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Ageing and Supportive Environments:Accessibility, Usability and Safety

in Urban Environments

Professor S. IwarssonCentre for Ageing and Supportive Environments

(Hosted by the Faculty of Medicine)Lund University, Sweden

Scientific approach• Environmental gerontology• Occupational therapy, physiotherapy• Community-based rehabilitation• Traffic planning and engineering• Social work• Housing and local community environments,

including public transport, as supportive environments for activity and health along the process of ageing

• Primary/municipal health care - rehabilitation, health promotion & preventive measures for older people in the community

• Physical planning, at local, regional, national and international levels, engaging end users and stakeholders

Knowledge gaps & research needs

Need for

- more explicit consideration of the environment in studies on older people and ageing

- better understanding and in-depth knowledge of person-environment fit processes

- exploration of relationships between environment and health among older people and along the process of ageing

Presentation Outline

• Theoretial perspectives• Core Concepts• Methodology

• The ENABLE-AGE Project• The ”Let’s Go for a Walk” Project

The Ecological Theory of Ageing

Person-environment fit, P-E Fit (Lawton & Nahemow, 1973)

The Disablement Process

THE MAIN PATHWAY

PATHOLOGY IMPAIRMENTS FUNCTIONAL LIMITATIONS DISABILITY

EXTRA-INDIVIDUAL FACTORS

INTRA-INDIVIDUAL FACTORSRISK FACTORS

Environmental Adaptations

Assistive Technology

Coping StrategiesPersonalityMotivation

Life StyleGenetic Factors

Adapted from Verbrugge & Jette (1994)

A relative concept, denoting the meeting between the person’sfunctional capacity and the demandsfrom the environment

Accessibility is an aspect of Person-Environment Fit (P-E fit)

Comprisesa) a personal componentb) an environmental component

Definition of accessibility

S. Iwarsson/maj 99

PERSONAL COMPONENTRating form for assessment of

functional limitations (N=13) and

dependence onmobility aids (N=2)

ENVIRONMENTAL COMPONENT

Part of rating formfor assessment of

environmentalbarriers (N=188)

(Iwarsson & Slaug, 2001)

The Housing Enabler

The Environmental Component

Based on official norms, guidelines & legislation

Stairs: Slippery walking surfaceNo handrails, handrails too short, handrails interruptedVisual pattern of the stairs camouflages edges of treads

Examples of frequent barriers

> 5 mm

Outdoors: Unstable walking surfacePath surface not level (cracks, holes deeper than 5 mm)

Examples of frequent barriers

Implies that a person should be able to use, i. e. to move around, be in and use, the environment on equal terms with other citizens

Comprises a third component;activity

Based on user perceptions

Definition of usability

“Universal design is an approach to design that incorporates products as well as building features which, to the greatest extent possible, can be used by everyone” (Mace, 1985)

Universal Design - is about social inclusion- denotes a process more than adefinite result

- is not about norms

Definition of Universal Design

Perceived safety = risks perceived by lay persons

Objective safety = actual risks as measured by experts (Jasanoff, 1998)

Requires specific instruments, e.g. fall risk checklists, systematic recording of falls and injuries

Related Concepts

Individual perspectivePatient - therapist= rehabilitation

Societal perspectivePopulation - health agents= health promotion

Different perspectives….

Micro - Meso - Macro level

Different societal arenas:Housing and private outdoor

environmentPublic outdoor environmentPublic facilitiesPublic transportation, vehicles

From origin to destination…

Different perspectives….

The consortium:LatviaSwedenUnited KingdomGermanyHungary

The ENABLE-AGE Project:Enabling Autonomy, Participation, and Well-Being in Old Age:The Home Environment as a Determinant for Healthy Ageing

Main aim

In very old age

In private households

Living alone

Risks andpotentials

HomeEnvironment

(objective,subjective)

“HealthyAgeing”

(autonomy, well-being,participation)

To examine, from a European perspective, the home environmentas a determinant for ”Healthy Ageing”Recommendations for evidence-based housing solutions acrossEurope

Aspects of Housing

ObjectiveHousing standardPhysical environmental barriersAccessibility

Perceived (subjective)Housing SatisfactionUsabilityMeaning of HomeHousing Control

Three-part Project DesignThe ENABLE-AGE Survey Study

Well-proven instruments and study-specific questions at home-visits.

Longitudinal design with a one-year interval (between T1 and T2).

- Basic demographics, socio-structural background- Objective person-environment fit (P-E fit) = accessibility- Perceived aspect of environment- Psychological components- Outcome of healthy ageing

The ENABLE-AGE In-depth Study

Qualitative semi-structured interviews in home-visits with a sub-sample of survey participants, followed by consultation interviews

Team-based approach informed by Grounded Theory

- Completed in two stages, after T1 and before / parallel to T2

Sample descriptionSampling in urban regions, stratified for age and genderCommunity dwelling very old people, living alone (T1, N = 1,918; T2, N = 1,356)Different life expectancy and different onset of “Fourth Age” in Eastern vs. Western European countries implications for sampling

In-depth studies, N = 189 Diversity sampling based on survey data

Age (at T1) Gender Sweden Germany United Kingdom

Hungary Latvia Total

Women --- --- --- 145 176 75-79 years old Men --- --- --- 36 21

378

Women 147 165 169 171 92 80-84 years old Men 53 47 76 40 14

974

Women 149 188 94 --- --- 85-89 years old Men 48 50 37 --- ---

566

Total N (T1) 397 450 376 392 303 1918

Total N (T2) 314 322 316 179 225 1356

The ENABLE-AGE Update Review

A five-country macro level update of housing policies and legislation, based on databases, literature, and expert consultations

1. Cross-national revision of instrument for accessibilityassessment2. National reports and cross-national comparison

Cross-national adaptation

1. Review of relevant building legislation in five countries - 188 different environmental barriers

2. Different approach to building legislation - one population or several?

3. Validity of norms?

4. Different status of norms and regulations

5. Different vocabularies for housing types and environmental details

SUFFICIENT INTER-RATER RELIABILITY

Core environmental barriers

A comprehensive methodological studyaiming at identifying the environmental barriers contributingthe most to accessibility problems…

Based on expert panels and statistical simulations – 188 items in three databases:

• ENABLE-AGE (Sweden, Germany, Latvia; urban), N=1,150

• Population sample, older people (Sweden; rural), N=133• Housing adaptatio cases (Sweden; rural and urban),

N=131

Screening version of the Housing Enabler

61 core items; environmental barriers

Correlation with original instrument:rs = 0.97 - 0.99, p < 0.0005

Makes evidence-based, valid and reliable housing accessibility screenings possible

(Carlsson et al., J of Applied Gerontology, in press)

Four-domain Model of Perceived Housing

Housing satisfaction (HSAT)A single item rating satisfaction with physical conditions (1-5)“Are you happy with the condition of your home”?

Usability in My Home (UIMH)4 items on activity aspects of usability (1-5)E.g., “In terms of how you normally manage your personal hygiene (…), to what extent is the home (…) suitably designed in relation to this”?6 items on physical environmental aspects of usability (1-5)E.g., “How usable do you feel that the entrance to your home is”?

Meaning of Home (MOH): "Being at home means for me..."7 items on physical housing aspects (0-10)E.g., “living in a place which is well-designed and geared to my needs”6 items on behavioral/activity aspects (0-10)E.g., “being able to change or rearrange things as I please”10 items on cognitive/emotional aspects (0-10)E.g., “feeling comfortable and cosy”5 items on social aspects (0-10)E.g., “meeting family, friends, and acquaintances”

Housing-related Control Beliefs (HCQ)16 items on external control (chance, powerful others) (1-5)E.g., “You just have to live with the way your home is; you cannot do anything about it”

Exploratory factor structure

(N = 1189) Factors and factor loading Communality

Domains of Perceived Housing 1 2 3 4

Meaning of Home: Physical Housing Aspects (7 items) .72 .26 -.09 .22 .65

Meaning of Home: Behavioural/Activity Aspects (6 items) .62 .54 -.00 -.10 .68

Meaning of Home: Cognitive / Emotional Aspects (10 items) .80 .13 .12 -.05 .67

Meaning of Home: Social Aspects (5 items) .67 -.18 -.38 .19 .66

Usability in My Home: Activity Aspects (4 items) .10 .83 -.15 .01 .72

Usability in My Home: Physical Environmental Aspects (6 items) .14 .74 -.12 .30 .67

Housing-related Control Beliefs: External Control (16 items) -.03 -.23 .91 -.00 .89

Housing Satisfaction (1 item) .09 .15 -.01 .94 .92

Note. Factor analysis using principal component analysis revealed a four-factor solution, explaining 73.2% of the variance.

Empirical evidence for a four factor solution: Each instrument reflects an important, separate aspect of perceived housing

Confirmatory factor structure

Note. Numbers attached to double-headed arrows: Correlations for German/Swedish/UK sample.

HousingSatis-faction

MOH1 MOH2 MOH3 MOH4 UMH1 UMH2 HEXC HSAT

Hous.-rel.ControlBeliefs

Usabilityin theHome

Meaningof

Home

1 1 1 1

1 1 1 1 1 1

0.36 / 0.31 / 0.19

0.18 / 0.21 / 0.34

0.48 / 0.56 / 0.58

-.21 / -.35 / -.380.37 / 0.36 / 0.26

-.10 / -.15 / -.16

-.37 / -.37 / -.34

RMSEA = 0.04NFI = 0.93CFI = 0.95χ2 = 125.6 (p < .001)

Multi-group SEM revealed that perceived housing is best displayed by the selected four constructs, reflecting four different domains

Conclusions; Perceived HousingThe four domains housing satisfaction, usability in the home, meaning of home, and external housing-related control beliefs are different aspects of perceived housing

The findings are confirmed for different research sites, indicating comparable concepts of perceived housing and cross-national validity of the instrumentation

Need to address the complexity of perceived housing

……in relation to objective aspects of housing

……in relation to aspects of health, e.g. independence and well-being

Oswald et al., J of Environmental Psychology

Project Design (2002-2004)

ENABLE-AGE „In-Depth Study“

Sub-sample

Development of an optimised methodology, comprising measures on objective and subjective housing

Development of evidence based recommendations for healthy

housing solutions across Europe

ENABLE-AGE „Survey Study“ T2

ENABLE-AGE„Policy Update Review“

ENABLE-AGE „Survey Study“ T1

2005-2007: Additional in-depth studies, Sweden2008: Five-year follow-up in Sweden, Germany

Example of Study AimsQ1: How is housing related to different aspects of

“healthy ageing”?H1: Housing (obj. / sub.) is linked to behavioral autonomy

and well-being (cognitive and emotional aspects)

Q2: Are there common or country-specific patterns of relationship?

H2: Links between housing and “healthy ageing” are partially independent from cultural background

Variables of „Healthy Ageing“Autonomy:ADL dependence (ADL-staircase, Sonn, & Hulter Åsberg, 1991)

- Sum-score (9 items)

Data Collection Methods

Cognitive and emotional aspects of “healthy ageing”

Behavioural aspect of “healthy ageing”

Well-being:Life satisfaction

- Single-item indicator (0-10)

Environmental mastery (Ryff, 1989)- Sum-score (9 items), e.g., „I am quite good at managing the many responsibilities of my daily life”

Affect (PANAS, Watson, Clark, & Telegen, 1988)- Sum-score on positive affect (10 items), e.g., interested, excited- Sum-score on negative affect (10 items), e.g., distressed, afraid

Depression (GDS, Yesavage et al., 1983)- Sum-score on depression (15 items)

Results

Basically comparable dataLower life satisfaction scores, East - WestHigher depression scores, East - West

Variable (M, SD) (N = 1918) Sweden Germany UK Hungary Latvia Age 80-89 80-89 80-89 75-84 75-84

ADL-independence (0-9) 7.6 7.8 8.0 7.9 8.2 Life satisfaction (0-10) 8.5 8.5 8.3 6.6 5.5 Environmental mastery (1-5) 4.0 4.4 3.9 4.0 3.2 Positive affect (1-5) 3.2 3.4 3.4 3.4 3.1 Negative affect (1-5) 2.1 2.0 2.0 2.1 2.5 Depression (0-15) 3.0 3.2 3.0 5.5 6.4

Basic description of "healthy ageing" indicators

Correlations objective housing x "healthy ageing“ indicators

Housing variables Country ADL-

independence Life

satisfaction Environmental

mastery Positive

affect Negative

affect Depression Germany 0.02 -0.04 -0.10 0.03 0.07 -0.05 Hungary -0.04 -0.03 -0.16 0.07 0.02 0.18

Latvia -0.00 0.05 0.03 -0.05 -0.15 -0.03 Sweden 0.12 0.06 -0.07 -0.09 -0.10 -0.03

Environmental barriers

UK -0.05 -0.04 -0.02 0.04 0.00 0.12 Germany 0.39 0.20 0.27 0.25 -0.15 -0.29 Hungary 0.49 0.32 0.40 0.16 -0.20 -0.47

Latvia 0.50 0.00 0.19 0.25 -0.03 -0.31 Sweden 0.41 0.18 0.27 0.20 -0.09 -0.31

Housing accessibility

UK 0.52 0.18 0.25 0.18 -0.11 -0.40

Note. Spearman partial correlations, controlled for basic health and socio-economic status indicators.

Not the barriers but low magnitude of accessibility problems (p-e fit) are related to higher behaviouralindependence and better environmental mastery as well as lower incidence of depression in all sites

+ + -

Correlations of subjective housing x "healthy ageing“

Housing variables Country ADL-independence

Life satisfaction

Environmental mastery

Positive affect

Negative affect Depression

Germany 0.21 0.28 0.39 0.24 -0.19 -0.28 Hungary 0.20 0.42 0.46 0.20 -0.20 -0.49

Latvia 0.25 0.31 0.45 0.23 -0.25 -0.47 Sweden 0.04 0.17 0.16 0.24 -0.05 -0.20

Meaning of home (physical aspects)

UK 0.26 0.34 0.39 0.31 -0.20 -0.48 Germany 0.38 0.31 0.43 0.23 -0.21 -0.31 Hungary 0.37 0.30 0.43 0.25 -0.19 -0.47

Latvia 0.52 0.24 0.41 0.36 -0.18 -0.52 Sweden 0.51 0.26 0.36 0.18 -0.21 -0.36

Meaning of home (behavioral aspects)

UK 0.46 0.33 0.35 0.25 -0.18 -0.44 Germany 0.11 0.21 0.24 0.17 -0.11 -0.14 Hungary 0.15 0.42 0.46 0.20 -0.32 -0.50

Latvia 0.22 0.30 0.41 0.33 -0.30 -0.52 Sweden 0.19 0.17 0.19 0.16 -0.07 -0.19

Meaning of home (cog./emotional aspects)

UK 0.10 0.31 0.28 0.28 -0.24 -0.34 Germany -0.09 0.07 0.16 0.17 -0.02 -0.10 Hungary 0.08 0.37 0.37 0.13 -0.23 -0.45

Latvia 0.20 0.29 0.43 0.33 -0.19 -0.50 Sweden 0.16 0.21 0.25 0.21 -0.16 -0.21

Meaning of home (social aspects)

UK 0.07 0.24 0.32 0.20 -0.08 -0.31 Germany 0.38 0.18 0.39 0.18 -0.12 -0.18 Hungary 0.13 0.22 0.24 0.18 -0.09 -0.17

Latvia 0.51 0.24 0.30 0.16 -0.10 -0.28 Sweden 0.30 0.13 0.26 0.23 -0.08 -0.24

Usability in my home (activity aspects)

UK 0.29 0.19 0.29 0.15 -0.12 -0.26 Germany 0.24 0.15 0.31 0.13 -0.13 -0.15 Hungary 0.26 0.18 0.23 0.10 -0.24 -0.25

Latvia 0.30 0.20 0.35 0.02 -0.24 -0.19 Sweden 0.20 0.13 0.24 0.18 -0.07 -0.16

Usability in my home (physical env. aspects)

UK 0.30 0.24 0.29 0.16 -0.14 -0.34 Germany -0.28 -0.14 -0.34 -0.24 0.21 0.27 Hungary -0.32 -0.39 -0.52 -0.35 0.18 0.46

Latvia -0.32 -0.10 -0.31 -0.33 0.13 0.38 Sweden -0.25 -0.15 -0.37 -0.21 0.08 0.26

Housing-related control beliefs (external control)

UK -0.35 -0.20 -0.47 -0.20 0.11 0.40 Germany 0.01 0.11 0.28 0.06 -0.21 -0.02 Hungary 0.12 0.16 0.15 0.08 -0.16 -0.18

Latvia -0.01 0.20 0.19 -0.06 -0.10 -0.07 Sweden 0.03 0.10 0.12 0.11 -0.07 -0.18

Housing satisfaction UK -0.01 0.10 0.17 -0.01 -0.10 -0.10

Note. Spearman partial correlations, controlled for basic health and socio-economic status indicators.

Further analyses are necessary to unpack this complexity

1. Subjective housing is linked to autonomy and well being

2. East-West differences in the relationship of meaning of home (cognitive / emotional, social aspects) and well-being

ConclusionsH1: “Healthy aging” is related to objective and subjective housing indicators in very old ageH1: The magnitude of accessibility problems (not barriers!) and activity-oriented usability and meaning is related to behavioral autonomy and well-being, controlled for basic health and SES Need to address both objective and subjective aspects of the home in relation to “healthy ageing”H2: There is a tendency towards partially comparable relationships between housing and “healthy aging”, although the level of p-e fit, life satisfaction, or depression is differentNeed to further analyze- country-specific patterns- changes over time in individual patterns of

housing and “healthy ageing” in very old age

Summary of Results (several studies)

- Accessibility problems (P-E fit) are important for health in very old age – not environmental barriers

- A list of the most important environmental barriers underlying accessibility problems in housing

- Objective aspects of housing are more important amongthose with higher functional capacity –perceived aspects are more important among those with lower

- Living in more accessible housing is related to perceiving home

as more meaningful and useful, lower degree of external control, higher ADL independence and life satisfaction

Summary of Results (several studies)

• Environmental barriers were very common -in all three national samples the 20 most prevalent barriers were found in 77-98% of the dwellings

• The magnitudes of accessibility problems were similar among the three samples and did not change over one year

• There were similarities and differences among the three countries in the types of environmental barriers generating the most accessibility problems

Summary of Results (several studies)

Generally positive perceptions……but there were risks for

accidents…and people were less positive

over time

Some uncertainity whether the home would suit if the situation changed…

The oldest persons haddifficulties managing theirhome, and things could havebeen more optimallyarranged…

Outdoor activities diminishedover time…

Implications for Societal Planning

• A better understanding of older people’s housingsituation

• Results based on data collected by means of scientific methodology

• Emphasizing the importance of understandingaccessibility/P-E fit as different from prevalence ofenvironmental barriers

• Informing older people, non-governmentalorganisations, estate owners, building

constructors,and municipalities about housing design

supportinghealthy ageing

Turning to Outdoor Environments

Evidence-based list of environmental barriersgenerating P-E fit problems (examples):

Irregular and/or unstable walking surfacesSteep gradientsRoutes with stepsHigh kerbsNo/too far between restingsurfaces

Poor lighting

“Let’s go for a walk”Evaluation of outdoor environment

measures regarding accessibility, safety & mobility for older persons

Professor Agneta Ståhl

Professor Susanne Iwarsson

2007-11-20

A Ståhl, S Iwarsson

Aim; • Increased accessibility / usability and

safety for older people in the close outdoor environment

By means of:• User involvement• Implementation of concrete measures• Evaluation

2007-11-20

A Ståhl, S Iwarsson

Research DistrictResearch District•• City of City of KristianstadKristianstad (South Sweden), (South Sweden), 79,000 inhabitants79,000 inhabitants

•• ApprAppr 3.000 inhabitants3.000 inhabitants•• ApprAppr 20% 65 years or older20% 65 years or older•• Various types of housingVarious types of housing•• Various traffic environmentsVarious traffic environments

Time schedule; 2002 Time schedule; 2002 -- 20072007

2007-11-20

A Ståhl, S Iwarsson

Participating authoritiesParticipating authoritiesMunicipality of KristianstadMunicipality of KristianstadSwedish National Road Administration Region SkSwedish National Road Administration Region Skåånene

Participating researchersParticipating researchersFaculty of Engineering &Faculty of Engineering &Faculty of Medicine, Lund UniversityFaculty of Medicine, Lund University

Participating users; target sampleParticipating users; target sampleAll older people (65+) in the geographical district,All older people (65+) in the geographical district,approx. 560 personsapprox. 560 persons

2007-11-20

A Ståhl, S Iwarsson

Method: Pre Method: Pre –– after studyafter study•• Postal questionnaire survey; all older people in Postal questionnaire survey; all older people in the geographical district (T02 N=330, T06 N=347) the geographical district (T02 N=330, T06 N=347) Overview of environmental barriersOverview of environmental barriers

•• Participant observations (T02 n=6, T06 n=11)Participant observations (T02 n=6, T06 n=11)To examine critical incidents when walking in the areaTo examine critical incidents when walking in the area

•• Research circles; discussions (T02 n=18)Research circles; discussions (T02 n=18)Older persons in the geographical district, authorities, associations,

interest organizations, researchers

•• ImplementationImplementation

••EvaluationEvaluation2007-11-20

A Ståhl, S Iwarsson

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Environmental barriers encountered outdoors in the study district

Winter maintenanceCycles, MopedsBenchesSignalized crossingsCurb cutsUneven pavementsHeavy traffic

Results; Mail questionnaire survey (n=340)

2007-11-20

A Ståhl, S Iwarsson

Results; Participant observations

More benchesWider pavementsMore and better curb cutsMore even pavementsBetter regulation of cyclists

2007-11-20

A Ståhl, S Iwarsson

Results; implementation schemeStrategy: benefit as many as possible of the people living in the area; focus on pedestrian routes

Older people

Accessibility for persons using walking aids; rollator

Regulation of bicycle traffic

Traffic regulations overall

Authorities

Simple measures; easy to plan and conduct, not too expensive

2007-11-20

A Ståhl, S Iwarsson

Example of measures takenWider pavement with new surface

2007-11-20

A Ståhl, S Iwarsson

Before After

Example of measures taken

New benches along important passages

2007-11-20

A Ståhl, S Iwarsson

Conclusions

Accessibility in the neighbourhood increasedExperienced environmental barriers have increased dramatically

Perceived safety increasedVery positive comments on safety related issues

Measures taken were valued positivelyCurb cutsEven pavementsSeparation pedestrian - bicyclists

Snow removal and slippery roads

Conclusions Outdoor activities did not increase – sub-group analyses neededThe proportion that wants to be more active increased None claimed barriers in the environment as the cause –rather health decline

Explanations:Health decline over time in old age The proportion reporting functional limitations Increased, as did the use of walking aids (rollators)

The actual measures taken varied in the area has an obvious impact on the results

An obvious and clear outcome of user involvement

Older peopleNew ways to better influence responsible parties in societyReal measures conducted in the outdoor environmentAwareness of their own responsibility for their situation and aging

processThe municipalityNew experience; small details are more important than large

infrastructure measuresThe Road AdministrationIncreased knowledge about the needs of older people

2007-11-20

A Ståhl, S Iwarsson

Factors for success• Trustworthy knowledge; The experiences and

knowledge of the older people themselves is the basis and the point of departure for the project

• Systematic research methodology; Triangulation of methods gives high validity

• Co-operation among all parties of interest gives abroader perspective

• Societal perspective; • Health, Safety and

Accessibility / Usability2007-11-20

A Ståhl, S Iwarsson

Thanks to funders, co-workers and collaborators!

Centre for Ageing & Supportive Environments

www.med.lu.se/casewww.enableage.arb.lu.se

www.enabler.nu

susanne.iwarsson@med.lu.se