Community-based interventions to support aging in place and functional independence in older adults: a systematic review of randomized controlled trials

Abstract

Background:

As the global population ages, ensuring the autonomy and wellbeing of older adults living at home has become increasingly important. Supporting independence is central to aging in place, which requires access to appropriate health and social resources. In this context, community-based public health interventions may play an important role in addressing physical, cognitive, and psychosocial challenges associated with aging.

Objective:

This systematic review aimed to synthesize evidence from randomized controlled trials examining community-based public health interventions that promote independence among older adults and to identify key components associated with successful aging in place.

Methods:

A systematic review of randomized controlled trials was conducted, including 91 publications representing 85 independent randomized controlled trials, retrieved from MEDLINE/PubMed, Embase, Web of Science, CINAHL, and PsycINFO. Community-based public health interventions were defined as structured programs delivered in non-institutional settings to support health, functional ability, and autonomy among community-dwelling older adults. Data extraction included intervention characteristics, outcomes related to independence, and levels of community engagement. Outcomes were categorized as primary independence measures (e.g., ADL/IADL performance, disability status), functional capacity proxies (e.g., gait speed, balance), and psychosocial enablers of independence (e.g., self-efficacy, depressive symptoms) to support interpretive clarity. Methodological quality was assessed using the Joanna Briggs Institute checklist for randomized controlled trials. Findings were analyzed using thematic synthesis.

Results:

Across 91 publications representing 85 independent randomized controlled trials, 45% of publications were classified as low risk of bias, 31% as moderate, and 24% as high. Community-based interventions such as physical activity programs, cognitive and psychological support, multidomain models, nutrition interventions, social engagement initiatives, and rehabilitation strategies were generally associated with improvements in direct and indirect independence-related outcomes, including functional ability, mobility, cognitive performance, mental well-being, and social participation, although the magnitude and consistency of effects varied across intervention types and outcome domains. Interventions integrating multiple components and tailored delivery formats were frequently associated with improvements in functional outcomes and psychosocial enablers related to independence.

Conclusion:

Community-based public health interventions that address the multidimensional needs of older adults may support the maintenance of functional ability and independence in later life. Structured, scalable models that integrate physical, cognitive, and social components may strengthen aging-in-place strategies and inform future public health planning.

Systematic review registration:

https://www.crd.york.ac.uk/prospero/display_record.php?ID=CRD42024596045. The study protocol was registered with PROSPERO (CRD42024596045).

Graphical Abstract

1 Introduction

The global population is undergoing a profound demographic shift, with the number of people aged 65 and older expected to double from 800 million in 2022 to nearly 1.6 billion by 2050 (1). In the United States (U.S.) alone, individuals over 65 are projected to make up 23% of the population by 2060, compared to 16% in 2020 (2). As life expectancy is projected to reach 19.6 years for 65-year-olds by 2050 (3) there is a need to develop strategies that promote independence for those who prefer aging in place. Yet, disparities in access to community support, rehabilitation services, and preventive care remain pronounced across regions and income levels. Older adults living in socioeconomically disadvantaged areas or belonging to minority groups often face barriers to health-promoting resources, digital access, and social participation. Addressing these inequities is central to achieving equitable health outcomes in aging populations and aligns with global public health goals under the SDG framework.

Aging in place refers to the ability to live in one’s home or community with access to health and social support (4, 5). Within this framework, independence may be understood as the capacity to maintain functional ability, autonomy in decision making, and self-management in daily life, including ADL and IADL (6, 7). Supporting independence, therefore, represents a central outcome and enabling condition of aging in place. This ability helps the well-being of older adults and reduces the strain on healthcare systems and social services by preventing unnecessary hospitalization and institutional care (8, 9). As the old-age dependency ratio (the proportion of people aged 65 and above to the working-age population) continues to rise globally (1), promoting independence among older adults becomes ever more vital for maintaining public health systems. In the U. S., Medicare spending is expected to increase from $829 billion in 2021 to $1.8 trillion by 2031 (10), driven largely by the aging population. These projections underscore the importance of cost-effective, community-based public health interventions that support independence while reducing long-term healthcare costs.

Community-based interventions that enhance physical, mental, and social well-being have been reported to improve functional status, mobility, and participation among older adults. However, such programs vary in design, delivery, and scope, and access to them differs across settings (11, 12). In low-resource or rural communities, limited infrastructure, underfunded primary care, and workforce shortages may restrict availability and participation. These programs emphasize prevention and aim to reduce the risk of chronic conditions and hospitalizations (13). For example, home modification programs, structured physical activity initiatives, and access to preventive healthcare have been shown to improve mobility, mental health, and social participation while reducing falls and related injuries (14, 15). In addition, interventions that promote social connectivity may reduce isolation, depressive symptoms, and cognitive decline among older adults (16–18). As community-based programs expand, identifying scalable and sustainable models remains critical for informing public health planning and implementation (19). For the purpose of this review, community-based public health interventions are defined as structured, non-institutional programs delivered in community settings such as homes, senior centers, or primary care linked community services, designed to promote health, prevent functional decline, or support autonomy among community-dwelling older adults. Thus, this systematic review of randomized controlled trials (RCTs) aims to synthesize evidence on community-based public health interventions that promote independence and support aging in place among older adults. The review addresses the following research questions:

• What types of community-based public health interventions have been evaluated to support independence among older adults?

• What independence-related outcomes are reported across these interventions?

• What factors influence the scalability and sustainability of these interventions in community settings?

While previous reviews have examined aging or health promotion programs more broadly, most have focused on single intervention domains or general healthy aging frameworks. Few have synthesized RCTs across diverse community-based interventions with independence as the central outcome among community-dwelling older adults. In addition, evidence regarding the long-term scalability and sustainability of such interventions remains dispersed across intervention areas. This systematic review addresses these gaps by rigorously synthesizing RCT evidence from diverse community-based public health interventions to identify common components, mechanisms, and implementation features associated with maintaining independence. The findings aim to inform public health planning and support the development of structured interventions that enable older adults to live independently and sustain functional ability within their communities.

2 Methods

2.1 Study design

This study was conducted as a systematic review of RCTs to synthesize evidence on community-based public health interventions promoting independence among older adults aged 65 years and over. The review was conducted in accordance with the Preferred Reporting Items for Systematic Reviews and Meta Analyses 2020 guidelines (20). The protocol was prospectively registered in PROSPERO (CRD42024596045).

2.2 Inclusion and exclusion criteria

Studies were eligible if they met the following criteria:

• RCT design;

• Participants aged 65 years or older living in community settings, or study populations primarily comprising older adults, defined as having a mean age of 65 years or above or clearly representing a later-life population;

• Evaluation of community-based public health interventions delivered in non-institutional settings; and.

• Reporting of outcomes related to independence.

Independence was operationalized a priori as maintenance or improvement in functional capacity, including activities of daily living (ADL), instrumental activities of daily living (IADL), mobility, cognitive capacity relevant to daily functioning, and psychosocial determinants influencing autonomous living, consistent with the World Health Organization’s framework of healthy ageing, which emphasizes functional ability as the core determinant of autonomy in later life (5, 15, 21, 22). Accordingly, outcomes reflecting independence included measures of physical function, ADL/IADL performance, mobility, frailty status, and related psychosocial indicators reported across trials.

Interventions included domains such as physical activity, cognitive support, nutrition, social support, rehabilitation, or multidomain approaches delivered in community settings. These interventions were considered public health relevant because they were delivered at the community level, emphasized prevention or preservation of functional ability, and were designed for implementation beyond specialized clinical settings. Many were embedded within scalable platforms such as senior centers, primary care linked services, community health worker programs, or structured home visit models. In the context of population ageing and aging-in-place policy frameworks, such interventions aim to maintain autonomy, delay functional decline, and reduce reliance on institutional care at the systems level.

Purely clinical rehabilitation programs delivered exclusively in hospital or institutional settings were excluded from this review. Eligible studies, published in English up to September 30, 2024, reported outcomes related to independence, including ADL, IADL, physical functioning, quality of life, mental well-being, or related functional outcomes. Studies were excluded if they were conducted in institutional or hospital settings, used non-randomized designs, or did not report independence-related outcomes.

2.3 Databases and search strategy

A comprehensive search strategy was developed to identify relevant literature across multiple electronic databases, including MEDLINE via PubMed, Embase, Web of Science, CINAHL, and PsycINFO. All databases were searched from inception to September 30, 2024, with the final search conducted on 1 October 2024 to ensure completeness. The search strategy combined controlled vocabulary and free-text terms using Boolean operators (AND, OR) and medical subject headings (MeSH) where applicable. Search terms were organized around three core concepts: population, intervention, and outcomes. To maximize sensitivity and minimize the risk of missing eligible studies, the search strategy was intentionally designed to be broad. Search terms were refined and expanded by examining terminology used in relevant RCTs and related systematic reviews identified during preliminary scoping searches.

In MEDLINE via PubMed, the built-in RCT publication type filter was applied during the database search to restrict results to RCTs. In databases where a validated RCT filter was not available, potential RCTs were identified using design descriptors such as “randomized,” “trial,” or “controlled trial,” and study design eligibility was subsequently confirmed during full-text review by verifying explicit random allocation to intervention and comparison groups. Title and abstract screening and full-text eligibility assessment were conducted independently by two reviewers. Disagreements at each stage were resolved through discussion and consensus.

The complete electronic search strategy for MEDLINE via PubMed, including all search terms and applied filters, is provided in Supplementary Table 6. Examples of the main search terms included:

• Population terms: (“elderly” OR “aged” OR “older” OR “geriatric” OR

• “elderly people” OR “old people” OR “seniors” OR “aging population”)

• Intervention terms: (“public health initiatives” OR “social care initiatives” OR “community-based approaches” OR “health programs” OR “aging in place” OR “home modifications” OR “social support networks” OR “health education” OR “preventive care programs”)

• Outcome terms: (“independence” OR “autonomy” OR “quality of life” OR “well-being” OR “health outcomes” OR “physical health” OR “mental health” OR “social connectivity” OR “mobility” OR “functional independence” OR “disability” OR “cognitive function” OR “loneliness” OR “social isolation”)

2.4 Data extraction strategy

To enhance conceptual clarity and ensure consistent outcome classification during data extraction, independent outcomes were categorized into three hierarchical levels. Primary independence outcomes included direct measures of functional autonomy such as ADL or IADL performance, disability status, institutionalization, or MMD, consistent with prior functional independence trials (5, 7, 15, 23). Functional capacity proxies included objective indicators of physical performance such as the Short Physical Performance Battery (SPPB) scores, gait speed, balance measures, falls, and strength assessments (22, 24–26). Enablers of independence included psychosocial and behavioral determinants such as self-efficacy, depressive symptoms, loneliness, social participation, and health literacy, which may influence an individual’s capacity to maintain autonomy in daily life (16, 27–30).

A structured data extraction form was developed and piloted prior to full extraction. The following key elements were extracted from each included publication: study characteristics (author(s), year, country, study design, and population characteristics); intervention characteristics (type of intervention, duration, delivery method, level of community involvement, and core components); outcomes (primary and secondary outcomes related to independence, quality of life, physical functioning, mental well-being, and reported scalability or sustainability considerations); and results (direction and magnitude of effects, outcome measures used, and reported implementation challenges). Two reviewers independently conducted data extraction using the predefined form. Discrepancies were resolved through discussion and consensus. Formal inter-rater reliability statistics were not calculated; however, the use of predefined extraction criteria, piloting of the data extraction form, and independent review by two reviewers were applied to enhance consistency and reduce subjective bias.

When multiple publications reported results from the same RCT, they were linked to a single underlying trial to avoid double counting. Some included articles represented secondary analyses of the same RCT (e.g., the Lifestyle Interventions and Independence for Elders [LIFE] study) and were retained as separate publications because they reported distinct outcomes. For synthesis and counting purposes, these publications were treated as one trial, and the review therefore includes 91 publications representing 85 independent RCTs (11, 22, 25).

2.5 Quality assessment

Methodological quality was assessed using the Joanna Briggs Institute (JBI) Critical Appraisal Checklist for RCTs (31). The checklist evaluates key domains of risk of bias, including random sequence generation, allocation concealment, baseline comparability, blinding of participants, personnel and outcome assessors, consistency and reliability of outcome measurement, completeness of follow-up, intention-to-treat analysis, and appropriateness of statistical analysis. Two reviewers independently assessed the risk of bias for each included publication using the predefined JBI criteria, and disagreements were resolved through discussion and consensus. Formal inter-rater reliability statistics were not calculated, but independent appraisal and consensus procedures were used to improve consistency in publication-level judgments. Detailed appraisal results for each included publication are presented in Supplementary Table 5.

Overall risk of bias was determined using a prespecified decision rule. Because blinding of participants and personnel is typically not feasible in behavioral and community-based interventions, domains D4 and D5 were retained in domain-level reporting but were not weighted as decisive in the overall study-level classification. This approach was based on methodological guidance for non-pharmacological and behavioral interventions, in which blinding of participants and personnel is often structurally difficult or not feasible, and these domains may therefore require cautious interpretation in overall study-level appraisal (32, 33). Studies were classified as low risk of bias if all remaining domains were rated as low risk, moderate risk of bias if at least one remaining domain was rated as unclear risk but none as high risk, and high risk of bias if one or more remaining domains were rated as high risk. Risk-of-bias assessments were conducted at the publication level because some RCTs were reported in multiple publications.

2.6 Data synthesis

Given the substantial heterogeneity in intervention types, outcome measures, reporting formats, and follow-up durations, a meta-analysis was not conducted. Outcome measures, intervention designs, and follow-up durations varied substantially across trials, with studies reporting diverse instruments, including SPPB, ADL/IADL scales, frailty indices, cognitive assessments, and quality-of-life measures. Because outcomes were measured using heterogeneous scales and reported at different follow-up intervals, quantitative pooling or meta-analysis was considered methodologically inappropriate. Across trials, more than 20 distinct outcome instruments were used, and follow-up durations ranged from several weeks to 4 years, which further limited statistical comparability and precluded meaningful pooled estimates. In addition, studies reported mixed directions and magnitudes of effect across intervention categories and outcome domains, further limiting the validity and interpretability of pooled summary estimates. Instead, findings were synthesized thematically using the approach described by Thomas and Harden (2008) (34), which involves line-by-line coding of extracted findings, the development of descriptive themes, and the generation of higher-order analytical themes through iterative comparison. Line-by-line coding was applied to the extracted text describing intervention characteristics, outcome patterns, and implementation-related observations reported in the included studies. Coding was primarily inductive in identifying recurrent findings across studies, however, was also informed deductively by the review objectives and predefined domains of independence, intervention type, scalability, and sustainability. Initial codes were grouped into descriptive themes corresponding to intervention domains and outcome patterns. These themes were then compared and refined iteratively across studies to generate higher-order analytical themes capturing common mechanisms, implementation features, and barriers relevant to independence. Two reviewers independently coded the extracted findings and discussed discrepancies until consensus was reached. Final themes were agreed upon through iterative review of the coding structure and alignment with the study aims. When reporting intervention effects, references to statistically significant or non-significant findings reflect the results reported by the original trial authors rather than pooled statistical analyses conducted in this review.

A wide range of instruments were used to assess independence-related outcomes, including the SPPB, ADL and IADL scales, frailty indices, cognitive assessments, and quality-of-life measures. Studies were therefore grouped deductively according to intervention type and outcome domains related to independence and functional ability. The analysis focused on identifying recurring intervention components and implementation features associated with reported improvements in independence-related outcomes, with particular attention to factors influencing feasibility, sustainability, and scalability across different community contexts.

For analytical clarity, interventions were categorized into seven groups: physical activity; cognitive and psychological interventions; multidomain approaches; health education; nutrition; social support and community engagement; and rehabilitation and supportive care. For synthesis purposes, related intervention types reported in Supplementary Table 2 were grouped into these seven broader analytical categories to facilitate thematic comparison across studies.

For the purposes of this review, scalability was defined as the potential for an intervention to be expanded, transferred, or implemented more broadly across community settings, populations, or service systems without substantial loss of feasibility or effectiveness, consistent with conceptualizations of scaling-up in public health implementation research (21, 35). Sustainability was defined as the capacity of an intervention to be maintained over time within routine community or health service delivery, including continued delivery, workforce support, participant engagement, and alignment with available organizational or financial resources (36). Few included studies explicitly evaluated scalability or sustainability as predefined implementation outcomes. Therefore, these dimensions were interpreted cautiously based on intervention delivery characteristics reported in the trials, including resource requirements, workforce involvement, integration with existing community or primary care systems, and delivery formats. Conceptual definitions of scalability and sustainability were informed by implementation science literature, including frameworks proposed by Milat et al. (35), Moore et al. (36), and the World Health Organization (21). Accordingly, interpretations related to scalability and sustainability should be understood as analytical inferences derived from intervention characteristics rather than as direct empirical outcomes reported by the trials. When available, information on scalability and sustainability was extracted from explicit descriptions provided by study authors regarding delivery models, workforce requirements, integration with existing services, follow-up structures, and reported implementation challenges.

3 Results

3.1 Characteristics of the studies

The study selection process is illustrated in the PRISMA flow diagram (Figure 1). The database search identified 4,156 records. After removing 3,646 duplicates, 510 records were screened based on titles and abstracts. A total of 187 full-text articles were assessed for eligibility, and 91 publications representing 85 independent RCTs were included in the final review (Table 1). The majority of studies were conducted in the United States (n = 38, 41.8%), followed by China (n = 9, 9.9%) and Japan (n = 6, 6.6%). Trials conducted in the United Kingdom, including those reported as England, accounted for 5.5% of studies (n = 5). Taiwan and Canada each contributed 4.4% (n = 4), while South Korea and Spain each represented 3.3% (n = 3). Sweden, Singapore, Hong Kong, and Germany each accounted for 2.2% of the included studies (n = 2). The remaining countries individually contributed 1.1% of studies (n = 1 each), including Australia, Switzerland, Portugal, Poland, the Philippines, New Zealand, the Netherlands, Malaysia, Israel, and Iran. One multisite trial conducted across China and Hong Kong (1.1%) was also included (Table 1). Because some publications evaluated multicomponent interventions, intervention categories were not mutually exclusive and are therefore presented as counts rather than percentages in Table 1. An increase in the number of published trials was observed in recent years. Detailed characteristics of the included RCTs are presented in Supplementary Table 1. Outcome measures and main reported results for each included study are presented in Supplementary Table 3.

Figure 1

3.2 Risk of bias

Across studies, random sequence generation (D1) and baseline similarity between groups (D3) were most frequently rated as low risk of bias, indicating that most trials used appropriate randomization procedures and achieved comparable baseline characteristics. In contrast, blinding of participants (D4) and personnel delivering the intervention (D5) was commonly rated as high risk of bias, as expected in behavioral and community-based interventions, where blinding is often not feasible. Because blinding of participants and intervention providers is structurally impractical in non-pharmacological community interventions, domains D4 and D5 were retained in domain-level reporting but were not weighted as decisive in the overall study-level classification, consistent with established guidance for behavioral intervention reviews. Allocation concealment (D2) was frequently rated as unclear, reflecting incomplete reporting of allocation procedures in several trials. Some concerns were also observed in follow-up completeness (D10) in studies with longer intervention or follow-up periods. Based on the remaining domains, 45.1% of publications (41/91) were classified as low risk of bias, 30.8% (28/91) as moderate risk, and 24.2% (22/91) as high risk (Supplementary Table 5). Overall, these findings indicate variability in methodological rigor across the included studies.

3.3 Intervention characteristics and independence-related outcomes

Across 85 independent RCTs, seven categories of community-based interventions were identified: physical activity; cognitive and psychological interventions; multidomain interventions; health education and self-management; nutrition interventions; social support and community engagement; and rehabilitation and supportive care. For each category, intervention characteristics, outcome measures used, principal findings, and null or mixed results are reported below. Comparator conditions across studies included usual care, waiting lists, health education programs, fall prevention booklets, optometric assessments, general nutrition education, reminiscence therapy, sedentary activities, successful aging programs, and attention-control conditions such as relaxation CDs or structured non-exercise activities (4–9, 11, 12, 14–19, 22, 23, 25–27, 29, 30, 37–96) (Supplementary Table 2). The synthesis below places primary emphasis on direct measures of independence (e.g., ADL/IADL performance and disability status), while functional performance indicators and psychosocial outcomes are presented as indirect contributors within the hierarchical outcome framework described in the Methods. An overview of the distribution of intervention categories across independence-related outcome domains is presented in Figure 2.

Figure 2

3.3.1 Physical activity interventions

Physical activity interventions included progressive resistance training, functional training, balance exercises, Tai Chi, structured walking programs, and combined aerobic and strength programs (8–18, 76–96). Outcome measures used across these trials included the SPPB, gait speed, quality-adjusted life years (QALYs), falls self-efficacy scales, fear of falling measures, and major mobility disability (MMD) assessments (6, 8, 11, 12, 22, 25, 37, 38, 40, 79, 80, 82, 83).

Across these trials, structured exercise programs were associated with improvements in strength, balance, and mobility through progressive resistance training, functional training, and flexibility components (6, 8, 24, 27, 37–43). Combined physical activity and health education programs reported improvements in physical function and reductions in MMD, including dose-dependent effects, while Tai Chi was associated with improvements in balance, strength, and flexibility among older adults with knee osteoarthritis (6, 25, 80). Mobility and fall-related outcomes were reported across long-term tailored programs and fall prevention interventions, including reductions in fall rates, improvements in gait, and gains in self-efficacy, particularly among participants with a history of falls (12, 26, 38, 40–43, 65, 82–88, 92, 94, 95). Regular physical activity was also linked to improvements in autonomy-related measures and reductions in frailty (41, 42, 89, 90), and among frail participants with mobility limitations, structured activity was associated with improvements in sleep quality and physical function (90, 94). Importantly, improvements in gait speed and balance were interpreted as functional capacity proxies supporting independence rather than direct measures of independence per se.

However, not all physical activity interventions demonstrated significant effects. The exercise arm of the ‘¡Caminemos!’ study did not produce significant improvements in depressive symptoms at all follow-up time points (27), and some fall prevention programs reported no significant reductions in fall rates in intention-to-treat analyses (26).

3.3.2 Cognitive and psychological interventions

Cognitive and psychological interventions included cognitive training programs, dual-task training, mindfulness-based approaches, aerobic exercise targeting cognition, peer support, positive psychology, and self-management strategies (17, 28, 44–47, 49, 52, 53, 97, 98). Outcome measures included working memory assessments, executive function tests, psychomotor speed measures, sleep quality scales, depression inventories, self-efficacy instruments, and cognitive performance batteries (28, 46, 49, 53, 97).

Interventions focusing on cognition and psychological well-being reported improvements across several domains through cognitive training (44–46), social interaction (17, 47, 97), mindfulness-based approaches (98), and structured self-management strategies (28, 49, 52, 53). Specifically, improvements were reported in spatial working memory (97), global cognitive function (17), and reductions in depressive symptoms accompanied by gains in self-efficacy and social engagement (28, 47, 49). Cognitive stimulation approaches, including dual-task training, reported improvements in executive function, memory, and psychomotor speed (46, 53). Self-management programs were associated with improvements in cognitive performance and gait among at-risk older adults (44, 45). Psychosocial interventions also reported improvements in perceived cognitive change, satisfaction with social activities, and quality of life (52). Increases in resilience were observed in cognitive stimulation trials (21), while pain management and self-efficacy outcomes improved among older adults with chronic pain conditions (28). Programs targeting memory and executive functioning similarly reported gains relevant to everyday task performance and cognitive competence in daily activities (44).

Overall, cognitive and psychological interventions were frequently associated with improvements in executive function, mood, and perceived cognitive change, although the magnitude and persistence of these effects varied across trials. In many studies, these improvements appeared to support independence indirectly by strengthening executive functioning, cognitive control, and psychosocial factors such as self-efficacy and social engagement. Within the three-tier framework used in this review, these outcomes are interpreted primarily as functional capacity proxies and enablers of independence rather than direct indicators of functional autonomy.

However, some cognitive and psychological interventions did not demonstrate significant effects. The Aging Mastery Program, evaluated in a community-partnered trial, did not demonstrate statistically significant improvements in intention-to-treat analyses (16). Similarly, some self-management interventions showed limited effects on primary cognitive outcomes at longer follow-up (52).

3.3.3 Multidomain interventions

Multidomain interventions combined two or more components such as physical activity, cognitive stimulation, social engagement, home modification, and nutritional support, and were delivered through tailored care plans, multidisciplinary team support, or technology-assisted platforms (5, 7, 14, 15, 18, 23, 48, 50, 51, 54–57, 99). Outcome measures included ADL and IADL dependence scales, frailty indices, life satisfaction measures, cognitive assessments, depressive symptom scales, and quality-of-life instruments (7, 14, 48, 55).

Multidomain interventions reported improvements in functional ability, independence, and health outcomes through tailored care plans (7, 14, 48, 50, 51), home modifications (15, 57, 99), and multidisciplinary team support (5, 18, 23, 54–56). Improvements were reported in life satisfaction, health perception, and quality of life (48), with mobility and fall prevention components associated with reductions in ADL and IADL limitations (14, 15). Gains in functional capacity and cognitive health were accompanied by reductions in dementia risk indicators and cognitive decline measures (18, 54, 55), while enhanced social engagement, reductions in frailty, and decreases in depressive symptoms were also observed (50, 51). Home modifications and environmental adaptations supported these gains by reducing ADL assistance needs, lowering disability risk, and enabling improvements in independence (5, 23, 51, 99). Improvements in health literacy further reinforced self-management behaviors and reductions in physical limitations across several trials (5, 18, 50, 56). Outcomes such as ADL and IADL performance constituted primary independence outcomes in these trials, while measures such as depressive symptoms and self-efficacy were interpreted as enablers of independence rather than direct functional autonomy indicators.

However, not all multidomain interventions demonstrated significant effects. The LoChro-Care intervention, a local collaborative and personalized care management program, reported no significant improvements in functional health or depressive symptoms over follow-up (50). The Embrace population-based, person-centered integrated care program showed no significant changes in well-being or ADL outcomes (56).

3.3.4 Health education and self-management interventions

Health education and self-management interventions included programs targeting physical activity behavior, chronic disease management, hypertension control, dementia literacy, medication adherence, and elder abuse prevention (4, 29, 58–63, 66, 68, 100, 101). Outcome measures included blood pressure readings, health literacy scales, self-efficacy instruments, medication adherence rates, bone mineral density (BMD), and quality-of-life measures (4, 29, 58–63, 66, 68, 100, 101).

Health education interventions, including those focused on physical activity, reported improvements in health literacy, disease management, and self-care behaviors (58, 59, 63, 100), as well as in nutrition knowledge (60–62) and chronic disease management (4, 29, 66, 68, 101). Specifically, improvements were reported in hypertension management, blood pressure control, and lifestyle changes (61, 66), as well as in dementia literacy and cognitive health (29, 63). Programs also reported improvements in self-efficacy related to nutrition and elder abuse prevention (68, 100, 101). Targeted health education interventions were associated with improvements in quality of life and physical function in occupational therapy settings (4) and increased medication adherence (59, 60). Occupational therapy and physical education programs reported improvements in daily functioning and independence-related measures (4, 60, 66). Health education interventions targeting social engagement reported improvements in resilience and emotional well-being, while nutrition-focused programs reported improvements in BMD and quality of life (68). These outcomes were interpreted within the three-tier hierarchy: blood pressure control and medication adherence as enablers of independence, and improvements in daily functioning as primary independence outcomes.

Health education alone showed limited impact in preventing declines in ADL in several studies, whereas studies combining education with physical or cognitive training reported improvements across a broader range of functional outcomes (56, 58, 62).

3.3.5 Nutrition interventions

Nutrition interventions included tailored nutritional counseling, dietary supplementation, and combined exercise and nutritional support programs targeting community-dwelling older adults (30, 51, 64, 65, 67). Outcome measures included dietary intake assessments, body composition measures, muscle strength tests, walking speed, aerobic capacity, cognitive function assessments, and healthcare cost analyses (30, 64, 65, 67).

Nutrition interventions reported improvements in dietary intake and health-related outcomes for chronic diseases through tailored nutritional counseling (30, 64, 67) and supplementation (51, 65). Enhanced nutritional intake and reductions in body fat were associated with improvements in physical mobility and health self-management measures (64, 65). Programs also reported increases in walking speed, aerobic capacity, and cognitive function (65, 67). Walking speed and aerobic capacity were interpreted as functional capacity proxies rather than direct independence measures, indicating meaningful gains relevant to functional autonomy. Nutritional interventions were more frequently associated with functional benefits when combined with structured exercise programs, particularly in addressing sarcopenic obesity (65).

3.3.6 Social support and community engagement interventions

Social support and community engagement interventions included peer-led programs, community partnership models, group-based social activities, health-social partnership programs, and integrated community care approaches (9, 16, 72, 74, 102). Outcome measures included loneliness scales, social participation measures, functional independence assessments, quality-of-life instruments, mental health inventories, and injury-related cost analyses (9, 16, 72, 74, 102).

Social support and community engagement interventions were associated with enhanced social interaction, reduced isolation, greater community participation, improved functional independence, and improved quality of life (9, 16, 72–75, 102). Similar social participation gains were also reported in multidomain trials that incorporated explicit social engagement components (99). Reductions in loneliness and improvements in social participation were classified as enablers of independence, reflecting their role in sustaining psychosocial resources that support autonomous daily living. However, not all social support interventions demonstrated significant effects. The Aging Mastery Program, which combined social engagement with health education and goal-setting components, was also discussed in the cognitive and psychological intervention category because of its multidimensional design. In intention-to-treat analyses, the program did not demonstrate statistically significant improvements (16).

3.3.7 Rehabilitation and supportive care interventions

Rehabilitation and supportive care interventions included individualized care plans, occupational therapy-led programs, home safety modifications, assistive device provision, caregiver-involved programs, palliative and supportive care, and self-management support for chronic conditions (13, 69–71, 76–78, 91, 93, 96, 103, 104). Outcome measures included functional independence scales, ADL performance assessments, hospital readmission rates, home safety evaluations, healthcare utilization data, caregiver burden measures, and quality-of-life instruments (13, 69–71, 76–78, 91, 93, 96, 103, 104).

Rehabilitation and supportive care interventions reported improvements in recovery outcomes, functional independence, and quality of life through individualized care plans (69–71, 78, 104), assistive devices (76, 77, 103), and home safety modifications (13, 91, 93, 96). Specifically, reductions in pain-related disability and improvements in mobility and quality of life were reported (91, 93). These interventions were also associated with reductions in hospital readmissions and long-term care utilization (77, 104). Programs addressing caregiver involvement reported improvements in quality of life and self-reported health (69, 76, 103), as well as reductions in caregiver burden and improvements in life satisfaction (13, 70, 71, 78). ADL performance and hospital readmission outcomes served as primary indicators of independence in these trials, while caregiver burden and quality of life were considered enablers of sustained independent living.

3.4 Mechanisms, scalability, sustainability, and implementation challenges

3.4.1 Mechanisms through which community-based interventions support independence

Across intervention categories, the included studies indicate recurring mechanisms through which community-based interventions relevant to public health practice support independence among older adults. At the physical level, improvements in strength, balance, gait speed, and endurance were consistently linked with reduced mobility disability, lower falls risk, and better performance in daily activities across structured physical activity, balance, and multimodal programs (6, 11, 22, 25, 26, 37, 79, 95). These physical performance improvements represent functional capacity proxies through which greater primary independence is achieved and sustained. Cognitive and executive capacity was also strengthened through community-delivered cognitive training, dual-task approaches, and aerobic activity programs targeting cognition, with reported gains in executive function, memory, and cognitive performance relevant to functional competence (18, 44–46, 53, 54, 97, 105, 106). Psychosocial resources, including self-efficacy, reduced depressive symptoms, and social connectedness, which were classified as enablers of independence, were improved in interventions incorporating peer support, positive psychology, purpose-driven engagement, group-based activities, and culturally tailored programs. These approaches supported sustained participation and adaptive coping among older adults (16, 27, 28, 47, 49, 52, 72, 98). At the environmental level, home-based adaptations and occupational therapy-led modifications reduced functional barriers and supported aging in place through hazard reduction and assistive strategies, with reported reductions in functional difficulties and disability risk (9, 14, 15, 57, 77). Integration with community and primary care infrastructures, including person-centered care, health-social partnerships, and community health service delivery, was associated with improved continuity, adherence support, and maintenance of independence-related outcomes over follow-up (50, 56, 73–75, 78, 104).

3.4.2 Scalability and sustainability

The observations below should be interpreted cautiously, as scalability and sustainability were not consistently evaluated as explicit trial outcomes and were often inferred from intervention characteristics, delivery models, and follow-up descriptions.

Physical activity interventions appeared more scalable when they used cost-conscious and adaptable delivery approaches. These included training visual rehabilitation officers (76), implementing minimal-equipment exercise programs (37), and utilizing standardized monitoring tools such as the SPPB (79). Sustainability of these interventions appeared more plausible when supported by stable funding mechanisms, trained personnel, and ongoing community engagement. Community-based programs, such as structured walking groups, reported maintenance of physical benefits over longer follow-up periods (38), while home-based exercise models were described as adaptable across diverse community settings (24) (Supplementary Table 4).

Cognitive and psychological interventions appeared more scalable when they leveraged existing community resources (97), incorporated non-professional staff (28), and adopted peer-led delivery models. These approaches may be particularly relevant for rural or resource-constrained areas, where low-cost and culturally relevant support structures are important (47, 49). Integration with primary healthcare or community health services also appeared to support scalability potential; however, longer-term sustainability seemed to depend on participant adherence, ongoing facilitator training, and continued community engagement (17, 98).

Healthcare-integrated multidomain interventions, including standardized care plans and coordinated case management models (50), appeared more scalable when supported by interdisciplinary collaboration and sustained community involvement (51). Telehealth platforms and digital delivery models (99), as well as low-cost technology-based education tools such as WeChat-based interventions (55), were described as potentially scalable alternatives, particularly when supported by both healthcare professionals and community stakeholders. Interdisciplinary coordination and cultural adaptation were recurrent features that appeared to improve feasibility across diverse contexts (18, 54).

Health education interventions appeared more scalable when delivered within established community infrastructures (66), using affordable educational materials (60), and standardized program formats (100). Sustainability appeared more likely when supported by facilitator training (61), interdisciplinary collaboration (63), and active community participation (101). The involvement of non-professional or community-based facilitators (4) and culturally tailored resources (62) was described as a potential strategy to reduce implementation costs and improve engagement.

Nutrition interventions appeared more scalable when embedded within existing healthcare or community service structures and delivered through relatively low-cost counseling models (64). Long-term sustainability appeared to depend on continued dietitian involvement (30), adherence monitoring, and structured follow-up systems (65). In rural settings, affordable and flexible delivery approaches appeared particularly important, with digital tools and community-based follow-up potentially supporting continued participation (67).

Rehabilitation and supportive care interventions appeared more scalable when integrated into community health service frameworks (70). Sustainability appeared more likely when supported by trained multidisciplinary teams (103), high participant satisfaction (71), and integration with existing care pathways. Programs incorporating low-cost assistive tools (e.g., Thera-Bands) and home-based adaptive modifications were described as feasible approaches to extend reach (58, 78, 91, 93, 96). Ongoing facilitator involvement and alignment with community health infrastructure were also described as potential contributors to longer-term sustainability.

3.4.3 Implementation challenges

Community-based interventions relevant to public health practice reported several implementation challenges across categories. Participant engagement and adherence difficulties were among the most frequently reported barriers (4, 11, 12, 19, 27, 37, 41–43, 45, 46, 48, 53, 64, 69, 79, 80, 84–86, 90, 92, 97, 101, 103, 105). Resource and funding constraints limited the feasibility and sustainability of several programs (9, 24, 49, 54, 58, 60, 66, 100). Technological and infrastructure barriers were identified in interventions utilizing digital platforms, telehealth, or remote delivery formats (17, 30, 70, 75, 81, 83, 99). Cultural and community-specific challenges, including language barriers, low health literacy, and limited cultural tailoring, were reported across diverse implementation settings (8, 16, 18, 28, 40, 50, 51, 55, 56, 61, 62, 71, 74, 87, 88, 102). Challenges related to scalability and long-term sustainability were also reported across intervention categories (7, 13, 15, 23, 26, 29, 30, 44, 52, 57, 67, 68, 72, 77, 78, 89, 91, 93–96, 104).

4 Discussion

This systematic review synthesizes evidence suggesting that community-based interventions relevant to public health practice may support older adults’ independence and well-being across physical, cognitive, and psychosocial domains. Across countries and intervention types, the evidence generally indicates that physical activity interventions, including tai chi, structured aerobic exercise, resistance training, and multidomain activity models, play an important role in improving mobility, balance, gait, and overall physical functioning (8, 22, 25, 80, 95). These outcomes are not merely intermediate fitness indicators; they are closely linked to fall risk, mobility disability, and the capacity to perform ADL without assistance. The LIFE trials provide particularly robust evidence that structured physical activity can reduce MMD and improve physical performance among older adults at elevated risk, thereby supporting the view that physical activity may represent a central strategy for preserving autonomy in later life rather than a supplementary lifestyle option (6, 22, 90). Importantly, the translation of structured interventions into community settings with maintained functional benefits suggests that effectiveness may not be confined to highly controlled research environments and, in some contexts, may be sustained under real-world conditions (19).

Beyond physical capacity, cognitive and psychological interventions were associated with improvements in memory, executive function, global cognition, emotional well-being, and self-efficacy (18, 44, 45, 54, 55, 97, 105, 106). Mind, body, and resilience-oriented programs demonstrated reductions in depressive symptoms and improvements in psychological outcomes among community-dwelling older adults (27, 47, 59, 98). These findings reinforce a multidimensional conceptualization of independence. Autonomy in later life depends not only on preserved mobility but also on cognitive vitality, emotional regulation, and the perceived capacity to manage daily demands. Consistent with the three-tier hierarchical framework applied in this review, cognitive gains may primarily function as proxies for functional capacity and enablers of independence rather than as direct measures of functional autonomy. Interventions that explicitly combine physical and cognitive elements appear particularly aligned with the intertwined trajectories of motor and cognitive aging and may better support functional competence in complex, everyday contexts than single-domain approaches (18, 54, 55). Improvements in psychosocial outcomes and functional proxies should therefore be interpreted as indirect contributors rather than as direct evidence of functional independence.

Social support, rehabilitation, and integrated care models further contributed to independence by addressing functional recovery, symptom burden, and environmental constraints. Community-partnered and peer-delivered programs improved engagement and psychosocial outcomes, including self-efficacy and perceived functional change (16, 28, 49, 52). Multidisciplinary and home-based approaches, including supportive care models and comprehensive assessment linked to follow-up, demonstrated improvements in function and health-related quality of life among older adults with chronic conditions and frailty (5, 23, 70, 73, 74, 102). These findings suggest that independence may be supported through coordinated support structures that extend beyond individual capacity building. Community-based recruitment, delivery in familiar settings, tailored progression, and ongoing monitoring appear to function as enabling conditions that strengthen adherence and sustained participation, thereby supporting more durable functional gains. While physical activity interventions demonstrated the most consistent improvements in mobility-related outcomes, psychosocial and supportive care interventions appeared particularly important for sustaining engagement, emotional well-being, and longer-term participation in community-based programs.

From a comparative perspective, the intervention categories differed in both outcome profiles and implementation demands. Physical activity interventions most consistently reported improvements in mobility-related outcomes such as balance, gait speed, and MMD (6, 8, 25, 90). Multidomain interventions appeared to influence broader independence-related outcomes, including ADL/IADL performance, frailty, and overall functional ability (14, 18, 51, 54, 55). Cognitive and psychological interventions primarily contributed through improvements in executive function, mood, self-efficacy, and perceived cognitive change, suggesting a stronger role as enablers of independence rather than direct determinants of functional autonomy (28, 44–47, 49, 97, 98, 106). Social support and community engagement interventions were particularly relevant for maintaining participation, reducing loneliness, and supporting psychosocial conditions that sustain independent living (9, 16, 72–75). In terms of delivery, low-cost group-based programs, home-based models, and interventions embedded within existing community infrastructures appeared more scalable, whereas interdisciplinary or person-centered models offered broader support but required greater coordination, workforce capacity, and sustained implementation fidelity (4, 24, 50, 56, 100, 101).

These findings are broadly consistent with previous studies and systematic reviews indicating that multidimensional community-based interventions may play an important role in supporting functional ability and independence in later life (107, 108). Earlier systematic reviews have similarly reported that physical activity interventions are among the most effective strategies for improving mobility and preventing functional decline among community-dwelling older adults (109, 110). At the same time, evidence from multidomain intervention trials and related studies suggests that interventions addressing multiple domains, including physical activity, cognitive engagement, and social participation, may produce broader benefits for maintaining independence and quality of life (14, 18, 51, 54, 55, 111). Building on this body of evidence, the present review synthesizes findings across a broader range of community-based public health interventions and highlights how intervention delivery formats, community integration, and contextual conditions may influence implementation feasibility and longer-term sustainability. Recent evidence further supports these observations. A 2024 systematic review and network meta-analysis by Crocker et al. reported that community-based complex interventions may have small positive effects on sustaining independence, while also noting that evidence was insufficient to determine the most effective service models across intervention types overall; individualized care planning, including medicines optimization and regular follow-up reviews, was identified as the intervention most likely to sustain independence (112). A 2025 systematic review by Elhag et al. similarly found that community-based interventions may benefit physical health, psychological well-being, and social connections among older adults, consistent with the multidimensional pattern observed in the present review (113).

The cross-country distribution of evidence adds important contextual nuance. In high-income countries with developed primary care and municipal infrastructures, community interventions are frequently embedded within formal systems or linked to established research-to-practice pipelines. In the United States, the LIFE program and related analyses illustrate how well-resourced, protocolized physical activity interventions can be implemented over extended follow-up periods and evaluated against clinically meaningful mobility outcomes (6, 8, 22, 28). Hybrid models combining supervised center-based sessions with home-based activity targets were commonly employed, reflecting adaptation to functional limitations while maintaining structured progression (6, 8, 22). In European contexts, person-centered integrated care models and population-based service approaches explicitly emphasized self-management, self-determination, and coordinated multidisciplinary follow-up, aligning with broader aging-in-place frameworks and municipal health strategies (56, 69). Pragmatic falls prevention programs delivered through health service networks in the United Kingdom further suggest that even modest functional gains can be population-relevant when interventions are feasible for wide-scale deployment (13). In these settings, the central implementation challenge appears less related to efficacy and more to integration, commissioning, workforce training, and sustained financing.

In middle-income and rapidly aging settings, community delivery often functions as an access strategy designed to address affordability, service continuity, and workforce limitations. In China, community health management and integrated hypertension programs combined lifestyle counseling, monitoring, and follow-up within community health service structures, reflecting an emphasis on reach and continuity in everyday environments (75, 100). In Iran, empowerment-based education addressing safety and self-efficacy targeted psychosocial determinants that directly influence vulnerability and autonomy (101). Programs implemented in low-income housing settings in Malaysia demonstrate that group-based, resource-efficient formats can improve functional performance and quality of life among underserved populations (12). These models suggest that scalability in such contexts may depend more on strengthening community-level capacity, including training for community health workers and local service providers, than on specialist-intensive designs. Together, these patterns suggest that while high-income countries often prioritize integration within established health systems, interventions in middle-income settings more frequently emphasize accessibility, community delivery, and workforce adaptability.

Across both high and middle-income contexts, cultural adaptation and community embeddedness appear to function as substantive mechanisms rather than superficial modifications. Culturally tailored dance and attribution retraining programs among older Latino populations in the United States (84, 85, 89), culturally grounded tai chi and combined music and tai chi interventions in East Asian settings (47, 63, 80), and community health worker-led positive psychology interventions for underserved African American older adults (28) demonstrate that social relevance and contextual fit likely influence engagement, adherence, and ultimately functional outcomes. Because many interventions rely on sustained participation to produce mobility and cognitive benefits, cultural resonance and accessibility may be central to effectiveness.

From a systems perspective, the convergence of findings across intervention categories supports the potential integration of community-based strategies within existing health and social care infrastructures. Physical activity programs with structured progression can be delivered through municipal services, primary care partnerships, and community organizations (6, 8, 22). Cognitive and psychosocial programs can be embedded within senior centers or community networks, supported by trained facilitators and peer models (18, 28, 44, 49, 52). Health education and self-management initiatives appear most effective when interactive and contextually tailored, strengthening perceived control and sustained behavioral change that underpin independence (29, 60, 62, 66). Coordinated multidomain approaches that combine physical activity, cognitive stimulation, and social participation may provide greater resilience against functional decline than isolated single-component interventions, particularly among older adults with multimorbidity or early functional impairment (18, 54, 55, 102).

Despite the generally positive pattern of findings, several trials reported null or mixed outcomes. Null findings observed in trials such as LoChro-Care, Embrace, and the Aging Mastery Program highlight the complexity of implementing coordinated community-based interventions. These programs often involve multiple service components and rely heavily on sustained participant engagement and system-level coordination. Variability in implementation fidelity, intervention intensity, and participant adherence may partially explain why some theoretically strong interventions failed to produce measurable functional gains. Metzner et al. (2023) reported no significant improvement in functional health or depressive symptoms following the LoChro-Care intervention (50), and Spoorenberg et al. (2018) found no meaningful changes in well-being or ADL outcomes in the Embrace integrated care program (56). Similarly, Guerrero et al. (2020) observed no statistically significant effects in intention-to-treat analyses of the Aging Mastery Program (16). In addition, approximately one-quarter of the included studies were classified as high risk of bias, further limiting confidence in some reported effects. These findings suggest that although community-based interventions show considerable promise for supporting independence among older adults, their effectiveness may vary across intervention models, populations, and implementation contexts. Successful implementation, therefore, depends not only on intervention design but also on contextual fit, implementation fidelity, and sustained community engagement.

Scalability may depend on more than low-cost design. Although group-based formats that use existing community spaces and minimal equipment are promising for broader implementation (58, 63, 95), sustained benefits may require alignment with funding structures, workforce development, and integration with primary care and municipal planning (50, 56, 74). Interventions that cultivate local ownership and cross-sector partnerships appear better positioned to achieve continuity beyond initial implementation phases.

From a public health perspective, equity considerations are critical when designing community-based interventions for older adults. Structural barriers, such as transportation limitations, language differences, financial constraints, and unequal access to community services, may limit participation among vulnerable populations. Future interventions should therefore prioritize inclusive delivery models, culturally adapted programs, and partnerships with local community organizations to ensure that aging-in-place strategies reach socially disadvantaged groups. Older adults in rural areas, low-income communities, and culturally diverse populations face structural barriers to transportation, cost, language, and limited-service availability. Evidence from culturally tailored interventions, peer support models, and housing site delivery indicates that locally embedded approaches can enhance participation and outcomes among underserved groups (12, 28, 84, 85). Ensuring accessibility for individuals with multimorbidity, sensory impairment, or cognitive decline is critical to avoid reinforcing disparities in later life. From a policy perspective, integrating community-based interventions into primary care systems, municipal health services, and local aging-in-place strategies may represent a scalable approach to sustaining independence among aging populations. Prioritizing workforce training, referral pathways, community-health partnerships, and long-term funding mechanisms will be essential to achieving this integration sustainably. These findings suggest that community-based interventions relevant to public health practice may play an important role in maintaining independence among older adults, particularly when they are context-sensitive, culturally responsive, and integrated within existing health and social care systems.

4.1 Implications for practice

Findings emphasize the value of tailored community-based interventions in supporting physical, cognitive, and emotional well-being among older adults. Physical activity programs, including tai chi, cognitive training, dance-based interventions such as BAILAMOS© (84, 88, 95), and multidomain approaches, demonstrated reductions in fall risk, improvements in mobility, and benefits for mental health outcomes (7, 18, 41, 54, 55, 82). Programs that were low-cost, group-based, and embedded within existing community infrastructures appeared particularly feasible for broader implementation. Nutrition and health education interventions were more sustainable when they incorporated family involvement, cultural tailoring, and interactive or empowerment-oriented components, supporting sustained behavior change (30, 64, 65, 67). Similarly, social support initiatives, including peer-led and community-based models, were associated with reductions in loneliness and increased engagement, particularly when locally embedded and culturally aligned (19, 77, 91, 93, 96, 103, 104). Rehabilitation and supportive care interventions delivered by multidisciplinary teams were associated with improvements in functional independence, reduced hospitalizations, and enhanced quality of life (13, 16, 69, 70, 72, 74, 75, 102). Their long-term sustainability may depend on integration into existing health and social care systems, stable funding mechanisms, and adequate workforce capacity.

4.2 Future research directions and recommendations

Across the included studies, several consistent research gaps were identified. In physical activity interventions, many studies recommended larger and longer trials to assess sustained effects on mobility, falls self-efficacy, and cognitive outcomes (11, 37, 79, 80). Several authors emphasized the need to integrate mental health components within physical activity programs and to examine subgroup differences, particularly among frailer adults and those with depressive symptoms (27, 81). Additional priorities included evaluating culturally adapted models, combined nutrition and exercise strategies for sarcopenic obesity (39, 41, 65), and community-based fall prevention approaches (26, 63).

In cognitive and psychological interventions, long-term follow-up was frequently recommended to determine the durability of memory and cognitive benefits, especially among populations with mild cognitive impairment and those at risk of dementia (97). Studies highlighted the need to combine cognitive and physical training, expand culturally adapted peer-delivered models, and test integrated cognitive behavioral approaches in underserved populations (16, 17, 28, 45, 49, 53). Multidomain interventions were often accompanied by calls for larger RCTs examining combined physical, cognitive, and social components over extended follow-up periods (18, 55).

Health education and chronic disease management interventions identified the need for further evaluation of healthcare utilization, sustained behavior change, and culturally adapted or peer-led delivery models (4, 58, 66, 68, 100). Several trials also recommended examining the role of digital tools in enhancing accessibility and adherence, including telehealth platforms, mobile applications, and blended delivery formats, with particular attention to family and community involvement (29, 59, 60, 62, 63, 101).

4.3 Limitations

This systematic review has several limitations. First, restricting inclusion to English-language publications may have introduced language bias and excluded relevant evidence published in other languages. Second, although limiting the review to RCTs strengthened internal validity, this decision excluded observational and qualitative studies that could have provided important contextual insights into implementation processes, participant experiences, and real-world feasibility. In addition, methodological quality varied across included studies, including potential risks related to allocation concealment, blinding, attrition, and selective outcome reporting, which may have influenced effect estimates. Relatedly, the decision to exclude blinding domains (D4 and D5) from the overall study-level risk-of-bias classification may have resulted in a more favorable quality profile than would have been obtained using stricter composite approaches, and this should be considered when interpreting the overall distribution of risk-of-bias ratings. Third, substantial heterogeneity in outcome measures, intervention designs, and follow-up durations posed challenges for synthesis and limited comparability across studies. Independence was operationalized in diverse ways, ranging from objective physical performance measures to self-reported quality-of-life and psychosocial indicators, complicating the direct aggregation and interpretation of findings. Publication bias also remains a concern because trials with statistically significant findings are more likely to be published. As a result, null or negative studies may be underrepresented, potentially inflating estimates of effectiveness. Fourth, the predominance of studies conducted in high-income countries limits the geographic diversity of the evidence base and may constrain transferability to low- and middle-income settings where community infrastructure, workforce capacity, service integration, and resource availability differ substantially. The relative underrepresentation of studies from lower-resource contexts restricts global generalizability, particularly in regions undergoing rapid demographic transition with distinct social support structures and health system configurations. In addition, many trials recruited community-dwelling older adults who were willing and able to participate in structured programs, which may reduce applicability to more socially isolated, cognitively impaired, or severely frail populations. Fifth, the limited follow-up duration in many studies constrains conclusions regarding the sustainability of intervention effects. Few trials assessed hard endpoints such as institutionalization, hospitalization, or mortality, thereby limiting insight into broader system-level impact. Sixth, variation in intervention intensity, dosage, delivery models, and contextual adaptations complicates the identification of optimal parameters for success. Limited reporting on implementation fidelity and adherence further constrains understanding of whether observed outcomes reflect the intervention design or delivery variability. Incomplete reporting of intervention components, community engagement processes, and resource requirements restricts replicability and limits assessment of cost-effectiveness and scalability in routine practice. In addition, conclusions regarding scalability and sustainability should be interpreted cautiously, as these dimensions were inconsistently or explicitly reported across trials and sometimes inferred from intervention characteristics, delivery models, and follow-up descriptions. Finally, underreporting of contextual and structural constraints may obscure barriers to implementation and limit understanding of how interventions perform across diverse real-world settings.

Considering these limitations, future research should prioritize pragmatic trials that evaluate long-term sustainability, cost-effectiveness, and the integration of community-based interventions within existing health and social care systems. In addition, greater attention is needed to evaluate the effectiveness of such interventions in low- and middle-income settings and among socially vulnerable older populations, where structural barriers may limit access to community-based services.

5 Conclusion

This systematic review synthesizes evidence from RCTs evaluating community-based interventions designed to support independence among older adults. Across diverse national contexts and intervention models, programs targeting physical activity, cognitive engagement, health education, nutrition, social participation, and restorative approaches were generally associated with improvements in functional capacity, psychological wellbeing, and social connectedness. Together, these domains may contribute to independence in later life, with functional capacity more directly related to autonomy and psychosocial outcomes acting mainly as indirect contributors.

Although several trials reported null or mixed findings, the overall pattern of evidence suggests that community-based approaches may support multiple determinants of independence in later life. The findings suggest that community-based delivery is not merely an alternative implementation setting but may provide a practical platform for integrating the physical, cognitive, and social dimensions of healthy aging. Interventions that were structured, culturally responsive, and embedded within existing community infrastructures appeared particularly adaptable across contexts. Multidomain models that combined physical, cognitive, and social components appeared especially aligned with the interconnected nature of functional decline and resilience in aging populations.

In the context of rapid global population aging, community-level public health strategies that preserve functional ability and participation may represent an important component of sustainable aging policy. Advancing implementation research, strengthening integration with primary care and municipal systems, and extending follow-up durations will be important for sustaining and extending gains relevant to later-life independence.

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