE JA was distributed to health planners, managers, and social-service representatives across EU Member States, yielding an 85% response rate. The survey captured national policies, strategies, and interventions for frailty prevention and management, and its results were categorized into five implementation levels. From these findings, ten priority activities for Slovenia were identified and compiled into a “Roadmap of Activities” [26], which we reviewed to inform and shape our project concept.
• Evidence Mapping/Preliminary literature review: A narrative review was conducted by searching academic databases with targeted keywords and snowballing techniques. In total, 92 full-text papers were screened, and 16 studies were included to prepare the project concept. Although no formal descriptive statistical analysis was performed at this stage, the key findings of each study were synthesized qualitatively. A comprehensive descriptive and quantitative analysis will be undertaken later as part of the project’s systematic review.
• Living Environment Assessment (OBO) Tool: The OBO tool (adapted from the JAHEE Place Standard Tool (https://www.ourplace.scot/tool (accessed on 10 May 2025)) for the Slovenian context) assesses both physical and social dimensions of the living environment through 14 indicators: public transport, traffic and parking, streets and public spaces, play and recreation areas, facilities and services, work and local economy, housing and community, social interaction, identity and belonging, perceived safety, care and maintenance, sense of influence and control, mobility, and access to natural spaces. Each indicator is supported by a few targeted questions, simplifying evaluation under each theme and laying the groundwork for a clear spider-web chart that highlights strengths and weaknesses of the assessed environment. Pilot testing will be carried out as part of the project.
• Field Data: (1) Municipal GIS layers (via https://gis.iobcina.si/ (accessed on 10 May 2025)): evaluated 5 basic urban design and planning indicators correlated with frailty risk (land-use mix; proximity to key services; green-space ratio; public transport infrastructure; and public spaces - descriptive assessment only; detailed GIS analysis to follow.) (2) Basic geographical characteristics: assessed 8 indicators: Slovenian statistical region; municipal area; population density; municipality type (City Municipality); Healthy City designation; disability-friendly municipality; age-friendly municipality; and general urban/rural classification. (3) Socio-demographic data (via https://www.stat.si/ (accessed on 20 May 2025)): analyzed 17 indicators, including total population; age-group shares; aging index; employment rate; migration; and access to recreational areas. (4) Pilot community selection: initially evaluated 9 municipalities using the above data; five were chosen for in-depth study (for the further investigation as part of the project). Informal discussions were held with some regional-unit representatives at their regular meetings.

Table 1. Descriptive Statistics of data.

Data Source	N/Scope	Key Metrics
Policy frameworks	2 documents	Qualitative extraction of high-level recommendations
Member States survey	22 Member states; 24 questions	Qualitative synthesis of national practices
Narrative literature review	91 full text papers screened, 16 studies included	Qualitative synthesis of key findings
Living Environment Assessment (OBO) tool	14 indicators	Prepared for frailty-risk adaptation
Field data	5 GIS-based indicators; 8 geographical indicators; 17 socio-demographic indicators	9 pilot communities evaluated; 5 selected for in-depth study

presents the data sources used for our study. Some of the data were obtained from other projects (policy frameworks, Member States surveys, the OBO tool). Field data was used for comparison of 9 pilot communities, five of them were selected for in-depth studies (the 9 evaluated municipalities ranged from 3000 to 55,000 inhabitants, with 21–28% of residents aged 65+; the municipal areas varied between 63 in 564 km², and population density ranged from 8 to 519 inhabitants/km²).

3. Results

3.1. Preliminary Literature Review

We conducted a quantitative analysis of the preliminary literature that presents the basis for the development of the project concept and the Healthy Communities work package. A total of 16 studies were identified, of which 10 were published within the last five years and one more than ten years ago. The geographic distribution was as follows: Asia 7 (Japan 3; China 3; joint Japan/China/Korea 1), Australia 1, Europe 1, UK 2, and 5 not geographically defined. By study type, there were 5 narrative reviews, 3 systematic reviews or meta-analyses, 5 longitudinal studies, 3 other original research articles (cross-sectional or multilevel analyses), and 1 other. Among the 16 studies, 12 exclusively addressed physical environmental factors, 3 examined combined social–physical components, and 1 focused only on social components. Fifteen studies focused on the built (outdoor) environment and its specific elements (4 of which addressed the built environment more generally), while one examined the indoor environment (thermal comfort). Main observed determinants were walkability, accessibility, physical activity and social frailty in general. The observed determinants, where many studies cover multiple elements, are summarized in

Table 2. Quantitative analysis of preliminary literature review.

Category	No. of Studies (n = 16)	Percentage of All Reviewed Articles
Study type
Review	5	31.3%
Systematic review or meta-analysis	3	18.8%
Longitudinal study	5	31.3%
Other original research (cross-sectional, multilevel analysis)	3	18.8%
Other	1	6.3%
Main observed determinants
Walkability	4	25.0%
Street connectivity	2	12.5%
Accessibility	5	31.3%
Physical activity	5	31.3%
Access to green spaces	2	12.5%
Housing and neighborhood characteristics (e.g., barrier-free access)	1	6.3%
Land-use mix and access (e.g., recreational facilities, community meeting spaces)	2	12.5%
Residential density	1	6.3%
Neighborhood perception	2	12.5%
Esthetics	2	12.5%
Safety	2	12.5%
Social frailty (e.g., social isolation and loneliness)	4	25.0%
Social cohesion	1	6.3%
Social participation	2	12.5%
Interactions	1	6.3%
Social network (e.g., community support networks)	1	6.3%

.

Through qualitative analysis of the preliminary literature review, we defined the key physical and social environmental factors that most strongly influence frailty risk in older adults.

Frailty in older adults is shaped not only by individual health factors but also by the environmental context in which they live. Studies indicate that aspects of the physical environment (like neighborhood design and amenities) and the social environment (community and social support) can significantly impact an older person’s risk of becoming frail. Both objective and perceived physical attributes of neighborhoods influence frailty: frailer individuals tend to perceive their neighborhoods more negatively, potentially leading to the life-space constriction that reduces mobility and decreases social-physical engagement [25]. Moreover, both objective and perceived neighborhood characteristics correlate with frailty levels, underscoring the need for environmental strategies in frailty prevention programs [26]. Notably, positive features of the built environments—such as walkability, accessible parks and sidewalks, recreational facilities, and overall esthetics—have been shown to have protective effects on older adults and may reduce the likelihood of developing pre-frailty or frailty [25,27].

In this context, urban design to address prefrailty should focus on creating environments that promote movement, encourage social interaction, and minimize the risk of falls and other negative health outcomes. This approach includes ensuring that spaces are safe, accessible, and promote social connections, while also considering the risk of cognitive decline linked to prefrailty [4].

While these findings suggest that modifying built environments could mitigate frailty risk, further verification is needed [28]. Nonetheless, designing environments that support better interaction between frail older adults and their surroundings improves usability and accessibility for a wide range of users, from children to other vulnerable groups [29].

Regular physical activity remains an important topic of healthy aging. Local authorities have a responsibility to promote physical activity among older people, but implementing population-level strategies is challenging. Evidence shows that regular physical activity is safe for both healthy and frail older adults and reduce the risk of developing major cardiovascular and metabolic diseases, obesity, falls, cognitive impairments, osteoporosis and muscular weakness when activities range from low-intensity walking to more vigorous sports and resistance exercises [30].

Higher neighborhood walkability and esthetic quality, along with safe environments, are linked to lower frailty prevalence by encouraging activity among older adults [31]. On the other hand, poor living conditions, such as inadequate lighting, physical barriers, and pollution, increase frailty risk [31]. Regular physical activity and access to recreational spaces also lower the likelihood of developing frailty [31,32], while strong social networks and support further decrease risk [32,33]. High social cohesion and frequent social participation are similarly protective [31], whereas social isolation and loneliness are powerful predictors of frailty and premature mortality [19,34,35,36]. Finally, the combined influence of physical and social factors strongly predicts both frailty risk and early death [34]. A multidimensional approach incorporating both physical and social factors is essential for the effective prevention and management of frailty [31,34]. To summarize the key physical and social environmental factors that reduce frailty risk, based on a preliminary literature review, we prepared

Table 3. Key Physical and Social Environmental Factors Influencing Frailty.

Physical Environmental Factors	Social Environmental Factors
Walkability (connectivity, accessibility, sidewalk quality)	Social cohesion (programs and events that foster social cohesion, such as community gatherings, workshops, and group activities)
Access to green spaces	Opportunities for interactions
Housing and neighborhood characteristics (barrier-free access via ramps, curb cuts, level entrances)	Social participation
Land-use diversity and access (recreational facilities, community meeting spaces)	Availability of community meeting places
Neighborhood perception	Social network (community support networks such as volunteer groups)
Esthetics and safety	Social isolation and loneliness

, with a comprehensive systematic review to follow as part of the project.

The living environment—encompassing spaces where people live, work, and spend leisure time—plays a pivotal role in maintaining and enhancing human health and well-being. It integrates the built, natural, and social environments that collectively influence individual and community quality of life through buildings, infrastructure, public open spaces, natural features, social connections, economic status, and other factors [37].

Whether urban (cities, towns) or rural (villages, natural areas), the living environment must ensure residents’ comfort, safety, and well-being [38] while simultaneously supporting health preservation and promotion [39]. To better understand the multifaceted relationships between human health, well-being and the living environment, it is essential to analyze both (1) environmental elements (accessibility, amenities, maintenance, green spaces, etc.) and (2) diverse health-related risk factors [40,41].

Through intentional design of living environments, we can help mitigate risk factors contributing to pre-frailty and frailty. For environmental assessments, practitioners can utilize the Living Environment Assessment Tool, which integrates data on both physical (built and natural) and social environments, including: mobility (active transport, public transit, traffic and parking), public spaces (streets and squares, natural environments, play and recreation areas), services and economy (local services, workplaces and community economy), community factors (housing and neighborhoods, meeting opportunities, identity and belonging), and safety and governance (perceived safety, maintenance and upkeep, community participation in decision-making). Developed under the JAHEE project and based on the Place Standard Tool [38], this tool provides a comprehensive framework for evaluating environments [42].

3.2. Conceptual Framework

This paper develops a conceptual mapping, which provides the methodological foundation for further empirical testing and outlines the conceptual basis of the Healthy Communities work package. Detailed analyses and empirical validation will be carried out within the project, while here we present the resulting framework concept.

The Healthy Communities work package was designed around a conceptual framework that links key environmental determinants to frailty risk. Drawing on our quantitative and qualitative literature syntheses, we identified six physical factors (walkability, access to green spaces, barrier-free housing and neighborhood features, land-use diversity and access, neighborhood perception, and esthetics and safety) and six social factors (social cohesion, interaction opportunities, social participation, availability of community meeting places, support networks, and social isolation and loneliness.) These factors are mapped onto frailty risk pathways to illustrate how aspects of the built and social environment may contribute to or mitigate the development of prefrailty and frailty in older adults. Figure 2 presents summary of preliminary literature review, a conceptual framework of healthy built environment to prevent frailty.

3.3. Healthy Communities Work Package with Assigned Project Tasks

Building on our preliminary analyses and conceptual framework, the Healthy Communities work package will have five key phases (Figure 3): situational analysis (systematic literature review); tool adaptation and protocol development (updating the OBO tool and drafting an implementation protocol); community engagement and co-design (stakeholder workshops and pilot validation across five diverse communities); pilot testing and evaluation; and synthesis and guideline production (translating results into real-world intervention guidelines).

To achieve our objectives, we will begin by conducting a systematic literature review and analyzing the current situation in Slovenia to evaluate existing efforts to reduce frailty risk factors both nationally and internationally. We will review the Living Environment Assessment (OBO) tool and adapt it to incorporate factors related to frailty prevention and management. Additionally, we will develop a protocol for its implementation, create user guidelines and pilot-test the tool. We will select five model communities in Slovenia where we will implement the Community-Based Approach and Community-Based Intervention Model for pre-frail individuals, integrated with the Living Environment Assessment (OBO) tool.

Our Community-Based Approach utilizes the adapted OBO tool to assess local conditions, establish priorities, and create targeted action plans for frailty prevention and management at the community level. This approach will bring together different stakeholders, including decision-makers (e.g., municipal representatives), health institutions, urban planners, architects, community representatives, and relevant non-governmental organizations (NGOs). In each pilot community, we will start by engaging existing local health groups and then expand to include also key actors in urban planning and neighborhood development, such as municipal representatives, urban planners, and relevant NGOs. Collaboration will be coordinated through joint meetings, during which participants will collectively assess the living environment using the OBO tool and co-develop targeted interventions. The approach will also include educating various stakeholders through collaborative engagement.

Pilot testing will be conducted in five selected local communities across diverse urban and rural settings, using both the Living Environment Assessment (OBO) tool and the Community-Based Intervention Model. Pilot sites will be chosen based on municipality type (urban vs. rural), population size, and the number of older adults. We will also consider whether the selected sites are part of existing networks or initiatives such as the Healthy Cities Network or the Age-Friendly Cities and Communities initiative, and whether a community-based health approach (e.g., through Health Promotion Centers) is already established.

Based on our findings, experience gained, and results analysis, we will develop a comprehensive set of intervention measures for preventing and mitigating frailty, along with recommendations and guidelines to support future implementation.

4. Discussion

Our findings offer a practical, community-based framework for translating research into age-friendly urban design. By applying the Living Environment Assessment tool, urban planners and local communities can collaboratively evaluate key features, such as walkability, green space access, recreational facilities, etc., and co-design interventions. This community-based health approach not only ensures that the needs and preferences of older adults are central to planning decisions but also builds stronger partnerships between residents and policymakers. In practice, municipalities can organize participatory workshops to identify environmental risk factors, prioritize age-promoting modifications (e.g., level sidewalks, pocket parks, barrier-free entrances), and implement co-created solutions. Moreover, this model shows that healthy-aging interventions produce widespread public health benefits and that measures effective for older adults also benefit the whole community. Figure 4 presents a conceptual framework for designing healthy communities to prevent and manage frailty.

4.1. Key Findings

We identified three main findings, derived from a synthesis of existing evidence, preliminary literature analyses, and the conceptual framework developed within the project:

• The living environment has an important impact on the health of older adults and is a key factor in managing and preventing frailty.
• The Living Environment Assessment (OBO) tool provides a structured and validated framework for shaping both built and social environments to prevent and mitigate frailty.
• A community-based health approach effectively bridges the health and planning sectors by bringing together public health experts, urban planners and designers, and local decision-makers to evaluate the living environment and co-create interventions that enhance safety, accessibility, and social engagement for older adults.

These findings are grounded in literature syntheses and validated through conceptual mapping of environmental determinants to frailty risk. While full statistical analyses will be conducted within the project’s empirical phases, the current results provide a methodological foundation and conceptual evidence base for further testing.

4.2. Comparison with Existing Literature

Our project builds on earlier studies linking neighborhood design and frailty outcomes [25,26,27,28,29,30,31,32,33,34,35,36]. By using the OBO tool, it not only assesses the environmental and social factors driving frailty but also guides stakeholders in co-creating targeted environmental interventions to improve living spaces and reduce frailty risk. This integration of comprehensive evaluation, intervention planning, and a community-based health approach sets our work apart and adds significant value to the existing literature. Unlike previous projects, which focused on policy alignment and clinical protocols, this project adopts a place-based, community-based approach that integrates environmental and social interventions.

4.3. Research Gaps and Theoretical Contribution

While the preliminary literature review provides valuable insights into the associations between environmental factors and frailty, several critical gaps and inconsistencies remain. First, the majority of studies were not conducted in contexts directly comparable to ours (only three studies were from the EU and UK). Due to differing geographical and climatic conditions, it is difficult to generalize the findings of studies from other regions to our setting. Second, most identified studies concentrated on outdoor built environment determinants, whereas research on indoor environments remains limited, especially on the physical indoor environment (there are only studies focused on thermal comfort and indoor air quality). The relationship between indoor and outdoor environmental factors also remains underexplored. Considering that older adults spend a large proportion of their time indoors, this represents a significant research gap. Third, methodological limitations are evident. Many studies relied on cross-sectional or narrative approaches, and frailty or environmental attributes were measured inconsistently, ranging from objective geospatial indicators to subjective self-reports, which complicates comparability and synthesis. Moreover, studies often addressed environmental factors in isolation, whereas frailty risk is more appropriately understood through a holistic perspective. Finally, few studies critically examined the combined or interacting effects of physical and social determinants, despite evidence pointing to their synergistic impact on frailty trajectories. Taken together, these gaps underscore the need for more robust, longitudinal, and multidimensional research designs to validate and extend current findings.

4.4. Implications

The combined assessment and co-design framework give urban planners a clear, step-by-step method for identifying and proposing age-friendly modifications. For policy-makers, it highlights the importance of adopting environmental and social factors, defined within OBO in all new developments and renovations. Finally, the community-based approach provides a structured way to connect health and planning professionals, building local capacity for ongoing, collaborative improvements to living environments.

4.5. Strengths and Limitations

A key strength of this project is its integration of public health and urban planning through the OBO tool and a community-based health approach. Piloting the approach in five diverse urban and rural communities highlights its adaptability across varied contexts. However, the project’s scope is limited to developing and prioritizing environmental and social interventions; full implementation and impact evaluation fall outside current funding. Variability in local community engagement, such as different levels of responsiveness or willingness to participate, may affect the results. Finally, the small number of sites and the project’s short duration limit both the generalizability of the findings and the assessment of long-term health outcomes.

4.6. Future Research

Future work, beyond the scope of this project, will involve implementing the interventions proposed through the community-based approach in real-life environments, and evaluating their effects. Additionally, integrating digital data streams, such as wearable activity and physiological sensors, can enable real-time monitoring of older adults’ interactions with their surroundings. Long-term, longitudinal studies will be needed to determine whether these environmental interventions produce sustained reductions in frailty prevalence and related health outcomes over time.

5. Conclusions

Creating healthy living environments that help prevent and manage frailty has broader benefits for all age groups—from children to older adults. We must design environments that are inclusive, safe, and accessible and that promote physical activities, social connections, and easy access to different services, thereby improving the overall health and well-being of the whole community. For example, safe sidewalks and parks benefit both children and older adults; community centers and multigenerational, multifunctional spaces bring people together, foster interactions, and help reduce loneliness. Our goal is to create environments that support not only physical health but also mental and social well-being.

With thoughtful and integrated design of the living environment, we can influence both the prevention and management of frailty. Integration of public health into urban planning at both the micro and macro levels ensures that interventions cover various aspects, from behavioral interventions (to promote the use of existing environments) to urban design approaches (through design elements that indirectly reduce the risk of frailty), and it ensures that they are part of the planning process rather than an afterthought. Unlike traditional urban planning, which often prioritizes zoning, land use, and traffic flow and only adds health features like sidewalks or parks after, our model puts health first by integrating epidemiological evidence and frailty risk metrics into site selection, design, and evaluation from the very beginning. The OBO tool guides planners in prioritizing which environmental elements should be changed first, while the community-based approach ensures that all stakeholders co-design the living environment.

Urban planners and architects should work closely with public health experts when designing living environments. Equally important is collaboration with decision-makers and the local community from the earliest planning stages (from problem definition to the development of shared solutions). The Community-Based Approach and Living Environment Assessment Tool proposed here will be key to that collaboration. To maximize impact, policy frameworks at the municipal, national, and EU levels should ensure that health-integrated planning standards, such as minimum requirements for walkability, green-space provision, barrier-free design, etc., are fully applied in all new developments and major renovations. Scaling this model across Europe will also require a standardized toolkit and training modules for local authorities, enabling regional adaptation, data sharing and best-practice exchange. By translating strategic public health objectives into concrete urban design interventions and empowering communities to co-create place-specific solutions, this project offers a replicable framework for healthier, more inclusive, and resilient living environments.

Finally, raising awareness among different stakeholders (from urban planners to policy-makers and local communities) about the living environment’s impact on health is critical. While it remains uncertain whether modifying the living environment directly reduces the risk of developing frailty, we believe that improving the living environments of older adults can contribute to lowering this risk. It is important to educate all those involved in urban planning and design on how to create environments that support healthy aging and reduce frailty risk. At the same time, it is important to empower the public to use these environments in ways that promote health and well-being.

The innovation of this project lies in the integration of public health principles into the urban planning and design process through a structured, community-based approach. While the community-based approach is well established in the field of health, and public engagement is common in urban planning and design, these two domains are rarely combined within a unified framework. This project addresses that gap by bringing together public health expertise and urban design practice. Using a community-based approach in health as a tool to address living environmental topics, such as public transport, public spaces, access to natural spaces, play and recreation areas, and opportunities for social interactions, the feeling of identity and belonging is an innovative concept. For the first time, a method for assessing places will be addressed to manage and prevent frailty, through an advanced, innovative methodology. Strategic public health frameworks will be translated into concrete urban design interventions and behavioral changes at the local level. This approach allows local stakeholders to co-create solutions that are site-specific and connected to real-life needs and can be applied elsewhere to promote healthier, more inclusive, and resilient living environments.