Reset: designing community-based, resilience-affirming support for older adults through participatory action research – an environmental perspective Open Access

The global population is ageing rapidly, with individuals aged 60 and over projected to reach 2.1 billion by 2050, nearly a quarter of the world’s total (WHO, 2024). While increased longevity reflects advances in public health and medicine, it is frequently accompanied by prolonged periods of poor health, placing pressure on health and social care (HSC) systems (WHO, 2025). In response, global frameworks promote healthy ageing, encompassing wellbeing, autonomy and social engagement, not the mere absence of disease (WHO, 2020).

However, people age differently, with lifelong socio-economic disparities shaping outcomes in later life, and many older adults facing poverty (Centre for Ageing Better, 2023), social isolation (Landeiro et al., 2017) and restricted access to care (United Nations, 2018). Global emergencies, including the COVID-19 pandemic and the cost-of-living crisis, have exacerbated these inequities, further eroding older adults’ resilience and access to essential resources (McHardy, 2025; Meadows et al., 2024). Addressing these challenges requires a holistic and equity-focused approach to policy and practice.

In response to these challenges, international and national policies have increasingly emphasised the importance of enhancing resilience among older adults and strengthening the community infrastructure that supports them (WHO, 2020; UK Government, 2021). However, there is limited empirical research examining how resilience-focused, community-based interventions function in practice, particularly for older adults with complex needs.

This paper presents findings from Reset – Edinburgh Community Resilience Programme (Górska et al., 2024), a collaborative initiative aimed at addressing a critical gap in support for older adults. Reset is an intersectoral partnership involving the Edinburgh Health and Social Care Partnership, Queen Margaret University and Cyrenians, a third-sector organisation that adopts a public health approach to addressing the root causes and consequences of homelessness. Building on earlier initiatives such as the Edinburgh Wellbeing Pact (Irvine Fitzpatrick and Maciver, 2025) and Cyrenians’ community navigator programme, an emerging dialogue between the three partners substantiated the rationale for addressing this gap.

Reset is dedicated to improving the resilience of individuals aged 50 and over. Its goal is to support timely hospital discharges, prevent readmissions and enable independent ageing in place. The programme aims to enhance health and wellbeing outcomes for older adults by fostering resilience through meaningful relationships, personalised support and access to community-based resources. This is achieved by integrating three key innovations: the community navigation approach (Leśniewska, 2021), the resilience framework (Górska et al., 2022) and the Incite model of intersectoral working (Irvine Fitzpatrick et al., 2021).

We conceptualise resilience as a dynamic, adaptive process shaped by the interplay between individual characteristics and environmental contexts (Górska et al., 2022). Drawing on our previous research (Górska et al., 2022; Whitehall et al., 2021), we understand resilience as the capacity to adapt to adversity, shaped by a dynamic and evolving interaction between personal needs and assets, and the supportive or constraining elements within one’s environment. This perspective contrasts with traditional views of resilience as a fixed personality trait, instead emphasising its fluid nature and capacity to change over time in response to adverse experiences and shifting availability of internal and external resources (Clark et al., 2018; Górska et al., 2022).

Research evidence highlights a wide range of factors, both internal and external, that influence resilience (MacLeod et al., 2016; Madsen et al., 2019; Górska et al., 2022). These include psychological attributes, quality of social relationships, access to material and emotional resources and wider contextual conditions. Such multifaceted influences underscore the importance of viewing resilience not as a static trait but as a contextually embedded process. Accordingly, understanding resilience requires attention to both individual-level and community-level determinants.

In later life in particular, resilience is influenced not only by internal coping capacities but also by external factors such as social networks, service access, community settings and cultural norms. These factors are critical to ageing in place, which depends on the availability of supportive social and physical resources. This ecological perspective acknowledges the complexity of later-life transitions, such as loss of a lifelong partner and/or friends through bereavement, deteriorating health, or loss of social roles through retirement (Cohen-Mansfield et al., 2016) and the need for responsive, individually tailored, community-based solutions.

While Reset was designed to support both personal and environmental factors shaping resilience, the emphasis on environment, both social and physical, in this paper is deliberate. While individual resilience is important, the environments in which older adults live have a profound impact on their ability to adapt and thrive. Social environments that foster connection, trust and participation can buffer against the harms of loneliness and isolation (Yang and Moorman, 2021). Physical environments, meanwhile, shape everyday experiences of mobility, safety and autonomy (Gripko and Joseph, 2024). Yet, although community-based interventions targeting the contextual and structural determinants of health and wellbeing are gaining traction, the existing literature highlights several gaps, including inconsistent evidence quality and limited research, specifically focused on resilience-affirming interventions for older adults (Paquet et al., 2023). There is also a scarcity of evidence supporting the role of environmental and contextual factors in fostering resilience in later life (Górska et al., 2022).

The Reset programme sought to deepen understanding of and to enhance resilience among older adults following hospitalisation by improving access to community resources and fostering meaningful social connections. Specifically, the study aimed to explore:

• the needs addressed by a resilience-affirming model of community support;

• barriers and facilitators to implementing such a model;

• workforce qualities valued by older adults in the context of resilience-building; and

• optimal way of applying the resilience framework within community support services.

This paper examines the environmental determinants of resilience identified through our research, highlighting how physical, digital and social environments can either support or undermine resilience. It also explores the role of systemic cultural factors within HSC, alongside broader societal structures, in shaping adaptive capacity in later life.

This study employed a Participatory Action Research (PAR) design, chosen for its emphasis on inclusive, iterative and transformative inquiry. PAR supports collective ownership of both processes and outcomes through cycles of planning, action, observation and reflection, making it particularly suited for research embedded in community settings (MacDonald, 2012). Guided by the “Incite” model (Irvine Fitzpatrick et al., 2021), our approach fostered intersectoral collaboration and inclusivity, enabling participants to co-construct meaning through dialogue and actively shape the research process in a democratic, locally responsive manner.

Reset was piloted across four localities in the city of Edinburgh, Scotland, each reflecting distinct socio-economic conditions. It aimed to develop a holistic, person-centred model of community-based HSC support in response to a projected 26.2% increase in the older population by 2030 (Edinburgh Integration Joint Board, 2022). A dedicated health and social care support worker (HSCSW) in each locality assisted older adults, often post-hospitalisation, in navigating local resources, including housing, income support, wellbeing services and social networks. The study involved 41 participants: 21 older adults (eight Reset beneficiaries and 13 community members), five HSCSWs, two informal carers, five referrers and eight partner organisation representatives. This diversity of perspectives, central to the participatory approach, strengthened the rigour and relevance of our findings.

Qualitative data was collected through semi-structured interviews, focus groups and narratives gathered by HSCSWs during one-to-one interactions. Eight individual interviews were conducted with older people supported by Reset to accommodate mobility needs and ensure a safe, comfortable environment. With consent, all interviews took place in participants’ homes. Eight focus groups were held with older people in community groups, HSCSWs, informal carers, referrers and staff from partner organisations (ranging from two to six participants). These were conducted at third sector partner’s premises or regular community group venues. The average age of older participants was 78 (range 55–101), with near-equal gender distribution (47.8% female; 52.2% male). Among this group, 79% lived alone; with 30.7% reporting widowed, 28.4% single, 21.6% married, 19.3% other marital status. Demographic data for other participant groups were not collected. Community partners included representatives from statutory, third and business sectors, such as carers’ organisations, Care & Repair, Edinburgh Garden Partners, Volunteer Edinburgh, Home Energy Scotland, Community Renewal, a local Community Health Project and the Edinburgh Health and Social Care Partnership.

Interview and focus group schedules were aligned with and explored key thematic areas outlined in the introduction. Visual aids were used to facilitate discussion. This approach supported accessible and reflective dialogue around perceptions of, or needs in relation to, resilience-affirming community support.

All interviews were conducted by the Reset researcher. Focus groups were co-facilitated by the researcher and a Reset HSCSW. The Cyrenians’ HSCSW team acted as co-researchers throughout, contributing to research design, data collection, reflexive analysis, interpretation and dissemination.

Data was analysed using inductive thematic content analysis and the constant comparative method (Glaser and Strauss, 1999), with coding supported by iterative mind mapping and categorisation (Morse and Field, 1995). The analysis process was conducted concurrently with data collection to support responsive adaptation of the research focus in subsequent PAR cycles.

To ensure rigour and trustworthiness, the study incorporated triangulation across data sources, member checking, prolonged engagement and ongoing reflexivity (Robson, 2002). Researchers continuously reflected on their positionality and its influence on the research process, thereby enhancing transparency and reducing potential bias (Finlay and Gough, 2008).

Favourable opinion was provided by the HSC Research Ethics Committee A (23/NI/0049). Informed consent was secured from all participants. General Data Protection Regulation requirements (UK Government, 2018) were applied to manage data and to ensure its security.

This research demonstrates that older adults have multifaceted and complex resilience needs, determined by a wide range of personal and environmental factors. These factors interact dynamically, making resilience outcomes highly individualised and contextual.

Through engagement with older adults and community partners, we identified a range of factors impacting the resilience. Personal resilience factors included self-efficacy, mental and physical health and loneliness/sense of social connection. Environmental resilience factors included social connections, access to resources, access to meaningful activities, person-centred conversations and support, skilled HSCS workforce and collaborative HSC working.

While we acknowledge the importance of personal resilience factors, we recognise that their role in shaping resilience in older adults is well documented through previous research (as detailed in our prior meta-analysis: Górska et al., 2022). As such, here we focus on environmental determinants of resilience, which, in interaction with personal factors, can either support or hinder resilience, with consequences for health and wellbeing outcomes.

Many older adults in this study experienced loneliness and social isolation, due to deteriorating health, mobility issues, age-related losses (change in social roles, bereavement) and inappropriate housing. Although some older adults were accustomed to being alone, and some even embraced it, many expressed a desire for social interaction. For those who found accessing social connections difficult, HSCSWs offered essential human interaction. However, service capacity and resource provision within community services (e.g. befriending services) was identified as a barrier. This related to limited funding which affected availability of both financial and human resources:

The importance of social networks, including family, friends, neighbours, professionals and community members (e.g. shop assistants), was consistently emphasised as vital to resilience. These networks provided practical support and opportunities for casual, meaningful interaction:

Participants reflected on the erosion of community ties, which limited opportunities for engagement and support. Nonetheless, the value of these networks was evident when family and friends support was limited:

Access to resources, including information, technology and services, was recognised as an important factor relative to supporting older adults’ resilience. Participants reflected that often, older adults are not aware of support that may be available to them. Therefore, providing information, raising awareness and facilitating access to resources within communities and through statutory means was crucial.

Often, the lack of awareness was compounded by growing reliance on technology relative to providing information about and facilitating access to resources and services. Older adults often lacked the skills to search for and navigate through technologically mediated information. Some expressed the desire and willingness to learn, but others lacked the confidence to engage with technology and required support to use it:

Many services are now only available through digital means (e.g. energy, welfare, housing, increasingly banking), limiting accessibility for groups with reduced resources or skills to navigate through complex telephone or internet-based systems. Some older adults lack a sense of security when interacting with such systems, which may result in disengagement and exclusion from accessing the required services:

Services tend to be technologically mediated by default, which places certain groups of people at a disadvantage. Navigating through automated systems to speak to a real person can be difficult for older adults, resulting in frustration or distress. Even if they are successful in getting through the automated stage of the call, they may experience difficulties identifying a suitable option and face a long wait to speak to someone. It highlighted the need for a better design of digital platforms, more digital literacy awareness training of staff handling technology-based services and availability of alternative methods of service provision to promote inclusion for all:

The ability to engage in meaningful activities i.e. those personally important to individuals, was a significant factor in resilience. Activities that offered routine, purpose or social interaction were especially valued.

However, declining health and mobility often limited participation. A lack of accessible, community-based activities that recognised diverse abilities and interests among older adults was a commonly reported unmet need:

Many older adults wished to actively participate and contribute to their communities, with social activities often perceived as opportunities to support others:

However, many experienced barriers related to physical accessibility of buildings and infrastructure or limited transport options:

Understanding and addressing older adults’ needs within their specific contexts is essential to effectively support resilience. Our findings indicate that resilience support takes diverse forms: for some, it involves encouragement, reassurance and physical assistance to improve mobility; for others, facilitating social interaction or providing help with income maximisation and fulfilment of basic needs such as food, energy, appropriate housing and healthcare. Most individuals require support that enhances their sense of self-efficacy and control, often adversely affected by prolonged hospitalisation, bereavement, inadequate housing or financial insecurity. Many older adults face multiple, intersecting resilience challenges simultaneously.

Face-to-face interaction was considered most effective when working with older adults, as it fostered trust and relationship-building, enabling more systematic and comprehensive needs assessment and delivery of tailored support:

Participants consistently emphasised the importance of conversational, trust-based, relational approaches to identifying and addressing older adults’ needs, viewing questionnaire-based methods as impersonal, inappropriate and disempowering:

Addressing complex needs requires a highly skilled, knowledgeable and compassionate workforce. Both older adults and community partners highlighted a wide range of competencies required of HSCSWs.

Reset HSCSWs operate across a wide scope of practice. They require extensive knowledge and skills, including an understanding of and ability to support physical and mental health, housing, social care, financial, digital literacy and safeguarding needs. Working with older adults facing complex challenges, such as poverty, trauma, loneliness and addiction, requires nuanced understanding of how these issues intersect with ageing, alongside recognition of individuals’ strengths and lived experiences.

Older adults emphasised the importance of personal values and people skills, including empathy, respect, kindness and sense of humour. They also valued practical support provided by staff e.g. shopping or assistance moving to more suitable housing; as well as their knowledge of, and the ability to facilitate access to, a broad range of services and resources.

Assessing individuals in their home environment was seen as particularly valuable, offering insights into their surroundings, lifestyle and potential risks affecting resilience. Being at home made individuals feel more at ease, fostering trust and openness about their challenges. This approach enabled HSCSWs to identify environmental issues such as deprivation, hazardous living conditions or intimidating communal spaces.

The combination of specialist knowledge, professional and people skills, and practical problem-solving, places HSCSWs in a highly demanding but uniquely impactful position to support the resilience and wellbeing of older adults:

All participants recognised the critical need for HSCSWs to develop and utilise a broad range of relationships and to engage in joint working with relevant services and community partners to address complex resilience needs of the population served.

Although the importance of partnership working across HSC was recognised, it lacked consistency, particularly between sectors. This often was exacerbated by incompatibility of digital platforms used by different organisations.

Information sharing between agencies was not always straightforward and referral forms were often submitted with limited information. This was due to the expectation that third sector staff had access to portals and systems used by NHS, Social Work and local Council, with crucial HSC information of clients:

On occasion, when liaising with statutory partners, HSCSWs experienced communication difficulties when enquiring about support for older adults. Some departments did not provide a telephone number to call, making it challenging to follow up. When support was unavailable, there was often no alternative signposting. Such challenges can be distressing and frustrating for older adults.

Professional participants reported that service pressures and overstretched capacity often left frontline staff with limited time for person-centred, collaborative practice. These constraints narrowed their focus and reduced opportunities to address complex HSC needs timely and holistically. Collaboration was often deprioritized due to its perceived demands on time and resources.

This study affirms the dynamic, reciprocal relationship between older adults and their environments (Górska et al., 2022), highlighting a range of personal and environmental factors that shape resilience in later life. While personal attributes, such as self-efficacy, physical and mental health, and social connectedness, are well-established contributors to resilience and wellbeing (Górska et al., 2022; Hornby-Turner et al., 2017), the influence of environmental determinants remains underexplored (Annear et al., 2014; Górska et al., 2022). Despite calls for resilience-affirming interventions that reflect its complex, contextual nature, evidence of their effectiveness is limited (MacLeod et al., 2016), underscoring the need for population-specific research. This paper addresses this gap by examining how systemic, cultural and societal factors affect older adults’ resilience. Although prior studies have recognised the role of social networks and access to care (Annear et al., 2014; Van Kessel, 2013), the impact of person-centred, relational care within community-based HSC systems remains understudied.

Our findings add to the evidence- and practice-based insights on relational service models, which view public service as a community act. In this approach, practitioners begin by forming meaningful relationships with individuals, recognising their unique strengths and priorities (Lowe et al., 2021; Wilson et al., 2024). Relational methods are particularly effective in addressing complex needs, as they support collaborative, adaptive working that empowers staff to respond flexibly at the local level (Cooke and Muir, 2012; Cottam, 2018). The Reset approach exemplifies this by removing the constraints of structured assessment tools, enabling open-ended, person-led conversations and allowing individuals to influence the timing, duration and nature of their support.

Emerging policy frameworks, such as networked governance, co-production and co-creation, are shaping new narratives in practice. Wilson et al. (2024) identify eight dominant themes, all emphasising the importance of relationship quality, equity, strengths-based approaches and active co-creation. The Reset programme implemented the “relational state” model, which shifts governance from service delivery to collaborative problem-solving with citizens (Cooke and Muir, 2012). It fostered trust-based relationships among older adults, professionals and institutions, improving outcomes across the system. Reset also operationalised “radical help” by designing support around lived experience, enabling transformative, person-centred change (Cottam, 2018).

This emerging focus on relational approaches to public services may reflect a broader societal need for more inclusive and connected communities. The WHO (2023) promotes age-friendly environments that support accessibility and inclusion. Yet, consistent with prior research, our findings highlight enduring cultural and structural barriers that restrict older adults’ participation in community life and access to essential services (Townsend et al., 2021).

The built environment remains a key factor, influencing mobility, social interaction, healthcare access and perceptions of safety (Gripko and Joseph, 2024). The digital environment is equally critical, shaping how older adults engage with their communities and sustain well-being (UNECE, 2021). However, ageist stereotypes and exclusion from technology design continue to impede these experiences (Mannheim et al., 2019). Our findings reinforce the view that digital exclusion is a structural, intersectional issue with significant health implications (Fang et al., 2021). Similarly, while social engagement and purposeful activity are widely recognised as vital to well-being (Monteiro et al., 2024; Owen et al., 2022), our data supports existing research suggesting that current opportunities often fail to reflect the diverse interests and experiences of older adults, an issue likely shaped by societal ageism and attribution biases (Garrido et al., 2022). These insights support calls for a shift in societal narratives around ageing, placing emphasis on diversity, contributions and interests, over decline (Madsen et al., 2019). Policy and practice should prioritise inclusive design, digital engagement and meaningful social roles to enhance quality of life, participation and resilience.

Effective collaboration and information sharing across HSC providers are also essential to support older adults’ independence (Cesari et al., 2022). The third sector plays a key coordinating role (Abendstern et al., 2018), yet barriers such as service fragmentation, limited resources, professional hierarchies and communication gaps persist (Lau et al., 2018). Addressing these issues requires sustained efforts to build interprofessional relationships and implement flexible, compatible data-sharing systems (de Bell et al., 2024).

Complex needs demand equally complex support (Skivington et al., 2021), delivered by a highly skilled workforce (Prior et al., 2023). This study identified a wide range of competencies and personal attributes essential for HSCSWs working with older adults. Our findings highlight the need to better recognise and invest in this workforce through improved recruitment, employment conditions, training, professional development, societal respect and professionalisation. These conclusions align with WHO (2018), which emphasises the critical, cost-effective role of community-based HSCSWs in delivering essential services. Despite this, the workforce remains under-recognised, under-supported, and under-rewarded. Evidence points to a persistent status gap between statutory professionals (e.g. nurses, social workers) and community HSCSWs, who often feel undervalued despite their complex skill sets (The Scottish Government, 2023). This sentiment was echoed in our findings. WHO (2018) offers practical guidance for addressing this gap, calling for integration of HSCSWs into local systems and investment in recruitment, education, supervision and career pathways to ensure the sustainability and effectiveness of this vital workforce.

While our findings offer important insights into the cultural and structural determinants of resilience in later life, they reflect the perspectives of volunteer participants. It is important to acknowledge that individuals who declined participation may hold different views and experiences regarding HSC needs (Blodgett et al., 2005). Additionally, participant recruitment was facilitated through collaboration with community and industry partners. While gatekeepers play a vital role in safeguarding potentially vulnerable individuals (Hellström et al., 2007) and can enhance contextual relevance, their involvement may also introduce limitations, including sampling bias and power dynamics that influence participant selection and data interpretation (Robinson, 2014).

Although the evidence base on the complex, context-dependent nature of resilience and the role of environmental factors is growing (Górska et al., 2022; Van Kessel, 2013), further large-scale, quantitative or mixed-methods studies are needed. Such research would enable meta-evaluation and inform the design of interventions aligned with a multidimensional understanding of resilience.

Finally, the implementation and sustainability of community-based interventions to support health, wellbeing and resilience remain constrained by broader economic and political conditions. A persistent challenge is the gap between emerging evidence and the political will to invest in long-term, relational, non-biomedical interventions.

Drawing on the perspectives of older adults, HSCSWs and professional partners, this study offers new insights into the contextual and systemic factors shaping resilience in later life. Findings emphasise the role of relational care and supportive community infrastructures, including societal framing of ageing and the impact of digital technologies, in fostering resilience. Implications for practice and policy are discussed, with a focus on strategies that promote inclusive, responsive and resilience-affirming environments to support ageing in place.

The authors would like to acknowledge contributions from all older adults, unpaid carers and professionals who participated in this research. The authors would also like to thank the advisory group and all Queen Margaret University and Cyrenians staff involved in the Reset programme from its onset. Special gratitude goes to Sylvia Leśniewska, for her contributions to the programme design and her leadership in its initial stages.

This work was funded by Edinburgh Health and Social Care Partnership, NHS Lothian.